HOOKED: How Human Traffickers Leverage Substance Use for Control

Human trafficking is "a crime that involves compelling or coercing a person to provide labor or services, or to engage in commercial sex acts." (1) Although obtaining accurate data on human trafficking victims continues to be a challenge, research has shown that approximately 400,000 US domestic minors are involved in trafficking each year, and 68% of trafficking victims present to a health-care provider at least once while being trafficked. (2) Victims may be reluctant to disclose their exploitation for a myriad of reasons (eg, trafficker retaliation, conflicting loyalties, shame). As such, the primary goal of the health-care professional should not be disclosure or rescue but rather the building of trust with the patient and addressing the patient's needs. (3)Traffickers identify and leverage vulnerabilities to create dependency. Although no single characteristic defines all trafficked victims, high-risk indicators include a history of domestic or sexual abuse, homelessness, illicit substance use, immigration status, and foster care. Medical factors such as disability, mental illness, chronic disease, or medication dependency may also increase susceptibility to trafficking. As mandated reporters, health-care professionals are required to report known or suspected instances of trafficking to the appropriate authorities. Importantly, there is no pathognomonic "look" of a trafficked child. Screening tools such as the Quick Youth Indicators for Trafficking (4) and the Short Screen for Child Sex Trafficking (4) can improve recognition of youth at risk for or victim to trafficking. (3)Potential indicators during history taking include untreated chronic conditions; repeated sexually transmitted infections, pregnancies, and/or terminations; and history of physical, sexual, and/or emotional abuse, among others. Findings on physical examination may include, but are not limited to, unexplained physical injuries; branding tattoos; vaginal, rectal, or oral injuries; and signs of substance use such as friable nasal mucosa or track marks on the extremities. Behaviors witnessed in the health-care setting may include avoidance of eye contact, inappropriate attire for the weather, and accompaniment by an individual who speaks for the child or refuses to allow patient privacy.The physical and sexual violence along with deprivation of basic needs (food and sleep) caused by trafficking results in numerous adverse medical sequelae that are often well-advanced by the time most victims access medical care. (3) Health problems include malnourishment, traumatic injury from physical abuse or work-related accidents, untreated infection, substance use disorder (SUD), mental illness (depression, anxiety, posttraumatic stress disorder), and complications from chronic untreated sexually transmitted diseases and pregnancies, among others. (3)SUD is both a risk factor and a negative health outcome of trafficking, with as many as 84% of individuals using substances during trafficking. (5) SUD, defined as the uncontrolled use of a substance despite negative consequences, is a spectrum disorder with addiction as its most severe form, wherein individuals develop physical and/or psychological dependence on the substance. Drug addiction can strip individuals of their physical, psychological, and sociocultural health, leaving victims vulnerable to targeting and exploitation by traffickers. Conversely, individuals may develop a substance dependency to cope with trafficking-induced trauma, increasing susceptibility to further exploitation. (6) Traffickers, often involved in the drug trade, capitalize on substance dependencies, manipulating and controlling victims using 1 or more of the following tactics: Reward a victim. Traffickers may use drugs to create chemically dependent victims. By inducing dependence, traffickers leverage substances as a "reward" for productivity or meeting a quota. The need for the next "fix" can keep victims loyal to their perpetrators. (7)Feed a habit. Traffickers target individuals with existing SUDs, luring them in by feeding their addiction and trapping them in financial debt. (8) Some exploiters even recruit directly from detox and addiction treatment centers. (8) This services-for-drugs exploitation allows traffickers and victims to view the circumstance as a reciprocal relationship, making it more challenging for the victim to recognize its coercive nature. (7)Induce compliance. Traffickers use various drugs to force obedience. Stimulants such as methamphetamines and cocaine create euphoria, maintain energy levels, and increase libido, thereby enabling individuals to work more arduous hours. (7) Alternatively, depressants such as opiates may promote detachment from physical and emotional pain. In these ways, traffickers use drugs as a tool to make victims numb to risky or humiliating experiences. Furthermore, drugs may be used to incapacitate an individual to keep them from fighting back or escaping. (7)Punish a victim. As a means of punishment, traffickers may withhold drugs from dependent victims or administer naloxone to induce an opioid withdrawal. (7) The drive to avoid painful physical and emotional withdrawal symptoms will motivate an individual to work for the drug, placing traffickers in supreme control over their victims.Criminalize a victim. Many traffickers know that victims under the influence of drugs may lose their credibility with health-care professionals or law enforcement. (9) Substance use issues may also lead trafficked individuals to commit secondary crimes such as theft and assault, which may also be encouraged by the trafficker. As law enforcement agencies respond to these drug-related crimes, their attention may be diverted away from recognizing the victimization of the trafficked individual, allowing traffickers to evade criminal charges for exploitation.Deny substance use. Alternatively, some traffickers exert control over their victims by prohibiting substance use. This is especially common in sex traffickers appealing to higher-end clientele, as drugs may "ruin the product" and hinder performance and profit. Traffickers may even help their victims overcome addiction. This tactic can be used to deceptively earn a victim's loyalty and create a sense of debt in the trafficker's favor. (7) Trafficked individuals may develop a sense of gratitude toward their exploiter, thereby reinforcing the emotional attachment to their abuser (ie, trauma bonding) and obscuring the manipulative nature of the relationship.The well-established link between trauma exposure (physical, psychological, and emotional) and substance misuse renders concurrent treatment integral to breaking the cycle of control by traffickers. Without this objective, individuals are vulnerable to relapse and/or retrafficking as perpetrators exploit ongoing vulnerabilities. Motivational interviewing is a goal-oriented therapeutic tool that can be used by pediatric providers to identify where patients stand in understanding their substance misuse. Motivational interviewing can facilitate discussion about a patient's own ambivalence to change as well as explore a patient's own reasons for behavioral change. Respecting an individual's right to self-determination in their own recovery process is integral to providing trauma-informed care, particularly for trafficking victims who are often stripped of their freedom of choice and particularly for adolescents who are developing autonomy and exploring decision-making. As patients move through the stages of change (precontemplation, contemplation, preparation, action, maintenance, and relapse), pediatricians can help in identifying triggers for substance use, developing healthy coping strategies, and creating a safety plan in the event of relapse. Other models for concurrent treatment of trauma and SUD include Seeking Safety, (10) the Addiction and Trauma Recovery Integration Model, (10) and Trauma Affect Regulation: Guide for Education and Therapy. (10) Familiarity with and referral to local trauma-informed programs that provide appropriate behavioral therapy, support groups, and medication can play a powerful role in a patient's healing journey. Additional recommended national resources relating to human trafficking, SUDs, and mental health are summarized in the Table.