Serial Sexual Murderers and Prostitutes as their Victims: Difficulty Profiling Perpetrators and Victim Vulnerability as Illustrated by the Green River Case

Gary Ridgway, the Green River killer, is the most prolific serial killer in U.S. history, preying upon the most vulnerable of victims: prostitutes. This paper examines the difficulty experienced by law enforcement officials when trying to develop the profile of a serial sexual murderer, as illustrated by the Green River case. The lives and experiences of prostitutes are examined to establish their level of susceptibility to crime while also exploring the customers who frequent them. A summary of current research on criminal profiling is analyzed in conjunction to the Green River case with the goal of obtaining an understanding of the drives and motivations behind these crimes. In addition, the forensic and ethical implications of the case are discussed

HIV Stigma Among Substance Abusing People Living with HIV/AIDS: Implications for HIV Treatment

HIV-related stigma has a major impact on quality of life and health among people living with HIV and AIDS (PLWHA). This study examines demographic, mental health, behavioral, contextual, and HIV care-related correlates of HIV stigma among 503 substance abusing PLWHA. Stigma was measured with the HIV Internalized Stigma Measure which has four subscales: stereotypes about HIV, self-acceptance, disclosure concerns, and social relationships. Severe substance dependence (55.3%) and depression (54.7%) were associated with higher HIV stigma across all domains. 49.9% of the sample reported antiretroviral (ARV) medication diversion (the unlawful sale and trading of ARV medications); diverters endorsed significantly higher stigma related to disclosure. 54.1% of the sample reported ≥95% ARV adherence; these individuals reported significantly lower stigma for self-acceptance, disclosure, and social relationships. Multivariate linear regression showed that depression and social support demonstrated significant main effects across stigma domains. Findings suggest that interventions to decrease HIV related stigma may be an important component of initiatives to increase engagement in HIV care

Environmental Influences on HIV Medication Adherence: The Role of Neighborhood Disorder

Objectives. We hypothesized that highly disordered neighborhoods would expose residents to environmental pressures, leading to reduced antiretroviral (ARV) medication adherence. Methods: Using targeted sampling, we enrolled 503 socioeconomically disadvantaged HIV-positive substance users in urban South Florida between 2010 and 2012. Participants completed a 1-time standardized interview that took approximately 1 hour. We tested a multiple mediation model to examine the direct and indirect effects of neighborhood disorder on diversion-related nonadherence to ARVs; risky social networks and housing instability were examined as mediators of the disordered neighborhood environment. Results: The total indirect effect in the model was statistically significant (P = .001), and the proportion of the total effect mediated was 53%. The model indicated substantial influence of neighborhood disorder on nonadherence to ARVs, operating through recent homelessness and diverter network size. Conclusions: Long-term improvements in diversion-related ARV adherence will require initiatives to reduce demand for illicit ARV medications, as well as measures to reduce patient vulnerability to diversion, including increased resources for accessible housing, intensive treatment, and support services

Benzodiazepine Dependence Among Multidrug Users in the Club Scene

Background: Benzodiazepines (BZs) are among the most frequently prescribed drugs with the potential for abuse. Young adults ages 18–29 report the highest rates of BZ misuse in the United States. The majority of club drug users are also in this age group, and BZ misuse is prevalent in the nightclub scene. BZ dependence, however, is not well documented. This paper examines BZ dependence and its correlates among multidrug users in South Florida\u27s nightclub scene. Methods: Data were drawn from structured interviews with men and women (N = 521) who reported regular attendance at large dance clubs and recent use of both club drugs and BZs. Results: Prevalences of BZ-related problems were 7.9% for BZ dependence, 22.6% BZ abuse, and 25% BZ abuse and/or dependence. In bivariate logistic regression models, heavy cocaine use (OR 2.27; 95% CI 1.18, 4.38), severe mental distress (OR 2.63; 95% CI 1.33, 5.21), and childhood victimization history (OR 2.43; 95% CI 1.10, 5.38) were associated with BZ dependence. Heavy cocaine use (OR 2.14; 95% CI 1.10, 4.18) and severe mental distress (OR 2.16; 95% CI 1.07, 4.37) survived as predictors in the multivariate model. Discussion: BZ misuse is widespread among multidrug users in the club scene, who also exhibit high levels of other health and social problems. BZ dependence appears to be more prevalent in this sample than in other populations described in the literature. Recommendations for intervention and additional research are described

Diversion of Benzodiazepines through Healthcare Sources

Background—Benzodiazepines (BZ) are often diverted from legal sources to illicit markets at various points in the distribution process which begins with a pharmaceutical manufacturer, followed by distribution to healthcare providers, and finally, to the intended users. Little is known about the extent of BZ diversion involving distribution points directly related to healthcare sources (e.g., a script doctor) as opposed to points further down the distribution chain (e.g., street dealers). The present study examines the scope of BZ diversion via mechanisms directly related to a healthcare source. It examines the association between BZ dependence and the direct utilization of particular healthcare-related diversion sources among a diverse sample of prescription drug abusers in South Florida. Method—Cross-sectional data were collected from five different groups of drug users: methadone-maintenance clients (n = 247), street drug users (n = 238), public-pay treatment clients (n = 246), private-pay treatment clients (n = 228), and stimulant using men who have sex with men (MSM; n = 248). Results—Findings suggest that those ages 26 to 35 years old, non-Hispanic White participants, private-pay treatment clients, those who are insured, and those with higher incomes had higher odds of utilizing healthcare diversion sources. Participants utilized a pharmacy as a diversion source more than other healthcare sources of diversion, and the highest number of BZs were obtained from doctor shopping compared to other diversion sources. Those who reported BZ dependence also had 2.5 times greater odds of using a healthcare source to obtain BZs than those who did not meet criteria for dependence. Discussion—Prevention of BZ diversion through healthcare sources should include strategies to reduce doctor shopping and diversion from pharmacies

Under Treatment of Pain: A Prescription for Opioid Misuse among the Elderly?

Objective: To examine the demographic, physical, and mental health characteristics; current drug use patterns; motivations for use; and diversion sources among elderly prescription opioid misusers. Design: Mixed methods design. Setting: Research field offices, or senior or community center offices in South Florida. Subjects: Individuals aged 60 and over reporting past 90-day prescription medication misuse; only prescription opioid misusers (N = 88) were included in the final analysis. Methods: The Global Appraisal of Individual Needs was the main survey instrument. A subsample of elderly reporting substantial prescription drug misuse were chosen for the in-depth interview (N = 30). Results: The mean age was 63.3. Fifty percent reported ever being admitted to a drug treatment program; several endorsed recent illicit drug use: powder cocaine and/or crack (35.2%), marijuana (30.7%), heroin (14.8%). The majority reported past year severe physical pain and discomfort (86.4%), and misuse of their primary opioid for pain (80.7%); over half (52.3%) obtained their primary opioid from their regular doctor. Qualitative data highlight the misuse of prescription opioids due to untreated or undertreated pain. Participants with primary opioid misuse for pain had over 12 times higher odds of obtaining the medication from their regular doctor (odds ratio [OR] = 12.22, P = 0.002) and had lower odds of using a dealer (OR = 0.20, P = 0.005). Conclusions: Findings suggest that this group of elderly participants often misuse their own prescriptions for pain management. This study highlights the need to educate prescribing professionals on appropriate pain management for older adults while still being sensitive to issues of substance abuse and dependence

Health and Social Problems associated with Prescription Opioid Misuse among a Diverse Sample of Substance-Using MSM

This study examines associations between prescription opioid misuse and demographics, substance use, sexual behavior, and related health and social problems. Baseline data were collected between 2008 and 2010 from 515 high risk men who have sex with men, ages 18–55, in the Miami-Ft. Lauderdale metropolitan area who reported heavy substance use and HIV risk in the past 90 days. Prescription opioid misuse was associated with other substance use, drug injection, substance dependence, and history of arrest. Implications, limitations, and directions for future study are discussed

Nonmedical Prescription Drug Users in Private vs. Public Substance Abuse Treatment: A Cross Sectional Comparison of Demographic and HIV Risk Behavior Profiles

Background: Little is known regarding the demographic and behavioral characteristics of nonmedical prescription drug users (NMPDUs) entering substance abuse treatment settings, and information on the HIV-related risk profiles of NMPDUs is especially lacking. Participation in substance abuse treatment provides a critical opportunity for HIV prevention and intervention, but successful initiatives will require services appropriately tailored for the needs of NMPDUs. Methods: This paper compares the HIV risk profiles of NMPDUs in public (n = 246) and private (n = 249) treatment facilities. Participants included in the analysis reported five or more recent episodes of nonmedical prescription drug use, a prior HIV negative test result, and current enrollment in a substance abuse treatment facility. A standardized questionnaire was administered by trained interviewers with questions about demographics, HIV risk, and substance use. Results: Private treatment clients were more likely to be non-Hispanic White, younger, and opioid and heroin users. Injection drug use was higher among private treatment clients, whereas public clients reported higher likelihood of trading or selling sex. Public treatment clients reported higher rates of HIV testing and availability at their treatment facilities compared to private clients. Conclusions: Findings suggest differing demographics, substance use patterns, profiles of HIV risk and access to HIV testing between the two treatment samples. Population tailored HIV interventions, and increased access to HIV testing in both public and private substance treatment centers, appear to be warranted

Medication Adherence Challenges Among HIV Positive Substance Abusers: The Role of Food and Housing Insecurity

This study examines the prevalence of food/housing insecurity and its association with psychological, behavioral, and environmental factors impacting antiretroviral (ARV) medication adherence and diversion among substance using HIV+ patients in South Florida. Five hundred and three HIV+ substance abusers were recruited through targeted sampling. Participants completed a standardized instrument assessing demographics, mental health status, sex risk behaviors, HIV diagnosis, treatment history and access, ARV adherence and diversion, and attitudes toward health-care providers. Chi-square and t-tests were used to examine differences by food/housing status and a multivariate linear regression model examined food/housing insecurity and its associations to ARV adherence. Food/housing insecurity was reported by 43.3% of the sample and was associated with higher likelihood of severe psychological distress and substance dependence. Nearly 60% reported recent ARV diversion; only 47.2% achieved 95% medication adherence over one week. Food/housing insecure participants had deficits in their HIV care, including less time in consistent care, lower access to medical care, and less favorable attitudes toward care providers. Multivariate linear regression showed food/housing insecurity demonstrated significant main effects on adherence, including lower past week adherence. Medication diversion was also associated with reduced adherence. Our findings suggest that food/housing insecurity operates as a significant driver of ARV non-adherence and diversion in this population. In the pursuit of better long-term health outcomes for vulnerable HIV+ individuals, it is essential for providers to understand the role of food and housing insecurity as a stressor that negatively impacts ARV adherence and treatment access, while also significantly contributing to higher levels of distress and substance dependence

Outcomes of a Behavioral Intervention to Reduce HIV Risk among Drug-Involved Female Sex Workers

Although street-based female sex workers (FSWs) are highly vulnerable to HIV, they often lack access to needed health services and medical care. This paper reports the results of a recently completed randomized intervention trial for FSWs in Miami, Florida, which tested the relative efficacy of two case management interventions that aimed to link underserved FSWs with health services and to reduce risk behaviors for HIV. Participants were recruited using targeted sampling strategies and were randomly assigned to: a Strengths-Based/Professional Only (PO) or a Strengths-Based/Professional-Peer condition (PP). Follow-up data were collected 3 and 6 months post-baseline. Outcome analyses indicated that both intervention groups displayed significant reductions in HIV risk behaviors and significant increases in services utilization; the Professional-Peer condition provided no added benefit. HIV seropositive FSWs responded particularly well to the interventions, suggesting the utility of brief strengths-based case management interventions for this population in future initiatives