Addiction and Violence During COVID-19

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The term "intimate partner violence" (IPV) is often used interchangeably with the term "domestic violence" (DV). IPV will be used throughout this Research Update, referring to both intimate partner violence and domestic violence. Intimate partner violence encompasses many different types of physical and emotional abuse, and affects the health, safety and quality of life for women, men and children worldwide, regardless of race, sexual orientation, or socioeconomic status. A 2015 national survey from the United States reported that about 1 in 4 women and 1 in 10 men experienced intimate partner violence during their lifetime and reported some form of IPV-related impact.¹ Women are significantly more likely than men to be sexually abused and suffer serious physical injury during an assault.¹ Research has found that perpetration by one partner is the strongest predictor of perpetration by the other partner^{2, 3} and the majority of violence in dating couples is mutual.^{4, 5} While IPV affects both men and women, research on male victimization and female perpetration is scarce.

The COVID-19 pandemic has affected nearly every aspect of our lives and is likely to change how we live and interact with each other for the foreseeable future. While perhaps the most obvious consequence of the pandemic has been widespread illness, the subsequent quarantine has also created repercussions for vulnerable populations. The quarantine has led to an increase in reported intimate partner violence and increased substance abuse.⁶ This trend has been labeled as "the pandemic paradox," suggesting that while the intention of the quarantine was to save as many lives as possible, it may also endanger individuals, for whom home is not a safe environment.⁷

The Link Between Intimate Partner Violence and Substance Abuse

Intimate partner violence and substance abuse are closely linked and often occur simultaneously. While they are intertwined, one does not always precede the other. Studies reveal a distinct relationship between the two risk behaviors and indicate that they can frequently co-occur.^{8, 9, 10} For both men and women, physical IPV victimization was associated with an increased risk of current poor health, depressive symptoms, substance use and developing a chronic disease, chronic mental illness and an injury.¹¹

IPV has a well-documented adverse impact on mental and physical health in women. Studies have found that anywhere from 31% to 67% of women entering substance abuse treatment or methadone clinics have experienced IPV within the last year, and nearly 90% had experienced IPV within their lifetimes. Other studies have found that women who have been abused by an intimate partner are more likely to use or become dependent on substances.¹² Women who have experienced IPV are at increased risk of multiple mental health conditions (e.g., depression, anxiety, eating disorders, posttraumatic stress disorder and substance abuse) as well as physical health (e.g., chronic pain, gastrointestinal problems, sexually transmitted infections, traumatic brain injury) and death.¹³ Researchers have increasingly recognized that the experience of IPV is not limited to women and that men can also be victims of abuse.¹⁴ However, most research has focused on the link between alcohol use or drug use with male perpetration or female victimization.¹⁵

Past Trends in IPV and Substance Abuse Following Disasters and Crises

Increases in intimate partner violence and substance abuse following major disasters and crises are well documented in the literature.^{16, 17} Following the eruption of Mount St. Helens and in the wake of Hurricane Katrina, increases in alcohol abuse, IPV, family stress and aggression were reported.¹⁶ Previous pandemics that required quarantine (e.g., severe acute respiratory syndrome [SARS] influenza A virus subtype H1N1) found that isolation can result in psychological distress, loneliness, depression, stress, post-traumatic stress disorder, anger, sleep disorders and problematic substance use,¹⁸ all factors that increase risk of violence.^{8, 19, 20} While this information is distressing, it could be key to understanding and predicting the trends of intimate partner violence and substance abuse that are emerging as the COVID-19 pandemic unfolds.

How Is COVID-19 Affecting Incidences of IPV?

Despite the public health protections intended by the quarantines resulting from COVID-19, it may have had unplanned consequences for victims of intimate partner violence. Data from various U.S. police departments have begun to emerge regarding rates of IPV in quarantined homes. After the implementation of the quarantine, data from the Portland (Oregon) Police Bureau recorded a 22% increase in arrests related to IPV compared to prior weeks.⁶ In Jefferson County, Alabama, the Sheriff's Office reported a 27% increase in IPV calls during March 2020 compared to March 2019.⁶ In New York City, during the month of March 2020, the New York City Police Department responded to a 10% increase in intimate partner violence reports compared to March 2019.⁶ Based on this data, it is evident that quarantine has not only exacerbated an unsafe home environment for victims of IPV but has also increased levels of reported violence.

For individuals who do not feel safe in their home, quarantine may be serving as a catalyst for abuse. A study investigating reports of family violence from around the world due to social isolation measures being implemented during COVID-19 found that these measures are resulting in intense and unrelieved contact within families as well as the depletion of existing support networks.²¹ The lack of contact with support networks outside of the household may allow for abuse to remain hidden with physical or emotional signs of family violence and abuse less visible to others.²¹ An article exploring the impact of natural disasters on reports of family violence discusses support systems for victims of family violence and highlights how the lack of access to schools, libraries and churches, all critical staples in family routines, can be detrimental to victims of IPV. These institutions often offer critical emotional support and provide opportunity for a "reprieve" from their abusive home environment—a reprieve they are not getting at this time.¹⁶ Isolation may also grant perpetrators of intimate partner violence greater freedom to act without scrutiny or consequence due to the lack of  interaction with individuals outside of the household.⁷ It is likely that the additional stressors (economic, school and child care closures, social isolation) caused by the stay-at-home orders during the COVID-19 pandemic have increased incidences of mutual violence as well.²²

There have also been recorded incidences of abusers using COVID-19 as a tool for manipulation of their victims. One study describing the particular plight of undocumented immigrant victims of IPV in Rhode Island notes that abusers control victims' finances, food and daily activities; physically and socially isolate them from support and resources; and threaten violence if not obeyed. This underscores the idea that the COVID-19 quarantine may increase the power and control that abusers hold over victims because victims are quarantined by the state and can be confined by their abusers.²³ While it is common for IPV abusers to isolate their victims as an act of control or to reduce opportunity for disclosure of abuse, the current quarantine conditions are likely furthering the impact of these actions.¹⁶ In the U.S., reports have surfaced of IPV perpetrators forbidding handwashing in an attempt to increase the victim's fear of contracting the virus and threatening to forbid medical treatment if the victim does contract the virus.¹⁶ In Australia, there have been reports of misinformation used by intimate partners related to the extent of quarantine measures.²¹ The U.S. National Domestic Violence Hotline reported that those experiencing IPV may be afraid to go to a hospital for fear of contracting COVID-19, among other forms of COVID-19-related abuse.²¹ This causes victims to feel stuck between two dangerous situations, forced to choose between two significant threats to health and safety. These incidents make it clear that the quarantine has not only allowed for an increase of intimate partner violence but has also given abusers new tools and opportunities for abuse.

How Is COVID-19 Contributing to Substance Use?

The COVID-19 pandemic and subsequent quarantine have also led to an increase in substance abuse, while reducing opportunities for substance use treatment and services. Substance abuse, particularly alcohol, has been linked to increased risk for IPV. Previous research indicates that the increase in psychological distress triggered by the interaction of social isolation and uncertainty about the future during and after crises like the COVID-19 pandemic can worsen patterns of alcohol use.²⁴ Many scientists have predicted that the social distancing, stay-at-home orders and quarantine measures society has undertaken as public health strategies for disease containment during this current pandemic will inadvertently lead to worsened mental health and increased substance misuse²⁵ as has been seen with other disasters.

A recent article in The Lancet discussing alcohol misuse risk factors similarly suggested that alcohol use during this COVID-19 pandemic may be a major public health concern.²⁶ Alcohol use has been linked to an accumulation of stressful events and a lack of social support, both of which are likely occurring as results of the pandemic.¹⁶ Research is emerging that pandemics can have important impacts on drinking and substance use behavior. As the COVID-19 pandemic began in March 2020, and social distancing measures came into place, alcohol sales rose more than 36% in Australia, and as restaurants, bars and pubs closed, people began drinking more within the confines of their homes.²¹ In March 2020, during the COVID-19 pandemic and while many Americans were under a stay-at-home order, market research by Nielsen showed that alcohol sales increased by 55% relative to the same time last year.²⁷ A recent Nanos poll similarly showed that Canadians are drinking more alcohol during the COVID-19 pandemic-related quarantine.²⁸ The largest increases were observed in 35- to 54-year-olds, where 25% acknowledged that they had increased their alcohol use during the pandemic, with 44% attributing this change to stress.²⁸ This trend of drinking at home is concerning because of the link between alcohol use and IPV.

Overdose Detection Mapping Application Program (ODMAP) is a surveillance system that provides near real-time suspected overdose data nationally, revealed an 18% increase in overdoses in March 2020, a 29% increase in April 2020, and a 42% increase in May 2020 when compared to the same time periods in 2019.²⁹ This suggests that not only has substance abuse increased but also that the pandemic could possibly be interfering with intervention efforts that prevent overdoses. Given that previous research has found that IPV and substance use have adverse impacts on mental and physical health,¹¹ awareness of this potential for increased IPV and substance use during the COVID-19 pandemic is needed so appropriate responses can be taken.

Who Can Help?

The universal quarantine has seriously limited contact with sources of support and intervention for victims of intimate partner violence and those struggling with substance abuse. The pandemic has left many people able to only interact with emergency medical service (EMS) personnel and health care professionals (HCPs). In recognition of this emerging trend, it is integral that EMS and HCPs are equipped to recognize signs of IPV and substance abuse, and respond effectively. Research is urging first responders, physicians and other HCPs to be made aware of the potential for increased intimate partner violence during the COVID-19 pandemic so they are able to respond appropriately.⁶ It should be noted that while HCPs may be facing the need to learn many new skills related to COVID-19, they must also maintain awareness of IPV and substance abuse, as well as become familiar with currently available local resources for patient referral.¹⁷ An article urging EMS and HCPs to take action against intimate partner violence highlighted the need for more innovative telehealth interventions, and specifically the need to be hypervigilant to patient evasiveness or discomfort during telehealth interventions.²³ With the reliance on governments and policymakers for current and accurate information about COVID-19, researchers suggest that these outlets should create awareness about an increased risk of IPV and substance abuse during the pandemic and emphasize the need for people to keep in touch with each other.²¹ With COVID-19 currently at the forefront of everyone’s mind, it is essential that awareness of IPV and substance abuse is not lost.