Substance Abuse in Women: Clinical & Program Issues

Substance Abuse in Women: Clinical & Program Issues

Joan E. Zweben, Ph.D.Executive Director, EBCRP

Clinical Professor of Psychiatry; UCSF

ADP Conference Burlingame, CA.June 18, 2008

IntroductionIntroduction

1970’s – first focus on gender disparities and women’s issues

90% of articles on gender published since 1990 (Back, 2007)

24% of substance abuse treatment facilities now provide specific programs or groups for women

(SAMHSA Facility Locator, 2007)

EpidemiologyEpidemiology Prevalence of AOD disorders greater in

men Gender differential is higher for alcohol

use disorders than drug use disorders Prescription drug abuse and tobacco use

in women only slightly less than men For adolescents, the gap disappeared for

alcohol, marijuana, cocaine and cigarettes

Minority Women and Alcohol UseMinority Women and Alcohol Use

Drinking patterns influenced by: Religious activity Genetic risk/protective factors Level of acculturation to U.S. society Historical, social and policy variables

(Collins & McNair, 2002)

African American WomenAfrican American Women

Relatively high rates of abstention and low rates of heavy drinking among black women

Most over 40 did not consume alcohol

High participation in religious activities is a protective factor

(Collins & McNair, 2002)

Asian American WomenAsian American Women

Regardless of national origin, Asian American women have low rates of alcohol use and problem drinking

Facial flushing response (occurring in 47-85% of Asians) is a protective factor

ALDH2-2 leads to perspiration, headaches, palpitations, nausea, tachycardia, and facial flushing

Women report being more embarrassed than the men do

Acculturation promotes increased drinking (e.g., Japanese women)

(Collins & McNair, 2002)

Native American WomenNative American Women Availability of distilled spirits, its use

outside specific cultural contexts, and modeling of heavy drinking by Europeans promoted binge drinking

Tribal policies about drinking on the reservation are influential

High density of alcohol outlets in poor urban communities

Marketing of high alcohol content to Native Americans (Crazy Horse)

(Collins & McNair, 2002)

LatinasLatinas Often did not drink, or drank small

amounts in country of origin, but drinking patterns changed more dramatically than male counterparts

More research on Mexicans than Puerto Ricans or Cubans

After three generations, the drinking patterns of Mexican-American women are similar to other U.S. women

(Collins & McNair, 2002)

Older WomenOlder Women

Risk Factors: Longer life expectancies Many losses Live alone longer Less likely to be financially

independent More susceptible to the effects of

alcohol, particularly as they age(Blow & Barry, 2002)

Diagnostic & Screening IssuesDiagnostic & Screening Issues

Women tend to seek treatment at mental health or primary care clinics

Both substance abuse and psychiatric conditions are often undetected

A single question about last episode of drinking can increase detection in primary care settings

Medical ComorbidityMedical Comorbidity

Biological FactorsBiological Factors Alcohol

Enzymes – lower concentration of gastric dehydrogenase

Higher fat/water ratio Drugs

Hormone fluctuation during menstrual cycle

Gender differential in brain activation by stress and drug cues

AlcoholAlcohol

Course of IllnessCourse of Illness Increased vulnerability to adverse

consequences “Telescoped” course

Females advance more rapidly from use to regular use to first treatment episode

Severity generally equivalent to males despite fewer years and smaller quantities

Biological and psychosocial factors contribute to this outcome

Biological FactorsBiological Factors

Alcohol: differences in bioavailability Enzymes – lower concentration of

gastric alcohol dehydrogenase (enzyme that degrades alcohol in the stomach)

Higher fat/water ratio (smaller volume of total body water so alcohol is more concentrated)

Breast CancerBreast Cancer Moderate consumption elevates the risk (linear

relationship between #drinks and risk) Occurs with all forms of alcohol Does alcohol raise estrogen levels? Metabolism of ethanol leads to the generation

of acetaldehyde (AA) and free radicals. Acetaldehyde is carcinogenic (e.g., GI tract cancers)

Research areas: specific drinking patterns, body mass index, dietary factors, family hx breast cancer, use of HRT, tumor hormone receptor status, immune function status

(10th Special Report to Congress: Alcohol & Health)

Psychiatric ComorbidityPsychiatric Comorbidity

Psychiatric ComorbidityPsychiatric Comorbidity More likely in girls and women:

Anxiety disorders (especially PTSD) Depression Eating disorders Borderline personality disorders

Onset more likely to precede the onset of the substance use disorder

More likely in boys and men: Antisocial personality disorder Conduct disorder

PTSDPTSD Convergence of trauma, PTSD and

SUDS particularly important Early life stress, esp sexual abuse, more

common in girls Higher risk of alcohol dependence in

women exposed to violence in adulthood

AOD use elevates risk for victimization Uncontrollable stress increases drug

self-administration in animals

Seeking Safety:Early Treatment Stabilization

Seeking Safety:Early Treatment Stabilization

25 sessions, group or individual format Safety is the priority of this first stage

tx Treatment of PTSD and substance

abuse are integrated, not separate Restore ideals that have been lost

Denial, lying, false self – to honesty Irresponsibility, impulsivity – to commitment

Seeking Safety: (2)Seeking Safety: (2) Four areas of focus:

Cognitive Behavioral Interpersonal Case management

Grounding exercise to detach from emotional pain

Attention to therapist processes: balance praise and accountability; notice therapists’ reactions

Seeking Safety (3):GoalsSeeking Safety (3):Goals

Achieve abstinence from substances Eliminate self-harm Acquire trustworthy relationships Gain control over overwhelming

symptoms Attain healthy self-care Remove self from dangerous situations

(e.g., domestic abuse, unsafe sex)(Najavits, 2002; www.seekingsafety.org)

Psychosocial InfluencesPsychosocial Influences Women more likely to have role models

in nuclear families and/or spouses who are alcohol dependent

Weight control is important factor in tobacco smoking

Relapse factors: women more likely to cite interpersonal and other stressors; men more likely to report external temptations

Treatment IssuesTreatment Issues

Evidence Based Practices:Important Distinctions

Evidence Based Practices:Important Distinctions Evidence-based principles and

practices guide system development Example: care that is appropriately

comprehensive and continuous over time will produce better outcomes

Evidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.

(Miller et al, 2005)

What Research is Relevant?What Research is Relevant? What is your research question? Random assignment studies (RCTs) are

considered the gold standard, but are not an appropriate method for all questions.

Many questions can be answered by longitudinal or observational studies (e.g., pathways and mechanisms of change, with or without treatment)

Therapeutic alliance is a major variable that remains insufficiently studied

Gender Differences in Treatment IGender Differences in Treatment I Women less likely to enter treatment

Sociocultural: stigma, lack of partner/family support

Socioeconomic: child care, pregnancy, fears about child custody

Children are a big motivator to enter treatment or avoid it

Availability of appropriate treatment for co-occurring disorders is important

Gender Differences IIGender Differences II Few differences in retention,

outcome, or relapse rates If there are differences, women

have better outcomes Show greater improvement in

other domains (e.g., medical), shorter relapse episodes, more likely to seek help following a relapse

Gender Differences IIIGender Differences III No strong evidence that gender-specific

treatments are more effective, but there are few controlled trials

Residential programs that include children have better retention rates

Gender is not a specific predictor overall, but specific treatment elements improve outcomes for various subgroups

(Greenfield et al 1006)

Key Services to Improve Outcomes for WomenKey Services to Improve Outcomes for Women Child care Prenatal care Supplemental services addressing women-

focused topics (e.g., trauma history) Mental health services; psychotropic meds Transportation Women-only groups Employment services (jobs with decent

pay)

Documented ImprovementsDocumented Improvements Length of stay; treatment completion Decreased use of substances Reduced mental health symptoms Improved birth outcomes Employment Self-reported health status HIV risk reduction

(Ashley et al 2003; Greenfield et al, 2007)

Readiness to Change: Start Where the Woman IsReadiness to Change: Start Where the Woman Is

Domestic violence Emotional problems Substance abuse HIV risk behaviorsRapidly address what the woman

indicates as high priority, and build a bridge to the other problems

(Brown et al, 2000)

Treatment CultureTreatment Culture Female role models at all levels of

hierarchy Positive male role models available Forthright feedback but not

aggressive confrontation Monitor the intensity, especially for

women who are more disturbed Sexual boundary issues

Women-Only vs Mixed Gender ProgramsWomen-Only vs Mixed Gender Programs Most consistent difference: provision of

services related to pregnancy and parenting Parenting classes Children’s activities Pediatric, prenatal, post-partum services

Also more likely to assist with housing, transportation, job training, practical skills training

(Grella et al, 1999)

Women-Only GroupsWomen-Only Groups Foster greater interaction, emotional

and behavioral expression More variability in interpersonal style Women in mixed groups engage in a

more restrictive type of behavior; men show wider variability (and interrupt women more).

(Hodgkins et al, 1997)

Relapse Issues for WomenRelapse Issues for Women Untreated psychiatric disorders,

especially depression and trauma sequelae (PTSD)

Intimate partner Underestimating the stress of

reunification or ongoing parenting Isolation; poor social support High level of burden

SLIDESSLIDES

www.ebcrp.org