The Effects of Co-Occurring Interpersonal Trauma and Gender on Opioid Use and Misuse

Abstract

The association between interpersonal trauma (IPT) and opioid misuse is well established. There are important gaps, however, in our understanding of this relationship. Studies often do not account for the co-occurrence of IPT across time (i.e., multiple experiences of the same type of IPT) and contexts (i.e., experiences of different types of IPT). In addition, few studies have examined the relationship between IPT and prescription opioid use or gender differences. To address these gaps, this study examines the impact of IPT co-occurrence and gender on prescription opioid use and opioid misuse. Data were collected through a cross-sectional online survey of 235 adults with a self-reported history of IPT (i.e., intimate partner violence, sexual assault, adverse childhood experiences). IPT co-occurrence and interactions between IPT, as continuous scales, were assessed as correlates of opioid use and misuse using multinomial regression models. IPT was associated with opioid misuse, but not use, adjusting for gender. The relationship between sexual assault and opioid misuse was confounded by exposure to other types of IPT. Intimate partner violence was associated with opioid misuse among men. Adverse childhood experiences were associated with misuse among women. The interaction between intimate partner violence and sexual assault increased odds of opioid use among women. This study highlights the importance of accounting for IPT co-occurrence and examining gender differences in clinical practice and research related to opioid use/misuse. These approaches are important for understanding the relationship between IPT and opioid use/misuse by more accurately representing the complexity of the lives of survivors.

Keywords

with Hx of abuse alcohol and drugs child abuse domestic violence sexual assault

Introduction

Opioid misuse is an important public health crisis: in the United States, an estimated 115 people die every day due to opioid overdose (Centers for Disease Control and Prevention & National Center for Health Statistics, 2017). Previous research highlights the role of interpersonal trauma (IPT) in contributing to the risk for opioid misuse. Intimate partner violence, sexual assault, and adverse experiences during childhood have been linked to prescription opioid misuse (Austin & Shanahan, 2018; Quinn et al., 2016; Stene et al., 2012), opioid use disorders (Afifi et al., 2012; Conroy et al., 2009), heroin use (Afifi et al., 2012; El-Bassel et al., 2005; Quinn et al., 2016; Stein et al., 2017), and opioid overdose (Stein et al., 2017). A compounding factor is that IPT is extremely common (up to 60% of adults will report at least one IPT experience), the effects of which tends to be cumulative and chronic (Breiding et al., 2014; Centers for Disease Control and Prevention, 2015).

While the extant research provides strong support for the relationship between IPT and opioid misuse, there are important gaps. Prior studies tend to be limited to a single type of IPT, such as intimate partner violence, sexual assault, or adverse childhood experiences (Afifi et al., 2012; Austin & Shanahan, 2018; Schafer et al., 2014; Smith et al., 2012; Stein et al., 2017; Stene et al., 2012; Young et al., 2011), and commonly analyze IPT as a dichotomous variable (i.e., victimization vs. no victimization) (Afifi et al., 2012; Austin et al., 2018; Balousek et al., 2007; Conroy et al., 2009; El-Bassel et al., 2005; Schafer et al., 2014; Smith et al., 2012; Stene et al., 2012; Wuest et al., 2007). These approaches do not account for the well-known co-occurrence of IPT across time and contexts (Hamby et al., 2018; Hamby & Grych, 2013; Turner et al., 2010). IPT is often not limited to a single isolated incident, but rather, individuals who experience IPT are more likely to experience repeat incidents of the same trauma over time (revictimization) and multiple types of victimization over different contexts (poly-victimization) (Hamby & Grych, 2013). Given the high degree of co-occurrence of IPT, studies that reduce IPT to a dichotomous occurrence or assess only a single type of IPT are likely to lead to inaccurate inferences.

One recent study by Garami and colleagues (2019) provides support for the role of IPT co-occurrence in our understanding of IPT and opioid misuse. This study examined the relationship between different types and severity of trauma and opiate addiction among a cohort of 36 participants receiving treatment for opiate addiction and 33 healthy controls. Two types of trauma were examined, childhood trauma and lifetime trauma, and each was examined continuously as an indicator of severity. Logistic regression analyses showed that after accounting for gender, childhood trauma, and perceived stress, lifetime trauma score showed the strongest association with opiate addition.

The role of IPT co-occurrence has also been shown in the larger substance abuse literature. Walsh et al. (2015) analyzed population-representative data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) to determine how lifetime exposure to gender-based violence is related to substance use disorders among women. They found that number of types (i.e., poly-victimization) and number of incidents (i.e., revictimization) of gender-based violence had a dose–response relationship with risk for substance use disorders, with number of types being the stronger predictor. Examining how IPT co-occurrence specifically impacts opioid misuse can provide a more comprehensive understanding of this relationship; one that captures the poly-victimization and revictimization of those impacted by IPT.

In addition, few studies have examined the relationship between IPT and prescription opioid use. Most have examined illicit opioid use (e.g., heroin), prescription opioid misuse and opioid dependence, often with samples currently receiving treatment for opioid use disorders (Afifi et al., 2012; El-Bassel et al., 2005; Quinn et al., 2016; Schafer et al., 2014; Smith et al., 2012; Stein et al., 2017). Understanding how IPT impacts prescription opioid use among community samples is an important area of investigation, given the high abuse potential of these medications and may inform future interventions aimed at preventing the transition from prescription opioid use to misuse.

Finally, little is known about the role of gender in the relationship between IPT and opioid use/misuse, despite important differences between men and women in experiences of IPT and the use of opioids. Women tend to report higher rates of IPT victimization compared to men (Breiding et al., 2014; U.S. Department of Health & Human Services, 2019). In addition, studies show that women are more likely to be prescribed opioids (Hirschtritt et al., 2018; Serdarevic et al., 2017), whereas men are more likely to misuse opioids (Back et al., 2010; Colliver & Gfroerer, 2008). Differences exist in the reasons for misuse, where men are more likely to report misusing opioids to cope with pain and increase feelings of euphoria, and women are more likely to misuse to cope with interpersonal stress (Back et al., 2011).

Despite these differences, gender is often overlooked in research about contributing factors in differences in prescription opioid use (Mazure & Fiellin, 2018). Most studies examining the relationship between trauma and opioid use limited their sample to women (Gilmore et al., 2018; Stene et al., 2012; Walsh et al., 2015; Wuest et al., 2007) or controlled for gender, that is, did not examine differential associations by gender (Austin et al., 2018; Douglas et al., 2010; Stein et al., 2017). The few studies specifically examining gender differences show that among prescription opioid users, women are more likely to report a history of trauma (Balousek et al., 2007; Schafer et al., 2014).

The role of gender in the relationship between trauma and opioid misuse is less clear. In another analysis of NESARC data, Smith et al. (2012) found that opioid disorders were associated with an increased risk of intimate partner violence victimization among women. Quinn and colleagues (2016) examined gender differences in the relationship between adverse childhood experiences and prescription opioid misuse using data from the National Longitudinal Study of Adolescent to Adult Health. They found that gender did not moderate this relationship with the exception of childhood sexual abuse, which had a stronger effect among males. Additional research is needed to inform better our understanding of the role of gender in the relationship between IPT and opioid use/misuse.

To address these gaps, this study examines the impact of IPT co-occurrence and gender on risk for prescription opioid use and opioid misuse. Specifically, this study addresses the following research questions:

Does severity and frequency of victimization impact the relationship of different types of IPT (i.e., intimate partner violence, sexual assault, and adverse childhood experiences) with prescription opioid use and opioid misuse (revictimization)?

Does the effect of IPT on prescription opioid use and opioid misuse differ depending on other kinds of IPT experienced (poly-victimization)?

Does gender moderate the relationship between IPT and prescription opioid use and opioid misuse?

Methods

Study Design

A cross-sectional, observational study design was used to examine the research questions. Data were collected through a confidential self-report online survey completed at one time point. The study protocol was approved by the local institutional review board before engaging in study activities.

Sample

To be eligible to participate in the study, participants had to be ≥18 years old, able to complete a survey in English, and report a history of at least one type of IPT (i.e., intimate partner violence, sexual assault, and/or adverse childhood experiences). Potential participants were screened for eligibility through a brief questionnaire prior to engaging in the study survey (those who did not meet eligibility criteria did not move on to the survey). Age and ability to complete a survey in English were assessed through two questions. IPT was assessed using six items from the Stressful Life Events Screening Questionnaire (SLESQ) (Goodman et al., 1998). These items measure six types of IPTs (sexual assault [penetration]; attempted sexual assault; molestation; child physical assault; adult physical assault by an intimate partner; threatened with weapon by an intimate partner). The SLESQ has adequate psychometric properties (convergent validity: r = .77, k = .64; test–retest reliability: r = .89, k = .73) (Goodman et al., 1998).

A convenience sample, consisting of 235 individuals, was recruited from the central North Carolina region using community-based and online recruitment strategies. Study advertisements were posted in general community locations (e.g., coffee shops and libraries) and distributed through research volunteer listservs. Recruitment materials were also posted in places likely to be frequented by our target population, including pain management clinics, substance abuse treatment centers, and domestic violence shelters. Recruitment materials described the research as examining how certain types of trauma can impact health and stated that an individual must have experienced domestic violence, sexual assault, or abuse as a child to participate. Recruitment materials did not characterize the study as specific to opioids so as not to deter individuals with no opioid use from participating.

Procedures

Data were collected from July 2018 to September 2018 through an online, self-report survey. Recruitment materials provided instructions for accessing the survey. Recruitment materials also provided information for contacting study staff by telephone or email if they needed assistance accessing the survey electronically (e.g., they did not have access to a computer or mobile device). If an interested individual needed computer access, study staff were available to meet with the individual and provide an electronic device with survey access. This, however, was not requested.

The first screen provided participants with general information about the study including purpose, eligibility criteria, and participant expectations. Individuals who were still interested in participating moved to the next screen to complete the eligibility questionnaire. Eligible individuals then moved to the informed consent screen. After reviewing the informed consent information, those who were still interested in participating and provided consent moved on to the study survey. After completing the survey, participants received a $25 gift card as compensation for their time.

Measures

Demographics

Demographic data were collected for sex/gender, age, race/ethnicity, highest education level attained, and employment status.

Intimate partner violence

The Revised Conflict Tactics Scale—Victimization (CTS2; 32 items, α = .96) was used to measure the lifetime occurrence of violence victimization within intimate relationships (Straus & Douglas, 2004; Straus et al., 1996). It assesses violence across four domains: psychological aggression, physical assault, sexual coercion, and injury. Participants were asked to report the number of times they experienced each item (never, 1 time, 2 times, 3 or more times). A total sum score was calculated across items with scores ranging from 0 to 96.

Sexual assault

The Sexual Experiences Survey, Short Form Victimization (SES-SFV, 35 items, α = .96) was used to identify unwanted sexual experiences since the age of 14, including unwanted sexual contact, attempted coercion, coercion, attempted rape, and rape. Participants were asked to report the number of times they experienced each item (never, 1 time, 2 times, 3 or more times) (Koss et al., 2007). A total sum score was calculated across items with scores ranging from 0 to 105.

Adverse childhood experiences

The Adverse Childhood Experiences Scale (ACE, 17 items, α = .87) examines childhood exposure to abuse, including experiences of psychological, physical, and sexual abuse, violence against the mother, and living with household members who were substance abusers, mentally ill or suicidal, or imprisoned (Felitti et al., 1998). Participants were asked to indicate if they experienced each item (yes/no). A total sum score was calculated across items with scores ranging from 0 to 17.

Opioid use and misuse

Prescription opioid use was assessed by asking participants if they had a prescription for pain medication in the past year (yes/no). Those who responded yes were asked to report on their opioid use behaviors assessed using the PROMIS^® Prescription Pain Medication Misuse 7a Scale (7 items, α = .94) (Pilkonis et al., 2017; PROMIS Health Organization, 2017). This scale asks participants to report the frequency of common prescription medication misuses in the past year. Illicit opioid use was assessed by asking participants to report on past year heroin use (yes/no) and past year use of a prescription pain medication that was not prescribed to them by a health provider (yes/no).

Reponses to these items were used to create an overall opioid use variable (no use, use, and misuse). Individuals who indicated illicit opioid use or had scores one standard deviation or higher (≥21) on the PROMIS Prescription Pain Medication Misuse 7a Scale were categorized into the “misuse” group. Individuals were categorized in the “use” category if they reported having a prescription for pain medication in the past year but had a score less than 21 on the PROMIS Prescription Pain Medication Misuse 7a Scale and no illicit opioid use. Participants who reported no to the prescription opioid use and illicit opioid use items were categorized as “no use.”

Data Analyses

Multinomial logistic regression was used to examine each research question, with opioid use classification (i.e., no use, prescription opioid use, and opioid misuse) as the dependent variable and IPT as the primary independent variables. No opioid use was treated as the referent category for the dependent variable. Using multinomial logistic regression, correlates of opioid use classification were assessed in a multivariable model without assuming an ordinal relationship between categories. First, each type of IPT was entered separately as the primary independent variable. Then, all three IPT variables were entered in the model to examine the effects of each IPT exposure while adjusting for exposure to the other types of IPT. Next, interaction terms were added between the IPT variables to examine the potential effects of poly-victimization. IPT variables were transformed to range from 0 to 10 to assist with interpretation of odds ratios; thus, each odds ratio corresponds to a 10% increase in score on the respective IPT scale.

We examined whether demographic variables (i.e., age, race/ethnicity, highest education level, and employment status) had a confounding effect. No clinically significant confounders were identified. For those significantly associated with an independent variable and the dependent variable, the highest change in the point estimate was 7% (less than the 10% cutoff applied) (Maldonado & Greenland, 1993). We also examined the potential moderating effects of gender in our models. Significant interactions were observed by gender when examining the relationships between IPT and opioid use/misuse. For this reason, and to sustain power for analyses of associations of interest, only gender was included as an adjustment variable in the models that included both males and females. Owing to the significant interaction between gender and IPT, models were also stratified by gender to examine differences in the relationships between IPT and opioid use/misuse among men and women. All analyses were conducted in SAS, version 9.4 (SAS Institute, Inc., Cary, NC).

Results

Participant Characteristics

Participant characteristics are presented in Table 1. A majority of the sample were female (n = 147, 62.6%), White, non-Hispanic (n = 126, 56.0%), had at least some college education (n = 174, 74.0%) and were either employed full-time (n = 79, 33.6%) or a student (n = 77, 32.8%). Approximately one fifth (n = 45, 19.1%) reported using prescription opioids and one quarter (n = 60, 25.5%) misused opioids. There was high co-occurrence of IPT, with 60.0% (n = 141) reporting at least one occurrence of all three types (Figure 1).

Table 1.

Participant Characteristics.

Characteristics	N or M (% or SD)
Characteristics	Total	Male	Female
N	235	88	147
Age	29.0 (11.0)	30.2 (11.7)	28.3 (10.6)
Race/ethnicity^a, n (%)
Asian	27 (12.0)	14 (17.3)	13 (9.0)
African American/Black	39 (17.3)	21 (25.9)	18 (12.5)
White, non-Hispanic	126 (56.0)	35 (43.2)	91 (63.2)
Hispanic/Latino, White	20 (8.9)	7 (8.6)	13 (9.0)
Multiple races/Other	13 (5.8)	4 (4.9)	9 (6.3)
Highest education level^a, n (%)
High school/GED	61 (26.0)	37 (42.0)	24 (16.3)
Some college or 2-year degree	88 (37.4)	28 (31.8)	60 (40.8)
College graduate	44 (18.7)	15 (17.0)	29 (19.7)
More than college degree	42 (17.9)	8 (9.1)	34 (23.1)
Employment status, n (%)
Full-time employed	79 (33.6)	27 (30.7)	52 (35.4)
Part-time employed	42 (17.9)	17 (19.3)	25 (17.0)
Not employed, seeking employment	26 (11.1)	12 (13.6)	14 (9.5)
Not employed, not seeking employment/retired	11 (4.7)	7 (8.0)	4 (2.7)
Not employed, student	77 (32.8)	25 (28.4)	52 (35.4)
Interpersonal trauma
Intimate partner violence (CTS)	28.7 (24.2)	27.8 (19.1)	29.3 (26.8)
Sexual assault (SES)^a	22.1 (26.8)	7.5 (13.7)	30.9 (28.8)
Adverse childhood experiences (ACE)^a	6.4 (4.5)	7.3 (4.4)	5.9 (4.5)
Opioid use, n (%)
No use	130 (55.3)	43 (48.9)	87 (59.2)
Use	45 (19.1)	16 (18.2)	29 (19.7)
Misuse	60 (25.5)	29 (33.0)	31 (21.1)

Note. Counts may not sum to sample total due to missing data. CTS = Conflict Tactics Scale; SES = Sexual Experiences Survey; ACE = Adverse Childhood Experiences Scale.

Significant (p ≤ .05) differences by sex.

Figure 1.

Co-occurrence of interpersonal trauma.

IPT Revictimization, Prescription Opioid Use, and Opioid Misuse

Results for the relationship between IPT, prescription opioid use, and opioid misuse are presented in Tables 2 and 3. After adjusting for gender, intimate partner violence, sexual assault, and adverse childhood experiences were all associated with opioid misuse but not prescription opioid use (Table 2). Similar results were found when stratified by gender, except for sexual assault, which was not associated with opioid misuse among males.

Table 2.

Associations Between Interpersonal Trauma, Prescription Opioid Use, and Opioid Misuse, Full Sample (Adjusted for Gender) and Stratified by Gender.

	Prescription Opioid Use			Opioid Misuse
	Odds Ratio	95% CI	p Value	Odds Ratio	95% CI	p Value
Full sample (n = 235)
Intimate partner violence	1.14	[0.98, 1.31]	.0846	1.44	[1.26, 1.65]	<.0001
Sexual assault	1.03	[0.88, 1.20]	.7110	1.24	[1.08, 1.42]	.0017
Adverse childhood experiences	1.07	[0.94, 1.23]	.3079	1.32	[1.16, 1.49]	<.0001
Male (n = 88)
Intimate partner violence	1.27	[0.91, 1.77]	.1521	1.90	[1.38, 2.59]	<.0001
Sexual assault	0.96	[0.63, 1.44]	.8344	0.83	[0.56, 1.22]	.3418
Adverse childhood experiences	1.15	[0.92, 1.46]	.2238	1.22	[1.01, 1.49]	.0439
Female (n = 147)
Intimate partner violence	1.10	[0.94, 1.29]	.2261	1.33	[1.15, 1.55]	.0002
Sexual assault	1.04	[0.88, 1.23]	.6425	1.33	[1.14, 1.55]	.0002
Adverse childhood experiences	1.03	[0.87, 1.22]	.7332	1.39	[1.18, 1.64]	.0001

Note. Results from separate models (one for each type of interpersonal trauma). CI = confidence interval.

Table 3.

Associations Between Interpersonal Trauma, Prescription Opioid Use, and Opioid Misuse, Full Sample (Adjusted for Gender and IPT Exposure) and Stratified by Gender (Adjusted for IPT Exposure).

	Prescription Opioid Use			Opioid Misuse
	Odds Ratio	95% CI	p Value	Odds Ratio	95% CI	p Value
Full sample (n = 233)
Intimate partner violence	1.20	[0.99, 1.45]	.0654	1.45	[1.21, 1.75]	<.0001
Sexual assault	0.90	[0.74, 1.10]	.3136	0.90	[0.75, 1.09]	.3014
Adverse childhood experiences	1.06	[0.92, 1.22]	.3980	1.25	[1.09, 1.43]	.0016
Male (n = 86)
Intimate partner violence	1.44	[0.96, 2.16]	.0802	2.65	[1.70, 4.12]	<.0001
Sexual assault	0.64	[0.37, 1.11]	.1109	0.36	[0.21, 0.65]	.0006
Adverse childhood experiences	1.19	[0.92, 1.55]	.1891	1.24	[0.95, 1.62]	.1067
Female (n = 147)
Intimate partner violence	1.14	[0.91, 1.43]	.2418	1.16	[0.93, 1.43]	.1904
Sexual assault	0.94	[0.75, 1.19]	.6306	1.14	[0.92, 1.42]	.2306
Adverse childhood experiences	1.01	[0.85, 1.21]	.8867	1.31	[1.10, 1.55]	.0024

Note. IPT = interpersonal trauma; CI = confidence interval.

When the full sample model was adjusted for IPT exposure (Table 3), intimate partner violence and adverse childhood experiences, but not sexual assault, continued to be significantly associated with opioid misuse. Among males, intimate partner violence continued to be associated with opioid misuse, and a large increase in effect size was observed (1.90 vs. 2.65). Sexual assault was found to be negatively associated with opioid misuse among males. Adverse childhood experiences were no longer significant among males after adjusting for other IPT exposure. Among females, only adverse childhood experiences remained significantly associated with opioid misuse in the adjusted model.

IPT Poly-Victimization, Prescription Opioid Use, and Opioid Misuse

Poly-victimization (i.e., the interaction of different IPT experiences) did not increase the odds of prescription opioid use or opioid misuse for most interactions examined (Table 4). The only exception was among females where the interaction between intimate partner violence and sexual assault was significantly associated with increased odds of prescription opioid use.

Table 4.

Effects of Poly-Victimization on Prescription Opioid Use and Opioid Misuse by Gender.

	Prescription Opioid Use			Opioid Misuse
	Odds Ratio	95% CI	p Value	Odds Ratio	95% CI	p Value
Male (n = 86)
Intimate partner violence × adverse childhood experiences	1.00	[0.87, 1.15]	.9734	0.98	[0.84, 1.15]	.8407
Intimate partner violence × sexual assault	1.16	[0.85, 1.57]	.3456	1	[0.72, 1.39]	.9883
Sexual assault × adverse childhood experiences	1.15	[0.94, 1.43]	.1817	0.97	[0.79, 1.20]	.8079
Female (n = 147)
Intimate partner violence × adverse childhood experiences	0.98	[0.92, 1.05]	.5916	1.01	[0.95, 1.08]	.6768
Intimate partner violence × sexual assault	1.07	[1.00, 1.15]	.0389	1.05	[0.99, 1.12]	.1091
Sexual assault × adverse childhood experiences	1	[0.94, 1.06]	.9983	0.99	[0.93, 1.05]	.6754

Note. Each interaction tested in a separate model, adjusting for all three types of interpersonal trauma. CI = confidence interval.

Discussion

Findings from this study provide continued support for the relationship between IPT and opioid misuse and improve our understanding of this relationship by examining specifically the role of IPT co-occurrence and gender differences.

Measuring IPT as continuous variables allowed us to address our first research question which aimed to determine the effects of revictimization on opioid use/misuse. Our findings provide support for the role of IPT severity and frequency of victimization in the relationship between IPT and opioid misuse. Higher scores for all three types of IPT were associated with greater odds of opioid misuse when examined separately in models (Table 2). However, when we controlled for exposure to intimate partner violence and adverse childhood experiences, sexual assault was no longer significant (Table 3). This provides evidence of the confounding effects of IPT and demonstrates how limiting research to one IPT type can result in misleading conclusions. While the confounding effects of IPT are not surprising, given the high rates of co-occurrence between different forms of IPT (Figure 1), few previous studies have accounted for this. One exception is the study by Garami and colleagues (2019), which provided evidence for the confounding effects of lifetime trauma on the relationship between childhood trauma and opiate addiction. These results stress the need to account for multiple types of IPT in future research examining the effects of trauma on opioid use.

To answer our second research question, we investigated the effects of poly-victimization on prescription opioid use and misuse through interactions between the different types of IPT. Our findings provided little support for the contribution of poly-victimization to opioid use and misuse beyond the effects seen individually for each type of trauma. A small but significant relationship was seen for the interaction between intimate partner violence and sexual assault with prescription opioid use among women (odds ratio [OR]: 1.07, confidence interval [CI]: 1.00–1.15, p = .0389). Larger effect sizes were seen among men for the interactions between intimate partner violence and sexual assault (OR: 1.16, CI: 0.85–1.57, p = .345) and sexual assault and adverse childhood experiences (OR: 1.15, CI: 0.94–1.43, p = .181) with prescription opioid use. These, however, were not statistically significant, possibly due to the low prevalence of sexual assault among men in this sample. To the best of our knowledge, this is the first study to examine the interaction effects of different IPT types on prescription opioid use and opioid misuse. Prior studies have shown that individuals with opioid dependence report higher rates of different IPTs compared to those without opioid dependence (Balousek et al., 2007; Garami et al., 2019; Lawson et al., 2013), providing some additional support for the role of poly-victimization; however, additional studies are needed specifically examining the interactive or cumulative effects of different IPTs.

Regarding our third research question, gender was found to moderate the relationship between IPT and opioid misuse. Among females, only adverse childhood experiences were associated with increased odds of opioid misuse after controlling for other types of IPT. Among males, intimate partner violence was associated with increased odds of opioid misuse, and sexual assault was inversely associated. These findings are inconsistent with the few prior studies examining gender differences in associations between IPT and opioid misuse (Quinn et al., 2016; Smith et al., 2012). One of the most surprising findings in our study was that the strongest effect size was seen for the relationship between IPT and opioid misuse among males (OR: 2.65, CI: 1.70–4.12, p < .0001). This is in conflict with the prior study by Smith et al. (2012) which found that opioid use disorders were associated with an increased likelihood of intimate partner violence victimization among women but not men. This study did control for intimate partner violence perpetration, but not other types of IPT which, may in part, explain this difference. Our finding also appears to conflict with prior research indicating that women are more likely than men to misuse opioids to cope with interpersonal stress (Back et al., 2011). Direct comparisons between our findings and previous research are challenging given the variation in IPT measurement. There do appear, though, to be differences in how males and females respond to different IPT experiences and research should account for the moderating effects of gender in future analyses.

Results from this study also have implications for clinical practice, particularly around how we assess risk for opioid misuse. Two of the most commonly used tools to help clinicians assess risk for future opioid misuse are the Opioid Risk Tool (ORT) (Webster & Webster, 2005) and Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R) (Butler et al., 2008). Both instruments account for the role of IPT in contributing to risk for opioid misuse to varying degrees. The original version of the ORT includes a single IPT item assessing whether an individual has experienced childhood sexual abuse (yes/no). Both men and women answer this item, but it is only scored for women. Recently, researchers have proposed a revised version of the ORT based on an evaluation of its discriminant predictive validity for opioid use disorder in a cohort of patients with chronic nonmalignant pain (Cheatle et al., 2019). They found that removing the sexual abuse item significantly improved the predictive validity of the ORT. In their sample, however, few individuals reported sexual abuse (4.8%), which likely contributed to this finding. The SOAPP-R (Butler et al., 2008) includes three IPT items assessing how often individuals have experienced sexual abuse, tension in the home, and an argument that got so out of control someone got hurt (a recently developed short version of the SOAPP-R excludes this last item (Finkelman et al., 2017)). Notably absent are items specific to adverse childhood experiences (although this may be captured in part through the sexual abuse item) and differentiation of risk by gender. Given the high level of IPT co-occurrence and gender differences seen in this study and other studies, including items that more robustly assess different types of IPT and account for co-occurrence and differing risk by gender may serve to further improve opioid risk assessment tools.

Limitations

Study findings should be considered within the context of the study limitations. This was a cross-sectional study, which does not allow for the identification of temporal sequencing between variables; therefore, causality cannot be established. Our recruitment and sampling design may have also introduced limitations regarding the generalizability of results. For example, this project was advertised as a study examining the effects of IPT on health. As such, individuals who expressed interest in participating are likely those who self-identify as having a history of IPT. Given the wide variation in how IPT is defined, some people who have experienced victimization may not recognize it as IPT, and thus, these individuals may be underrepresented in this study. In addition, participants were required to have internet access to complete the study survey. While efforts were made to assist individuals with obtaining internet access if needed, some individuals may have been dissuaded from participating due to this barrier. Data were obtained through self-report methods which may introduce bias due to social-desirability or recall. Finally, the relatively small sample size increases uncertainty regarding the estimated effects and limits interpretation of findings, particularly regarding the stratified analyses. For example, among males, adverse childhood experiences were associated with opioid misuse before adjusting for exposure to other forms of IPT (Table 2) but were not significant in the adjusted model (Table 3) despite a slight increase in the effect size (1.22 vs. 1.24). Additional studies are needed with longitudinal designs, validation of self-report data, and larger samples.

Conclusions

This study highlights the importance of accounting for IPT co-occurrence and the moderating effects of gender when examining the relationship between IPT and opioid use/misuse. The paucity of research examining these factors reflects the larger field of IPT research, policy, and practice, which tends to be conducted in “silos,” focusing on specific forms of IPT or isolated genders. Despite calls for addressing the interconnections between different IPT types, co-occurrence is still not routinely examined (Finkelhor et al., 2007; Hamby & Grych, 2013; Slep & Heyman, 2001). This is a critical goal for advancing our understanding of the impact of IPT on opioid use/misuse, one that more accurately represents the complexity of the lives of survivors.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported though internal funding provided by the University of North Carolina at Chapel Hill School of Nursing.

ORCID iD

Jessica Roberts Williams

Author Biographies

Jessica Roberts Williams, PhD, MPH, PHNA-BC, is an assistant professor at the University of North Carolina at Chapel Hill School of Nursing. Her research interests focus on improving the role of the health care system in addressing long-term health outcomes among those affected by gender-based violence. Her work is facilitated through community engagement methodology and dissemination and implementation science.

Susan Girdler, PhD, FABMR, is a professor in the Department of Psychiatry at the University of North Carolina at Chapel Hill. Her long-standing research career focuses on physiologic stress reactivity, endogenous pain regulation, and the predictive ability of histories of trauma and histories of depression to identify clinically distinct subgroups of women with reproductive mood disorders.

Weston Williams, PhD, MHS, is a senior statistical analyst at Public Health Analytic Consulting Services, Inc. His research focus is on the design and analysis of HIV prevention and treatment adherence program evaluations and studies in epidemiology. He has more than 10 years consulting experience providing analytic and statistical support to government agencies, universities, and nonprofit organizations.

Martha Grace Cromeens, JD, BSN, RN, is a PhD student at the University of North Carolina at Chapel Hill School of Nursing. Her research interests focus on the intersection of the legal and health care systems, with an emphasis on issues in delayed diagnosis of endometriosis.

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