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. Author manuscript; available in PMC: 2021 Sep 1.
Published in final edited form as: Int J Drug Policy. 2020 Jul 9;83:102843. doi: 10.1016/j.drugpo.2020.102843

Using Actor-Partner Interdependence Modeling to Understand Recent Illicit Opioid Use and Injection Drug Use Among Men in Community Supervision and Their Female Partners in New York City

Alissa Davis 1, Andrea Norcini Pala 1, Louisa Gilbert 1, Phillip L Marotta 2, Dawn Goddard-Eckrich 1, Nabila El-Bassel 1
PMCID: PMC7669699  NIHMSID: NIHMS1611106  PMID: 32653669

Abstract

Background

The United States’ opioid crisis disproportionately affects individuals in the criminal justice system. Intimate partners can be a source of social support that helps reduce substance use, or they can serve as a driver of continued or increased substance use. Better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions.

Methods

Using actor-partner interdependence models, we examined individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision settings in New York City (n=229) and their female partners (n=229).

Results

Higher levels of depression (aOR 1.98, 95% CI [1.39–2.82], p≤0.01) and anxiety (aOR 1.98, 95% CI [1.42–2.75], p≤0.01) were associated with recent opioid use among males in community supervision. Females with a partner having higher levels of anxiety were more likely to have recently used opioids (aOR 1.52, 95% CI [1.06–2.16], p≤0.05). Males with a female partner with higher levels of anxiety (aOR 2.16, 95% CI [1.31–3.56], p≤0.01) or depression (aOR 1.70, 95% CI [1.01–2.86], p≤0.05) were more likely to recently inject drugs. Women with a male partner who had been in prison were more likely to have recently injected drugs (aOR 3.71, 95% CI [1.14–12.12], p≤0.05), but women who had a male partner who had been arrested in the past three months were less likely to have recently injected (aOR 0.08, 95% CI [0.02–0.46], p≤0.01).

Conclusions

Results suggest that recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner factors, highlighting the need for couple-based approaches to address the opioid epidemic.

Keywords: opioid use, injection drug use, mental health, criminal justice, dyads, actor-partner interdependence model

INTRODUCTION

The United States’ opioid crisis disproportionately affects individuals in the criminal justice system -- roughly two-thirds of people in correctional settings have a diagnosable substance use disorder.1,2 Although increasing attention is being paid to incarcerated individuals, the largest part of the criminal justice system – community supervision – remains overlooked. Community supervision includes individuals who are on probation or parole, have attended community courts, or are in alternative to incarceration programs. The community supervision population does not include individuals who are incarcerated in jails or prisons. In 2016, one in 55 US adults were under community supervision.3 People of color, particularly African-Americans, are disproportionately represented in community supervision settings. Although African-Americans comprise only 13 percent of the US population, they account for 30 percent of those on probation or parole.3 Rates of substance use disorders among those in community supervision are two to three times those of the general population.3–5 Prevalence of substance use among different racial/ethnic groups varies by substance type.6 In a study among 19,422 substance users in community corrections (60% of whom were black), 32% of black participants reported opioids was their drug of choice, 39% reported cocaine as their drug of choice, and 55% reported marijuana as their drug of choice.7 In comparison, 87.5% of white participants reported opioids was their drug of choice, 38% reported cocaine as their drug of choice, and 24% reported marijuana as their drug of choice.7 Despite the high burden of substance use disorders among this population, individuals under community supervision, especially those of color, have been largely ignored in the discussions surrounding the current opioid epidemic.3 Given their disproportionately high rates of substance use disorder, individuals in community supervision should be a key target population in addressing the nation’s opioid epidemic.

Substance use disorders are the result of complicated causal factors, yet most intervention programs continue to primarily rely on individual methods of behavior change.8 The ‘risk environment’ framework illuminates how social contexts influence health in general, as well as substance use in particular, and comprises multiple individual, interpersonal, and structural factors.8,9 Individual factors related to substance use disorders may include personal mental health disorders, history of trauma or child abuse, and life stressors,10–12 and thus are important targets for treatment in addressing opioid misuse. For example, individuals under community supervision have disproportionately high rates of mental health problems. One study found that 27% of individuals on probation had mental health disorder symptoms, as compared to 17% of the general population.13 A study among African-Americans under community supervision in the US found that 30% screened positive for moderate to severe depression and 21% screened positive for bipolar disorder (12% were positive for both depression and bipolar disorder).14 Another study found the prevalence of psychiatric disorders among people on probation was higher than in the general population,15 and people on probation with substance abuse had higher rates of major depression and suicide risk.15 Additionally, a large proportion of individuals in community supervision have prior trauma histories, higher rates of post-traumatic stress disorder, and a greater number of life stressors than individuals in the general population.13,15

Interpersonal factors include relationships with intimate partners, intimate partner behaviors and characteristics, and peer influences. For example, research indicates that intimate partners exert substantial influence on an individual’s substance use behaviors.16,17 Studies of clinical samples have found high rates of addiction in the spouses of individuals seeking treatment for alcohol and drug abuse or dependence. In a treatment sample of 72 people addicted to heroin, all of the addicted women had husbands with substance use problems.18 Sakai et al. found significant correlations between mothers and fathers for the average number of substance dependence symptoms.19 Likewise, the mental health status of intimate partners may impact individual substance misuse. An intimate partner with good mental health may be able to provide more emotional and social support to their partners, and thus, could serve as a protective factor against substance misuse. On the other hand, if an intimate partner has a mental health disorder, they may not be able to provide emotional support to their partner and may be engaging in substance misuse behaviors themselves. In these cases, lack of intimate partner support and the additional stress of living with an intimate partner with a mental health or substance use disorder increases the likelihood the individual will engage in substance misuse.

Structural factors, such as drug laws, police presence, and criminal justice involvement can also facilitate substance misuse, particularly among marginalized populations.9 While involvement with the criminal justice system may influence an individual’s own substance use, it may also impact the substance use of their partners. These structural influences may have differential effects on men and women. The strength and direction of these effects may depend on which partner experiences these structural factors, such as interaction with the police or criminal justice system involvement.

While there have been some studies examining partner effects on substance use, most of the literature has focused on problem drinking and has been conducted among primarily white populations.13,20–22 To our knowledge, no studies have examined partner effects on illicit opioid use among primarily racial/ethnic minority individuals in community supervision. However, the effects of partner characteristics on an individual’s illicit opioid use should not be ignored in this population. Substance use is a key reason for initial entry and recidivism into probation and parole settings,23 and intimate partners can be a source of social support that helps individuals in the criminal justice system reduce substance use, or they can serve as a driver of continued or increased substance use. A better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions that address not only individual, but also interpersonal factors associated with illicit substance use. This study aims to address the gap in the literature by using actor-partner interdependence models to examine individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision and their primary female sex partners.

METHODS

Participants

Data are from a randomized controlled trial (RCT) to assess the effectiveness of a couple-based HIV prevention intervention (Project PACT – Protect and Connect) among drug-involved men in community supervision programs and their female primary sex partners in New York City. The RCT was conducted from July 2013 (first recruitment) through May 2016 (last randomization). Detailed eligibility criteria are described in-depth elsewhere.24

Procedures

Trained research assistants (RAs) approached male clients at community supervision programs in New York City and gave them informational flyers describing the study. If a male client indicated he was interested in study participation, the RA completed informed consent and screening to determine eligibility. Once eligibility was established, he was asked to invite his primary female sex partner to participate. The female partner was then consented and screened for eligibility. The majority of women were screened within 2–7 days of their male partner. If the couple met the criteria, they were scheduled for a baseline assessment. Male and female participants completed surveys in separate private rooms. A total of 460 individuals (230 heterosexual couples) were included in the study. All study procedures were approved by the Columbia University Institutional Review Board.

Measures

Recent Illicit Opioid Use

Participants were asked “Have you used heroin in the past 3 months?” (yes/no) and “Have you used non-prescribed opioids in the past 3 months?” (yes/no). Participants who answered yes to either or both questions were coded as having recently used illicit opioids. The study also included questions on frequency of recent illicit opioid use, but due to the non-normal distribution of frequencies and small numbers of participants who had used illicit opioids in the past 3 months, results were not significant. Thus, we used a dichotomous outcome for this analysis.

Recent Injection Drug Use

Participants were asked “Have you injected drugs in the past 3 months?” (yes/no). As was the case for recent illicit opioid use, frequencies were not normally distributed and there was a small number of participants who had recently injected drugs, thus, we used a dichotomous outcome.

Sociodemographics

We assessed participant age, race/ethnicity, and education level.

Mental Health

Depressive symptoms and anxiety were assessed using the Brief Symptom Inventory (BSI) depressive symptom and anxiety subscales.25 Each subscale contains six items that are rated on a five-point scale from 0 (not at all) to 4 (extremely). For each subscale, the item scores were summed and the mean obtained. Higher scores indicate higher levels of depressive symptoms and anxiety. Previous research supports convergent and construct validity and reliability.25–28 In this study, Cronbach’s α for depressive symptoms was 0.92 for females and 0.91 for males. Cronbach’s α for anxiety was 0.93 for females and 0.92 for males.

Participants were also asked whether they had ever been diagnosed with bipolar disorder (yes/no) and whether they had ever been diagnosed with schizophrenia (yes/no). Postraumatic stress disorder (PTSD) was assessed using the PTSD Checklist – Civilian Version (PCL-C).29 The PCL-C is a standardized self-report scale for PTSD comprising 17 items that correspond to the key symptoms of PTSD as outlined in the DSM-IV.30 Previous research supports the reliability and validity of the PCL-C.31 In this study, Cronbach’s α was 0.97 for females and 0.96 for males.

Stressful life events were assessed using the Stressful Life Events Screening Questionnaire (SLESQ).32 The SLESQ is a 13-item self-report measure designed to assess lifetime exposure to a variety of traumatic events (yes/no). We added an additional 5 traumatic items to the questionnaire that were likely to be experienced by our study population. These items included ever experiencing homelessness, ever losing custody of children, ever witnessing parents physically hurting each other, ever removed from home and placed in foster care as a child, and ever run away from home as a child. In this study, Cronbach’s α was 0.88 for females and 0.82 for males.

Criminal Justice Involvement

Participants were asked if they had been arrested (yes/no), if they had been in jail (yes/no), if they had been stopped by the police but not arrested (yes/no), and if they had been convicted of a misdemeanor (yes/no) in the past 90 days, and if they had ever been in prison (yes/no). Because frequency data for criminal justice measures were not normally distributed and the majority of participants who had frequency data had a frequency of 1, these variables were collapsed into dichotomous variables.

Data analysis

A total of 229 couples were included in the analysis. (One couple had missing data on all variables listed and were thus excluded from this analysis.) We compared characteristics between male and female partners using paired sample t-tests and McNemar-Bowker tests. The arms of the RCT were not of primary interest in this analysis, and for our purposes, we used cross-sectional baseline data collected before the start of the intervention.

We examined whether data were dependent within dyads so that nonindependence could be taken into account in the model building process.33 Tests of nonindependence revealed dyadic dependences in the data for recent illicit opioid use (kappa = 0.54) and recent injection drug use (kappa = 0.49). If we were to ignore these dependencies, we would run the risk of alpha inflation. Consequently, we did not use standard models (e.g., logistic regression), and applied more conservative modeling techniques to estimate significance. This approach minimizes Type I errors and increases confidence in the significance of the findings. Given the dyadic dependence of the data, multilevel modeling is recommended; however, the use of such models is limited to outcomes measured at the interval level.34 For non-interval outcomes, such as binary outcomes, Loeys et al. recommend the use of generalized estimating equations (GEE).34

To determine the impact of male and female partner characteristics on their own recent illicit drug use as well as their partner’s recent drug use, the actor-partner interdependence model (APIM) with distinguishable dyads for categorical data was calculated using GEE.34,35 The APIM is used to determine how outcomes are influenced by both members of the dyad, in this case male partners involved in the community supervision system and their female partners. For this study, the actor effect was the impact of a person’s characteristics on his or her own recent illicit opioid use and recent injection drug use outcomes. The partner effect was the impact of each person’s characteristics on his or her partner’s recent illicit opioid use and recent injection drug use. Each predictor was tested independently in a two-intercept model with recent illicit opioid use or recent injection drug use as the outcome that contained: (a) a dummy code for male (coded 1 = male, 0 = female), (b) an interaction between the dummy code and the actor effect of the predictor, and (c) an interaction between the dummy code and the partner effect of the predictor. We also examined which partner effects were significant among male and female partners utilizing the same models used to determine actor effects. We examined sociodemographic characteristics to identify potential confounders and found that race was significantly associated with the outcome variables and correlated with gender, and thus we controlled for race in all of our APIM analyses. All analyses were conducted using SPSS version 24 and SAS version 9.4.

We conducted a power analysis for the APIM using the APIMPower software.36 With a sample size of 229 dyads, assuming an alpha-level of .05, the power to detect a significant prediction model for recent illicit opioid use or injection drug use is near 100% for a large effect size and 95% for a medium effect size.37

RESULTS

Characteristics of male and female dyads

A total of 229 male-female dyads were included in the analysis (Table 1). The mean age of both men and women was roughly 35 years. The majority of men (78.2%) and women (69.9%) were non-Hispanic black. Over a third of men (37.7%) and women (34.4%) had less than a high school diploma.

Table 1:

Sociodemographic characteristics of male and female partners in New York City, 2013–2016 (N=458; 229 couples)

Male Female
Variable N (%) N (%) McNemar
Race 15.70**
Non-Hispanic Black 179 (78.2%) 160 (69.9%)
Hispanic 42 (18.3%) 45 (19.7%)
Other race 8 (3.5%) 24 (10.5%)
Marital Status
Single, never married 131 (57.2%) 140 (61.1%) 10.44*
Married 84 (36.7%) 73 (31.9%)
Other 14 (6.1%) 16 (7.0%)
Live with study partner 113 (49.3%) 124 (54.1%) 5.26*
Less than a high school education 86 (37.7%) 78 (34.4%) 0.57
Arrested in the past 3 months 66 (28.9%) 20 (8.8%) 30.68**
In jail in the past 3 months 51 (22.4%) 11 (4.8%) 28.17**
Ever been in prison 91 (39.7%) 23 (10.0%) 51.01**
Stopped by police in the past 3 months 101 (44.1%) 46 (20.1%) 30.06**
Misdemeanor in the past 3 months 52 (22.7%) 12 (5.2%) 27.16**
Ever in drug or mental health court 36 (15.7%) 13 (5.7%) 12.41**
Ever diagnosed with bipolar disorder 36 (15.7%) 56 (24.5%) 4.75*
Ever diagnosed with schizophrenia 16 (7.0%) 19 (8.3%) 0.14
Ever hospitalized for mental health or emotional reasons 44 (19.2%) 56 (24.5%) 1.95
PTSD in the past month 66 (28.8%) 89 (38.9%) 5.56*
Used opioids in the past 3 months 34 (14.8%) 26 (11.4%) 2.67
Injected drugs in the past 3 months 15 (6.6%) 12 (5.3%) 0.69
Mean (SD) Mean (SD) t-test
Age (years) 35.68 (12.47) 34.52 (13.18) −0.97
Length of relationship (years) 4.96 (6.23) 5.12 (6.55) −0.16
BSI depression score 0.81 (0.97) 1.07 (1.08) 2.76**
BSI anxiety score 0.66 (0.93) 0.95 (1.12) 3.14**
Stressful Life Events 4.75 (3.82) 4.94 (4.27) 0.51
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*

= p≤0.05

**

= p≤0.01

Male participants were significantly more likely to have been arrested in the past three months, been in jail in the past three months, been stopped by police (but not arrested) in the past three months, been convicted of a misdemeanor in the past three months, and ever been in prison than female partners (p≤0.01). For mental health indicators, female participants had significantly higher levels of depression (p≤0.01) and anxiety (p≤0.01) than male participants. Female participants were also more likely to have PTSD in the past month (38.9% vs. 28.8%, p≤0.05) and have ever been diagnosed with bipolar disorder (24.5% vs. 15.7%, p≤0.05) than male participants. Nearly fifteen percent of men and 11.4% of women had used illicit opioids in the past three months, while 6.6% of men and 5.3% of women had injected drugs in the past three months. Results did not indicate significant gender differences for recent illicit opioid use or injection drug use.

Actor and Partner Effects on Recent Illicit Opioid Use

Individual Factors

Several mental health factors were found to have actor effects for recent illicit opioid use (Table 2). A higher level of depression in the past three months (adjusted odds ratio (AOR) 1.98, 95% confidence interval (CI) [1.39–2.82], p≤0.01) or higher level of anxiety (AOR 1.98, 95% CI [1.42–2.75], p≤0.01) was associated with recent illicit opioid use among men. Males with higher stressful life event scores (AOR 1.15, 95% CI [1.04–1.26], p≤0.01) and females who had ever been hospitalized for a mental health or emotional reason (AOR 2.59, 95% CI [1.02–6.60], p≤0.05) were significantly more likely to have recently used illicit opioids.

Table 2:

Adjusted Odds Ratios from Actor-Partner Interdependence Model analyses for Illicit Opioid Use in the past 3 months (N=458; 229 couples)

Variable Actor Effects Partner Effects
Female Male Female Male
Criminal Justice Involvement AOR [95% CI] p AOR [95% CI] p AOR [95% CI] p AOR [95% CI] p
Arrested in past 3 months 1.86 [0.51–6.80] 0.35 1.26 [0.54–2.95] 0.60 1.14 [0.26–5.05] 0.86 0.67 [0.23–1.93] 0.45
In jail in past 3 months 3.29 [0.80–13.60] 0.10 1.95 [0.81–4.72] 0.14 0.46 [0.03–7.25] 0.58 1.10 [0.37–3.30] 0.87
Ever been in prison 0.72 [0.20–2.56] 0.61 1.89 [0.83–4.30] 0.13 2.52 [1.07–5.94] ≤0.05 1.60 [0.48–5.37] 0.44
Stopped by police but not arrested in past 3 months 2.44 [1.04–5.76] ≤0.05 0.92 [0.43–1.99] 0.83 3.14 [1.41–6.99] ≤0.01 0.48 [0.20–1.16] 0.10
Convicted of misdemeanor in past 3 months 4.79 [1.34–17.12] ≤0.05 1.83 [0.78–4.28] 0.17 1.15 [0.19–7.02] 0.88 1.52 [0.58–3.95] 0.40
Mental Health
BSI Depression score 1.23 [0.89–1.70] 0.21 1.98 [1.39–2.82] ≤0.01 1.21 [0.88–1.67] 0.23 1.35 [0.98–1.86] 0.07
BSI Anxiety score 1.21 [0.87–1.68] 0.26 1.98 [1.42–2.75] ≤0.01 1.38 [1.03–1.85] ≤0.05 1.52 [1.06–2.16] ≤0.05
Ever diagnosed with bipolar disorder 2.03 [0.88–4.70] 0.10 1.62 [0.64–4.11] 0.31 2.03 [0.92–4.50] 0.08 0.62 [0.18–2.11] 0.44
Ever diagnosed with schizophrenia 1.18 [0.23–5.93] 0.84 1.35 [0.45–4.04] 0.59 3.75 [1.42–9.89] ≤0.01 0.92 [0.18–4.70] 0.92
PTSD in the past month 1.37 [0.59–3.20] 0.47 1.41 [0.64–3.09] 0.39 1.82 [0.84–3.95] 0.13 1.01 [0.42–2.42] 0.99
Stressful Life Events 1.09 [0.99–1.19] 0.07 1.15 [1.04–1.26] ≤0.01 1.11 [1.02–1.21] ≤0.05 1.12 [1.01–1.24] ≤0.05
Ever hospitalized for mental health or emotional reasons 2.59 [1.02–6.60] ≤0.05 1.32 [0.52–3.37] 0.56 2.60 [1.12–6.04] ≤0.05 0.42 [0.11–1.57] 0.20
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*

Adjusted for race/ethnicity

Interpersonal Factors

Mental health factors also had partner effects (Table 2). Males who had a female partner with higher levels of anxiety (AOR 1.38, 95% CI [1.03–1.85], p≤0.05), diagnosed with schizophrenia (AOR 3.75, 95% CI [1.42–9.89], p≤0.01), with higher stressful life event scores (AOR 2.60, 95% CI [1.12–6.04], p≤0.01), or who had been hospitalized for mental health or emotional reasons (AOR 2.60, 95% CI [1.12–6.04], p≤0.05) were more likely to have recently used illicit opioids. Females who had a male partner with higher levels of anxiety (AOR 1.52, 95% CI [1.06–2.16], p≤0.05), or with higher stressful life event scores (AOR 1.12, 95% CI [1.01–1.24], p≤0.01) were more likely to have recently used illicit opioids.

Structural Factors

Women who had been stopped by police in the past three months (AOR 2.44, 95% CI [1.04–5.76], p≤0.05) or were convicted of a misdemeanor (AOR 4.79, 95% CI [1.34–17.12], p≤0.05) were more likely to have used illicit opioids. For partner effects, men who had female partners who had ever been in prison (AOR 2.52, 95% CI [1.07–5.94], p≤0.05) or who had been stopped by the police in the past three months (AOR 3.14, 95% CI [1.41–6.99], p≤0.01) were more likely to have recently used illicit opioids.

Actor and Partner Effects on Recent Injection Drug Use

Individual Factors

Several mental health factors had actor effects on recent injection drug use for both males and females. Males with higher depression (AOR 2.55, 95% CI [1.60–4.08], p≤0.01) or anxiety (AOR 3.58, 95% CI [2.08–6.16], p≤0.01), who had PTSD (AOR 4.54, 95% CI [1.24–16.62], p≤0.05), or higher stressful life event scores (AOR 1.20, 95% CI [1.04–1.39], p≤0.05) were more likely to have recently injected drugs (Table 3). Females diagnosed with bipolar disorder (AOR 3.55, 95% CI [1.16–10.82], p≤0.05), who had higher stressful life event scores (AOR 1.20, 95% CI [1.04–1.39], p≤0.05), or were hospitalized for mental health or emotional reasons (AOR 3.34, 95% CI [1.01–11.07], p≤0.05) were more likely to have recently injected drugs.

Table 3:

Adjusted Odds Ratios from Actor-Partner Interdependence Model analyses for Injection Drug Use in the past 3 months (N=458; 229 couples)

Variable Actor Effects Partner Effects
Female Male Female Male
Criminal Justice Involvement AOR [95% CI] p AOR [95% CI] p AOR [95% CI] p AOR [95% CI] p
Arrested in past 3 months 5.59 [1.16–26.98] ≤0.05 0.63 [0.14–2.85] 0.55 4.84 [0.80–29.12] 0.09 0.08 [0.02–0.46] ≤0.01
In jail in past 3 months 5.70 [1.18–27.54] ≤0.05 1.85 [0.41–8.39] 0.43 2.56 [0.19–35.58] 0.48 0.42 [0.08–2.17] 0.30
Ever been in prison 1.57 [0.41–6.04] 0.51 1.38 [0.34–5.58] 0.65 2.66 [0.38–18.54] 0.33 3.71 [1.14–12.12] ≤0.05
Stopped by police but not arrested in past 3 months 3.07 [1.01–9.28] ≤0.05 0.79 [0.20–3.12] 0.74 4.77 [1.28–17.83] ≤0.05 0.63 [0.20–1.99] 0.44
Convicted of misdemeanor in past 3 months 10.33 [2.32–45.97] ≤0.01 1.42 [0.31–6.52] 0.65 6.51 [1.08–39.44] ≤0.05 0.98 [0.26–3.73] 0.97
Mental Health
BSI Depression score 1.31 [0.85–2.02] 0.23 2.55 [1.60–4.08] ≤0.05 1.70 [1.01–2.86] ≤0.05 1.59 [1.06–2.38] ≤0.05
BSI Anxiety score 1.36 [0.92–2.01] 0.12 3.58 [2.08–6.16] ≤0.05 2.16 [1.31–3.56] ≤0.01 2.06 [1.34–3.16] ≤0.01
Ever diagnosed with bipolar disorder 3.55 [1.16–10.82] ≤0.05 0.90 [0.15–5.52] 0.91 3.18 [0.86–11.76] 0.08 0.68 [0.18–2.67] 0.58
Ever diagnosed with schizophrenia 1.33 [0.16–10.98] 0.79 2.39 [0.49–11.66] 0.28 5.99 [1.58–22.66] ≤0.01 1.85 [0.28–12.06] 0.52
PTSD in the past month 1.72 [0.53–5.55] 0.37 4.54 [1.24–16.62] ≤0.05 2.58 [0.68–9.81] 0.17 1.56 [0.50–4.84] 0.44
Stressful Life Events 1.21 [1.10–1.33] ≤0.01 1.15 [1.00–1.33] ≤0.05 1.20 [1.04–1.39] ≤0.05 1.15 [1.04–1.28] ≤0.01
Ever hospitalized for mental health or emotional reasons 3.34 [1.01–11.07] ≤0.05 3.07 [0.79–11.96] 0.11 1.82 [0.43–7.65] 0.42 0.76 [0.18–3.33 0.72
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*

Adjusted for race/ethnicity

Interpersonal Factors

Mental health factors also had significant partner effects among both males and females. Males who had female partners with higher depression scores (AOR 1.70, 95% CI [1.01–2.86], p≤0.05), higher anxiety scores (AOR 2.16, 95% CI [1.31–3.56], p≤0.01), higher stressful life event scores (AOR 1.15, 95% CI [1.04–1.28], p≤0.01), or had been diagnosed with schizophrenia (AOR 5.99, 95% CI [1.58–22.66], p≤0.01) were significantly more likely to have recently injected drugs. Females who had a male partner with higher depression scores (AOR 1.59, 95% CI [1.06–2.38], p≤0.05), higher anxiety scores (AOR 2.06, 95% CI [1.34–3.16], p≤0.01), or higher stressful life event scores (AOR 1.15, 95% CI [1.04–1.28], p≤0.01) were significantly more likely to have recently injected drugs.

Structural Factors

Women who had been arrested in the past three months (AOR 5.59, 95% CI [1.16–26.98], p≤0.05), had been in jail in the past three months (AOR 5.70, 95% CI [1.18–27.54], p≤0.05), had been stopped by the police in the past 3 months (AOR 3.07, 95% CI [1.01–9.28], p≤0.05), or had been convicted of a misdemeanor in the past three months (AOR 10.33, 95% CI [2.32–45.97], p≤0.01) were significantly more likely to have recently injected drugs. For partner effects, men who had female partners stopped by the police in the past three months (AOR 4.77, 95% CI [1.28–17.83], p≤0.05) or convicted of a misdemeanor (AOR 6.51, 95% CI [1.08–39.44], p≤0.05) were more likely to have recently injected drugs. Women who had a male partner who had been in prison (AOR 3.71, 95% CI [1.14–12.12], p≤0.05) were more likely to have recently injected drugs. However, women with a male partner who had been recently arrested were less likely to have recently injected drugs (AOR 0.08, 95% CI [0.02–0.46], p≤0.01).

DISCUSSION

Few studies have examined actor-partner effects of factors associated with substance use among men in community supervision and their female partners. This article helps to fill this important gap by assessing whether a partner’s characteristics influence his/her own and his/her partner’s recent use of illicit opioids and injection drug use.

Research has shown that people with opioid use disorder (OUD) have a disproportionately high rate of co-occurring mental health disorders; between 50–75% of people with OUD are estimated to have a co-occurring mental health disorder.38,39 In 2015, 1.5 million adults with serious mental illness misused opioids.40 Similarly, in our sample, we found that several mental health problems were associated with recent illicit opioid use and injection drug use, especially for men, highlighting the need for integrated treatment for substance use and mental health disorders. While it is recommended that individuals with co-occurring mental health and OUD receive treatment for both disorders at the same time,39 unfortunately, treatment for OUD and mental health problems are rarely integrated or coordinated in the current U.S. health system.41,42 Our results suggest a need for integrated, holistic care for mental health and substance use disorders. In addition to individual mental health factors, our results indicated that the mental health status of intimate partners was also associated with recent illicit opioid use and injection drug use. This was particularly true for men who had a female partner with mental health problems. Given that an intimate partner’s mental illness may also be associated with an individual’s opioid use, the current structure of our treatment system for OUD is likely inadequate. Intimate partner mental health disorders are rarely considered in treatment plans for individuals with OUD; however, our findings indicate addressing intimate partner mental health in OUD treatment plans may be critically important.

Criminal justice factors were also associated with recent illicit opioid use and injection drug use. Being stopped by the police and being convicted of a misdemeanor in the past three months were associated with both recent illicit opioid use and injection drug use among women, but not men. While this gender disparity in association is unclear, it may be that men, particularly African-American men, are so routinely stopped by law enforcement that they anticipate it and have developed resiliency to cope with these interactions to minimize disruption in their lives. It may be that women experience greater disruption to their lives (e.g., food insecurity, homelessness) due to criminal justice involvement than men (who often have greater access to and control over more resources), which may lead to increased drug use among women. Further research is needed to examine relationships between criminal justice involvement and opioid use and how these relationships vary between different populations and genders.

Women who had a male partner who had been arrested in the past 90 days were significantly less likely to inject drugs. Although the reasons behind this finding are not clear, we speculate that women may perhaps reduce their injection behaviors due to resource sharing opportunities being reduced when male partners are arrested. This may include less money to purchase drugs and the absence of a male partner to purchase, cook, or inject the drugs if the female partner is unwilling or unable to do it herself. 43–45 Recent involvement of male partners in the criminal justice system may thus result in reduced injection drug use among female partners, although such a reduction may only be temporary.

This study has a number of limitations. First, it was conducted in New York City only among heterosexual couples, thus findings from this study may not be generalizable to all community supervision populations in the US. Second, assessments of mental health and other indicators were based on self-report, and thus, responses may be biased. This is a marginalized population that is unlikely to have high rates of healthcare utilization, and many may never have received a mental health assessment, thus the prevalence of mental health disorders in this population may be under-reported, thus, the actor and partner effect sizes in our results are likely conservative. Third, this study was limited to men and their primary female sex partners. It is not known whether casual partners have similar effects on substance use outcomes. Fourth, sample sizes for some categories were quite small (e.g., criminal justice involvement and recent injection drug use), creating wide confidence intervals. Despite small sample sizes, significant effects were still found. We expect these effect estimates are conservative and that the strength of association would be stronger with a larger sample size. Fifth, intimate partner characteristics, such as marital status, length of relationship, and living together may influence the association between individual and partner characteristics. However, our limited sample size precluded us from being able to examine these moderating effects. Sixth, the data were cross-sectional baseline data, which does not allow for inferences of causality between mental health and criminal justice indicators and recent illicit opioid use or injection drug use. Future research should examine dyad-level factors longitudinally to determine whether causal relationships exist.

In conclusion, recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner characteristics. As we move forward to address the opioid epidemic in the United States, we should strive to develop interventions and programs that address factors at multiple levels, including the dyad-level. Intimate partners can play an important role in reducing or increasing substance use. Intimate partners can provide important social support that can help alleviate mental health problems and reduce substance use. Conversely, having an intimate partner who is stressed or has a mental health problem may fuel an increase in individual substance use. Leveraging couple relationships and dynamics to reduce substance use behaviors, increase engagement in harm reduction strategies, and facilitate the utilization of healthcare resources to address co-morbidities may be an effective strategy for reducing opioid misuse among this population.

ACKNOWLEDGEMENTS

This work was supported by the National Institute on Drug Abuse (R01DA033168). Dr. Davis is also supported by the National Institute on Drug Abuse (K01DA044853) for career development. The funders had no role in study design, data collection or in analysis and interpretation of the results, and this paper does not necessarily reflect the views or opinions of the funding agency.

Footnotes

Conflict of Interest Statement: All authors declare no conflicts of interest.

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