October 2021

Violent overlap: In the drug world, the hits keep coming

Most frontline workers have little trouble connecting problematic drug use with violence, either in the lives of their clients or in anecdotal or actual evidence of family violence. While alcohol remains by far the main contributor to violence involving substances, the complex and difficult ecosystem of the illicit drug world has a violent edge. The key to assisting people may be to attempt a trauma-informed approach.

Alan Eade is no stranger to walking into the homes of people who use drugs. As a veteran of a quarter-century of working inner-city paramedic shifts for Ambulance Victoria, Alan has lost count of how many times he’s been the first responder to a call from such a dwelling. It’s given him a strong empathy for the danger and unsafe environment some people who use drugs survive in.

Alan Eade

”They’re normally living in a house and it’s unclear sometimes who else is a resident or who’s a visitor in that premises. There can be people who seem to come and go. Invariably, the house is unkempt and untidy with evidence of not only tobacco smoking and alcohol but usually drug use as well. There’s often damaged furniture or damage to the doors and sometimes someone might storm out while I’m talking to them, or somebody will storm out of a room and the patient might not actually know who they are.”

When confronting violence in the drug world, either suffered by drug consumers or initiated by them, Alan can’t help but circle back to home, sweet home. “This seems to be the living environment,” he says, thinking back to the scene he’s witnessed so many times. “So, is that housing secure? It doesn’t feel secure to me. Do they have regular food? Do they have regular income? There seems to be a transient nature, or nature of people coming through their life, that seems to put them at a greater risk of theft or opportunistic crime. While there might not be violence at that moment, it wouldn’t surprise me if that person was subjected to violence in a very short space of time and that must be a terrible environment to exist in where you’re living under that threat pretty much 24/7.”

The firm consensus among the experts contacted for this article is that violence among, caused by or happening to people who use drugs breaks down clearly into two categories, with one dwarfing the other. Alcohol is the cause of most drug-related violence in our community. The smaller subset of people who are dependent on drugs and are involved on either side of drug transactions make up the other. In between are the party-pill poppers and people who are dependent on pharmaceutical drugs, who face their own issues but don’t necessarily live an intrinsically violent existence.

According to a report from the Drug Use Monitoring in Australia (DUMA) project, 66 per cent of 40,000 police detainees over a 13-year period tested positive to at least one drug and 47 per cent reported having taken drugs at the time of their offending. An earlier survey of police detainees found regular consumers of both amphetamine and heroin self-reported violent and property offences at a rate more than five times higher than prisoners with no history of frequent drug use. Recent data also released by DUMA indicated that in 2020, almost half of the detainees reported having used cannabis (47 per cent) and methamphetamine (45 per cent) in the past 30 days.

It’s a fraught existence, and Katherine Hancy, a community pharmacist in Bendigo, Victoria, sees the unbearable anxiety and tension in the ice consumers she engages with, not to mention the known local consumers who have robbed her pharmacy more than once.

“One patient broke both his legs,” Katherine says, adding with some scepticism: “He told me he fell off a ladder.”

She estimates that roughly one-fifth of her patients seem to live in what she terms “that lifestyle”. One patient, who always dressed well in designer-label tracksuits and gold chains, not only held up the pharmacy a while ago but would do deals in his car right outside the premises. “A lot of the violence seems to be financially driven as well as drug-driven,” Katherine says. “Once our donation box was stolen, for the cash, but another time we were held up because the drugs were needed straight away.”

A lot of the violence seems to be financially driven as well as drug-driven. Once our donation box was stolen, for the cash, but another time we were held up because the drugs were needed straight away.

Katherine Hancy

Berry Street clinician Alex D’Abaco specialises in family violence involving alcohol and other drugs. She draws a clear distinction between family violence and wider community violence, because her world focuses on very specific behaviour being perpetrated against somebody else to control or dominate them on an ongoing basis, whereas community violence is more random and situational.

“Victims of family violence can have this kind of hopelessness because one of the tactics that perpetrators of family violence use is to make that person feel worthless, emotional abuse, putting them down, isolating them from their family and friends – you know, disconnecting them,” Alex says. “Then when we have an overlay of substance abuse on top of that as well, people will feel like they’re worthless. If the victim is using substances, it ties into the emotional abuse: telling them that they’re worthless because of their substance use, threatening to call child protection if they have kids or threatening to tell their family and friends that they’re using.”

If the victim of family violence is using substances, it ties into the emotional abuse: telling them that they’re worthless because of their substance use, threatening to call child protection if they have kids or threatening to tell their family and friends that they’re using.

Alex D’Abaco

In Alex’s experience, perpetrators of family violence tend not to recognise alcohol or other drugs as a major component of their situation because they’re often trying to downplay their use of violence. “But for victims and survivors, absolutely. I’ve worked with many women who are just like ‘If he would just stop drinking or stop doing this, things would be better’, because they can see the link with his behaviour.

“In terms of educating, we’re very clear in saying that substance use doesn’t cause someone to use violence – specifically, family violence. It just exacerbates that violence,” she says. “The causes of family violence have to do with gender inequality and power imbalance and a range of other things, so while there is no evidence to say that alcohol or other drugs cause family violence, it definitely does exacerbate it and makes the behaviours more high-risk.”

That’s a sentiment echoed by Marianne Crowe, of St Vincent’s Hospital, Melbourne, who sees a strong connection between family violence and the use of drugs including ice. St Vincent’s has a strong focus on providing care for patients with complex health needs, including harmful substance use and dependence, mental health issues and homelessness.

Marianne’s team collects details of risk factors among patients suffering or perpetrating family violence and implements the Multi-Agency Risk Assessment and Management (MARAM) Framework that emerged from Victoria’s 2016 Royal Commission into Family Violence. She says the framework is an essential tool to ensure St Vincent’s has an “appropriate response to any person who walks through our door who may be experiencing family violence”.

“We’ve been collecting data since 2009 but our statistics since 2019 show that roughly one-third of the family violence reports are perpetrators. Both victim-survivors and perpetrators may have multiple risk factors. We’ve seen perpetrators use substance dependence as a way to control someone. Drug dependence can also severely impact a victim-survivor’s ability to safety plan for themselves. Anecdotal reports of ice dependence from heroin consumers say it makes heroin look like icing sugar, it’s so addictive. That craving supplants everything else.”

Marianne says she would encourage anybody whose work involves drugs and violence to adopt a trauma-informed care approach to people, including to perpetrators. “Many people who use substances problematically to the point where they are harming their health or impacting their life are often using the substance to block the pain of life out, or to medicate the impact of past trauma, or using the substance to feel safe, or to stave off withdrawal symptoms,” she says. “A trauma-informed understanding of substance dependence in terms of someone using that substance to medicate the pain and symptoms of past trauma or to feel safe can be helpful.”

Many people who use substances problematically to the point where they are harming their health or impacting their life are often using the substance to block the pain of life out, or to medicate the impact of past trauma, or using the substance to feel safe, or to stave off withdrawal symptoms.

Marianne Crowe

Alan Eade says the public perception of random street violence being carried out by people who use drugs such as methamphetamine is out of step with the reality, which is that consumers of such drugs are responsible for “a small amount of violence in comparison with alcohol”. Alan is quick to acknowledge the many harmful effects of ice on the community and people who use it. “But as the principal cause of drug-related or substance-related violence? That still remains alcohol,” he says.

That’s not to say healthcare workers and first responders don’t need to remain wary of the potential for aggression among people who use drugs, especially consumers who might be in an altered state. A study released last year by Melbourne Health and the University of Melbourne that took 229 saliva samples from patients who attacked staff in the Royal Melbourne Hospital emergency department over a six-month period found that 40 per cent tested positive to drugs and, of those, 92 per cent tested positive to methamphetamines.

Even then, Alan says, such violence is usually misdirected rather than targeted at first responders because of who they are. “It’s that there’s somebody who is annoying me and I don’t know who they are because I can’t process that as an effect of whatever it is affecting me,” he says. “However, we don’t accept that violence against paramedics or other first responders is ever justified and there is a wariness that we bring to those scenes because violence could occur at any stage. It’s not just our safety either; it’s also about the safety of the person who may be injured or subject to violence themselves. We step into that bubble with them.”

– Nick Place

In the frame: keeping you and your clients safe

Victoria’s MARAM (Multi-Agency Risk Assessment Management) Framework emerged five years ago from the Royal Commission into Family Violence to help workers across all parts of the health and community sectors to effectively identify, assess and manage family violence risks.

Even if you’re not in Victoria, it provides a great roadmap for dealing with a difficult part of the job.

Alcohol and other drugs, or AOD, was identified early on as a service in which providers urgently needed to be able to effectively use the new framework to keep clients safe.

As NSPs are designed to provide an anonymous and confidential service, there is no requirement for NSPs to formally align with MARAM, and NSP workers are not required to attend MARAM training.

However, it is recommended NSP workers develop an understanding of the shared definition of family violence (see below), evidence-based risk factors, and signs of family violence.

The full fact sheet can be found on the Victorian Government health website.

You can learn more about the MARAM Framework online as well.