{"id":145488,"date":"2019-09-20T16:30:08","date_gmt":"2019-09-20T20:30:08","guid":{"rendered":"https:\/\/www.bu.edu\/sph\/?p=145488"},"modified":"2020-09-17T10:20:35","modified_gmt":"2020-09-17T14:20:35","slug":"opioids-and-abuse","status":"publish","type":"bu-article","link":"https:\/\/www.bu.edu\/sph\/news\/articles\/2019\/opioids-and-abuse\/","title":{"rendered":"Opioids and Abuse"},"content":{"rendered":"\n
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September 20, 2019<\/div>\n\t\t\n\t\t\t\t
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\"\"On a clear morning in mid-March, Emily Rothman<\/a> drives into Barre, Vermont, a former granite-quarrying town about 20 minutes outside of Montpelier in Washington County. Rothman\u2014 professor of community health sciences and advocate and researcher in the areas of intimate partner violence, sexual assault, human trafficking, and pornography\u2014is back in the town where her career began.<\/p>\n

As a new college graduate in 1996, Rothman worked at Circle<\/a>, 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.<\/p>\n

But after a couple of years at Circle, Rothman says she was frustrated by the limitations of what she could do. \u201cI would go to court with a woman and a totally messed up thing would happen,\u201d she says, \u201clike she would go in seeking a restraining order and walk out with less custody of her children.\u201d Rothman decided to return to school to study public health in the hopes of making structural change.<\/p>\n

More than 20 years later, Rothman has returned to Barre, and Circle, <\/span>to take a new look at this long-standing issue<\/span>: Through a three-year grant from the Robert Wood <\/span>Johnson Foundation, <\/span>she is researching the intersection of intimate partner violence and opioid use disorder in the hopes of better addressing the overlapping public health crises.<\/p>\n

\u201cRight now, people are told, \u2018You have opioid use disorder? Go here. You\u2019re experiencing intimate partner violence? Go here,\u2019\u201d she says. \u201cA human being doesn\u2019t work like that. They need help with what\u2019s actually happening in their lives.\u201d<\/p>\n

A Dangerous Intersection<\/strong><\/h4>\n

With a population of about 9,000, Barre is slightly bigger than Vermont\u2019s state capital. In the middle of downtown, next to a gazebo, is <\/span>a large granite statue of a man kneeling with a sword and shield, <\/span>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.<\/p>\n

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<\/a>, 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<\/a>.<\/p>\n

At the beginning of 2019, Rothman returned to Barre with a $350,000 grant from the Robert Wood Johnson Foundation\u2019s Interdisciplinary Research Leaders program<\/a>, which supports three-person teams\u2014two researchers and one practitioner\u2014working to address systemic inequities. Diane Kinney, Circle\u2019s co-director, is the team\u2019s practitioner, and Rebecca Stone, an assistant professor of sociology at Suffolk University, is the other researcher.<\/p>\n

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.<\/p>\n

\u201cIn 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,\u201d 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: \u201cWe have had women in the shelter who are attempting to do their treatment and run into their abuser,\u201d she says. Medication-assisted treatment clinics are few and far between, and have limited hours, Kinney says: \u201cIf they can\u2019t get there then, then they don\u2019t get their dose.\u201d<\/p>\n

Rothman points to a range of other potential challenges. \u201cAbusive partners actually become more aggressive when they\u2019re using opioids, and especially when they\u2019re withdrawing,\u201d she says. \u201cPeople who are being abused use opioids after an assault because of the pain and also the emotional trauma.\u201d 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\u2019s 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.\u00a0<\/span><\/p>\n

As Stone puts it, \u201cWe 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.<\/p>\n

\u201cWe want to learn how women are falling into that gap.\u201d<\/p>\n

\u201cYou Can’t Just Do One Thing\u201d<\/strong><\/h4>\n

On this mid-March morning, in Circle\u2019s cozy administrative offices\u2014located separately from the shelter, to protect the women receiving services\u2014Rothman points out a poster that reads, \u201cThe best activism is equal parts love and equal parts anger.\u201d<\/p>\n

That sentiment perfectly describes Rothman\u2019s drive since she first worked at Circle two decades ago. \u201cHere was this issue where I could express both love and outrage, anger and survival,\u201d she says. \u201cIt felt like the right issue for me.\u201d<\/p>\n

Part of Rothman\u2019s anger comes from partner violence\u2019s invisibility: It has always been hard to bring attention and funding to partner violence as a public health issue. (Rothman\u2019s 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.)<\/p>\n

\u201cPartner violence is seen as this crunchy women\u2019s issue,\u201d she says, while opioid use disorder\u2014which kills twice as many men as women\u2014is seen as more \u201cmasculine.\u201d \u201cIt\u2019s very weird, because we\u2019re talking about homicide and assault, and people calling for emergency shelter, and the feeling in the room is, \u2018That\u2019s your cute little women\u2019s issue.\u2019\u201d<\/p>\n

Such dismissal is one reason Rothman says it is vital to study intersecting public health issues. \u201cYou have to keep pivoting,\u201d she says. \u201cIf 100 percent of all public health research money was going to Ebola, I would look at the relationship between Ebola and partner violence.\u201d<\/p>\n

The situation in Vermont illustrates her point: the state has invested and innovated a great deal to combat opioid use disorder, including pioneering the \u201cHub and Spoke\u201d model of rapid and long-term, medication-assisted treatment, and beginning to succeed: Washington County\u2019s rate of fatal overdoses has plateaued, and neighboring Chittenden County\u2019s was halved from 2017 to 2018. But the rate of partner homicides in Vermont is rising.<\/p>\n

\u201cSome of that money should go to the intersection with partner violence,\u201d Rothman says.<\/p>\n

Julia Campbell (SPH\u201919), Rothman\u2019s research assistant, agrees that intersections like this one are exactly where public health needs to direct its attention. \u201cPeople who have one vulnerability have other vulnerabilities,\u201d she says. \u201cIt\u2019s sad to think about, but you have to think about it if you want to do anything good.<\/p>\n

\u201cYou can’t just do one thing.\u201d<\/p>\n

A Holistic Approach<\/strong><\/h4>\n

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.<\/p>\n

In these interviews (anonymous and over the phone), the women share their experiences and then are asked what could have helped them\u2014what services, logistics, support, or knowledge would have made getting help and getting out of these situations less difficult.<\/p>\n

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. \u201cEveryone I\u2019ve spoken to so far has been able to say, \u2018This 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,\u2019\u201d Campbell says.<\/p>\n

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: \u201cNothing about us without us.\u201d<\/p>\n

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.<\/p>\n

\u201cIt\u2019s really hard to have a healthy relationship with an active addiction, with the desperation that comes with addiction and withdrawal,\u201d McDougal says.<\/p>\n

And treating the overlapping problems is fraught: \u201cThe window of opportunity when people want to get help is very small, because addiction tries to trick you,\u201d she says. \u201cI 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: \u2018It\u2019s your fault that I\u2019m back in this position, and you owe me because of that.\u2019\u201d<\/p>\n

Going Forward<\/strong><\/h4>\n

On this March morning, Rothman and Kinney are presenting their project to the Washington County Domestic Violence Coordinated Committee Response. (Stone wasn\u2019t able to make the trip up this time.)<\/p>\n

The meeting is in a room at the Barre City Courthouse. Sometime in the past, someone carved the word \u201cSTUCK\u201d into the surface of the table, but the dozen people gathered around it now\u2014partner violence advocates, a parole officer, social workers, service providers, and the only man: a police detective\u2014are 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.<\/p>\n

Rothman says meetings like this are refreshing after years working in Massachusetts and other more populous states. \u201cIn Vermont, it\u2019s possible to wrap your arms around a problem,\u201d she says.<\/p>\n

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.<\/p>\n

Rothman tells the group that the solutions may wind up being fairly simple, like transportation help, or a women-only opioid treatment meeting group. \u201cThey do not have to be expensive fixes,\u201d she says.<\/p>\n

Then, she corrects herself: \u201cOr they could <\/em>be expensive!\u201d she says, which elicits a small cheer from some of the people in the room. \u201cThen, our job becomes lobbying legislators and using those public health skills to show the return on investment.\u201d (In fact, as part of their grant, Rothman, Kinney, and Stone recently went to Washington, DC, for a lobbying training.)<\/p>\n

What comes out of this project will likely be useful beyond Vermont\u2019s borders, Stone says later. \u201cIt’s very likely that this is also something affecting women here in Massachusetts and in many other parts of the country, too.\u201d Even if the solutions are only relevant to the particular conditions in Vermont, or in Washington County, she says, \u201cwe\u2019re 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.\u201d<\/p>\n

After the meeting at the courthouse, Rothman and Kinney go to Circle\u2019s office before their next meeting, at the Central Vermont Medical Center with the Washington County Substance Abuse Regional Partnership.<\/p>\n

Not long after they settle in, the phone rings, and Kinney answers. Circle\u2019s 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.<\/p>\n

\u2014Michelle Samuels<\/em><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

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