Substance Abuse

ISSN: 0889-7077 (Print) 1547-0164 (Online) Journal homepage: https://www.tandfonline.com/loi/wsub20

The intersection of intimate partner violence and

substance use among women with opioid use
disorder

Chelsea Pallatino, Judy C. Chang & Elizabeth E. Krans

To cite this article: Chelsea Pallatino, Judy C. Chang & Elizabeth E. Krans (2019): The
intersection of intimate partner violence and substance use among women with opioid use disorder,
Substance Abuse, DOI: 10.1080/08897077.2019.1671296

To link to this article: https://doi.org/10.1080/08897077.2019.1671296

Published online: 22 Oct 2019.

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SUBSTANCE ABUSE
https://doi.org/10.1080/08897077.2019.1671296

ORIGINAL RESEARCH

The intersection of intimate partner violence and substance use among women
with opioid use disorder
Chelsea Pallatino, PhD, MPHa,b, Judy C. Chang, MD, MPHa,b, and Elizabeth E. Krans, MD, MSca,b
a
Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA; bDepartment of Obstetrics, Gynecology, and Reproductive Sciences,
University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA

ABSTRACT KEYWORDS
Background: Women with opioid use disorder (OUD) report high rates of intimate partner violence Substance use; intimate
(IPV) and there is limited understanding of how IPV influences substance use behaviors among partner violence; opioid
women with OUD. Methods: Semi-structured qualitative interviews were conducted with a sample use disorder
of 40 women with OUD participating in an ongoing clinical trial evaluating postpartum contracep-
tive utilization patterns for this population. Interviews were audio-recorded, transcribed verbatim
and lasted approximately 45 min. Interview questions focused on women’s perceptions and experi-
ences with IPV and how these experiences impacted their substance use behaviors. Transcripts
were coded independently in Atlas.ti and qualitatively analyzed using a general qualitative inquiry
approach for emerging themes. Results: Participants were aged 24–29, and the majority were
white, single, unemployed, had Medicaid insurance and a high school degree. Although personal
IPV experiences were not necessary to be selected for this qualitative sub-study, all participants
reported some lifetime experience with IPV. Four overarching themes emerged: (1) women attrib-
uted physical IPV to their partner’s substance use; (2) emotional abuse prevented women from
fully engaging in their recovery; (3) financial abuse prevented women from gaining independence
from abusive partners; and (4) women coped with IPV experiences through substance use.
Conclusions: IPV had a significant influence on women’s substance use behaviors including their
perceived risk of relapse and treatment discontinuation. These findings demonstrate the need to
integrate assessment, evaluation and management of IPV into substance use treatment settings.

Introduction substance use behaviors and contribute to substance use

Women with substance use disorders experience a dispro-
portionately high rate of intimate partner violence (IPV).
Between 47% and 90% of women of reproductive age
(15–44 years) with a substance use disorder (SUD) have
experienced IPV compared to 1–20% in non-SUD popula-
tions.1–5 Further, women are at highest risk for IPV and
intimate partner homicide during their reproductive years.6,7
In a study of over 10,000 female victims of homicide from
the National Violent Death Reporting System (NVDRS),
72% of victims were aged 18–49.7 While substance use
among women of reproductive age is associated with IPV
risk, substance use among partners is also associated with
increased risk for IPV perpetration.8–11 Over 50% of men in
batterers intervention programs (BIPs) have problematic
substance use and 50% of men in SUD treatment have per-
petrated IPV in the previous year.12,13 Thus, substance use
among women and substance-using partners is bidirection-
ally linked to IPV risk and experiences.14,15
While substance use often co-occurs with IPV, there is
limited understanding of how IPV may influence women’s
treatment outcomes. Previous research focused on the co-
occurrence of IPV and substance use have largely been
quantitative evaluations focused on IPV prevalence rates
among women with SUDs including marijuana, alcohol,
cocaine or opioid use.5,16–28 In a study of women in SUD
treatment, the prevalence of IPV varied by type of SUD
including alcohol (47.6%), cannabis (13.5%), cocaine
(2.6%) and polysubstance (2.4–9.0%) use.29 Further, previ-
ous research has largely been limited to evaluations of the
physical and sexual dimensions of IPV.6,23,30 Instead, IPV
encompasses a wide spectrum of coercive behaviors
including psychological, financial and emotional abuse that
have negative repercussions on mental, physical, and
reproductive health outcomes. Despite this, the prevalence
and effect of nonphysical IPV behaviors on substance use
has not been evaluated among women with OUD. As the
prevalence of opioid use disorder (OUD) escalates among
women, the role that the spectrum of IPV behaviors plays
in OUD treatment is critical for improving health out-
comes. Therefore, the purpose of this research was to
conduct a detailed qualitative exploration of how women

CONTACT Chelsea Pallatino, PhD, MPH clp44@pitt.edu Magee-Womens Research Institute, Magee Medical Building, 3380 Boulevard of the Allies,
Pittsburgh, PA 15213, USA.
ß 2019 Taylor & Francis Group, LLC
2 C. PALLATINO ET AL.

with OUD experience IPV including physical and non-
physical dimensions of IPV and how IPV influences wom-
en’s substance use behaviors.
Materials and methods
Study design and sampling
We chose an open, descriptive qualitative approach using
individual interviews to understand the issue of OUD and
IPV from the perspectives of women with OUD to avoid
imposing our biases or assumptions with any predetermined
theoretical framework or pre-determined answer selections.
For our sampling and recruitment, we were able to use
infrastructure and staff support from an existing trial that
was actively recruiting women who fit characteristics tar-
geted for our sampling. From September 2017 to January of
2018, women with OUD were sampled from participants in
an ongoing clinical trial evaluating contraceptive use pat-
terns in the first year postpartum. Participants in the parent
study were recruited during pregnancy or the immediate
postpartum period (i.e. prior to discharge from the birth
hospitalization) from a large, tertiary care maternity hospital
in Pittsburgh, Pennsylvania, were
18 years old, and met
DSM-V criteria for OUD. During enrollment in the parent
study, participants were given the option to give consent to
be contacted to participate in future research opportunities.
Women who consented were contacted by phone or email
and invited to participate in this qualitative sub-study focus-
ing on the intersection of IPV and OUD. We chose this
recruitment strategy as our research team had already devel-
oped trust and rapport with this group of participants and
we wished to focus primarily on women who were recently
pregnant given that pregnancy often causes women to reflect
upon their behaviors and consider changes.31–34 However,
despite sampling in the postpartum period, qualitative inter-
views focused on women’s lifetime experiences of the inter-
section of IPV and substance use behaviors and no
participants discussed IPV experiences specific to pregnancy
or the postpartum period. We also chose not to restrict
interview eligibility by IPV experience because we wished to
obtain a deeper understanding of what types of behaviors
and interactions women with OUD identified and perceived
as IPV.
Approval for this study was obtained through the
University of Pittsburgh IRB.
Data collection
Prior to the one-time qualitative interview, participant socio-
demographic information, substance use behaviors, and psy-
chosocial history was collected via Qualtrics Survey
Software. Lifetime and current substance use history of par-
ticipants were derived from validated instruments including
the Alcohol Use Disorders Identification Test (AUDIT)
and the Composite Quantity Frequency Index.35,36 A semi-
structured qualitative interview guide was created by CP, JC
and EK and consisted of 10 core open-ended questions and
follow-up probes to explore participants’ definitions and
perceptions of IPV, lifetime experiences IPV and the influ-
ence of IPV on substance use behaviors (Table 1).
Interviews were semi-structured and were conducted in a
manner that emphasized participant openness, honesty, and
control; thus, questions were adapted to the narratives of
each of the participants and did not follow a standard or
predetermined order. In this manner, the interview guide
served as a tool to ensure that each topic was covered, but
wording, order, and sequence of the questions were not
necessarily the same for each interview. Questions asked
women to share their perceptions of what they felt repre-
sented IPV and to describe any current or prior experience
of controlling, violent, or demeaning behavior from an
intimate partner in their lifetime. We then used probes to
explore the topic more deeply and focus on how they per-
ceived the interaction between these unhealthy relationships
and their substance use behaviors. Each interview was con-
ducted by CP by phone after obtaining verbal consent in a
private location via a phone number that was designated as
safe by the participant. All interviews were digitally recorded
and participants were offered a list of community resources
that included IPV and other social service-related resources,
which was shared via email or over-the-phone, based on the
participant’s preference and what she determined to be most
safe and convenient.

Table 1. Interview guide.

Topic
IPV definitions and perceptions
IPV dimensions
Intersection of IPV and OUD
Interview questions and follow-up probes
How would you define or characterize violence or abuse in a relationship with a partner?
Tell me about any experiences that you may have had with violence or abuse?
What are some examples of behaviors that you consider to be physically violent?
 Tell me about any experiences you have had with this type of violence?
What are some examples of behaviors that you consider to be harmful or abusive, but that were not
physically violent?
 Tell me about any experiences you have had with your partner that were emotionally or mentally upsetting,
disturbing or made you feel negatively about yourself?
 Tell me about any experiences you have had with a partner who tried to control your money or ability
to work?
Tell me about any experiences you have had with a partner who has tried to prevent you from seeking or
continuing your participation in a drug treatment program?
 How do you think any of these experiences influenced your decision to use drugs or seek treatment?
Has your partner tried to interfere with your recovery?
 In what ways has your partner tried to interfere in your recovery process?
 SUBSTANCE ABUSE 3

Data analysis Table 2. Characteristics of study sample, n ¼ 40.

Demographics n (%)
All audio files were transcribed verbatim by a professional Age (years)
transcriptionist and each interview transcript was reviewed 18–23 4 (10.0)
for accuracy. After the interviews were completed, interview 24–29 22 (55.0)
30–34 9 (22.5)
codes and transcripts were uploaded into Atlas.ti Qualitative 35–45 5 (12.5)
Data Analysis and Research Software Version 8 for data Race
analysis and management. Qualitative analysis was con- Caucasian 37 (92.5)
African American 1 (2.5)
ducted using a “generic qualitative inquiry” approach, where Othera 2 (5.0)
codes were identified without explicitly framing participant Marital status
responses within the context of a particular theoretical or Single 39 (90.0)
Married 1 (2.5)
epistemological grounding.37 This approach is also often Employment
referred to as “qualitative description,” whereby researchers Employed 11 (27.5)
convey fact-based details through their interpretation of par- Unemployed 22 (55.0)
Otherb 7 (17.5)
ticipants’ narratives.38 This approach emphasizes summariz- Insurance
ing and interpreting participant responses in a way that Medicaid 38 (95.0)
other researchers and participants would agree is accurate.38 Private insurance 2 (5.0)
Income
Prior to the coding process, a codebook was developed <$10,000 18 (45.0)
and refined by CP, JC and EK based on topics addressed in $10,000-$29,999 12 (30.0)
the interview guide. CP coded all transcripts using an open $30,000 and above 3 (7.5)
Unsure 7 (17.5)
coding process, where each line of data was reviewed and Education Level
analyzed to discern the meaning of the data shared through Some high school 5 (12.5)
participants’ responses. Data collection and coding of study High school/GED 13 (32.5)
Trade/vocational school/some college 16 (40.0)
transcripts occurred simultaneously. Throughout the coding Bachelor’s Degree 6 (15.0)
process, new codes were developed, expanded and refined Number of children [mean (±SD)] 2.5 (±1.3)
Substance use historyc
iteratively. New codes were incorporated into the codebook Opioid usec
during the coding process after being reviewed by all Heroin 32 (80.0)
authors. These codes were developed according to a data- Prescription opioidsd 34 (85.0)
Polysubstance usec
driven process based on review and analysis of participant Cocaine/Amphetamines 30 (75.0)
responses. Finally, codes were linked to relevant phrases in Benzodiazepines 30 (75.0)
participant responses and quotes were organized by theme. Alcohol 18 (45.0)
Marijuana 34 (85.0)
Once a final coding scheme was developed, it was reapplied Othere 24 (60.0)
to all transcripts a second time to ensure all transcripts were Medication-assisted treatmentf
coded with the final list of codes. Codes were then examined Buprenorphine 18 (45.0)
Methadone 19 (47.5)
and sorted by relationships, categories, and patterns. CP led Psychosocial history
the coding process and discrepancies were resolved by a Psychiatric co-morbidities
rereview of the relevant transcripts and codes by all of the History of a psychiatric diagnosisg 30 (75.0)
History of suicide attempt 8 (20.0)
authors. Descriptive statistics were used to report partici- Homelessness in past year 9 (22.5)
pants’ sociodemographic characteristics. a
Includes biracial and other.
b
Disability and “other”.
c
Response refers to lifetime prevalences.
d
Results Hallucinogens, barbiturates, inhalants, other sedatives and
tranquilizers.
e
Overview Percocet, vicodin, codeine, dilaudid.
f
Currently engaged in medication-assisted treatment program
Among 80 women with OUD approached for participation, at time of data collection.
g
Anxiety, depression, bipolar disorder, post-traumatic
40 (50%) agreed to participate in a one-time qualitative stress disorder.
interview. Interview discussions ranged from 27 to 48 min in
length. Most women with OUD were aged 24–29, white, sin-
gle, unemployed, on medical assistance, had two or more Over 20% of participants experienced homelessness in the
children and an income
$10,000, and graduated high past year.
school (Table 2). The majority of women with OUD When asked to describe IPV, participants focused primar-
reported a lifetime history of polysubstance use including ily on physical and sexual violence, emotionally manipula-
marijuana, benzodiazepines, cocaine/amphetamines, halluci- tive/hurtful behaviors (e.g. name calling, demeaning/
nogens, barbiturates, tranquilizers, sedatives, and alcohol humiliating comments) from intimate partners, and experi-
use. Most participants were engaged in a medication-assisted ences of financial abuse where intimate partners often con-
treatment (MAT) program and received either methadone trolled money and prevented women from gaining financial
(47.5%) or buprenorphine (45.0%). Among participants, independence. When asked about any personal experiences
75% reported a lifetime history of a psychiatric diagnosis with IPV, all 40 participants described a personal experience
and 20% reported a lifetime history of a suicide attempt. with some combination of physical, sexual, emotional or
4 C. PALLATINO ET AL.
financial IPV in their lifetime from a past or current part-
ner. Four major themes regarding perceived relationships
between OUD and IPV were: (1) women attributed physical
IPV to their partner’s substance use; (2) emotional abuse
prevented women from fully engaging in their recovery; (3)
financial abuse prevented women from gaining independ-
ence from abusive partners; and (4) women coped with IPV
experiences through substance use. The following sections
describe each of four major themes in detail and provide
illustrative quotations. Interview quotations have been short-
ened and repetitive clauses (e.g. um, ah, like) have been
removed for clarity of presentation.
Women attributed physical IPV to their partner’s
substance use
Participants shared experiences of their partners using
illicit drugs or alcohol and described their beliefs about
how their partner’s substance use either resulted in IPV
behaviors or caused ongoing IPV to become more fre-
quent and severe. Participants often blamed their partner’s
substance use as the reason for IPV, disclosing experiences
of IPV that occurred immediately after their partners
used drugs:
He started trying different drugs … he started hallucinating
and … thinking that I had … brought guys into his mother’s
house and … chased me around … with a 2x4. … He
would … come down from the drugs; that is when the physical
abuse would start.
Another participant noted how their relationship
changed, with her partner perpetrating violence more often,
when she or her partner used drugs:
Whenever my ex started using, it made him more aggressive
and it caused a lot more fights and arguments and it was just
really not a good time period at all … I mean it varied on and
off … sometimes I was clean and sometimes he was
using … sometimes we were both using … .When he was just
using … he became more aggressive and angry and … I isolated
[myself] … . I tend, whenever I use, I use alone. But it seems
like when I did that … it would cause more arguments and
fights, and it would change my attitude to where … I didn’t
want to deal with him.
Another participant explained how physical IPV esca-
lated when she and her partner were using drugs to the
point where he strangulated her, and her life was
in danger:
Whenever we were both on heroin, things just got really bad.
Whenever he didn’t have something–he would just go nuts. He
would grab my throat … it just wasn’t a healthy environment
or situation.
Some participants reflected on their past experiences of
IPV and recognized that they misplaced blame for IPV on
their partner’s substance use behaviors when IPV continued
to occur after their partners were not using drugs. One par-
ticipant shared her IPV experiences after her partner became
clean:
I used to think that he hit me because of the heroin … then he
had 3 years clean … and it still happened. So, I know it wasn’t
the drugs … . It was just him … It was worse when he was
on drugs.
Emotional abuse prevented women from fully engaging
in their recovery
In addition to physical abuse, women often described expe-
riences of psychological and emotional maltreatment which
had a negative effect on substance use behaviors and treat-
ment engagement. Some participants described experiences
of emotional abuse where perpetrators would use women’s
history of substance use to denigrate their self-esteem
and confidence:
More often than not it was the emotional abuse … if I would
start to feel good and get ahead he would start cutting me
down … I’m a recovering addict and you know always throwing
things I did years ago in my face to make sure you know you
aren’t really better.
Participants also described how emotional abuse from
partners would prompt them to seek additional help or sup-
portive services for their substance use:
By the time I figured it out that I was an addict it was too
late … I’m sure maybe some things maybe got me to that
point … just like the name calling with the mental abuse
whenever you know I was doing really bad, sometimes would
just bring me back to the reality and that is when I would ask
for help or call rehab.
Unfortunately, participants also spoke about how partners
made them feel guilty for their history of use and for engag-
ing in MAT. This often made women feel negatively about
themselves, despite being in recovery:
When I first got pregnant … I was still using actually and I went
to my doctor, I said I’m pregnant but I’m using, so they started
me on a Methadone program which I still go to … my boyfriend
that I am with now … he wasn’t very accepting of it because of
me being on Methadone, and he didn’t really know the whole
facts and stuff and he like didn’t care to … he just wasn’t very
nice … about the whole situation … he didn’t want to have the
kids or anything … that was … emotional abuse.
Financial abuse prevented women from gaining
independence from abusive partners
Many women disclosed experiences of their partners being
financially controlling and often described arguments with
partners over money that was frequently used to buy drugs.
One participant shared how her partner took her money to
buy drugs after a physical and verbal altercation, leading to
her subsequent drug use:
We were trying to quit … then we would get into … a physical
fight over money because he wanted money to go buy
drugs … he would … bring them back and I would say well fck
it, if you beat the sht out of me and stole my money, I might
as well get high on it.
Partners often controlled women’s finances because they
often needed money or transportation to support their sub-
stance use. One woman described physical IPV from an ex-
partner who tried to control her finances and how his abuse

impacted her ability to stay clean and maintain a job even
after they ended their relationship:
There was the one incident when he picked up a gigantic rock
and was going to throw it through my windshield … to get him
drugs … he didn’t have the means to get drugs. I was also his
ride to and from to get drugs … because he couldn’t find
somebody else to take him … . he controlled my finances … he
never worked … When I was pregnant with my daughter … he
would want money from me and I was working a minimum
wage job just trying to save money for our child and he wanted
money to go buy alcohol or … get drugs … if his friends came
over I had to support them with drugs and alcohol and that
impacted my job because I wasn’t getting proper rest … .
eventually I quit my work.
Participants often shared experiences of abusive partners
forbidding them from working or sabotaging their current
working situation. One participant described extreme experi-
ences from an ex-partner that would threaten to harm him-
self and others to keep her from working while he would
use her money to support his drug habit:
My ex-boyfriend … we were using … and we had a place
together … I would go to work and he would … tell me he was
going to kill himself … like right when my shift would
start … he did it a lot … a lot of the time … I would be the only
one with a job … if I was using … we would use all my money
but I would get clean and they would still be using and they
would … force me to give them my money … they would just
say awful things … like he was going to go and stab somebody
and steal all their money if I didn’t give them money … I missed
work one job … I didn’t show up for a shift because he said he
was going to kill himself and he didn’t want me to leave.
One participant described how her current partner both
restricts her ability to use her money and has sabotaged job
opportunities because of his lack of trust in her and need
for financial control:
He was like oh no it is different because she is a drug addict
and she will blow the money … even now … he doesn’t want
me to have too much money … he is scared I’ll go relapse
… there is a level of that controlling behavior … His perfect
scenario would be that I have absolutely no access to any
money, even now … I started working … wanting to have me
deposit my paychecks in his bank account … not letting me
touch any of it … the money goes in the joint account and I’ll
get like an allowance … I have to provide receipts … He would
want me to get a job, he wanted the added income … but when
I would have interviews, there were so many that he would end
up sabotaging … he was supposed to be home from work to
watch the kids so I could go and something would come up … it
took … months before I could actually even get to the interview.
Women coped with IPV experiences through
substance use
Women often described how using drugs was the only way
they knew how to get through experiences of IPV with an
abusive partner. Substance use often immediately followed
experiences of IPV and women described IPV as their rea-
son for continuing to use substances:
That was always my excuse to keep getting high. I can deal with
him as long as I can get high. I think that was my way of
dealing with stress or emotions … more than anything it would
SUBSTANCE ABUSE 5
be we would have an argument and that would be my
justification … you find [a] reason to storm off … that would be
my excuse to stop at the ATM and blow some money.
Participants frequently described using drugs and relaps-
ing to feel numb and forget the pain of their experiences
with abusive partners:
At that time period … I didn’t know but like looking back
now … I’m not in denial about anything, I kind of like put all
my cards on the table … . and see … that I was trying to escape
it … I didn’t want to deal … when you are hurt and in pain, you
don’t want to feel … I would numb myself. There were periods
where I would get clean but I kept finding myself relapsing and
I didn’t know why. Not until this last time where I really like
owned everything.
Some participants described only feeling good when they
were using and how using allowed them to justify staying
with an abusive partner:
After my self-worth being broken down so much, I just didn’t
care anymore … whenever I was using, it made me feel good. It
made me feel accepted by the guy that I was with and I felt like
I was a part of something … I just wanted to feel that love, to
have that connection with somebody.
Discussion
Our findings indicate that women with OUD frequently
experience multiple dimensions of IPV including physical
and nonphysical abuse and IPV experiences have a profound
influence on substance use behaviors including relapse and
treatment engagement either directly or through the loss of
a women’s self-confidence and self-worth. Our findings are
consistent with a previous qualitative evaluation among
reproductive-aged women with substance use disorders
which highlighted the pervasiveness of IPV experiences
including experiences of physical IPV and psychological
abuse and control.27 However, our study expanded on previ-
ous findings by identifying additional dimensions of IPV
including financial abuse and exploring the relationship
between IPV experiences and adverse substance use behav-
iors including women attributing relapse and treatment dis-
continuation as a mechanism to cope with persistent
emotional and psychological abuse from partners.
Participants also perceived that substance use by abusive
partners caused physical IPV to occur more frequently and
at higher levels of severity, including strangulation. In a pre-
vious study, 93% of survivors reported that their perpetra-
tors were using substances at the time of physical
strangulation incidents, while another study found that per-
petrator substance use is associated with a higher risk for
intimate partner homicide.1,39 Because up to 79% of female
victims of intimate partner homicide report physical abuse
prior to the fatal incident, our study findings suggest that
providers should discuss the risk for lethality among women
with SUDs in abusive relationships.1 While our findings
support studies that have shown IPV risk increases when
both partners and survivors use substances, our findings
also indicate that women often excuse or attribute abusive
behaviors to their partner’s substance use and do not
6 C. PALLATINO ET AL.
initially blame their partner.16,25 This misplaced attribution
may indicate one reason why many women may be hesitant
to leave an abusive relationship and highlights the need for
providers to reinforce to women that they did not deserve
to experience the IPV and that the partner is still account-
able for his behavior regardless of his substance use status.
This type of counseling can then emphasize that help for
IPV is available for them.
We found that nonphysical dimensions of IPV such as
emotional, psychological and financial abuse were often
experienced by our participants in addition to physical or
sexual IPV. Previous quantitative studies have found that up
to 90% of women with SUD report lifetime experiences of
psychological abuse and up to 71% report emotional abuse
in the past year.24 Participants shared how these nonphysical
dimensions including emotional and financial abuse made
the recovery and treatment process increasingly difficult. To
our knowledge, financial abuse and its impact on substance
use behaviors has not been previously described in studies
among women with SUD and partner control and violence
over money and finances had a significant impact on sub-
stance use behaviors. Among the limited number of studies
evaluating financial abuse, 41–99% of non-SUD women
report financial abuse from partners in previous relation-
ships.15,40 Employment and financial independence is essen-
tial for socioeconomic self-reliance and the financial abuse
reported by participants exacerbated the profound social and
economic challenges that they already faced by many
women with SUDs. Further, participants’ lack of control
over money prevented them from becoming financially inde-
pendent enough to leave their abusive relationship and
abstain from substance, indicating that addressing financial
abuse is critical for supporting women with OUD’s safety
planning and treatment needs. Our participants’ disclosure
of experiences of multiple non-dimensions of IPV suggest
the need for more comprehensive assessment of these con-
trolling and psychological hurtful behaviors as they may not
be interpreted as IPV by women with SUDs.
Importantly, participants shared how IPV experiences
were often the catalyst for substance use behaviors, includ-
ing relapse. Substance use as a mechanism to cope with IPV
has even been described among non-SUD populations. IPV
survivors are more likely to use tranquilizers as well as pre-
scription and non-prescription drugs to grapple with abuse-
related trauma.41–44 Given that up to 72% of IPV survivors
report substance use and up to 90% of substance users
report IPV, the co-occurrence of IPV and substance use
continues to be a critical public health issue.45
Despite the strengths of our findings, our study has limi-
tations that deserve mention. Our focus was on lifetime IPV
experiences among women with OUD and women who
have a substance use disorders other than OUD may
describe different issues and themes related to IPV. The
majority of participants were also white, and thus our results
may not necessarily reflect the perspectives of minority
women. Our participants were willing to discuss their IPV
experiences, thus the perspectives and narratives of individu-
als who may not have wanted to discuss their IPV
experiences were not obtained. IPV in general is historically
underreported, thus participant responses may not be
reflective of the full range of IPV experiences of among
women with SUD.
Overlapping experiences of substance use and IPV com-
plicate women’s ability to discontinue illicit drug use, access
and adhere to substance use treatment, and safely disengage
from an abusive relationship with an intimate partner.
Unfortunately, patients and providers are often unaware of
the different dimensions of IPV, such as financial and emo-
tional abuse, which often go unmeasured. In a multicity
study of intimate partner homicides, 41% of victims visited
a healthcare provider in the year preceding their death but
were not screened for IPV.46 In a similar study in North
Carolina, 67% of obstetricians did not know their patients
were experiencing IPV.47 Thus, there is an urgent need to
educate and train providers on the importance of asking
and talking about IPV, including a discussion of how to
identify physical and nonphysical IPV behaviors. Further,
due to the frequent co-occurrence of substance use and IPV,
clinical providers must address them in tandem and use a
trauma-informed approach to substance use treatment.48–51
As many women may not perceive that what they are expe-
riencing is IPV, providers may wish to explore the topic
with a focus on their perceived safety (e.g. “Does your part-
ner or anyone else make you feel threatened, unsafe, or
afraid?” “Does you partner hurt you in any way?”), auton-
omy (e.g. “Does your partner or anyone else limit your free-
dom or choices?”) or ability to address their OUD (e.g.
“How does your partner or anyone else make it hard for
you to stay clean?”). Additionally, use of the IPV Danger
Assessment, can assess risk for intimate partner homicide
among women who may be at high risk.52 Providers have a
responsibility to evaluate all women with SUDs for IPV as
ending abusive relationships is essential for long-term recov-
ery from substance use and for the safety and autonomy of
women and their children.
Disclosure statement
Dr. Krans is an investigator on grants to Magee-Womens Research
Institute from the National Institutes of Health, Gilead and Merck out-
side of the submitted work. The other authors did not report any
potential conflicts of interest or have any financial or material support
to disclose. Each author has confirmed compliance with the journal’s
requirements for authorship.
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