Spouse and Child Abuse Associated With Illicit Drug Use in Iran: A Systematic Review and Meta-Analysis

Abstract

Background:

There is a high prevalence of substance use disorders, especially among men, in Iran and is associated with a high burden on families. We aimed to systematically review the association between illicit drug use and spouse and child abuse in Iran.

Method:

Comprehensive terms were used to search three international databases (ISI, Medline, and Scopus) and a national database of Scientific Information Database up to September 2019. The retrieved citations were screened based on the eligibility criteria and then data were extracted, and the risk of bias was assessed by two independent investigators. Data were analyzed using random-effects model to estimate pooled odds ratios (ORs) and the heterogeneity of studies.

Results:

The search yielded 18 articles that met the inclusion criteria. Illicit substance use in husbands was associated with increased odds of current violence (OR = 3.50; 95% CI [2.09, 5.86]), current physical violence (OR = 5.41; 95% CI [3.50, 8.35]), current psychological violence (OR = 6.20; 95% CI [3.74, 10.30]), and current sexual violence (OR = 7.23; 95% CI [4.06, 12.87]) against spouse. In studies on child abuse, the odds of current physical child abuse by parents who used an illicit substance was 3.88 times (95% CI [1.50, 10.01]) higher than parents who did not use any illicit substance.

Conclusion:

The results of the current study showed that illicit substance use is associated with an increased risk of spouse and child abuse. This is an important social and health consequence of drug use and should be addressed in all drug control plans.

Keywords

addiction maltreatment family wife aggression epidemiology domestic violence intimate partner violence (IPV)

Substance use disorders are associated with significant negative psychosocial consequences, which may affect the family members. These consequences consist of a broad range of family disruptions and conflicts such as domestic violence (Gilchrist et al., 2015), low school performance (McGrath et al., 1999), and divorce (Collins et al., 2007; Keenan et al., 2013). Substance use disorders are also associated with other comorbid psychiatric conditions as well as aggressive and criminal behaviors (Amin-Esmaeili, Rahimi-Movaghar, Sharifi, et al., 2016).

Iran suffers from a high prevalence of drug use disorders and the associated burden (Danaei et al., 2019; Naghavi et al., 2014). According to the Iranian Mental Health Survey in 2011, 2.1% of the adult population (3.8% of male and 0.4% of female population) suffer from illicit drug use disorders in the past 12 months (Sharifi et al., 2015). The country has a high rate of opioid use (3.02%), in general, and opium use (2.64%), in particular. The prevalence of opioid dependence (1.56%) is substantially higher than its global (0.22) estimate (Degenhardt et al., 2014; Rahimi-Movaghar et al., 2014).

The majority of people who use illicit drugs in Iran are married and live with their families (Akbari et al., 2019; Amin-Esmaeili, Rahimi-Movaghar, Gholamrezaei, et al., 2016; Jafari et al., 2009; Narenjiha et al., 2009). Therefore, addiction might have a greater impact on family members. Prior studies in Iran have also shown a significant association between addiction and family conflicts (Fereidouni et al., 2015), domestic violence (Mohammadhosseini et al., 2010), and divorce (Habibi et al., 2016). In Iran, many studies have assessed the negative consequences of addiction on families, but as we know no systematic review has assessed the role of using drugs on violence perpetration, considering the country’s unique pattern of drug use and specific cultural considerations. Also, existing studies have a small sample size, and their results cannot be generalized to the entire Iranian population.

The prevalence of domestic violence among Iranian women is estimated to be between 23% (Adineh et al., 2016) and 66% (Hajnasiri et al., 2016). These estimates are quite higher than what has been reported globally (Garcia-Moreno et al., 2006). Given the high prevalence of violence toward Iranian women as well as a higher rate of opioid use disorder in men, the present study will have enough power to highlight the contribution of illicit drug use to this phenomenon. The current study aims to systematically review the association between illicit drug use and domestic violence, including spouse and child abuse in Iran. Pooling the data from eligible studies could provide a more comprehensive understanding of the association between drug use and spouse and child abuse.

Method

The study used the preferred reporting items for systematic reviews and meta-analyses (PRISMA) for all quantitative observational studies, consisting of cross-sectional, cohort, or case–control studies, conducted on spouses or children and evaluated the association of spouse and child abuse with illicit drug use. In this review, violence was defined as any physical, psychological, sexual abuse, or neglect committed by a spouse within a marital relationship (spouse abuse) or by a parent toward the child (child abuse).

Search Strategy

To retrieve relevant studies, a systematic search of international databases consisting of Scopus, ISI, and Medline (via PubMed) and the national database of Scientific Information Database (SID) was conducted in September 2019. No limitation was applied for the year and the language of publications. For the international databases, we developed a search strategy using three clusters of keywords: (1) names of common illicit drugs in Iran along with the general terms for substance use, abuse, dependence, and addiction; (2) spouse and child abuse; and (3) the names related to the country of Iran and its major cities (Table A1 of Appendix). The search strategy for the first and the third clusters was developed by the research team and had been used in previous studies as well (Amin-Esmaeili et al., 2012). The SID was searched using Persian keywords related to domestic violence. Documents were imported in a reference manager software (Endnote Version 7), and duplicate studies were deleted afterward. In addition, the list of references of the included studies was reviewed (backward citation tracking).

Inclusion Criteria

The inclusion criteria were (1) spouse abuse or child abuse was assessed; (2) violence and/or its specific aspects (physical, psychological, sexual, or neglect) were reported; (3) illicit drug use in the spouse/parent who was the perpetrator of the violence was reported; (4) indicators needed for a systematic review, such as percentages or odds ratios (ORs) of violence, were clearly provided or could be calculated from the presented data.

Screening and Data Extraction

First, we screened the titles and the abstracts and excluded nonrelevant studies. Then, the full texts of the selected studies were acquired. Two investigators independently assessed the inclusion criteria based on the full text of articles and extracted the data. If a study was not eligible, the reasons for exclusion were stated (Table 1).

Table 1.

Excluded Documents (n = 39) From the Systematic Review.

Reasons for Exclusion	First Author (Publication Year)
All of the study population were those with illicit drug use	Azizi (2013) Hadeiy (2019) Khajedaluee (2013) Kholasezadeh (2007) Kholasezadeh (2010) Rostami (2010) Saberizafarghandi (2019) Zarrabi (2016)
All of the study population were women with illicit drug user spouse	Noori (2013)
All of the study population had violence experience	Arabghol (2016) Hashemi (2011) Khangholi (2019) Rahnavardi (2017)
Illicit drug use was not evaluated in parents or partners	Abbasi-Ghahramanloo (2018) Hadianfard (2014) Jahanfar (2007) Khayat (2017) Mahram (2013) Poorkahkha (2016)
Illicit drug use in the family was assessed, but not in the perpetrators	Arab (2015)
Victims of violence were not child or spouse or it was unclear	Bazargan-Hejazi (2014) Ghodousi (2011) Hadinezhad (2019)
The data required for this review (odds ratio or detailed data on violence and illicit drug use) were not provided	Afshani (2013) Amiri (2018) Arab, 2015 Asadi (2019) Derakhshanpour (2014) Eslami-Shahrbabaki (2013) Fakharzadeh (2017) Hajian (2014) Hosseini (2013) Jouybari Jouybari (2010) Nejatizade (2017) Saffari (2017) Sayyari (2001) Sheikhbardsiri (2017) Shokoohi (2019) Vakili (2014) Yaghoubi-Doust (2013)

Note. The data extraction form inquired about the paper’s bibliometric characteristics (authors’ names, year of publication, the journal’s name, and the language of the full text), study information (study design, city and the province, year of the study implementation, study setting, participants, sampling, sample size, instruments, and data collection method), and data on spouse and child abuse (the type of violence, time frame for violence assessment, i.e., current and lifetime), substance use (definition and the type of substance), and the association between violence and substance use (percentages, ORs, and confidence intervals). Data extraction forms were completed independently by two investigators and then the extracted data were compared. All the inconsistencies were resolved through discussion.

Risk of Bias Assessment

Risk of bias assessment for each of the included studies was performed using eight quality criteria for cross-sectional studies and eight criteria for case–control studies. The decision about each criterion was reported as “low risk,” “high risk,” or “unclear risk” of bias (Table 2). The quality criteria for cross-sectional studies were (1) Was the source of sampling well presented? Studies presenting a clear definition of a population from which the study sample was drawn were considered to have a low risk of bias; (2) Was the sample representative of the target population? Studies providing a representative sample of married women (or children) in the general population were considered to have a low risk of bias; (3) Was the method of sampling appropriate? Random sampling, census, stratified, and time–location sampling methods were considered as methods with a low risk of bias; (4) Were the study subjects and the setting described in detail? Studies providing detailed information about the subject’s characteristics, setting, year of the study implementation, and the place of the study were considered to have a low risk of bias; (5) Was the response rate provided? Studies with a response rate higher than 70% and studies having tested the differences between the respondents and nonrespondents in the main subgroups were considered as having a low risk of bias; (6) Was the family violence clearly defined and accurately measured by a valid method, including the type of violence and time frame? Studies presenting a clear definition of family violence including the type of violence, time frame of experiencing violence, and validity and reliability of research instrument were considered to have a low risk of bias; (7) Was substance, including the type of substance, clearly defined and accurately measured by a valid method? Studies presenting a clear definition of substance use, the type of substance, and the validity and reliability of the research instrument were considered to have a low risk of bias; (8) Were subgroup analyses for types of violence performed? Studies providing separate data by the types of violence were considered to have a low risk of bias.

Table 2.

Characteristics of the Included Studies.

No.	First Author (Publication Year)	Language of Full Text	Year of Study	Type of Study	Province (City)	Target Population	Setting	Sampling Method	Data Collection Method (Paper & Pencil/Web-Based)	Sample Size (Female, Male)	Response Rate	Risk of Bias ^a
No.	First Author (Publication Year)	Language of Full Text	Year of Study	Type of Study	Province (City)	Target Population	Setting	Sampling Method	Data Collection Method (Paper & Pencil/Web-Based)	Sample Size (Female, Male)	Response Rate	Low	Unclear	high
Spouse abuse
1	Amir Aliakbari (2018)	English	2015	Cross-sectional	Hormozgan (Bandar Abbas)	All women who referred to health centers of Bandar Abbas	Health centers	Systematic random	Interviewer-administered questionnaires (not reported)	(400, 0)	100	1, 2, 4–6	3	7, 8
2	Ahmadi (2016)	English	2015	Cross-sectional	Guilan (Rasht)	Married women	Household	Cluster random	Self-administered questionnaire (not reported)	(2,091, 0)	87.1%	1–6, 8	—	7
3	Khalkhali (2016)	English	2013–2014	Cross-sectional	Guilan (Rasht)	Spouses of three target groups: (1) hospitalized patients due to psychiatric disorders (n = 30); 2) hospitalized patients due to amphetamine psychosis (n = 30); (3) healthy people (n = 60)	Psychiatric hospital	Simple random	Self-administered questionnaire (not reported)	(120, 0)	NR	1, 3, 4, 6, 7, 8	5	2
4	Adib-Hajbaghery (2015)	English	2013	Matched case–control	Isfahan (Kashan)	Wives of addicts who were under treatment in the three addiction treatment centers (n = 112) and married women referred to the health care centers with nonaddicted husbands, education level and income matched (n = 100)	Addiction treatment centers and health care centers	Census for case group	Self-administered questionnaire (paper & pencil)	(200, 0)	83.3% in case group	1, 4–6, 8	7	2, 3
5	Rafiei (2014)	Persian	2011	Cross-sectional	Tehran (Tehran)	Women with husbands suffering from illicit drug use (n = 200) and control group (n = 200)	Addiction treatment centers, prisons, snow balling	Random	Interviewer-administered questionnaires (not reported)	(400, 0)	NR	—	3, 5	1, 2, 4, 6, 7, 8
6	Sheikhan (2014)	English	2010–2011	Cross-sectional	Tehran (Tehran)	Women with infertility	Infertility centers	Convenient	Interviewer-administered questionnaires (paper & pencil)	(400, 0)	NR	1, 4, 6	5	2, 3, 7, 8
7	Kafaei-Atrian (2012)	Persian	2008	Cross-sectional	Isfahan (Kashan)	Women referring public health center for postnatal care	Public health center	Systematic random	Interviewer-administered questionnaires (paper & pencil)	(143, 0)	NR	1, 3, 4, 6	5	2, 7, 8
8	Dortag-e-Raberi (2010)	Persian	2007	Cross-sectional	Tehran (Tehran)	Pregnant women at 16th week of pregnancy	Public health center	Consecutive	Self-administered questionnaire (paper & pencil)	(370, 0)	NR	1, 3, 4, 6, 8	5	2, 7
9	Mohammadhosseini (2010)	English	2006–2007	Cross-sectional	Fars (Jahrom)	Married women with a 6- to 18-month old child	Public health center	NR	Interviewer-administered questionnaires (not reported)	(300, 0)	NR	1, 3, 4, 6, 7, 8	5	2
10	Hasheminasab (2007)	Persian	2005–2006	Cross-sectional	Kordistan (Sanandaj)	Pregnant women hospitalized for delivery or abortion	Two general hospitals	Systematic random	Interviewer-administered questionnaires (paper & pencil)	(840, 0)	NR	1, 3, 4, 5, 6, 8		2, 7
11	Salehi (2006)	Persian	2003	Cross-sectional	Chaharmahal & Bakhtiari (Shahr-e Kord)	Pregnant women referring to public health center	Public health center	Convenient	Interviewer-administered questionnaires (paper & pencil)	(1,600, 0)	NR	1, 4, 6	5	2, 3, 7, 8
12	Jokar (2005)	Persian	2003	Cross-sectional	Kohgiluyeh & Boyer-Ahmad (Yasuj)	Married women referring to the public health center	Public health center	Random	Self-administered questionnaire (not reported)	(517, 0)	NR	1–3	5	4, 6, 7, 8
13	Mousavi (2005)	English	2002	Cross-sectional	Isfahan (Isfahan)	Married women	Household	Cluster random	Self-administered questionnaire (not reported)	(386, 0)	89%	1–5	—	6–8
14	Nazparvar (2002)	Persian	1996	Case–control	Tehran (Tehran)	The case group consisted of 100 women referring to forensic centers and the control group consisted of 70 women	Legal medicine organization	Random	Interviewer-administered questionnaires (not reported)	(170, 0)	NR	1	6, 7	2–5, 8
Child abuse
1	Pirdehgha (2015)	English	2013	Cross-sectional	Yazd (Yazd)	Middle-school student	School	Multiple cluster	Self-administered questionnaire (not reported)	(301, 399)	94%	1–6, 8	—	7
2	Stephenso (2006)	English	2003	Cross-sectional	Kordestan (eight cities and neighboring villages)	Students aged 11–18 years	School	Systematic random	Self-administered questionnaire (not reported)	(858, 512)	90%	1–6	—	7, 8
3	Miri (2005)	Persian	2002	Cross-sectional	Kerman (Bam)	High-school students	School	Random	Self-administered questionnaire (not reported)	(291, 271)	93.7	1–6	—	7, 8
4	Namdari (2003)	Persian	1998	Cross-sectional	Lorestan (Khorramabad)	Middle-school student	School	Cluster random	Self-administered questionnaire (paper & pencil)	(117, 123)	NR	1–4, 6	5	7, 8

Note. NR = not reported.

^a The numeral of each quality criteria is based on the type of study and is compatible with the numeral of items in method section.

The quality criteria for case–control studies were (1) Were the cases defined precisely? Studies providing detailed information about the eligibility criteria, sources, and methods of case ascertainment were considered to have a low risk of bias; (2) Were the cases representative of the defined population? Studies applying an appropriate method of sampling (including random sampling, census, stratified, and time–location sampling) to select cases among the defined population were considered to have a low risk of bias; (3) Were the controls defined precisely? Studies providing detailed information about the eligibility criteria, sources, and methods of the control group selection were considered to have a low risk of bias; (4) Were the controls representative of the designated population? Studies with a similar or comparable source of population for cases and controls were considered to have a low risk of bias; (5) Were the exposure variables clearly defined and accurately measured by a valid method? Studies presenting a clear definition of exposure, and validity and reliability of research instrument, were considered to have a low risk of bias; (6) Were cases and controls ascertained in the same method? Studies presenting a similar exposure measurement method in cases and controls were considered to have a low risk of bias; (7) Was the response rate high and/or were not different in case and control groups? Studies with a response rate higher than 70% and almost equal in both the case and the control groups were considered to have a low risk of bias; (8) Were the potential confounding factors controlled in the design and/or analysis? Studies presenting restriction in design and techniques, for example, modeling, stratification, regression, or sensitivity analysis were considered to have a low risk of bias.

The quality criteria for case–control and cross-sectional studies were adapted from the Critical Appraisal Skills Programme and Joanna Briggs Institute critical appraisal checklist, respectively. The quality of all the included studies was assessed independently by two investigators. Each item was rated as unclear, high, or low risk of bias. Disagreements were resolved through discussion.

Statistical Analysis

To provide meta-analysis of the association between illicit drug use and spouse and child abuse, ORs and standard errors were used. In cases where ORs or standard errors were not provided, these two statistics were calculated from the number of subjects with or without violence and illicit drug use. The meta-analysis was performed in different subgroups of violence type and time frames and presented in two separate sections, that is, spouse abuse and child abuse.

Current violence was defined as experiencing violence during the past 12 months prior to the study. Studies had reported different types of violence including physical, nonphysical, psychological, emotional, sexual violence, and neglect. We classified violence into four categories of physical abuse, psychological abuse, sexual abuse, and neglect. Nonphysical and emotional abuse were categorized as psychological abuse. Whenever the year of the study implementation was missing, 3 years prior to the publication date (corresponding to the average years of the included studies) was considered as the year of the study implementation.

In “current any violence” and “current physical violence” subgroups, for which an adequate number of studies were included, we compared pooled OR of studies that used a self-administered questionnaire with the studies that used an interviewer-administered questionnaire. We also performed a sensitivity analysis to evaluate the effect of studies with a high risk of bias. To accomplish this, we excluded studies with more than four criteria with high or unclear risk of bias and then checked their impact on results.

The meta-analysis was performed using STATA (Version 14.0) software. Random-effects model was used to provide a more conservative estimate of pooled ORs, and the results were presented in forest plots. Heterogeneity of studies was assessed using χ² tests and I² statistics. To evaluate the publication bias in studies on spouse abuse, a funnel plot was provided, and Egger’s regression and Begg’s test were conducted. These analyses were not conducted for child abuse due to the small number of studies.

Results

The initial search of the databases (after removing the duplicates) along with the reference tracking resulted in 1,387 studies. Following the screening of the titles and abstracts, 1,330 documents were excluded. Then, 57 full texts were assessed using eligibility criteria, and 18 were included. Among the 18 documents, 14 were on spouse abuse and four were on child abuse. The characteristics of the included studies on spouse and child abuse and the result of risk of bias assessment for each study are provided in Table 2.

Quality assessment of the included studies was performed using two specific eight-item tools for appraising cross-sectional and case–control studies. None of the studies met all quality criteria. The minimum and the maximum number of quality criteria met in the included studies were 0 (in one study) and 7 (in two studies). There were less than three criteria with high or unclear risk of bias in seven studies, and there were more than four criteria with high or unclear risk of bias in five included studies. The most prevalent unmet criterion was providing a clear definition of substance use, using a valid method for its measurement, and providing the type of substance (Table 2).

Spouse Abuse

Fourteen studies examined the association between spouse abuse and drug use by the husband (Table 3). The total number of participants in the included studies was 7,937, ranging from 120 to 2,091. The publication dates of the included studies ranged from 2002 to 2018. Thirteen studies were cross-sectional. Four studies were conducted in Tehran, that is, the capital city of the country, and others in the cities of Rasht, Isfahan, Yasuj, Shahr-e Kord, Sanandaj, Jahrom, Kashan, and Bandar Abbas. Study settings consisted of public health centers (seven studies), forensic medicine organization (n = 1), households (n = 2), general hospitals (n = 1), addiction treatment centers (n = 2), prisons (n = 1), infertility treatment centers (n = 1), and psychiatric hospitals (n = 1). The sampling methods consisted of random sampling method (n = 9), convenient sampling (n = 2), consecutive sampling (n = 1), and the sampling method was unclear in one study. Eight studies used face-to-face interviews and six used self-administered questionnaires.

Table 3.

Findings of the Studies on Spouse Abuse.

ID	First Author (Publication Year)	Age Characteristics (Mean ± SD [Range])	Type of Drug (n)	Type of Violence (Time Period)	Husbands With Illicit Substance Use (n)	Nonuser Husbands (n)	Violence Among Illicit Substance User (n)	Violence Among Nonusers (n)	OR [95% CI]
1	Amir Aliakbari et al. (2018)	32.74 ± 8.4	NR	Current physical violence	48	352	35	121	5.14 [2.62, 10.08] ^a
				Current psychological violence	48	352	44	174	11.25 [3.95, 31.98]^a
				Current sexual violence	48	352	35	105	6.33 [3.22, 12.45] ^a
				Any current violence	48	352	44	218	6.76 [2.38, 19.24] ^a
2	Khalkhali (2016)	HDU 39.7 ± 8.5 & HNDU 39.17 ± 7.8 ^b	Methamphetamine (30)	Current psychological violence	30	60	26	28	10.29 [3.40, 31.12]^a
				Current physical violence	30	60	25	15	15.00 [4.87, 46.16]^a
				Current sexual violence	30	60	16	6	10.29 [3.40, 31.12]^a
				Current severe physical violence	30	60	12	2	19.33 [3.95, 94.57]^a
3	Ahmadi (2016)	35.9 ± 8.9 (18–75)	NR	Current psychological violence	90	2,001	78	1162	4.69 [2.53, 8.67]
				Current physical violence	90	2,001	52	531	3.78 [2.46, 5.82]
4	Adib-Hajbaghery (2015)	—	Opium (NR), heroin (NR), synthetic substances (NR)	Any current violence	100	100	97	65	17.41 [5.13, 58.98]
				Current physical violence	90	2001	52	531	3.78 [2.46, 5.82]
5	Sheikhan (2014)	30.50 ± 6.2	Medication and opium (24)	Any current violence	24	376	NR	NR	1.78 [0.99, 3.20]
6	Rafiei (2014)	HDU 32.90 ± 7.3 & NDUH 33.01 ± 8.3	NR	Lifetime physical violence	200	200	62	17	4.84 [2.71, 8.64] ^a
7	Kafaei-Atrian (2012)	26.9 ± 5 (14–42)	Alcohol (5) or narcotics (6)	Current physical violence	NR	NR	NR	NR	5.30 [1.12, 25.00]
				Any current violence	NR	NR	NR	NR	3.10 [1.09, 8.80]
8	Mohammadhosseini (2010)	27 ± 4.2 (18–40)	Opium (15)	Lifetime sexual violence	15	105	NR	NR	3.81 [1.17, 12.46]
				Lifetime psychological violence	15	105	NR	NR	10.29 [3.40, 31.12]
				Any lifetime violence	15	285	14	180	10.29 [3.40, 31.12]^a
9	Dortag-e-Raberi (2010)	26.27 ± 6 (16–42)	Alcohol (12), opium (14), and other drugs (9)	Any current violence	35	335	27	193	2.48 [1.10, 5.63] ^a
10	Hasheminasab (2007)	—	Narcotic drugs (16)	Current physical violence	16	824	6	65	7.01 [2.47, 19.89] ^a
11	Salehi (2006)	27.4 ± 4.6 (16–48)	NR	Any current violence	158	1442	123	793	2.88 [1.95, 4.25] ^a
12	Jokar (2005)	29.16 ± 6.1	NR	Any lifetime violence	30	461	30	353	10.29 [3.40, 31.12]^a
13	Mousavi (2005)	35.7 ± 10.9 (15–78)	Alcohol and drug (NR)	Any lifetime violence	22	364	17	125	10.29 [3.40, 31.12]^a
14	Nazparvar (2002)	31.7 ± 9.1	Narcotics (35)	Lifetime physical violence	35	135	33	67	16.75 [3.86, 72.59]^a

Note. CI = confidence interval; HDU = husband with drug use; NDUH = nondrug using husband; OR = odds ratio; NR = not reported; SD = standard deviation.

^a The ORs and CIs were calculated by the reviewers. ^b In this study, two nondrug using groups were included and the mean and SD of age for each group were reported separately. We merged the two groups and calculated a single mean and SD for age.

Meta-analyses of the association between violence and drug use were conducted in subgroups of the time frame of violence (current and lifetime) and the type of violence (any violence, physical, psychological, and sexual abuse).

The meta-analysis demonstrated that the ORs of the lifetime and current experience of any violence among women who had a drug-using spouse, compared to women who had a non-drug-using spouse, were 8.04 (95% CI [3.98, 16.27], I ² = 0%, P for heterogeneity = 0.836) and 3.50 (95% CI [2.09, 5.86], I ² = 63.2%, P for heterogeneity = 0.018), respectively.

When comparing women with a drug-using spouse to women with a non-drug-using spouse, other types of violence also showed a significant association with drug use by the husband. The OR for current physical abuse was 5.41 (95% CI [3.50, 8.35], I ² = 29.4%, P for heterogeneity = .226), for current psychological abuse was 6.20 (95% CI [3.74, 10.30], I ² = 6.1%, P for heterogeneity = .345), and for current sexual abuse was 7.23 (95% CI [4.06, 12.87], I ² = 0%, P for heterogeneity = .464).

Two studies had assessed lifetime physical abuse in the spouses. The OR of lifetime physical abuse in the spouse of a drug-using husband compared to those with a non-drug-using husband was 7.44 (95% CI [2.34, 23.71], I ² = 58%, P for heterogeneity = .123). Furthermore, a single study reported the association of lifetime psychological abuse (OR = 8.59, 95% CI [1.06, 69.80]) and lifetime sexual abuse (OR = 3.81, 95% CI [1.17, 12.46]).

The effect of data collection method on estimates was evaluated. In the “current physical violence” subgroup, pooled OR in the two studies using a self-administered questionnaire and the four studies using an interviewer-administered questionnaires were estimated to be 6.22 (95% CI [0.93, 41.85]) and 2.84 (95% CI [1.82, 4.41]), respectively. In the “current physical violence” subgroup, the pooled OR in the two studies with a self-administered questionnaire and three studies with an interviewer-administered questionnaires were estimated to be 6.81 (95% CI [1.79, 25.83]) and 5.59 (95% CI [3.28, 9.51]), respectively. The sensitivity analysis was performed by removing the studies with more than four criteria with high or unclear risk of bias in studies on spouse abuse. The pooled OR changed to 5.11 (95% CI [2.24, 11.64]) in “current any violence” subgroup and 6.80 (95% CI [2.73, 16.95]) in “lifetime any violence” subgroup. The single study included in “lifetime physical violence” subgroup was removed due to the high risk of bias.

To assess the publication bias, we examined a funnel plot and performed Egger’s test to determine the bias coefficient (Figure 4). The funnel plot revealed asymmetry, suggesting publication bias, and the Egger’s test (P = .001) and the Begg’s test (P = .008) confirmed bias.

Figure 1.

Flowchart showing how the peer reviewed articles were identified and selected.

Figure 2.

Forest plot of the association between illicit drug use and spouse abuse.

Figure 3.

Forest plot of the association between illicit drug use and child abuse.

Figure 4.

Funnel plot of studies examining the association between illicit drug use and spouse abuse with pseudo.

Child Abuse

To provide a meta-analysis of the association of child abuse and drug use by the parents, four studies were included (Table 4). These studies were published from 2003 to 2015, and all were cross-sectional. Sample sizes ranged from 240 to 1,370 participants with a total sample of 2,872. All studies were conducted at schools using self-administered questionnaires.

Table 4.

Results of the Studies on Child Abuse.

ID	First Author (Publication Year)	Age Characteristics (Mean ± SD (Range)]	Type of Drug	Type of Violence (Time Period)	Parents With Illicit Substance Use (n )	Nonuser Parents ( n )	Violence Among Illicit Drug Users ( n )	Violence Among Nonusers ( n )	OR [95% CI]
1	Pirdehghan et al. (2015)	13.3 ± 0.9 (12–18)	NR	Lifetime neglect	118	550	110	448	3.13 [1.47, 6.62]
				Lifetime psychological violence	118	557	101	414	2.05 [1.19, 3.55]
				Lifetime physical violence	118	549	59	178	2.08 [1.39, 3.12]
				Lifetime sexual violence	116	549	48	140	2.06 [1.35, 3.12]
2	Stephenson et al. (2006)	(11–18)	Addictive substances (375) (cigarette, alcohol, or narcotics)	Lifetime physical violence	—	—	—	—	2.77 [1.24, 6.19]
3	Miri (2005)	—	NR	Current physical violence	44	518	39	346	3.88 [1.50, 10.01]
4	Namdari (2003)	—	NR	Lifetime physical violence	26	214	23	117	6.35 [1.85, 21.08]
				Lifetime psychological violence	26	214	26	197	4.70 [0.27, 80.39]

Note. CI = confidence interval; NR = not reported; OR = odds ratio; SD = standard deviation.

Compared to those with non-drug-using parents, children with drug-using parents were at greater risk of violence. The OR for lifetime psychological abuse was 2.11 (95% CI [1.23, 3.62], I ² = 0%, P for heterogeneity = .57), for lifetime physical abuse was 2.21 (95% CI [1.54, 3.16], I ² = 0%, P for heterogeneity = .53), for lifetime neglect was 3.13 (95% CI [1.48, 6.62]), and for current physical abuse was 3.88 (95% CI [1.50, 10.01]).

Discussion

The current systematic review revealed that illicit drug use was highly associated with increased risk of spouse and child abuse. It also showed that illicit drug use was associated with a greater risk of current (ORs from 3.50 to 7.23) and lifetime (ORs from 3.81 to 8.59) physical, psychological, and sexual abuse against spouse. Our meta-analysis showed that illicit drug use by a parent is associated with a higher risk of child abuse, both physical and psychological (ORs from 2.1 to 3.9).

Several studies from other countries have also shown the association between illicit drug use and spouse and child abuse. A systematic review of industrialized countries indicated that perpetration of family violence is positively associated with illicit drugs and alcohol use, although the review did not provide any pooled estimates (Choenni et al., 2017). There is similar evidence from low- and middle-income countries. For example, the United Nations multicountry study in Asia and the Pacific indicated that current drug use was associated with the perpetration of violence in low-income countries (Fulu et al., 2013). Also, a review of existing literature in low- and lower-middle-income countries indicated that drug use in men was an important risk factor for male-to-female violence (Halim et al., 2018). Our review is also consistent with the results of other reviews and has quantified this association. It seems that the association is a global phenomenon and exists in a variety of societies with different levels of income. Esquivel-Santoveña et al. (2013) indicated that the overall prevalence of partner abuse is higher in developing countries compared to industrialized countries. Some studies have suggested that economic development and reduction of poverty might have an important role in the country’s norms and the acceptability of domestic violence (Lansford et al., 2014), thus having a protective impact against family violence (Vyas & Watts, 2009). Since poverty can exacerbate the correlation of illicit drug use and violence, addressing this issue is of utter importance for drug policies of the country.

Opioids are the predominant illicit drugs leading to dependence in Iran (Amin-Esmaeili, Rahimi-Movaghar, Sharifi, et al., 2016), but there has also been a rise in stimulant use through the recent years (Noroozi et al., 2018; Shadloo et al., 2017). None of the included studies investigated the role of different types of drugs in spouse and child abuse. Various studies from other countries have examined the strength of the association between the types of drugs and domestic violence. For example, several studies have illustrated that alcohol was more strongly associated with violence than other types of substances (Lammers et al., 2014; Shorey et al., 2011). Moore et al. (2008) in a meta-analytic review assessed the relationship between drug abuse and aggression among intimate partners and found that cocaine had the strongest relationship with intimate partner violence compared to other illicit drugs.

Different types of substances have different pharmacological effects. For instance, hallucinogens might cause perceptual disturbances (Choenni et al., 2017) resulting in paranoid ideation and marital conflicts. Cocaine and other stimulants have been shown to cause impaired judgment and aggression (Spunt et al., 1990). Withdrawal symptoms have also been proposed as an underlying mechanism. Several studies have shown more irritability during the withdrawal phase (Kraanen et al., 2010; Smith, 2002). Some other studies have proposed changes in the central nervous system after using different types of substances (opioids, amphetamines, marijuana, and phencyclidine), resulting in impairments in the individual’s social skills and coping mechanisms (Habil et al., 2010).

In addition to the specific pharmacological effects of each type of substance, generally with any substance dependence syndrome, a shift happens in the priorities and interests of people who use illicit drugs, that is, focusing mainly on obtaining and using the drug. This might be associated with increased family tensions. In Iran, people who use drugs frequently face functional impairments (Amin-Esmaeili Rahimi-Movaghar, Sharifi, et al., 2016), leading to financial hardship in the family. In many traditional families, women are housewives with no income. This might increase the financial burden to the family when the breadwinner remains nonfunctional. Sexual dysfunction associated with opioid use might be another source of conflict in intimate relationships. Other physical and psychiatric consequences of substance use might also result in family disruptions.

There might also be a family predisposition toward violent behavior among those who use drugs. In Iran, many people who use drugs come from disrupted families, marked by poor parental supervision and other psychopathologies such as aggression (Sadeghi et al., 2014). These experiences might make the individual prone to substance use and violence. Moreover, a significant number of drug users live in socially disadvantaged and suburban areas, which might be associated with higher rates of violent behaviors.

Iran is going through a cultural transition, from a traditional paternalistic (male-dominant) family structure toward a more modern model, where women’s rights are less neglected. However, in the majority of the families, the male partner is still dominant, and recent studies have also shown a high risk of violence toward spouse by men who use drugs. In this review, although the number of the included studies was low, studies were from different cultures and geographical areas and covered urban and rural areas as well as small to large cities. We, the authors, believe that the pooled estimate might be representative of the country, but variations between different geographical areas could not be assessed.

It has been for 2 decades that research on harms associated with drug use and drug control policies have mainly focused on HIV, hepatitis C virus (HCV), and other blood-borne diseases (Degenhardt et al., 2019; Malekinejad et al., 2015; Rahimi et al., 2020). But there has been inadequate attention to mental health and family burden associated with drug use. The current study is the first review focusing on spouse and child abuse from Iran as important harm of illicit substance use on families.

Limitations

The majority of the included studies had low quality and did not assess the role of confounding factors. Some investigators have proposed that by weighting the confounding factors (socioeconomic status or comorbid psychiatric conditions), the association between substance use and violent behavior would become less significant (Lipsey et al., 2002).

In addition, the types of substances were not reported in some of the included studies. In those studies that recruited participants with different types of substances, none provided the data for violence by the type of substance. Therefore, subgroup analysis to evaluate the association between violence and the type of substance was not possible. Furthermore, time and duration of substance use were not reported in the included studies, therefore temporality between substance use and violence perpetration could not be assessed.

Unmarried cohabitation is considered a crime in Iran, which makes it extremely hidden. This subject is rarely addressed in the studies conducted in Iran. In this review, we did not find any study on violence among unmarried couples living together.

Substance use by the husband or parent was based on self-report or the subjects’ perception of their husband’s or parent’s use of an illicit substance. It is recommended that future studies consider the current limitations and implement a more detailed assessment of drug use in their methodology.

Although few studies were included in the subgroup analyses of violence, the heterogeneity between studies was substantial, which suggests that the results should be interpreted with caution. A further consideration for using the estimates of the present study is necessary due to the small sample sizes of the majority of the included studies. In addition, the sample sizes varied widely across the studies, and different studies could not make the same contribution for the estimates. It is worth mentioning that the present review only included published studies, omitting gray literature.

Conclusion

The results of the current study showed that illicit substance use is associated with an increased risk of spouse and child abuse and highlights the need for effective interventions to provide prevention and care for violence against spouses and children of people who use illicit drugs. For this purpose, it is necessary to increase the individual’s and family’s social awareness about the vulnerability of women and children, and appropriate measures should be taken to improve relevant social and life skills. In addition, specialized social and legal services need to be developed, and the psychological and health needs of the victims should be addressed. Governmental support must be provided, so that these services become easily accessible and affordable (Table 5).

Table 5.

Critical Findings.

Illicit drug use is highly associated with increased risk of domestic violence.

The odds of perpetration of current and lifetime violence toward spouse were 3.5 and 8 times greater for drug users compared to nondrug users, respectively.

The odds of perpetration of lifetime physical violence toward children was 2.2 times greater among drug-using parents compared to nondrug using parents.

Table 6.

Implications for Practice, Policy, and Research.

Policy Recommendations:

Providing specific services to support families of people who use drugs is of utter importance.

Effective interventions for empowering individuals against violence should be developed for families of people who use drugs.

It is necessary that welfare organizations and other authorities, including social emergency services, pay special attention to the victims of domestic violence in families of people who use drugs and provide appropriate care.

Within the school system, counselors should be wary of this risk of violence among children who have a parent that uses drugs and provide appropriate interventions, if necessary.

Health-care staff providing treatment for people who use drugs should pay more attention to the existing training of emotion regulation and anger management within the treatment protocols.

Major changes should be made within the laws on violence against women. These changes within the legislations could provide a preventive approach toward this health issue.

Because addiction is a widespread problem in the Iranian community, developing screening programs for domestic violence with a focus on addiction is necessary for the general population

Future Research:

Conducting high-quality focusing on the role of illicit drug use in domestic violence is recommended. For this purpose, the following subjects need to be addressed:

○ Assessing variables of drug use (e.g., types of substance, severity of addiction including use and use disorder, duration of use, temporality between drug use and violence perpetration) using standard tools.

○ Assessing confounding and predisposing factors (e.g., socioeconomic status, education, race, place of residence, personality characteristics and mental health of perpetrators and victims).

○ Assessing more details about violence (e.g., types of violence, the severity of violence, time of experience).

○ Evaluating violence against other family members of drug users (e.g., parents or siblings).

Violence against drug users could also be assessed in future studies.

Due to the cultural context of Iran, all studies assessed violence only in women. Violence against men by women who use drugs should be addressed in future studies.

Footnotes

Appendix A

Table A1.

Search Strategy in the Electronic Databases (Pubmed, Scopus, and Web of Science).

	Search Query
#1	(opium[Title/Abstract] OR morphin[Title/Abstract] OR codein[Title/Abstract] OR methadon[Title/Abstract] OR narcotic[Title/Abstract] OR heroin[Title/Abstract] OR opioid[Title/Abstract] OR opiat[Title/Abstract] OR tramadol[Title/Abstract] OR hydromorphon[Title/Abstract] OR diphenoxylate[Title/Abstract] OR pentazocine[Title/Abstract] OR buprenorphin[Title/Abstract] OR dihydrocodeine[Title/Abstract] OR norgesic[Title/Abstract] OR temgesic[Title/Abstract] OR “substance related disorders”[Title/Abstract] OR street [Title/Abstract]) AND (drug[Title/Abstract] OR “recreational drugs”[Title/Abstract] OR illicit[Title/Abstract] OR substance [Title/Abstract]) AND (abus[Title/Abstract] OR substance [Title/Abstract]) AND (dependen[Title/Abstract] OR drug [Title/Abstract]) AND (abus[Title/Abstract] OR drug [Title/Abstract]) AND (dependen[Title/Abstract] OR substance [Title/Abstract]) AND (use [Title/Abstract]) AND (disorder[Title/Abstract] OR addict[Title/Abstract] OR stimulant[Title/Abstract] OR amphetamin[Title/Abstract] OR methamphetamin[Title/Abstract] OR methyl [Title/Abstract]) AND (amphetamin[Title/Abstract] OR ephedrin[Title/Abstract] OR deoxyephedrine[Title/Abstract] OR “deoxy ephedrine”[Title/Abstract] OR cannabi[Title/Abstract] OR marijuana[Title/Abstract] OR lsd[Title/Abstract] OR “lysergic acid”[Title/Abstract] OR cocain[Title/Abstract] OR ecstasy[Title/Abstract] OR phencyclidin[Title/Abstract] OR pcp[Title/Abstract] OR hallucinogen[Title/Abstract] OR alcohol[Title/Abstract])
#2	(iran* OR persia* OR i.r.iran OR ir.iran OR tehran* OR babol* OR tabriz* OR rasht* OR mashhad* OR mashad* OR zahedan* OR fars* OR shiraz* OR ahvaz* OR “jundi shapur” OR “jundi shapur” OR jondishapour OR jundishapour OR beheshti OR ferdowsi OR isfahan* OR esfahan* OR yasooj* OR yasouj* OR yasuj* OR arak OR kerman* OR rafsanjan* OR bakhtaran* OR urmia* OR orumieh* OR oroomieh* OR oroumieh* OR behzisti OR mazandaran* OR gilan* OR guilan* OR guillan* OR gillan* OR semnan* OR yazd* OR hormozgan* OR kohgilooye* OR kohgilouye* OR kohgiluye* OR kohkiluye* OR sanandaj* OR baqiyatallah OR baghiatallah OR baghiatollah OR qazvin* OR sabzevar* OR ardabil* OR ardebil* OR bushehr* OR booshehr* OR boushehr* OR modares OR modarres OR ilam* OR golestan* OR gorgan* OR kordestan* OR kurdistan* OR kordistan* OR kurdestan* OR karaj* OR shahrekord* OR rafsanjan* OR jahrom* OR shahroud* OR shahrud* OR shahrood* OR kashan* OR hamedan* OR hamadan* OR zanjan* OR birjand* OR tonkabon* OR lorestan* OR khoramabad* OR khorramabad*)
#3	(physical[Title/Abstract]) AND (violence[Title/Abstract] OR somatic[Title/Abstract]) AND (violence[Title/Abstract] OR mental[Title/Abstract]) AND (violence[Title/Abstract] OR sexual[Title/Abstract]) AND (violence[Title/Abstract] OR verbal[Title/Abstract]) AND (violence[Title/Abstract] OR emotional[Title/Abstract]) AND (violence[Title/Abstract] OR familial[Title/Abstract]) AND (violence[Title/Abstract] OR domestic[Title/Abstract]) AND (violence[Title/Abstract] OR marital[Title/Abstract]) AND (violence[Title/Abstract] OR strife[Title/Abstract] OR aggress[Title/Abstract] OR anger[Title/Abstract] OR atrocities[Title/Abstract] OR mistreatment[Title/Abstract] OR child[Title/Abstract]) AND (mistreatment[Title/Abstract] OR spous[Title/Abstract]) AND (abuse[Title/Abstract] OR marital[Title/Abstract]) AND (abuse[Title/Abstract] OR child[Title/Abstract]) AND (violence[Title/Abstract] OR spous[Title/Abstract]) AND (violence[Title/Abstract] OR abusive[Title/Abstract]) AND (husbands[Title/Abstract] OR child[Title/Abstract]) AND (abuse[Title/Abstract] OR elder*[Title/Abstract]) AND (abuse[Title/Abstract])
#4	#1 AND #2 AND #3

Note. In the Scopus and Web of Science databases, keywords were searched in “TITLE-ABS-KEY” and “TOPIC,” respectively.

Authors’ Note

The funding source had no role in the study design, implementation, analyses, and interpretation of the data and the writing of the manuscript

Acknowledgment

We would like to express our sincere appreciation to Dr. Sedigheh Amir Aliakbari and Dr. Mojdeh Banaei for providing additional information related to their studies.

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 financially by the Iranian National Institute for Medical Research Development (NIMAD; Grant No. 940043).

ORCID iD

Shahab Baheshmat

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