Competing Constructivisms: The Negotiation of PTSD and Related Stigma Among Post-9/11 Veterans in New York City.

Posttraumatic stress disorder (PTSD) stands as a form of psychopathology that straddles moral and psychiatric domains. Grounded in discrete instances of trauma, PTSD represents an etiological outlier in an era of increased attention to the genetics of mental illness and a prime location for social constructivist analyses of mental illness. This examination of PTSD narratives-as voiced in qualitative interviews and focus groups with 50 veterans of the recent Iraq and Afghanistan wars living in New York City-attends to the processes through which veterans conceive and navigate PTSD symptoms and diagnoses. In so doing we highlight the social constructivist positions undertaken by veterans themselves as they varyingly challenge and internalize symptomology in dialogue with psychiatric definitions and the stigma associated with PTSD. Findings demonstrate the rejection of classic psychopathological etiology-in brain disease, for example-by many veterans as well as the complex balancing of benefit and stigma that veterans undertake when making decisions about presenting to psychiatric clinicians. Drawing on veterans' accounts, we argue for greater cultural specificity in characterizing the diagnosis-seeking behavior of trauma survivors and a greater appreciation for the contradictions and compromise related to both acceptance and rejection of a mental health diagnosis.

Opioid-Involved Overdose Among Male Afghanistan/Iraq-Era U.S. Military Veterans: A Multidimensional Perspective.

BACKGROUND: Mirroring nationwide trends in a broad range of U.S. populations, an alarming number of Afghanistan/Iraq-era U.S. Military veterans have experienced opioid-related overdoses. A growing body of research has examined the proximal behaviors that can precipitate an overdose; considerably less is known about more distal physiological, psychosocial and structural influences on these risk behaviors. OBJECTIVES: This study adopts a multidimensional approach to better understand opioid-related overdose among U.S. Military veterans, and seeks to explore not only the proximal behavioral precipitants of overdose events, but also the complex nexus of physiological, psychological, and sociological influences that undergird overdose events. METHODS: This qualitative examination is based on interview data from 36 male veterans who were discharged from the military after September 2001 and experienced at least one opioid-related overdose during or after military service. Participants were recruited in New York City during 2014 to share narrative accounts of their overdoses. RESULTS: Veterans' accounts indicate that background experiences, such as self-medication for social and psychological pain, trauma, social alienation and isolation, and histories of illicit drug use, precondition the more immediate factors and behaviors that precipitate overdose (including bingeing on drugs, mixing drugs, naiveté about dosage, and ambivalence about life/death). CONCLUSIONS: Findings suggest the need for comprehensive drug safety and overdose education that is sensitive to veterans' physiological, psychological, and sociological conditions. A multidimensional understanding of the distal and proximal overdose risks faced by veterans and other vulnerable groups may help lay a foundation for more inclusive/holistic approaches to overdose prevention and education.

Introduction to the special issue: drugs, wars, military personnel, and veterans.

This special issue examines major structural, sociocultural, and behavioral issues surrounding substance use and misuse among U.S. military personnel and veterans who served in recent military conflicts in Iraq and Afghanistan. This introduction provides a brief historical review of the US's experiences of the linkages between war and substance use, misuse, and abuse. It then describes how the various topics covered in this issue span the military-veteran life course and explains the significance of each contribution.

Prescription opioid initiation, correlates, and consequences among a sample of OEF/OIF military personnel.

Prescription opioid (PO) misuse represents a major health risk for many service members and veterans. This paper examines the pathways to misuse among a sample of U.S. veterans who recently returned from Iraq and Afghanistan to low-income, predominately minority sections of New York City. Recreational PO misuse was not common on deployment. Most PO misusers initiated use subsequent to PO use for pain management, an iatrogenic pathway. However, most PO users did not misuse them. Veterans that misused POs were more likely to have other reintegration problems including drug and alcohol use disorders, traumatic brain injury (TBI), unemployment, and homelessness.

Substance use and other mental health disorders among veterans returning to the inner city: prevalence, correlates, and rates of unmet treatment need.

Estimates of substance use and other mental health disorders of veterans (N = 269) who returned to predominantly low-income minority New York City neighborhoods between 2009 and 2012 are presented. Although prevalences of posttraumatic stress disorder, traumatic brain injury, and depression clustered around 20%, the estimated prevalence rates of alcohol use disorder, drug use disorder, and substance use disorder were 28%, 18%, and 32%, respectively. Only about 40% of veterans with any diagnosed disorder received some form of treatment. For alcohol use disorder, the estimate of unmet treatment need was 84%, which is particularly worrisome given that excessive alcohol use was the greatest substance use problem.

Opioid and other substance misuse, overdose risk, and the potential for prevention among a sample of OEF/OIF veterans in New York City.

This paper describes veterans' overdose risks and specific vulnerabilities through an analysis of qualitative data collected from a sample of recently separated, formerly enlisted OEF/OIF veterans in the New York City area. We illustrate how challenges to the civilian readjustment process such as homelessness, unemployment, and posttraumatic stress disorder can render veterans at increased risk for negative health consequences and then present veterans' perspectives as they outline several innovative solutions to these obstacles. We conclude by discussing several overdose prevention efforts currently underway and how they might be adapted to meet the opioid and substance misuse challenges veterans face.

Unmet need for treatment of substance use disorders and serious psychological distress among veterans: a nationwide analysis using the NSDUH.

Many veterans returning from Afghanistan and Iraq experience serious mental health (MH) concerns including substance use disorders (SUD), post-traumatic stress disorder, traumatic brain injury, depression, or serious psychological distress (SPD). This article uses data from the 2004 to 2010 National Survey on Drug Use and Health to examine the prevalence of unmet MH needs among veterans aged 21 to 34 in the general population. The prevalence of untreated SUD among veterans (16%) was twice as high as untreated SPD (8%), a nonspecific diagnosis of serious MH concerns. Surprisingly, similar rates of untreated SUD and SPD were found among a nonveteran comparison sample matched on gender and age. These findings suggest that reducing unmet need for MH treatment for veterans in the general population may require improving outreach to all Americans and creating greater acceptance for MH treatment. The need for further analyses of reasons for not obtaining treatment is discussed.

Drug Generations in the 2000s: An Analysis of Arrestee Data.

Much empirical evidence indicates that the popularity of various drugs tends to increase and wane over time producing episodic epidemics of particular drugs. These epidemics mostly affect persons reaching their late teens at the time of the epidemic resulting in distinct drug generations. This article examines the drug generations present in the 2000s among arrestees in the 10 locations served by the Arrestee Drug Abuse Monitoring-II program. At all 10 locations, our findings show that crack use is still common among older arrestees but not among arrestees born more recently. Marijuana is the drug most common among younger arrestees. The article also examines trends in heroin, methamphetamine, and powder cocaine use among arrestees at the few locations where their use was substantial.

The opiate pain reliever epidemic among U.S. arrestees 2000-2010: regional and demographic variations.

The increasing rate of opiate pain reliever (OPR) use is a pressing concern in the United States. This article uses a drug epidemics framework to examine OPR use among arrestees surveyed by the Arrestee Drug Abuse Monitoring program. Results demonstrate regional and demographic variation in use across nine focal cities. High rates of OPR use on the West Coast illustrate the expansion of use from its initial epicenter. By 2010, OPR use had plateaued in all focal cities. Findings suggest directions for ongoing research into pathways to use and vectors of diffusion and for regionally specific interventions sensitive to age and ethnic diversity.

Drug markets during the Katrina disaster.

PURPOSE: The purpose of this paper is to examine the experiences of poor drug users and sellers who remained in New Orleans during Hurricane Katrina in 2005 to identify their special needs and the unique challenges they present to disaster management. DESIGN/METHODOLOGY/APPROACH: Semi-structured, open-ended interviews were conducted with 119 poor, predominantly African-American, drug users and sellers. Their stories in their own words provide a mosaic of drug-related experiences from the period immediately preceding the storm through evacuation and reveal the motivations behind their behaviors. FINDINGS: Many drug users placed partying, maintaining their habits, and making money ahead of personal safety and evacuation. Drug use and sales led many not to evacuate before the storm, to use drugs in congregate shelters, to avoid shelters, to roam through flooded debris-strewn streets, to loot stores and homes of drug dealers, and to use violence or the threat of violence to achieve their drug-related aims. ORIGINALITY/VALUE: During a disaster, many poor drug users place risks on themselves, their families, their communities and ultimately on rescue workers. The conclusion presents pragmatic and humanitarian guidelines for successfully addressing this additional challenge. The recommendations are consistent with other suggestions concerning the special needs of indigent populations.

Drug use and conflict in inner-city African-American relationships in the 2000s.

Inner-city relationships face numerous challenges including illegal drug use and its consequences. The nature of this challenge, however, has changed dramatically with a shift from the crack subculture of the 1980s and early 1990s to the subsequent marijuana/blunts subculture. This study presents data concerning 95 inner-city relationships where illegal drug use was present from people who were interviewed in 2004-2006 and reinterviewed in 2008. Hard drug use was still problematic in the 2000s even with the passing of the crack epidemic and its associated behavioral norms. Hard drug (primarily crack) users reported drug use was a problem, reported conflict over drugs, reported higher levels of conflict than others and were the most likely to have broken up with their partner. On the other hand, the experiences and subcultural norms associated with marijuana use appeared to be much less detrimental to relationship harmony. Subjects who used marijuana but not hard drugs reported much less relationship conflict. Indeed, many reported that they enjoyed using marijuana with their partner. These subcultural insights further the understanding that young adults have constructed a much more socially productive subculture regarding marijuana use than their predecessors had constructed around use of crack.

Normalization of violence: experiences of childhood abuse by inner-city crack users.

An increasing literature mostly based on retrospective surveys has been consistently documenting a correlation between physical abuse in childhood (CPA) and substance abuse in adulthood (ASA). This article uses ethnographic data to reveal the processes behind and context of this linkage for one population-poor, inner-city New York residents who became crack users. Life in the inner city is qualitatively different than in more fortunate circumstances. CPA is but one of numerous stressors and factors contributing to ASA. Approximately half of the subjects reported clear recollections of being physically beaten by their mothers or their various male partners. Although several denied being beaten in childhood, they typically reported various forms of physical assaults that they "deserved." Physical assaults, especially by mothers, were often understood as expressions of love. As such, these respondents viewed their ongoing physical assaults as an ordinary part of their childhood and adolescence. Such physical punishment also socialized and prepared children for the violence that would likely occur during their childhood in their inner-city communities. This analysis highlights how reducing substance abuse in the inner city may require a much more comprehensive effort than a focus on reducing CPA. These findings also have important implications for quantitative research regarding CPA and ASA. Such studies should subdivide their analyses by socioeconomic status to more clearly measure how much of a risk factor CPA represents among wealthier populations and how much not being abused may serve as a protective factor among poor inner-city populations.

An Analysis of Alternatives to New York City's Current Marijuana Arrest and Detention Policy.

During the 1990s, the New York Police Department (NYPD) instituted a policy of arresting and detaining people for minor offenses that occur in public as part of their quality-of-life (hereafter QOL) policing initiative. The number of NYPD arrests for smoking marijuana in public view (MPV) increased from 3,000 in 1994 to over 50,000 in 2000, and have been about 30,000 in the mid 2000s. Most of these arrestees (84%) have been minority; blacks have been 2.7 more likely and Hispanics 1.8 times more likely to be detained than whites for an MPV arrest. Minorities have been most likely to receive more severe dispositions, even controlling for demographics and prior arrest histories.This paper examines the pros and cons of the current policy; this is compared with possible alternatives including the following: arrest and issue a desk appearance ticket (DAT); issue a non-criminal citation (violation); street warnings; and tolerate public marijuana smoking. The authors recommend that the NYPD change to issuing DATs on a routine basis. Drug policy reformers might wish to further pursue changing statutes regarding smoking marijuana in public view into a violation (noncriminal) or encourage the wider use of street warnings. Any of these policy changes would help reduce the disproportionate burden on minorities associated with the current arrest and detention policy. These policies could help maintain civic norms against smoking marijuana in public.

Opioid Use Initiation, Progression, and Motivations Among OEF/OIF/OND-Era Veterans in New York City: An Age-Period-Cohort Analysis.

This study examines the temporal relationship between prescription opioid (PO) and heroin use among veterans in New York City. Drawing on survey data from a convenience sample of 214 Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)-era opioid-using military veterans, analyses demonstrate substantial cohort-level variation. Most notably, heroin use prior to PO initiation and prior to military enlistment was reported more frequently among the cohorts born prior to 1970 and after 1984. Across all cohorts, high percentages of participants reported alleviation of emotional/psychological pain as a reason for both PO and heroin use. Cohort-level variation highlights the need for tailored interventions and targeted prevention efforts.

The potential for accurately measuring behavioral and economic dimensions of consumption, prices, and markets for illegal drugs.

There are numerous analytic and methodological limitations to current measures of drug market activity. This paper explores the structure of markets and individual user behavior to provide an integrated understanding of behavioral and economic (and market) aspects of illegal drug use with an aim toward developing improved procedures for measurement. This involves understanding the social processes that structure illegal distribution networks and drug users' interactions with them. These networks are where and how social behaviors, prices, and markets for illegal drugs intersect. Our focus is upon getting an up close measurement of these activities. Building better measures of consumption behaviors necessitates building better rapport with subjects than typically achieved with one-time surveys in order to overcome withholding and underreporting and to get a comprehensive understanding of the processes involved. This can be achieved through repeated interviews and observations of behaviors. This paper also describes analytic advances that could be adopted to direct this inquiry including behavioral templates, and insights into the economic valuation of labor inputs and cash expenditures for various illegal drugs. Additionally, the paper makes recommendations to funding organizations for developing the mechanisms that would support behavioral scientists to weigh specimens and to collect small samples for laboratory analysis-by providing protection from the potential for arrest. The primary focus is upon U.S. markets. The implications for other countries are discussed.

A behavioral typology of opioid overdose risk behaviors among recent veterans in New York City.

OBJECTIVE: To identify meaningful classes of opioid-using military veterans in terms of self-reported opioid overdose risk behaviors. METHOD: The study recruited a sample of 218 military veterans in the NYC area who were discharged from active duty service after September 11, 2001 and reported past-month opioid use. Survey data including measures of mental health, social stressors, substance use, and opioid-related overdose risk behaviors were analyzed using Latent Class Analysis (LCA). RESULTS: A five group solution had excellent fit scores and interpretability. Factor analysis confirmed the existence of two major dimensions of variation: non-adherence and heroin use. The five groups included lower-risk prescription opioid users, non-adherent prescription opioid users and heroin users. The non-adherent prescription opioid users and heroin user classes were both further subdivided into "occasional" and "regular" use categories. In addition to endorsing a greater number of overdose risk behaviors, users in the regular use classes were more likely to screen positive for alcohol and substance use disorders, reported greater self-medicating opioid use to relieve anxiety, reported greater problems with physical pain, were more likely to have had mental health, alcohol and drug treatment, and were less likely to be employed or in school. Heroin users also were less likely to report stable housing. CONCLUSIONS: Findings indicate that opioid overdose risk classes are grounded in contextual factors related to experiences of psychological, physiological, and social adjustment pain and distress which should be addressed in tailored interventions targeting opioid users' unique constellations of risk behaviors and comorbid conditions.

Family Transitions in Cohabiting Families: a Longitudinal Investigation of the Role of Parent Depressive Symptoms in Youth Problem Behaviors.

Cohabiting family structures are becoming increasingly prevalent in the United States but are less stable than married family unions. In this longitudinal study we examine the change in psychosocial adjustment of adolescents when a non-biologically related male cohabiting partner (MCP) transitions out of the family home. Of particular interest, the role of maternal and MCP depressive symptoms was examined as a moderator. At wave 1, the sample was comprised of 111 low-income urban Black families, consisting of an adolescent (42.3 % male; Mage = 13), a biological mother, and a non-biologically-related male cohabiting partner (MCP). Wave 2 and 3 assessments occurred over the course of the subsequent 29 months, with 38 % of MCPs transitioning out of the home. We used latent growth curve modeling to characterize trajectories of youth internalizing and externalizing symptom change across the 3 waves. Both maternal and MCP depressive symptoms interacted with whether a transition occurred, consistent with the notion that adolescent problem behaviors are shaped by the dynamic interplay of individual- and family-characteristics.

Smoking marijuana in public: the spatial and policy shift in New York City arrests, 1992-2003.

BACKGROUND: During the 1990s, the New York Police Department (NYPD) greatly expanded arrests for smoking marijuana in public view (MPV). By 2000, MPV accounted for 15% of all arrests. The NYPD's supporters report this arrest activity is just part of quality-of-life (QOL) policing, which seeks to promote order in public locations by aggressively patrolling for behaviors that offend the general population. The NYPD's critics contend the NYPD has disproportionately targeted poor, black and Hispanic communities. METHODS: This paper analyzes the geographic distribution of MPV arrests from 1992 to 2003 to evaluate these alternative perspectives. A sequence of maps identify that the focus of MPV arrests shifted over time. RESULTS: In the early 1990s, most MPV arrests were recorded in the lower half of Manhattan (NYC's business and cultural center) and by the transit police. However, in the later 1990s and into the 2000s, most MPV arrests were recorded in high poverty, minority communities outside the lower Manhattan area and by the NYPD's policing of low-income housing projects. CONCLUSION: These findings suggest that current levels of MPV arrests in NYC may not be justifiable, at least based solely on the purpose of QOL policing. Accordingly, we suggest the NYPD seriously consider less stringent measures for public marijuana smokers, especially for use outside of highly public locations in recessed locations hidden from open view (like the stairwell of a housing project). Alternatives could include Desk Appearance Tickets, fines, or simply requiring smokers to desist, discard their product, and move along.