Risky Substance Use Behavior and Polyvictimization Among Adults Who Inject Drugs in Rural Kentucky

Background/Purpose: People who inject drugs (PWID) are vulnerable to risky substance use behaviors (e.g., use of fentanyl and fentanyl-related analogues), resulting in related adverse effects (e.g., overdose deaths). Research concludes that PWID are vulnerable to fentanyl use and its harmful effects due to experiences of multiple forms of violence, also known as polyvictimization. However, few studies have examined the effect of risky drug use behaviors and related adverse effects on polyvictimization among socially vulnerable PWID. This study assessed whether risky substance use, including lifetime fentanyl use and overdose experiences, is associated with lifetime polyvictimization while controlling for demographic, mental health, and substance use disorders.

Methods: The current study used cross-sectional data from an exploratory study of 350 PWID conducted between 2018 and 2021 that sought to identify socio-ecological factors influencing the uptake of newly implemented syringe service programs (SSPs) among PWID in rural Appalachian Kentucky. Eligibility included being 18 years or older, having injected drugs at least once in the past 30 days, and residing in either Clark, Knox, or Owsley County in Appalachia, Kentucky. Descriptive analyses included means with standard deviations for continuous variables and proportions for categorical variables. Multinomial logistic regression (MLR) analysis examined whether lifetime overdose experiences (0=no and 1=yes) and fentanyl injection, i.e., alone/in combination with other drugs (0=no and 1=yes), was associated with lifetime polyvictimization (i.e., 0=no violence experience vs. 1=experience of one type of violence vs. 2=experience of two or more types of violence), controlling for demographics, including age (M=37.6, SD=9.6), gender (0=male and 1=female), race (0=White and 1=non-White), past year homelessness (0=no and 1=yes), and mental health and substance use disorders, including past year severe substance use disorder (SUD, 0=no and 1=yes) and past year severe mental health disorder (MHD, 0=no and 1=yes).

Results: PWID reported more significant experiences of lifetime violence (83.7%), with more than half (52.0%) experiencing two (2) or more types of violence. A majority reported experiencing emotional violence (69.9%), followed by physical violence (61.6%), being attacked by a weapon (57.6%), and, finally, sexual violence (33.2%) in their lifetime. The mean age of first-time exposure to violence was mid-adolescence (M=14.5; SD=9.5). MLR analysis showed that PWID reporting one type (OR 6.14; 95% CI 2.95, 12.78) and two or more types (OR=7.49; 95% CI 3.69, 15.19) of violence compared to no violence experience were more likely to be female than male. Additionally, PWID with two or more types of violence were likely to experience past year severe MHD (OR=5.88; 95% CI 1.30, 26.63), past year severe SUD (OR=2.40; 95% CI 1.06, 5.41), and lifetime fentanyl injection (OR=2.29; 95% CI 1.09, 4.78).

Conclusions and Implications: Findings from this study suggest an association between risky substance use behaviors, specifically lifetime fentanyl use, and experiences of polyvictimization. These findings emphasize the importance of implementing policy and practice interventions that support individuals in navigating their relationships and communities and inform social work research, particularly regarding the integration of trauma-informed care across ecological levels of influence, to mitigate the risks of polyvictimization among vulnerable PWID.