Opioids and Abuse.
On a clear morning in mid-March, Emily Rothman drives into Barre, Vermont, a former granite-quarrying town about 20 minutes outside of Montpelier in Washington County. Rothman— professor of community health sciences and advocate and researcher in the areas of intimate partner violence, sexual assault, human trafficking, and pornography—is back in the town where her career began.
As a new college graduate in 1996, Rothman worked at Circle, a local organization and shelter serving women experiencing intimate partner violence. She aided in emergency sheltering, answered the hotline, and accompanied and assisted women in court.
But after a couple of years at Circle, Rothman says she was frustrated by the limitations of what she could do. “I would go to court with a woman and a totally messed up thing would happen,” she says, “like she would go in seeking a restraining order and walk out with less custody of her children.” Rothman decided to return to school to study public health in the hopes of making structural change.
More than 20 years later, Rothman has returned to Barre, and Circle, to take a new look at this long-standing issue: Through a three-year grant from the Robert Wood Johnson Foundation, she is researching the intersection of intimate partner violence and opioid use disorder in the hopes of better addressing the overlapping public health crises.
“Right now, people are told, ‘You have opioid use disorder? Go here. You’re experiencing intimate partner violence? Go here,’” she says. “A human being doesn’t work like that. They need help with what’s actually happening in their lives.”
A Dangerous Intersection
With a population of about 9,000, Barre is slightly bigger than Vermont’s state capital. In the middle of downtown, next to a gazebo, is a large granite statue of a man kneeling with a sword and shield, a memorial for residents who died in the First World War, and a reminder of when granite made the town prosperous. Now the statue looks out at a main street with several empty storefronts.
Like many rural areas across America, Washington County was hit hard by the opioid epidemic. The county saw 12 residents die from opioids in 2018, out of a population of under 60,000 people. In the same year, another 12 Washington County residents were murdered by a current or former partner.
At the beginning of 2019, Rothman returned to Barre with a $350,000 grant from the Robert Wood Johnson Foundation’s Interdisciplinary Research Leaders program, which supports three-person teams—two researchers and one practitioner—working to address systemic inequities. Diane Kinney, Circle’s co-director, is the team’s practitioner, and Rebecca Stone, an assistant professor of sociology at Suffolk University, is the other researcher.
When Rothman first reached out to Kinney to find out whether the intersection of opioids and partner violence was worth exploring, Kinney made clear that attention was long overdue.
“In the last two years, we have had six women that we have been involved with die, and only one of the women was not opioid-involved,” Kinney says, adding that one woman had a fatal overdose only two days after leaving the Circle shelter. Nor is opioid use disorder treatment designed with partner violence in mind: “We have had women in the shelter who are attempting to do their treatment and run into their abuser,” she says. Medication-assisted treatment clinics are few and far between, and have limited hours, Kinney says: “If they can’t get there then, then they don’t get their dose.”
Rothman points to a range of other potential challenges. “Abusive partners actually become more aggressive when they’re using opioids, and especially when they’re withdrawing,” she says. “People who are being abused use opioids after an assault because of the pain and also the emotional trauma.” Opioids also become a way for an abuser to control their partner, and abuse can get worse when someone goes into recovery and their partner sees that they are losing control of them. There are challenges with legal proceedings, when someone’s history with opioids can be used against them when they are trying to get sole custody of their child from an abuser. Opioid treatment service providers are also often untrained in handling partner violence, she says, and vice versa.
As Stone puts it, “We have the substance use treatment sector, and we have the intimate partner violence response sector, and they might not be understanding each other or working to meet women who are in the middle.
“We want to learn how women are falling into that gap.”
“You Can’t Just Do One Thing”
On this mid-March morning, in Circle’s cozy administrative offices—located separately from the shelter, to protect the women receiving services—Rothman points out a poster that reads, “The best activism is equal parts love and equal parts anger.”
That sentiment perfectly describes Rothman’s drive since she first worked at Circle two decades ago. “Here was this issue where I could express both love and outrage, anger and survival,” she says. “It felt like the right issue for me.”
Part of Rothman’s anger comes from partner violence’s invisibility: It has always been hard to bring attention and funding to partner violence as a public health issue. (Rothman’s doctoral dissertation at the Harvard T.H. Chan School of Public Health in the mid-2000s was only the second the school had ever had on the topic.)
“Partner violence is seen as this crunchy women’s issue,” she says, while opioid use disorder—which kills twice as many men as women—is seen as more “masculine.” “It’s very weird, because we’re talking about homicide and assault, and people calling for emergency shelter, and the feeling in the room is, ‘That’s your cute little women’s issue.’”
Such dismissal is one reason Rothman says it is vital to study intersecting public health issues. “You have to keep pivoting,” she says. “If 100 percent of all public health research money was going to Ebola, I would look at the relationship between Ebola and partner violence.”
The situation in Vermont illustrates her point: the state has invested and innovated a great deal to combat opioid use disorder, including pioneering the “Hub and Spoke” model of rapid and long-term, medication-assisted treatment, and beginning to succeed: Washington County’s rate of fatal overdoses has plateaued, and neighboring Chittenden County’s was halved from 2017 to 2018. But the rate of partner homicides in Vermont is rising.
“Some of that money should go to the intersection with partner violence,” Rothman says.
Julia Campbell (SPH’19), Rothman’s research assistant, agrees that intersections like this one are exactly where public health needs to direct its attention. “People who have one vulnerability have other vulnerabilities,” she says. “It’s sad to think about, but you have to think about it if you want to do anything good.
“You can’t just do one thing.”
A Holistic Approach
Over the course of the three-year grant, the research team will work in three phases. In the first, current phase, they are interviewing 40 Vermont women (mainly but not exclusively in Washington County) who have struggled with opioids in the last five years and experienced partner violence in the last 10.
In these interviews (anonymous and over the phone), the women share their experiences and then are asked what could have helped them—what services, logistics, support, or knowledge would have made getting help and getting out of these situations less difficult.
Revisiting these periods can be painful for the interviewees, says Campbell, who has been conducting most of these interviews. But the women have been eager to tell their stories, and to be able to help other women facing these issues. “Everyone I’ve spoken to so far has been able to say, ‘This is the hard stuff I have dealt with, but this is how I’m doing better, this is what’s helped me, and this is what I recommend for other women to get help too,’” Campbell says.
The team is also recruiting an advisory board of five women who have experienced both opioid use disorder and partner violence. A guiding principle of the project is a phrase borrowed from the disability rights movement, Rothman says: “Nothing about us without us.”
One of the advisory board members is Liz McDougal, a substance use disorder recovery coach at Central Vermont Medical Center. She says that opioid misuse and partner abuse go together more often than not.
“It’s really hard to have a healthy relationship with an active addiction, with the desperation that comes with addiction and withdrawal,” McDougal says.
And treating the overlapping problems is fraught: “The window of opportunity when people want to get help is very small, because addiction tries to trick you,” she says. “I constantly see people go into recovery together, and then one of them changes their mind and pulls the other one out. Then you have the resentment and blame: ‘It’s your fault that I’m back in this position, and you owe me because of that.’”
Going Forward
On this March morning, Rothman and Kinney are presenting their project to the Washington County Domestic Violence Coordinated Committee Response. (Stone wasn’t able to make the trip up this time.)
The meeting is in a room at the Barre City Courthouse. Sometime in the past, someone carved the word “STUCK” into the surface of the table, but the dozen people gathered around it now—partner violence advocates, a parole officer, social workers, service providers, and the only man: a police detective—are hopeful. There is laughter, a sense of comradery in shared frustrations, and offers to help with the project. Several people grab stacks of interview recruitment flyers to distribute in their own offices and clinics.
Rothman says meetings like this are refreshing after years working in Massachusetts and other more populous states. “In Vermont, it’s possible to wrap your arms around a problem,” she says.
She and Kinney explain that, after interviewing 40 women, as well as stakeholders (many of them in the room), the researchers and advisory board will come together to interpret the findings, and use human-centered design principles to generate possible solutions. In the third phase, the researchers will implement and evaluate some of those solutions.
Rothman tells the group that the solutions may wind up being fairly simple, like transportation help, or a women-only opioid treatment meeting group. “They do not have to be expensive fixes,” she says.
Then, she corrects herself: “Or they could be expensive!” she says, which elicits a small cheer from some of the people in the room. “Then, our job becomes lobbying legislators and using those public health skills to show the return on investment.” (In fact, as part of their grant, Rothman, Kinney, and Stone recently went to Washington, DC, for a lobbying training.)
What comes out of this project will likely be useful beyond Vermont’s borders, Stone says later. “It’s very likely that this is also something affecting women here in Massachusetts and in many other parts of the country, too.” Even if the solutions are only relevant to the particular conditions in Vermont, or in Washington County, she says, “we’re hoping that people working in other states will get ideas about the things that they might address in their own area, or do research that centers the voices of the people who have direct experience.”
After the meeting at the courthouse, Rothman and Kinney go to Circle’s office before their next meeting, at the Central Vermont Medical Center with the Washington County Substance Abuse Regional Partnership.
Not long after they settle in, the phone rings, and Kinney answers. Circle’s hotline rings about 15 times a day, and for this caller Kinney quickly arranges emergency shelter beginning that night. Then, she calls the shelter to prepare for the new arrival, before she and Rothman sit down again to continue discussing what comes next.
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