Elsevier

Drug and Alcohol Dependence

Volume 205, 1 December 2019, 107685
Drug and Alcohol Dependence

Full length article
Aggression and violence at ambulance attendances where alcohol, illicit and/or pharmaceutical drugs were recorded: A 5-year study of ambulance records in Victoria, Australia

https://doi.org/10.1016/j.drugalcdep.2019.107685Get rights and content

Highlights

  • A study of aggression and violence in ambulance attendances involving substance use.

  • Patients in aggressive/violent attendances are more likely to be younger and male.

  • Alcohol is the substance most to be likely involved in aggressive/violent attendances.

  • Late-night weekend attendances are more likely to involve aggression/violence.

  • Findings are similar in both metropolitan and regional populations.

Abstract

Background

This study describes the frequency and characteristics of aggression and/or violence in ambulance attendances involving alcohol, illicit and/or pharmaceutical drug use in Victoria, Australia between January 2012 and January 2017.

Methods

Patient characteristics, context, and substance use involvement in ambulance attendances were examined to determine associations with attendances where aggression and/or violence was recorded.

Results

There were 205,178 ambulance attendances where use of alcohol, pharmaceutical drugs or illicit substances contributed to the reason for the attendance. Paramedics recorded acts of aggression and/or violence in 11,813 (5.76 %) of these attendances. Aggression/violence was more likely to be recorded in certain contexts. Compared with attendances where aggression/violence was not recorded, attendances where aggression/violence was recorded were significantly more likely to involve younger and male patients, and occur on Friday and Saturday nights. Alcohol intoxication was involved in more than half of attendances where aggression/violence was recorded, and was almost twice as prevalent as those involving illicit drug use where aggression/violence was recorded. This pattern was consistent across all hours, high-alcohol hours only, by metropolitan/regional location, and by police co-attendance.

Conclusions

Aggression and violence are frequently recorded in ambulance attendances involving alcohol, pharmaceutical drugs or illicit substances, and, most often involve alcohol. This violence poses a recurring threat to the health and safety of paramedics, bystanders, and patients. Greater priority should be given to reducing alcohol-related violence through evidence-based policy measures targeting high-risk groups (e.g. young adult males) and contexts (e.g. weekends, late at night) where harm is most likely to occur.

Introduction

In 2016, approximately 25 % of Australians aged 14 years and over consumed alcohol at levels placing them at risk for short-term harms at least once a month (Australian Institute of Health and Welfare, 2017). Additionally, approximately 12 % and 5 % had recently used illicit drugs or misused pharmaceutical drugs, respectively (Australian Institute of Health and Welfare, 2017). The use of alcohol or illicit drugs is also linked to harmful activities, such as verbally abusing someone (6.8 % of single occasion risky drinkers and 2.8 % of illicit drug users) and physically abusing someone (1 % of single occasion risky drinkers and 0.6 % of illicit drug users) (Australian Institute of Health and Welfare, 2017).

Considerable research identifies both alcohol and illicit drug use as significant individual risk factors for aggressive and violent behaviour (Boles and Miotto, 2003). Alcohol use, for example, can instigate and increase aggression due to pharmacological effects that depress an individual’s executive functioning and lead to disinhibition of aggressive impulses (Giancola et al., 2010). Illicit drug use is also associated with aggressive and violent behaviour, not only because of the pharmacological effects, but also because of the economic and systemic ties between illicit drug markets and violence (Goldstein et al., 1989). A recent longitudinal study of methamphetamine users found evidence of a dose-response increase in violent behaviour, largely independent of psychotic symptoms (McKetin et al., 2014). There is also some evidence, though mixed, of a link between some types of pharmaceutical drug use (e.g. benzodiazepines) and violent behaviour (Albrecht et al., 2014). However, not all substance users are violent, and the effect of substance use on violent behaviour is contingent on a host of individual factors (e.g. age, gender, childhood experiences, personality traits), patterns of substance use, the different pharmacological effects of substances and their interactions, as well as various social, cultural and contextual factors that shape attitudes and behaviours towards substance use and violence in the population (Fals-Stewart et al., 2005).

Studies have shown that although perpetrators of substance-related violence are frequently known by their victims (e.g. relatives, intimate partners, friends, co-workers), a large proportion of perpetrators are strangers to the victim (Laslett et al., 2011; Sommers and Baskin, 2006). In the latter case, those who attend to, and care for, individuals experiencing acute effects and harms from substance use (e.g. intoxication, overdose, injury), including law enforcement officers (Donnelly et al., 2007; Legislative Assembly Committee on Law and Safety, 2017; Roche et al., 2009), hospital workers (Drugs and Crime Prevention Committee, 2011; Egerton‐Warburton et al., 2016; Phillips, 2016), and pre-hospital workers such as paramedics (Grange and Corbett, 2002; Heilbronn et al., 2015; Petzäll et al., 2011), are at particular risk of aggressive and/or violent behaviour.

There are increasing media reports of violence at ambulance attendances in Australia (Dow, 2018; Power, 2018), and growing recognition by governments of this problem as a significant community safety issue (Andrews, 2018). A small body of Australian research measures and describes the magnitude of the problem (Boyle et al., 2007; Heilbronn et al., 2015; Koritsas et al., 2009; Maguire, 2018; Maguire et al., 2014). While there are policies in place in Australia that attempt to reduce aggression/violence at ambulance attendances (Victorian Government, 2015), there is a lack of peer-reviewed literature on the effectiveness of any interventions to curb the increasing experience of violence (Maguire et al., 2018). A number of factors may contribute to violence at ambulance attendances, including paramedic factors (e.g., qualifications, gender, hours per week in contact with patients), patient factors (e.g., alcohol and drug use, being a victim of violence, mental health disorders), and environmental risk factors (e.g., time of day) (Gillespie et al., 2010; Koritsas et al., 2009). A recent parliamentary inquiry in Australia identified substance use, along with other factors such as mental illness, as one of the main individual-level contributing factors to violence at ambulance attendances (Legislative Assembly Committee on Law and Safety, 2017). However, given the research evidence of differences between substance types in their contribution to violence (Boles and Miotto, 2003), the differences in substance availability and legal status in Australia, and hence, the different implications for policy and program investment decisions, it is important that the involvement of substance use in aggression and/or violence at ambulance attendances is examined in detail. Ambulance data can provide comprehensive information regarding identifying trends in aggression and/or violence and identifying at-risk groups (Masho et al., 2014; Quigg et al., 2017) and provide information that is not available in ED data (e.g., exact location of aggression/violence; Downing et al., 2005). The relatively scarce resources for alcohol and other drug treatment programs in Australia, which represent just 0.8 % of total health-care expenditure (Ritter et al., 2015), further underlines how important it is that policies and government investment in programs to reduce substance-related harm are informed by sound evidence.

This study uses data from an internationally unique, ongoing surveillance system of ambulance attendances involving alcohol, illicit and/or pharmaceutical drug use in Victoria, Australia. We aimed to address the question of which individual, contextual, and substance type factors are more likely to characterise ambulance attendances where aggression and violence are recorded, compared with attendances where aggression and violence is not recorded. This aggression and/or violence may be aggression directed from or towards other members of the public (known or unknown to the individual being treated), aggressive behaviour that leads to property damage, or aggression/violence directed towards paramedics or police on the scene. The study adds to existing knowledge about substance-related harm in the population by examining aggression and violence in ambulance attendances, which is often not fully captured by analyses that rely only on police or hospital data (Ariel et al., 2015; Quigg et al., 2017; Taylor et al., 2016). By identifying salient characteristics of ambulance attendances where aggression and violence is recorded, this study aimed to provide evidence to inform policy responses to substance-related violence in the community.

Section snippets

Data

This study uses data from a unique surveillance system known as the Ambo Project: Drug and Alcohol-Related Ambulance Attendances (for details see Dietze et al., 2000; Lloyd and McElwee, 2011). In brief, data are sourced from Ambulance Victoria’s clinical electronic patient care record system, VACIS®. All attendance records are filtered to identify those where alcohol, other drugs or mental health symptomology are associated with the attendance. The records selected from the filtering include

Frequency and characteristics ambulance attendances where aggression and/or violence was recorded

There were 205,178 ambulance attendances where substance use was recorded in Victoria between January 2012 and January 2017, and aggression and/or violence was recorded in 11,813 (5.76 %) of these attendances. Table 1 shows that, compared to attendances where aggression/violence was not recorded, in attendances where aggression/violence was recorded the patient was significantly more likely to be younger (t = 26.47, ρ< 0.001) and male (χ2 (1) = 578.90, ρ< 0.001). Approximately three-quarters

Discussion

Aggression and violence are frequently recorded at ambulance attendances that involve substance use. Clinical records indicate that aggression/violence was recorded in around one in 20 substance-involved ambulance attendances in Victoria over a 5-year period. At attendances involving substance use and where aggression/violence was recorded, individuals were more likely to be younger and male, compared with those attendances where aggression/violence was not recorded. This is consistent with the

Conclusion

Preventing substance-related aggression and violence at ambulance attendances represents a major public health and safety challenge for health care providers, governments, and the wider community. This study has shown that, in Australia’s second most populous state, Victoria, alcohol use is the leading type of substance use involved in ambulance attendances where aggression/violence is recorded. However, in recent years, preventing harm attributable to alcohol use appears to have been treated

Role of funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Kerri Coomber receives funding from Australian Research Council, Foundation for Alcohol Research and Education, Lives Lived Well, Australian Rechabites Foundation, and the Queensland government.

Peter Miller receives funding from Australian Research Council and Australian National Health and Medical Research Council, grants from NSW Government, National Drug Law Enforcement

Contributors

KC, AC, PGM, DS, CH, and SM developed the study, analysis plan, and conducted initial analyses. BV drafted the paper. JW and FM conducted further analyses. All authors contributed to the drafting and critical review of the manuscript, and approved of the final manuscript as submitted.

Declaration of Competing Interest

No conflict declared.

Acknowledgments

The authors wish to acknowledge and thank those who have provided valuable assistance with this study, including Ambulance Victoria and its paramedics for data entry, and coding staff at Turning Point, Eastern Health for coding of ambulance records. The Ambo Project is funded by the Victorian Department of Health and Human Services. We would like to acknowledge the contribution of Prof Paul Dietze for his work on the original Ambo Project dataset.

References (52)

  • Australian Institute of Health and Welfare

    National Drug Strategy Household Survey 2016: Detailed Findings

    (2017)
  • M. Boyle et al.

    A pilot study of workplace violence towards paramedics

    Emerg. Med. J.

    (2007)
  • K. Coomber et al.

    Larger regional and rural areas in Victoria, australia, experience more alcohol‐related injury presentations at emergency departments

    J. Rural Health

    (2013)
  • P. Dietze et al.

    Ambulance attendance at heroin overdose in Melbourne: the establishment of a database of ambulance service records

    Drug Alcohol Rev.

    (2000)
  • N. Donnelly et al.

    Estimating the Short-term Cost of Police Time Spent Dealing With Alcohol-related Crime in NSW

    (2007)
  • A. Dow

    Paramedic in Hospital After Being’ Punched in the Face’ by Patient

    (2018)
  • Drugs and Crime Prevention Committee

    Inquiry into Violence and Security Arrangement in Victorian Hospitals and, in Particular, Emergency Departements: Final Report

    (2011)
  • A.A. Duke et al.

    Alcohol, drugs, and violence: a meta-meta-analysis

    Psychol. Violence

    (2018)
  • D. Egerton‐Warburton et al.

    Perceptions of Australasian emergency department staff of the impact of alcohol‐related presentations

    Med. J. Aust.

    (2016)
  • W. Fals-Stewart et al.

    The occurrence of male-to-female intimate partner violence on days of men’s drinking: the moderating effects of antisocial personality disorder

    J. Consult. Clin. Psychol.

    (2005)
  • P.R. Giancola et al.

    Alcohol myopia revisited: clarifying aggression and other acts of disinhibition through a distorted lens

    Perspect. Psychol. Sci.

    (2010)
  • G.L. Gillespie et al.

    Workplace violence in healthcare settings: risk factors and protective strategies

    Rehabil. Nurs.

    (2010)
  • P.J. Goldstein et al.

    Crack and homicide in New York City, 1988: a conceptually based event analysis

    Contemp. Drug Probs.

    (1989)
  • C. Heilbronn et al.

    Violence in Alcohol and Drug Related Ambulance Attendance in Victoria: Developing Models of Harms

    (2015)
  • S. Koritsas et al.

    Factors associated with workplace violence in paramedics

    Prehospital Disaster Med.

    (2009)
  • K. Kypri et al.

    The National Alcohol Strategy 2018–2026 has to become a set of commitments

    Drug Alcohol Rev.

    (2018)
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