Examining Recovery Status and Supports before and after Substance Abuse Disorder Treatment Among Clients Who Experienced Lifetime and Recent Firearm-Related Threats

Abstract

Firearm-related risks have often been overlooked in the sequela of substance use and substance use disorders. This study compares adult substance abuse disorder treatment (SADT) clients who experienced recent (n = 274) and lifetime (n = 889) firearm threats to adults who were not threatened with a firearm (n = 2029) before and 12 months after program entry. More men experienced firearm threats (38.8%) than women (34.2%). However, among those with any firearm threats, more women (27.2%) experienced firearm threats in the year before program entry than men (20.2%). Being threatened with a firearm was associated with increased economic vulnerability, criminal justice system involvement, mental health problems, and victimization both before and after SADT program entry. A higher number of adverse childhood experiences were associated with firearm threats and particularly recent firearm threats. Results of this study underscore the importance of screening for firearm-related risks in substance abuse disorder treatment programs.

Keywords

gun violence substance abuse treatment recovery firearm-related risks

Firearm-related risks and substance use are often treated independently; however, firearm-related risks intersect with alcohol and illicit drug use in multiple ways (Branas, Han, & Wiebe, 2016; Buschmann, Prochaska, Baillargeon, & Temple, 2017; Dittmer, Davenport, Oyler, & Bernard, 2021; Lu & Temple, 2020). For example, both impact younger adults (18–30 years old) at higher rates and early involvement in either is associated with negative outcomes in later adulthood (Everytown for Gun Safety, 2020; Grant et al., 2006; Moss, Chen, & Yi, 2014; Parsons, Thompson, Vargas, & Roco, 2018; Teplin et al., 2021). Additionally, firearm-related risks have often been overlooked in the sequela of substance use and substance use disorders (Schulte & Hser, 2013). Several recent studies have found that one-third to one-half of adults entering substance abuse disorder treatment (SADT) or residential recovery housing programs have experienced firearm-related victimization (Logan & Cole, 2021a, 2021b). However, no studies to date have examined SADT outcomes among clients who have experienced firearm victimization.

Firearm victimization has been associated with increased psychological symptoms and substance use (Boeck, Strong, & Campbell, 2020; Vella et al., 2020). More specifically, several studies have found that individuals exposed to firearm-related threats had higher emotional distress and functioning problems than those victimized without a weapon or those victimized with a weapon other than a firearm (Kagawa et al., 2020; Weigend Vargas & Hemenway, 2021). Women who experience firearm threats from an abusive intimate partner also report increased distress compared to women with abusers who did not threaten them with a firearm (Logan & Cole, 2021; Logan & Lynch, 2018; Logan, Lynch, & Walker, 2021; Logan & Lynch, 2021a; Lynch & Logan, 2018; Sullivan & Weiss, 2017). Several studies have also found that victimization with a firearm is associated with increased substance use (Farrell & Zimmerman, 2017; Vella et al., 2020). In addition, research suggests that individuals exposed to firearm threats are at increased risk of revictimization including revictimization with firearms as well as increased risk of firearm violence perpetration (Beardslee et al., 2018; Goldstick et al., 2019a; Kalesan, Zuo, Ramachandran, & Galea, 2019; Rowhani–Rahbar et al., 2015; Schmidt et al., 2019; Teplin et al., 2021; Turner, Phillips, Tigri, Williams, & Hartman, 2016; Wallace, 2017). One study found that both men and women who had access to, or were threatened with, a firearm during adolescence were more likely to own a gun, carry a gun in public, perpetrate firearm violence, and to be threatened with a weapon in adulthood (Teplin et al., 2021).

Although firearm victimization has been associated with prior victimization (Goldstick et al., 2019b; Logan & Cole, 2021a, 2021b; Rajan, Branas, Myers, & Agrawal, 2019; Turner et al., 2016; Wallace, 2017), there has been limited examination of whether there is an association of adverse childhood experiences and firearm victimization. One study found that childhood trauma was associated with firearm violence among homeless youth (Hsu et al., 2021). In general, adverse childhood experiences have been associated with negative outcomes in adults including poorer mental health outcomes, suicidality (Hughes et al., 2017; Thompson, Kingree, & Lamis, 2019), physical health outcomes, and substance use (Hughes et al., 2017; Letendre & Reed, 2017; Merrick et al., 2019; Petruccelli, Davis, & Berman, 2019) as well as economic vulnerability in adulthood (Merrick, Ford, Ports, & Guinn, 2018; Merrick et al., 2019). In particular, those experiencing more adverse childhood experiences had a higher risk of substance use disorders and other negative mental and physical health outcomes (Boullier & Blair, 2018; Hughes et al., 2017; Merrick et al., 2019; Waehrer, Miller, Silverio Marques, Oh, & Burke Harris, 2020). This study expands the literature by examining adverse childhood experiences among adults entering SADT and whether there are differences in adverse childhood events among clients who have, and clients who have not, been threatened with a firearm.

Relapse, or return to use of alcohol or illegal drugs, are typically the primary outcome measures in evaluations of SADT programs (Richardson, Blount, & Hanson–Cook, 2019; White, 2012). However, recovery extends beyond the use of substances to include enhancements in physical health, mental well-being, quality of life, and community reintegration, and these goals can often be met even when there are minor relapses (Kaskutas et al., 2014; Laudet & White, 2008; Richardson et al., 2019; White & Kurtz, 2005). Further, recovery supports such as economic resources, social support, and positive health and mental health are needed to maintain SADT program engagement and to facilitate recovery efforts (Laudet & Humphreys, 2013; Laudet & White, 2010; Logan, Cole, & Walker, 2020). Thus, individuals exposed to firearm victimization have significant risks, but how firearm victimization exposure may or may not be associated with relapse and recovery status after SADT program entry has not been previously examined.

Within this context, this study is one of the first to compare outcomes after entry to a SADT program among adults who did not experience firearm threats, adults who experienced firearm threats but not in the year before SADT program entry, and adults who experienced firearm threats in the year before SADT program entry. Specifically, this study (1) compared bivariate differences at program entry and at follow-up on economic resources, criminal justice system involvement, physical and mental health status, interpersonal victimization, substance use, and social support by firearm threat group (no firearm threats n=2029; firearm threats, n = 889; past year firearm threats, n = 274) for adults who entered a SADT program and who were followed up about 12 months later; (2) examined adverse childhood experiences by firearm threat group; (3) identified differences by firearm threat group on economic resources, criminal justice system involvement, physical and mental health status, interpersonal victimization, substance use, and social support 12 months after SADT program entry; and (4) explored factors, including firearm threat group, associated with any problem alcohol or illicit drug use 12 months before follow-up using logistic regression. Gender differences were also examined.

Method

Participants

Overall, this study includes men (n = 1556) and women (n = 1636) who entered SADT program at one of 16 Regional Community Mental Health Centers across one state and completed an assessment at program entry between September 2016 and June 2019 and then completed a follow-up assessment about 12 months later.

Measures

Sociodemographic Characteristics. At program entry, clients were asked about their date of birth, race, marital status, and whether they lived with any children under 18 years old the year before SADT entry. At program entry and follow-up clients were also asked “what was your usual employment pattern in the past 12 months?” Response options were 1 = (Full-time [35+ hours a week], 2 = part-time [less than 35 hours a week], 3 = part-time [irregular work], 4 = unemployed student, 5 = retired, 6 = on or applied for disability, 7 = unemployed homemaker/caregiver, 8 = unemployed, and 9 = looking for work, or unemployed and living in a controlled environment) and the unemployment category included response options 7 through 9.

Survey items about difficulty meeting basic needs were modified from the Survey of Income and Program Participation (Beverly, 2001; Iceland & Bauman, 2007; She & Livermore, 2007). The program entry and follow-up assessments included eight (yes/no) questions asking about the past 12 months: (1) Did you/your family have difficulty paying the full amount of rent or mortgage? (2) Were you/your family evicted from your home/apartment for not paying the rent? (3) Were you/your family unable to pay your phone/cell phone bill? (4) Were you/your family unable to pay the gas or electric bill? (5) Was there at time when there was not enough food in your household to eat? (6) Has there been a time when you or someone in your household needed to see a doctor or go to the hospital but was not able to because of financial reasons? (7) Has there been a time when you or someone in your household needed to see a dentist but did not go because of financial reasons? and (8) Has there been a time when you or someone in your household needed to fill a prescription for medication but was unable to because of cost? Participants were asked if they considered themselves homeless at any time during the 12 months before entering or in the 12 months before the follow-up (yes/no).

Criminal Justice System Involvement. Clients were asked during the 12 months before program entry and follow-up: (a) how many nights they were incarcerated in jail, prison or a detention center; and (b) how many times they were arrested and charged with any offense. Responses greater than 0 were recoded into 1 = Yes, and responses of 0 were recoded into 0 = No. Individuals were also asked at both program entry and follow-up if they were on probation or parole (Yes/No).

Quality of Life, Physical and Mental Health Status. Participants were also asked to rate their quality of life with response options on a scale: 1 = worst imaginable, 5 = the good and bad parts are about equal, and 10 = the best imaginable. Clients were allowed to select their rating anywhere along the scale. Those who rated their quality of life between 1 and 4 were classified into the low quality of life rating category.

Participants were asked to rate their overall health in the 12 months before entering the program [and the follow-up] (1 = poor, 2 = fair, 3 = good, 4 = very good, and 5 = excellent). This question was adapted from the Behavioral Risk Factor Surveillance System (BRFSS) Health-Related Quality of Life (Hennessy, Moriarty, Zack, Scherr, & Brackbill, 1994b).

Individuals were asked about depression symptoms at program entry and follow-up with specific questions from the Mini International Neuropsychiatric Interview (M.I.N.I., 5.0.0) (Sheehan et al., 1998). Two gating items asked clients if they had experienced a 2-week period at some point in the past 12 months where they were consistently depressed or down most of the day nearly every day and/or where they were much less interested in most things or much less able to enjoy the things they used to enjoy most of the time. Individuals who responded “Yes” to either of those questions were asked seven items about other depression symptoms. Individuals who answered yes to one of the two gating items and who reported at least five of the nine symptoms were classified as having met criteria for depression.

Generalized anxiety was assessed with items from the Generalized Anxiety Disorder (GAD) section of the M.I.N.I. (5.0.0) (Spitzer, Kroenke, Williams, & Löwe, 2006). Clients were asked whether, in the 12 months before program entry [and follow-up] whether they had a period lasting 6 months or longer where they worried excessively or were anxious about multiple things on more days than not for all 6 months (like family, health, finances, school, or work difficulties) (Yes/No). Individuals who responded “Yes” were then asked six additional Yes/No questions about anxiety symptoms. Individuals who reported having at least three of the six symptoms were classified as having met criteria for generalized anxiety. Comorbid depression and anxiety was indicated if clients met study criteria for both depression and generalized anxiety.

Two items from the Addiction Severity Index (McLellan et al., 1992) were used to assess suicidality. Specifically, clients were asked (1) whether they had thought about ending their life or committing suicide (yes/no) and (2) whether they had attempted to commit suicide in the 12 months before and the 12 months after entering the program.

Clients were asked, “Thinking about your mental health, which includes stress, depression and problems with emotions, during the 30 days before entering this program and during the 30 days prior to completing the follow-up assessment, “how many days was your mental health not good?” This question was from the Behavioral Risk Factor Surveillance System (BRFSS) Health-Related Quality of Life (Hennessy, Moriarty, Zack, Scherr, & Brackbill, 1994a).

Interpersonal Victimization. Clients were asked if they had ever experienced several specific types of interpersonal victimization including (Yes/No): (a) been robbed or mugged (someone took your wallet, money, or other personal valuables) by someone who used force or threats of force? (b) been physically assaulted or attacked by someone; (c) been directly or indirectly threatened with a gun or held at gunpoint; (d) been frightened or concerned for their safety or the safety of others close to then because someone repeatedly followed them, repeatedly contacted them, and/or repeatedly showed up at their house or other places when they did not want them to (stalked or obsessively pursued them); (e) been threatened or forced to have sexual intercourse against their will; and (f) been abused by a dating or intimate partner? (a partner physically assaulted, controlled, or emotionally abused them that made them scared or afraid for their safety). Participants were then asked whether any of these had occurred in the past 12 months before program entry or before the follow-up (Yes/No).

Clients were asked at program entry whether they had experienced five types of abuse/neglect and five types of household dysfunction before the age of 18, using an adaptation of the Adverse Childhood Experiences Study (ACE) items (Felitti et al., 1998). The items are shown in Table 2. Scores were calculated by summing the number of “Yes” responses for each type of experience with a range from 0 to 10.

Substance Use. Measures of substance use were adapted from the Alcohol Severity Index (ASI) fifth Edition (McLellan et al., 1992) with timeframes focused on use in the 12 months prior to program entry [and follow-up]. Clients were asked about specific substances including alcohol use (any use, using to intoxication, and binge drinking), marijuana; illicit use of opioids (including prescription opioids, methadone, and buprenorphine); heroin; illicit use of central nervous system (CNS) depressants (i.e., tranquilizers, barbiturates, benzodiazepines, and sedatives); illicit use of stimulants (i.e., amphetamines, prescription stimulants, and cocaine), and other drugs (e.g., hallucinogens/psychedelics, inhalants, and synthetic or designer drugs). Problem drinking was operationalized as using alcohol to intoxication and/or binge drinking.

Clients were asked to self-report whether they had experienced any of the DSM-5 diagnostic criteria for substance use disorder (SUD). Specifically, clients were asked whether they had used drugs or alcohol in larger amounts or over a longer period of time than they had planned, whether they felt craving or strong desire or urge to use drugs or alcohol, or whether they had continued substance use in spite of physical or emotional problems related to drugs or alcohol. Computing a sum of the criteria to which a client responded “yes” was used to classify clients as having severe substance abuse disorder per the DSM-5 (American Psychiatric & American Psychiatric Association, 2017). Participants were asked how many times in their lifetime they had received services for substance abuse problems including detox, drug court, and other programs before the current admission to a SADT program.

Clients were also asked if, in the past 30 days, they had contact with family or friends who were supportive of their recovery at program entry and at follow-up.

Procedure

Data for this analysis were collected as part of a multi-year outcome evaluation, which involved an assessment at program entry and follow-up about 12 months later. A total of 3182 clients completed an assessment with treatment staff as they entered a SADT program at one of 16 Regional Community Mental Health Centers across one state between September 2016 and June 2019 and completed a follow-up assessment about 12 months later with staff from a state university contracted to conduct the follow-up interviews. The Regional Community Mental Health Centers offer a variety of SADT programs including inpatient, detox, counseling, and residential treatment programs and clients can mix treatment modalities as well. The intake and follow-up data are not connected to service data. The firearm threats groups were operationalized as: clients who reported they had never experienced firearm threats were in the no firearm threats group; clients who experienced firearm threats but not the 12 months before SADT program entry were in the lifetime firearm threats group; and clients who experienced firearm threats in the 12 months before SADT program entry were in the recent firearm threats group. All research activities associated with this project were approved by the University of Kentucky Institutional Review Board (IRB).

Analysis Plan

Chi-square tests of independence and one-way Analysis of Variance (ANOVA) were used to examine bivariate differences for individuals who experienced no firearm threats, lifetime firearm threats, and recent firearm threats groups overall and by gender. Because of the number of comparisons, bivariate comparisons significant at p < .01 are reported while group comparisons were adjusted using Bonferroni. A logistic regression was conducted to examine factors associated with any problem alcohol and/or illicit drug use in the 12 months before follow-up with status at intake for: age, gender homelessness [Yes/No], unemployment as usual employment pattern [Yes/No], arrest/incarceration [Yes/No], DSM SUD level [ranging from none to severe], overall health rating, suicidality [Yes/No], quality of life rating, no contact with individuals supportive of recovery in the past 30 days [Yes/No], past year interpersonal victimization [Yes/No], firearm threat group, and ACEs total. Independent variables were examined for multicollinearity and the tolerance and variance inflation factor (VIF) were within the acceptable ranges (tolerance >0.10 and VIF <1.4, Mertler & Vannatta, 2005).

Results

Sample Description

Clients in the sample were, on average, 35 years old (range: 18–76 years old), 48.7% of the sample were men and 51.3% were women. Most identified as White (92.8%), with a small minority who identified as Black (5.1%). Over half (51.7%) were married or cohabiting. The majority of both men and women (71.5%) were referred to the program by the Department of Corrections (DOC), the courts, or child protective services.

Firearm Threats

Overall, 36.4% of the clients in the sample had ever experienced a firearm threat. More men experienced any firearm threats than women (38.8% vs. 34.2%, X² (1) = 7.442, p < .01). However, more women reported recent firearm threats compared to men (20.2% vs. 27.2%, X² (1) = 7.883, p < .01).

Demographics and Characteristics at Program Entry

As Table 1 shows, individuals with recent firearm threats were significantly younger than adults in the other two groups while individuals with lifetime firearm threats were significantly older than the other two groups. Close to half, regardless of firearm threat group, were living with children under 18 years old in the year before SADT program entry although more individuals with no firearm threats were living with minor children than individuals who had ever been threatened with a firearm. When examining gender differences and living with minor children there were no significant differences for men but more women in the no firearm threat group lived with minor children than the other two groups (no firearm threat Group 53.5%, lifetime firearm threat Group 43.1%, and recent firearm threat Group 45.0%, X² (2) = 16.621, p < .001).

Table 1.

Demographics and characteristics at SADT program entry by firearm threat group.

N (%)	No Firearm Threats (n = 2029)	Lifetime Firearm Threats (n = 889)	Recent Firearm Threats (n = 274)	Total (n = 3192)	Df	X² or F-statistic
Sociodemographic
Age	34.7_a (SD 10.2)	36.0_b (SD 10.0)	31.6_c (SD 9.2)	34.8 (SD 10.1)	2, 3186	19.885**
Living with children under 18^a	966 (53.5)_a	338 (43.1)_b	109 (45.0)_b	1413 (49.9)	2	26.140**
Economic vulnerability
Usual employment was unemployed	558 (27.5)	255 (28.7)	93 (33.9)	906 (28.4)	2	4.981
Consider yourself homeless	430 (21.2)_a	275 (30.9)_b	156 (56.9)_c	861 (27.0)	2	166.364**
Difficulty meeting basic needs	867 (42.7)_a	497 (55.9)_b	175 (63.9)_b	1539 (48.2)	2	72.393**
Criminal justice system involvement
Arrest	1147 (56.5)_a	537 (60.4)_a	194 (70.8)_b	1878 (58.8)	2	21.559**
Incarceration	1198 (59.0)_a	601 (67.6)_b	193 (70.4)_b	1992 (62.4)	2	27.549**
Supervision^a	812 (40.0)_a	438 (49.3)_b	111 (40.5)_a	1361 (42.6)	2	22.176**
Quality of life rating	6.6_a (SD 2.2)	6.2_b (SD 2.3)	6.0_b (SD 2.4)	6.3 (SD 2.3)	2, 3186	14.548**
Overall health rating^a	2.7_a (SD 1.0)	2.5_b (SD 1.0)	2.4_b (SD 1.0)	2.5 (SD 1.0)	2, 3186	20.027**
Mental health
Depression	998 (49.2)_a	538 (60.5)_b	204 (74.5)_c	1740 (54.5)	2	80.072**
Anxiety	936 (46.1)_a	528 (59.4)_b	201 (73.4)_c	1665 (52.2)	2	97.531**
Comorbid depression and anxiety	762 (37.6)_a	423 (47.6)_b	180 (65.7)_c	1365 (42.8)	2	89.775**
Suicidality	311 (15.3)_a	206 (23.2)_b	110 (40.1)_c	627 (19.6)	2	103.923**
Days mental health not good past 30	11.3_a (SD 11.8)	15.4_b (SD 12.2)	17.6_c (SD 12.1)	14.8 (SD 12.1)	2, 3186	60.723**
Any lifetime victimization	48.2%_a	84.0%_b	90.9%_c	90.9%_c	2	444.308**
Any past year victimization	324 (16.0)_a	231 (26.0)_b	187 (68.2)_c	742 (23.2)	2	374.974**
Substance use
Problem drinking^a	748 (36.9)_a	366 (41.2)	132 (48.2)_b	1246 (39.0)	2	15.335**
Illicit drug use^a	1750 (86.2)_a	799 (89.9)_b	258 (94.2)_b	2807 (87.9)	2	18.606**
DSM SUD level severe	1172 (57.8)_a	581 (65.4)_b	222 (81.0)_c	1975 (61.9)	2	61.690**
Prior treatment experiences	1.5_a (SD 2.9)	2.3_b (SD 4.0)	2.1_b (SD 3.5)	2.0 (SD 3.3)	2, 3186	21.457**
No contact with friends or family supportive of recovery	230 (11.3)	85 (9.6)	27 (9.9)	342 (10.7)	2	2.266

*p < .01; **p < .001; _a,b,c subscripts that differ are significant at p<.05.

^asignificant firearm threat group x gender.

Although there were no differences in unemployment by firearm threat groups, more individuals with lifetime and recent firearm threats reported they had been homeless and had difficulty meeting basic needs in the year before entering SADT compared to individuals with no firearm threat exposure. More individuals with recent firearm threats reported they had been homeless than the other two groups (see Table 1).

More adults with recent firearm threats had been arrested in the 12 months before program entry compared to adults with no firearm threats and individuals with lifetime firearm threats, while more individuals with lifetime and individuals with recent firearm threats had been incarcerated in the 12 months before program entry compared to individuals with no firearm threats. More adults with lifetime firearm threats indicated they were on supervision compared to adults with no firearm threats and adults with recent firearm threats (see Table 1). Among men, there were no differences in probation or parole by firearm threat group (no firearm threat Group 45.0%, lifetime firearm threat Group 50.6%, and recent firearm threat Group 45.1%, X² (2) = 4.12, p > .01; not depicted in a table). However, more women in the lifetime firearm threat group were on probation or parole than the other two groups (no firearm threat Group 35.7%, lifetime firearm threat Group 47.7%, and recent firearm threat Group 35.5%, X² (2) = 18.656, p < .001; not depicted in a table).

Individuals with any firearm threats (lifetime and recent) had lower quality of life ratings compared to individuals with no firearm threats. Individuals with lifetime and recent firearm threats had a lower overall health rating than individuals who were not threatened with a firearm. More individuals with recent firearm threats had depression, anxiety, comorbid depression and anxiety, suicidality, and days mental health was not good before program entry compared to the other two groups. More individuals with lifetime firearm threats had depression, anxiety, comorbid anxiety and depression, suicidality, and days mental health was not good in the past 30 compared to individuals who had never been threatened with a firearm.

More individuals with recent firearm threats reported any victimization (e.g., robbery, assault, sexual assault, partner abuse, and stalking) as well as victimization in the year before program entry than the other two groups. More individuals with lifetime firearm threats experienced any lifetime and past year victimization compared to individuals with no firearm threats.

More individuals with recent firearm threats engaged in problem drinking (e.g., intoxication, and binge drinking) than those with no firearm threats. More individuals with lifetime and recent firearm threats reported using illicit drugs in the 12 months before program entry than individuals who had not been exposed to firearm threats. More individuals with recent firearm threats met the criteria for severe SUD than either of the other two groups while more individuals with lifetime firearm threats met criteria for severe SUD than individuals who did not experience firearm threats. Additionally, individuals with any firearm threats reported more prior treatment episodes than individuals with no firearm threats. There were gender differences by firearm threat group for both illicit drug use and problem drinking. More men with lifetime and recent firearm threats reported illicit drug use than those in with no firearm threats (no firearm threat group 81.3%, lifetime firearm threat group 88.0%, and recent firearm threat group 92.6%, X² (2) = 17.701, p < .001), while there were no differences for illicit drug use for women (no firearm threat group 86.2%, lifetime firearm threat group 89.9%, and recent firearm threat group 94.2%, X² (2) = 4.212, p > .01; not depicted in a table). More women with recent firearm threats reported problem drinking before SADT program entry than the other two groups (no firearm threat group 30.4%, lifetime firearm threat group 34.9%, and recent firearm threat group 50.7%, X² (2) = 25.235, p < .001) while there were no differences in problem drinking by firearm threat group for men (no firearm threat group 44.2%, lifetime firearm threat group 46.5%, and recent firearm threat group 45.1%, X² (2) = .665, p > .01; not depicted in a table).

Adverse Childhood Experiences

As Table 2 shows, individuals with recent firearm threats had the greatest number of ACEs compared to the other two groups, and individuals with lifetime firearm threats had a greater number of ACEs compared to individuals with no firearm threats. Additionally, 71.2% of individuals with recent firearm threat victimization experiences reported four or more ACEs compared to 59.4% of those with lifetime firearm threats and 36.9% of those with no firearm threat experiences. Examining the specific ACE items there is a similar pattern: significantly fewer individuals who did not experience firearm threats experienced each ACE item. Additionally, more individuals in the recent firearm threat group reported someone in the household going to prison, emotional abuse and neglect, and sexual abuse than individuals in the lifetime firearm threats.

Table 2.

Adverse Childhood Experiences by firearm threat groups.

N (%)	No Firearm Threats (n=2029)	Lifetime Firearm Threats (n=889)	Recent Firearm Threats (n=274)	Total (n=3192)	Df	X² or F-statistic
Average Number of Types of Adverse Childhood Experiences (0–10)	3.0_a (Sd 2.7)	4.7_b (Sd 3.0)	5.3_c (Sd 3.0)	4.3 (Sd 3.0)	2, 3186	171.031**
Experienced 4+ Adverse Childhood Experiences	748 (36.9)_a	528 (9.4)_b	195 (71.2)_c	1471 (46.1)	2	202.155**
Someone in your household went to prison	356 (17.5)_a	233 (26.2)_b	107 (39.1)_c	696 (21.8)	2	79.501**
Parents were separated or divorced	1121 (55.2)_a	560 (63.0)_b	192 (70.1)_b	1873 (58.7)	2	31.337**
Someone in household was a problem drinker or used illicit drugs	962 (47.4)_a	575 (64.7)_b	189 (69.0)_b	1726 (54.1)	2	101.027**
Someone in household was depressed, mentally ill, or attempted suicide	627 (30.9)_a	421 (47.4)_b	150 (54.7)_b	1198 (37.5)	2	109.266**
Witnessed domestic violence	479 (23.6)_a	365 (41.1)_b	124 (45.3)_b	968 (45.3)	2	120.700**
Emotional neglect	661 (32.6)_a	443 (49.8)_b	166 (60.6)_c	1270 (39.8)	2	130.924**
Physical neglect	350 (17.2)_a	279 (31.4)_b	104 (38.0)_b	733 (23.0)	2	107.887**
Emotional abuse	674 (33.2)_a	498 (56.0)_b	177 (64.6)_c	1349 (42.3)	2	192.972**
Physical abuse	476 (23.5)_a	406 (45.7)_b	135 (49.3)_b	1017 (31.9)	2	182.293**
Sexual abuse	423 (20.8)_a	294 (33.1)_b	122 (44.5)_c	839 (26.3)	2	99.138**

**p < .001; _a,b,c subscripts that differ are significant at p<.05.

Characteristics by Firearm Threat Group at Follow-up

More individuals with both recent and lifetime firearm threats reported homelessness in the 12 months prior to the follow-up than individuals with no firearm threats (see Table 3). More individuals with lifetime firearm threats indicated they had difficulty meeting basic needs than the other two groups. More men with lifetime and recent firearm threat before program entry reported homelessness after SADT program entry than those with no firearm threats (no firearm threat group 4.4%, lifetime firearm threat group 9.4%, and recent firearm threat group 8.2%, X² (2) = 14.055, p < .01) while there were no differences in homelessness at follow-up for women (no firearm threat group 8.1%, lifetime firearm threat group 9.1%, and recent firearm threat group 12.6%, X² (2) = 3.432, p > .01; not depicted in a table).

Table 3.

Characteristics at follow-up by firearm threat group.

N (%)	No Firearm Threats (n = 2029)	Lifetime Firearm Threats (n = 889)	Recent Firearm Threats (n = 274)	Total (n = 3192)	Df	X² or F-statistic
Economic Vulnerability
Usual employment is unemployed	564 (28.1)	214 (24.3)	86 (31.6)	864 (27.3)	2	6.670
Homelessness^a	129 (6.4)_a	82 (9.2)_b	29 (10.6)_b	240 (7.5)	2	11.334^a
Difficulty meeting basic needs	731 (36.0)_a	418 (47.0)_b	114 (41.6)	1263 (39.6)	2	31.753**
Criminal justice system involvement
Arrest	536 (26.8)_a	275 (31.2)_b	105 (38.5)_b	916 (29.0)	2	18.843**
Incarceration^a	629 (31.2)_a	324 (36.7)_b	113 (41.5)_b	1066 (33.6)	2	16.585**
Supervision^a	697 (34.6)_a	383 (43.2)_b	120 (43.8)_b	1200 (37.8)	2	23.836**
Quality of life rating	7.9 (SD 2.0)	7.7 (SD 2.0)	7.6 (SD 2.2)	7.7 (SD 2.0)	2, 3167	3.404
Overall health rating	3.3_a (SD 1.1)	3.2_b (SD 1.1)	3.3 (SD 1.1)	3.2 (SD 1.1)	2, 3183	5.081^b
Mental health
Depression	619 (30.7)_a	345 (38.9)_b	103 (37.7)	1067 (33.6)	2	20.816**
Anxiety	559 (27.7)_a	327 (37.0)_b	104 (38.1)_b	990 (31.2)	2	31.480**
Comorbid anxiety and depression	395 (19.6)_a	236 (26.7)_b	75 (27.5)_b	706 (22.3)	2	22.478**
Suicidality	146 (7.2)_a	100 (11.3)_b	46 (16.8)_c	292 (9.1)	2	33.270**
Days mental health not good past 30	5.4_a (SD 8.8)	6.7_b (SD 9.7)	7.1_b (SD 10.1)	6.4 (SD 9.2)	2, 3174	9.082**
Victimization
Past year firearm threats	38 (1.9)_a	47 (5.3)_b	22 (8.0)_b	107 (3.4)	2	42.477**
Any past year victimization (other than firearm threats)	205 (10.1)_a	143 (16.1)_b	67 (24.5)_c	415 (13.0)	2	54.305**
Substance use
Problem drinking	302 (14.9)	141 (15.9)	48 (17.5)	491 (15.4)	2	1.5
Illicit drug use	646 (32.1)	317 (35.9)	109 (39.8)	1072 (33.8)	2	8.693
Any problem alcohol or illicit drug use	788 (38.8)	374 (42.1)	123 (44.9)	1285 (40.3)	2	5.362
Severe SUD per DSM criteria	519 (26.1)	251 (29.2)	92 (34.1)	862 (27.6)	2	9.126
No contact with friends or family supportive of recovery	204 (10.1)_a	61 (6.9)_b	15 (5.5)_b	280 (8.8)	2	12.047^a

*p < .01; **p < .001; _a,b,c subscripts that differ are significant at p<.05.

^asignificant firearm threat group x gender.

More individuals in the recent and lifetime firearm threat groups indicated they had been arrested, spent time in jail or prison, and were on supervision than individuals with no firearm threats. More women with any firearm threats reported incarceration at follow-up than women with no firearm threats (no firearm threat group 29.5%, lifetime firearm threat group 38.9%, and recent firearm threat group 44.1%, X² (2) = 20.794, p < .001) while there were no differences in incarceration by firearm threat group for men (no firearm threat group 33.2%, lifetime firearm threat group 34.7%, and recent firearm threat group 38.3%, X² (2) = 1.414, p > .01; not depicted in a table). More women with any firearm threats reported being on probation or parole at follow-up than women with no firearm threats (no firearm threat group 30.8%, lifetime firearm threat group 43.0%, and recent firearm threat group 42.8%, X² (2) = 23.988, p < .001), while there were no differences in criminal justice supervision by firearm threat group for men (no firearm threat group 39.0%, lifetime firearm threat group 43.3%, and recent firearm threat group 45.1%, X² (2) = 3.461, p > .01).

Individuals with lifetime firearm threats had a lower overall health rating and more had depression than individuals with no firearm threats. More individuals with lifetime and recent firearm threat reported anxiety, comorbid anxiety and depression and suicidality and days mental health was not good in the past 30 days at follow-up compared to those with no firearm threats. More individuals in the recent firearm threat group reported suicidality than individuals with lifetime firearm threats.

More individuals with lifetime and recent firearm threat reported new firearm threats and other interpersonal victimization experiences in the 12 months before the follow-up compared to individuals who did not experience firearm threats before program entry. More individuals in the recent firearm threat groups reported victimization in the 12 months before follow-up than individuals in the lifetime threat group.

There were no differences by firearm threat group in problem drinking, illicit drug use, or severity of SUD level. More individuals with any firearm threats reported they had no contact with friends or family supportive of recovery compared to the no firearm threat group.

Logistic Regression Analysis

Table 4 shows the factors associated with any problem alcohol and/or illicit drug use include younger age, being male, having not been arrested or incarcerated at intake, having a higher DSM SUD criteria level, suicidality at intake, and lower quality of life rating.

Table 4.

Logistic regression results of factors associated with any illicit drugs or problem alcohol use at follow-up.

	Any Problem Drinking or Illicit Drug Use 12 months before Follow-Up
Intake Factors	Wald	OR
Age	10.060	.988**
Gender	26.785	.660***
Homelessness	.137	1.034
Usual employment is unemployed	.449	1.058
Arrest/incarceration	19.660	.702***
DSM SUD criteria level	21.569	1.164***
Overall health rating	.018	1.005
Suicidality	5.076	1.247^a
Quality of life rating	18.864	.928***
No contact with friends or family supportive of recovery	1.365	1.150
Past year victimization	.836	1.093
Firearm threat group	.001	.998
ACEs total	2.328	1.022

*p < .05; **p < .01; ***p < .001.

Discussion

Currently, firearm-related risk research is limited, particularly among individuals involved with problem drinking and/or illicit drugs. However, it is crucial to develop data-driven, evidence-based interventions that address the full scope and nature of firearm-related risks particularly for high-risk populations such as substance-involved individuals. It should be noted that about half of the SADT clients in the current study were living with minor children in the year before program entry. Thus, addressing firearms-related risks can save lives not only for individuals involved with alcohol and illicit drugs, but for family members, including children, who may have risks of self- or accidental injury or violence perpetration. This study is one of the first to examine whether and how firearm threat victimization is associated with client status and supports before and after SADT program entry. Overall, more than one-third of SADT clients in the current study had ever experienced a firearm threat and 9% of the full sample experienced a firearm threat in the year before SADT program entry. There were five main results that are discussed including (1) firearm threats were associated with increased economic vulnerability, criminal justice system involvement, mental health problems, and victimization both before and after SADT program entry; (2) a greater number of adverse childhood experiences were associated with firearm threat victimization; (3) clients with any firearm threats had a higher number of prior treatment episodes than individuals with no firearm threats; (4) although the multivariate analysis did not find a significant independent association of firearm threats with follow-up use of problem alcohol and illicit drug use, many of the factors associated with firearm threat in the bivariate analysis were associated with problem alcohol and illicit drug use at follow-up; and (5) there were few gender differences associated with firearm threat exposure.

In the general population, about one-quarter of adults report they or someone in their family had been threatened with a firearm (Parker, Horowitz, Igielnik, Oliphant, & Brown, 2017). That rate of firearm threat victimization is much lower than what was found in the current study, with over one-third of SADT clients reporting they had been threatened with a firearm. More individuals with any firearm threat victimization, and especially recent firearm victimization, reported homelessness and difficulty meeting basic needs at intake and more individuals who reported any firearm victimization also reported homelessness at follow-up. In general, poverty and social disadvantage have been associated with violent crime and firearm mortality (Males, 2015). A few other studies have found associations between economic vulnerability and firearm violence (Boeck et al., 2020; Everytown for Gun Safety, 2020; Kim, 2019). One other study found high rates of firearm threat victimization among homeless youth (Hsu et al., 2021). Safe and stable housing should be one of the highest priorities for individuals with substance use disorders who are homeless or at risk of becoming homeless (Reif et al., 2014; Rog et al., 2014). The lack of safe and stable housing increases the risk of substance use and involvement in the criminal justice system as well as (re)victimization (Chavira & Jason, 2017; Cusack & Montgomery, 2017; Polcin, 2016). The overlap between firearm victimization among those with unsafe or unstable housing may make maintaining SADT program participation and recovery more difficult (Jason, Olson, Ferrari, & Lo Sasso, 2006; Logan et al., 2020; Milby, Schumacher, Wallace, Freedman, & Vuchinich, 2005; Polcin, Korcha, Bond, & Galloway, 2010a, 2010b; Reif et al., 2014; Shaham, Shalev, Lu, De Wit, & Stewart, 2003). Further, economic vulnerability in childhood has been associated with increased adverse childhood experiences and negative health outcomes in adolescence and adulthood (Fabio, Tu, Loeber, & Cohen, 2011; Finkelhor, Shattuck, Turner, & Hamby, 2013; Males, 2015; Walsh, McCartney, Smith, & Armour, 2019).

Negative life experiences including adverse childhood experiences and other victimization have been associated with firearm violence (Hsu et al., 2021). One study found that exposure to domestic and/or community violence was associated with an increased number of firearm-related assaults, although this research was done with individuals who had firearm injuries (Wamser–Nanney, Nanney, & Constans, 2020). Another study found that exposure to firearm violence in childhood is associated with increased distress (Mitchell et al., 2019). Other research suggests that access and exposure to firearms during adolescence increase risk of owning and carrying a firearm as well as experiencing and perpetrating firearm violence (Teplin et al., 2021). However, it is not clear whether or how cumulative negative life experiences such as adverse childhood experiences and adult victimization might increase firearm-related risks. There has been criticism of the ACE questions as they are limited and do not include items such as peer victimization, poverty, or community violence (Finkelhor et al., 2013). Others suggest that because suggest that firearm violence exposure should be added to the assessment of adverse childhood events (Rajan et al., 2019). Intervening early with children exposed to violence and firearms may reduce firearm risks in adulthood particularly those with lingering trauma reactions from their early adversity. One study found that even a modest 10% reduction in adverse childhood experiences can save around $105 billion annually (Bellis et al., 2019).

In addition to adverse childhood experiences, SADT clients in the current study reported other types of victimization. Prior victimization has been associated with increased likelihood of firearm-related conflicts particularly when there is involvement in substance use (Carter et al., 2017; Goldstick et al., 2019b; Schmidt et al., 2019). There is also an increased risk of revictimization with a firearm after a firearm threat for both men and women (Beardslee et al., 2018; Goldstick et al., 2019a; Kalesan et al., 2019; Rowhani–Rahbar et al., 2015; Schmidt et al., 2019; Teplin et al., 2021; Turner et al., 2016; Wallace, 2017). For women, the increased risk of revictimization may be more likely for those who were threatened by intimate partners who often repeat abuse and violence (Logan et al., 2021; Logan & Lynch, 2021a, 2021c). For men, retaliation motives may be associated with an increased likelihood of conflict involving a gun after an assault or threat (Carter et al., 2017). Another study found that individuals who perceive they were shot for no reason were more likely to possess a firearm, which may further increase firearm-related risks (Carter et al., 2017) especially when there is elevated use of substances and/or mental health problems.

In general, victimization is associated with perpetration of violence (Jennings, Piquero, & Reingle, 2012) which may be particularly pronounced among individuals with multiple victimization experiences (Farrell & Zimmerman, 2017). That general pattern appears to hold for victimization with firearms and perpetration of firearm violence (Beardslee et al., 2018; Goldstick et al., 2019a; Kalesan et al., 2019; Rowhani-Rahbar et al., 2015; Schmidt et al., 2019; Teplin et al., 2021; Turner et al., 2016; Wallace, 2017). One study found that twice the number of individuals who experienced threats with a weapon as an adolescent reported they perpetrated firearm violence in adulthood (43.8% vs. 20.6%) and almost half of those who had a gunshot injury in adolescence reported perpetrating firearm violence as an adult (48.4%) (Teplin et al., 2021). Other studies have found that victimization as an adolescent was associated with carrying a gun to school or work as an adult (Turner et al., 2016; Wallace, 2017) and carrying a gun is associated with increased substance use (Buschmann et al., 2017) as well as increased risk of firearm victimization and perpetration (Branas, Richmond, Culhane, Ten Have, & Wiebe, 2009; Oliphant et al., 2019). Factors such as aggression tendencies, impulsivity and beliefs regarding violence as well as prior victimization have been associated with later victimization and aggression (Farrell & Zimmerman, 2017). However, much of this literature has not examined firearm violence separately from general violence so it is not known whether those factors are similar or whether there are unique factors associated with risk of firearm violence victimization and perpetration (Wamser-Nanney et al., 2020).

The current study also found that more individuals with firearm threats were involved in the criminal justice system in the year before program entry and, although substance use was high regardless of firearm threat group, more individuals with firearm threats reported problem drinking, illicit drug use, and severe SUD than individuals who had not been threatened with a firearm. Further, more clients with recent firearm threats reported meeting criteria for the severe level of DSM SUD than the other two groups. Although the research literature has found an association of substance use and firearm risks and violence (Banks et al., 2017; Beardslee et al., 2018; Chen & Wu, 2016; Sigel, Mattson, & Mercado, 2019) pathways have not been clearly identified. It may be that firearm access and readiness (e.g., unsafe storage and carrying a loaded gun) is motivated by self-defense as a result of involvement in the illicit drug trade. It may also be that both substance use and firearm involvement are influenced by social networks. Involvement with illicit drugs may increase firearm-related victimization as a crime of opportunity or the effects of drugs or alcohol use on judgment and/or increases in impulsivity and agitation may be associated with increased firearm-related risks. Other research found that substance use increases after firearm victimization (Vella et al., 2020). The drug use context may include handling guns while using drugs and alcohol, buying or selling guns for drugs, or self-protection when selling drugs (Logan & Lynch, 2021a). Future research is needed to better understand how the nature, frequency, and severity of illicit drug and alcohol use may be associated with firearm-related risks.

Firearm threats overall, and in particular recent firearm threats, were associated with mental health symptoms including depression, anxiety, comorbid anxiety and depression, suicidality and days mental health were not good. Other research has found that being victimized with a gun is associated with significant distress even more than other types of weapons (e.g., knives), and the negative physical and emotional impacts can last months (Vella et al., 2020; Weigend Vargas & Hemenway, 2021). Further, although victimization is associated with distress and mental health symptoms which can last for a month or longer, many do not report the crime to police or seek help through victim services (Langton & Truman, 2014). Rates of suicidality in the current study were especially concerning with 40% of those with recent firearm threats, 23% for those with lifetime firearm threats, compared to 15% of those with no firearm threats at intake and over 10% of those with any firearm threats reporting suicidality at follow-up (11.3% for those with lifetime firearm threats and 16.8% for those with recent firearm threats). One study found that individuals who report suicidality also report having greater access to a firearm than individuals who do not report suicidality (Fulginiti et al., 2020). Several other studies have found access to and familiarity with firearms is associated with suicide risk (Anestis & Capron, 2018; Anestis & Houtsma, 2018). Yet another study found that more women who planned to get a gun soon reported recent suicidality suggesting screening should incorporate not only current gun owners but those who plan to get a gun (Logan & Lynch, 2021e). Because firearm victimization is associated with greater distress and suicidality in the current study as well as in previous research (Kagawa et al., 2020; Langton & Truman, 2014; Vella et al., 2020; Weigend Vargas & Hemenway, 2021), screening for victimization and in particularly firearm victimization, may be important among substance abuse treatment clients in order to provide support to reduce risk of self-injury, revictimization or perpetration of firearm violence.

There were a number of factors associated with problem alcohol and illicit drug use in between the intake and follow-up including being younger, being male, criminal justice system involvement, DSM SUD criteria level, suicidality, and quality of life rating. It should be noted that firearm threats were not associated with follow-up use of substances. Clearly those with firearm threats struggled with substance abuse treatment as they had more prior treatment episodes. It should be noted that SADT clients with recent firearm threat victimization were significantly younger than the other two groups but had the same number of prior treatment episodes as clients with lifetime firearm threats. Individuals who use substances and who are especially vulnerable, such as those who are homeless or who are transitioning out of jails or prisons, and may have many complex needs making SADT engagement and recovery more difficult (Chen, 2018; Davidson et al., 2010; Hennessy, 2017; Kahn, Vest, Kulak, Berdine, & Granfield, 2019; Padgett, Tiderington, Tran Smith, Derejko, & Henwood, 2016; Priester et al., 2016).

Successfully addressing substance use disorders requires, at some level, removing personal and environmental obstacles while establishing and maintaining an environment supportive of recovery, identifying and engaging with community-based services to support ongoing recovery needs, and increasing efficacy, hope, motivation, confidence and skills needed to initiate and maintain the difficult and prolonged work of recovery (Davidson et al., 2010). When an individual is struggling to meet basic needs such as shelter, food, safety, access to medical care, and experiencing disconnection from friends and family, and severe mental health problems such as suicidality, they may have greater difficulty with the tasks needed to address substance use disorders (Browne et al., 2016; Kahn et al., 2019; Lee et al., 2017; Padgett et al., 2016). Increased resources may then facilitate recovery and those with firearm-related victimization may have increased or unique needs.

One limitation of this study is the lack of diversity in that the sample was mostly White. Research suggests that certain racial/ethnic groups may be at increased risks of firearm injuries and deaths (Boeck et al., 2020; Everytown for Gun Safety, 2019; Hink et al., 2019). Another limitation of the study is the lack of contextual factors associated with understanding firearm threats, including age of victimization, repeat victimization, and whether firearm threats were made in the context of other victimization (e.g., robbery, assault, and rape) and/or how firearm victimization intersects with illicit drug or problem alcohol use involvement. Also, firearm threats vary (e.g., witnessing, and indirect threats) and this study measured threats more narrowly (Logan et al., 2020). Further, analyzing associations of firearm threats by kind of treatment received may yield varying results. Unfortunately, the data used for this study does not include service data.

Even within the limitations of this study, the current study provides important information with a large sample of adults entering SADT and their status 12 months after program entry. Overall, there were few gender differences although more women reported recent firearm threats than men (27.2% vs. 20.2%). Firearm threats impact a significant number of men and women coming into SADT; yet, screening for firearm threats is not standard practice in most health services (Diurba et al., 2020; Naureckas Li, Sacks, McGregor, Masiakos, & Flaherty, 2019). One study found that greater behavioral health treatment capacity may have a small impact on firearm suicide which may underscore the importance of increased efforts at screening and support among SADT clients impacted by gun violence (Goldstein, Prater, & Wickizer, 2019). The current study results underscore the importance of screening for firearm risks across a wide variety of services and providing education and interventions to individuals at higher risk such as to individuals who use substances, adolescents who have been exposed to adverse events in childhood and who use substances, and women and girls with abusive partners. Further, although associations of illicit drug use and firearm-related risks have been identified, firearms research is still relatively limited. Some studies indicate firearm-related risks are associated with substance use, while other studies have found mixed results (Chen & Wu, 2016). Inconsistent findings could be due to using a narrow measurement of firearm-related risks and/or due to a narrow assessment of substance use. Thus, to develop effective interventions, more comprehensive research is needed to identify the most important factors to target in reducing firearm-related risks among substance-involved adults. Addressing firearm-related risks among substance-involved individuals can save lives and effective interventions need to be data-driven and tailored to high-risk populations.

Footnotes

Acknowledgments

The data collected for this study was supported by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities, and Division of Behavioral Health.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

TK Logan

Author Biographies

TK Logan, Ph.D. is a professor at the University of Kentucky, Department of Behavioral Science. Her research focuses on firearms violence, stalking, partner abuse, sexual assault, and safety and coping with victimization. Dr. Logan is currently the principle investigator on five projects to evaluate substance abuse treatment programs that serve adults, adolescents, and pregnant women.

Jennifer Cole, Ph.D. is an associate professor at the University of Kentucky, Department of Behavioral Science. Her research focuses on the intersection of interpersonal victimization and substance use, and evaluation of community responses to individuals with victimization experiences and substance use disorders.

Maggie Schroeder, MS, LCADC is currently the Program Manager for the Adult Substance Use Treatment and Recovery Services Branch at the Division of Behavioral Health, Developmental & Intellectual Disabilities for the State of Kentucky. She has over 30 years of experience in providing behavioral health and substance abuse services to individuals and their families including case management and therapeutic interventions services as well as providing clinical and administrative supervision.

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