Maggie Schroeder, MA, CADC Branch Manager Katie Stratton, MS, LPCA Training and Development Specialist Dept. Behavioral Health, Development and Intellectual Disabilities; Adult Substance Use Treatment and Recovery Services Branch Dept. Behavioral Health, Development and Intellectual Disabilities; Adult Substance Use Treatment and Recovery Services Branch 502-782-6188 502-782-6192 Maggie.schroeder@ky.gov Katie.stratton@ky.gov Biological Sociological Psychological Intoxication Rate Telescoping Effect Medical Complications Biological Reproductive and Hormonal Genetic Risk Lower proportion of water, women have less than men pound for pound (NIH, 2013) Lower activity of alcohol dehydrogenase in gastric mucosa (Back, Contini, and Brady, 2006) At similar levels of alcohol consumption, women: Have higher blood alcohol concentrations Have a higher risk of psychosocial problems (stressful life experiences, interpersonal stressors) resulting in dependence on alcohol (Back, Contini, and Brady, 2006) Intoxication Rate Telescoping Effect Medical Complications Biological Reproductive and Hormonal Genetic Risk When dependence progresses more quickly in women than in men Women develop more physical problems within fewer years of usage onset Develop abuse or dependence in fewer years (telescoping) Women often become impaired more easily and impairment could last longer Have more medical problems and higher mortality rates Bradley, KA, et al. (1998). Faster progression of dependence (telescoping) Faster addiction within 1st year of use Fewer years of use prior to treatment entry with comparable or more severe addiction severity as men at treatment entry May be more likely to inject and inject more frequently By 2011–2013, opioid pain reliever abuse or dependence was more common among heroin users than alcohol, marijuana, or cocaine abuse or dependence. Zilberman, et al. (2002), Harvard Health Publication (2010), CDC: Morbidity and Mortality Weekly Report (2013) Women are more likely to visit the emergency rooms because they abuse opioids, suggesting that they suffer more medical consequences. Women are more likely than men to be prescribed opioids, to use them chronically, and to receive prescriptions for higher doses of opioids Women also might be more likely than men to engage in "doctor shopping" CDC: Morbidity and Mortality Weekly Report (2013) Hormonal fluctuation during the menstrual cycle can increase responsiveness to cocaine cues or more severe use. Back, Contini, & Brady (2006) Women more often report unsafe sexual and unsafe drug injection practices, increasing risk of sexually transmitted diseases, including HIV (Note: screen women for HIV, Hep B and C, and liver functioning) Zilberman, et al. (2002) Women report using cocaine at much younger ages than men and quickly develop dependence. Harvard Health Publications (2010) During 2002–2013, past-year heroin use increased among persons reporting past-year use of other substances. The highest rate was consistently found among users of cocaine; during 2011–2013, this rate was 91.5 per 1,000. During the study period, the largest percentage increase, 138.2%, occurred among nonmedical users of opioid pain relievers. Intoxication Rate Telescoping Effect Medical Complications Biological Reproductive and Hormonal Genetic Risk Women have higher mortality rates than men at lower levels of drinking Higher relative risk of death from cirrhosis, cancer, and injury Risk increases for women who drink more than 2 to 3 drinks a day Risk for men increases at four or more drinks per day Bradley, KA, et al. (1998). Women who drink are more likely to develop alcoholic hepatitis then men who drink the same amount (NIH, 2013) Women more likely to develop and die from liver disease than men drinking at comparable levels Risk of liver disease and cirrhosis increases when women drink 7 drinks per week and men drink 14 drinks per week Bradley, KA, et al. (1998). More sedation with equivalent BAL Quicker brain shrinkage, peripheral neuropathy Bradley, KA, et al. (1998). Chronic heavy drinking is the leading cause of heart disease. Among heavy drinkers, women are more susceptible to alcohol related heart disease than men (NIH, 2013) Female smokers are 2x more likely to have a heart attack Women who consume about one drink per day have a 10% higher chance of developing breast cancer than women who do not drink at all. For every extra drink they have per day, increases that risk by 10% more More severe psychiatric, medical, and employment complications (Hernandez-Avila, et al., 2004) Increased frequency of medical problems, especially genitourinary and respiratory (Zilberman, et al., 2002) More likely to accept needles from HIV+ associates and have multiple sex partners/get paid for sex than male users (Eaves, 2004) Abuse or Opioids during pregnancy is a problem for women of childbearing age Health-care providers should include discussions of pregnancy plans within the context of treatment and monitoring of patients taking Opioids for medical or nonmedical reasons. Women treated for Opioid abuse should be counseled regarding risks to the fetus during pregnancy. The risks and benefits of treatment of chronic conditions with Opioids during pregnancy should be weighed carefully. Use of benzodiazepines and antidepressants during pregnancy, or at any time in combination with Opioids, also should be considered carefully by women and their health-care providers. Psychological conditions, which might co-occurr with pain or substance abuse, need to be assessed and addressed within a treatment regime. CDC: Morbidity and Mortality Weekly Report (2013) Greater risk for cardiovascular complications and other cocaine-related emergencies (Hernandez-Avila, et al., 2004) Gender-specific impairment on visuospatial recall memory Overall neuropsychologic impairment more prominent in males Zilberman, M., Tavares, H., Blume, S., and el-Guebaly, N. (2002). Intoxication Rate Telescoping Effect Medical Complications Biological Reproductive and Hormonal Genetic Risk Infertility (6 or more drinks > 5 times/week; opiates)…but low use of contraception Spontaneous abortion (> 2 drinks/day) Menstrual symptoms (irregular, painful, heavy) Disrupted sex hormones Breast cancer (2-5 drinks/day) Uterine and ovarian cancers Early menopause Bradley, et al. (1998), Harding and Ritchie (2003) and Zilberman, et al. (2002). First trimester use of alcohol– low birth weight, decreased birth length and head circumference, minor physical anomalies, and fetal alcohol effects Second and third trimester use of alcohol– developmental delay, adverse psychosocial/behavioral/physical/intellectual consequences Prenatal use of drugs can cause low birth weight, preterm labor, hard-to-sooth infants, neonatal abstinence syndrome, possibly some emotional/learning problems Bradley, KA, et al. (1998). Women appear to have a greater subjective response to cocaine and amphetamine, especially during follicular phase of menstrual cycle Back, Contini, Brady (2006) Preliminary research suggests that women who time their quit date to occur during the follicular phase (which begins after menstruation and ends at ovulation) are more likely to abstain from cigarettes for a longer period than women who quit during the luteal phase. One theory is that the increase of estrogen levels during the follicular phase decreases anxiety and improves mood, helping a woman cope better with the challenges of smoking cessation. Intoxication Rate Biological Telescoping Effect Reproductive and Hormonal Medical complications Genetic Risk 50-60% of risk in males attributed to heritability Research less clear for females Fewer female subjects in studies Twin studies show similar genetic risk for females Prescott, 2002 Rate Differences Sociological Childcare Responsibilities Stigma Other Barriers to Services Financial and Employment Discrepancies Assortative Mating Men are more likely to drink and more likely to be heavy drinkers Men drink larger quantities, drink more frequently, and report more problems Male: Female ratios range from 4:1 to 8:1 Wilsnack, S. and Wilsnack, R. (1994). The figure to the right shows crude rates for drug overdose deaths and drug misuse- or abuse-related emergency department (ED) visits among women, by select drug class, in the United States during 2004-2010. During 2004-10, opioid pain reliever (OPR) death rates and ED visit rates increased substantially among women. During this period, the rate of OPR deaths among women increased 70% and the rate of OPR misuse- or abuse-related ED visits more than doubled. Cocaine deaths and ED visits declined during the same period. Starting in 2008, more women visited EDs because of misuse or abuse of benzodiazepines or OPRs than for cocaine. CDC: Morbidity and Mortality Weekly Report (2013) Death rates varied by age and race. The rate for all drug overdose deaths among women was highest among those aged 45–54 years (21.8 per 100,000 population). American Indian/Alaska Native (14.5) and non-Hispanic white (12.7) women had the highest drug overdose death rates. The rate of suicide drug overdose deaths was similar for women (1.8) and men (1.7), although drug overdose– related suicide deaths accounted for 34% of all suicide deaths among women compared with 8% among men. OPRs were involved in one in 10 suicides among women. CDC: Morbidity and Mortality Weekly Report (2013) High school girls are catching up Marijuana Inhalents Cocaine Boys Girls Tranquilizers Stimulants Painkillers Alcohol Tobacco 0 CASA (2003). 10 20 30 40 50 60 ~30% of girls have smoked < age 13 ~35% of girls have tried alcohol < age 13 ~9% of girls have tried THC< age 13 Early puberty is a risk factor for girls CASA (2003). Males use at higher rates in all countries studied Large variation in differences between men and women May be a biological basis, but may also be social forces Women are known to use substances at rates similar to males when the substances are available to them Wilsnack and Wilsnack, 2002 Rate Differences Stigma Financial and Employment Discrepancies Sociological Childcare Responsibilities Other Barriers to Services Assortative Mating Shame Social marginalization Degradation ATOD use = slut or prostitute Parenting ability disputed (Kandall, 1998, and Ehrmin, 2001) In younger cohorts, attitudes more permissive (Hernandez-Avila, et al., 2004) Rate Differences Stigma Financial and Employment Discrepancies Sociological Childcare Responsibilities Other Barriers to Services Assortative Mating Women make less money than men Women in treatment More educational deficits Lower employment rates Lack employment skills Fewer economic resources More likely to be single or divorced Have financial burden of children Wechsberg (1998), Moran (1998), Oggins, Guydish, & Delucchi (2001), Gregoire and Snively (2001) Rate Differences Stigma Financial and Employment Discrepancies Sociological Childcare Responsibilities Other Barriers to Services Assortative Mating Women entering treatment are 2X more likely to have children at home and custody Childcare issues Fear of losing custody Not want to leave children to go to treatment Wechsberg, Craddock, & Hubbard (1998), Moras (1998) Rate Differences Stigma Financial and Employment Discrepancies Sociological Childcare Responsibilities Other barriers to services Assortative Mating Lack of adequate services Lack of appropriate services Lack of outreach to women Transportation Partner limiting Social support Marsh (2002) Rate Differences Stigma Financial and Employment Discrepancies Sociological Childcare Responsibilities Other Barriers to Services Assortativ e Mating Possibility for an increase in the risk and severity of the disorder in consecutive generations. Daughters of alcohol-abusing mothers, the rate of alcohol abuse was significantly higher. Association between personality features and the liability to substance abuse. Vanyuko, et al. (1996) May lead to further strengthening of the association between the liabilities to substance abuse and other behavioral deviations due to increase in both genetic and environmental mental correlations between the traits. Females often marry men that present with a similar substance use disorder, men do not. 80% of husbands were alcoholics if at least 1 of her parents were alcoholics compared to 33% of the husbands. Vanyuko, et al. (1996) Reasons for using Co-occurring disorders Psychological Victimization Relational Strengths and Risks Girls who use are more likely to be depressed, suicidal, or feel sad and hopeless Women attribute initial heroin use to social reasons (Eaves, 2004) Girls tend to use to improve mood, increase confidence, reduce tension, cope with problems, lose inhibitions, enhance sex, or lose weight. Boys use to seek sensation or enhance social status. (CASA, 2003). Reasons for using Cooccurring Disorders Psychological Victimization Relational Strengths and Risks More common in women than in men Mental Health problems more common in women than men (general population) 70% 60% 50% 40% 30% 20% 10% 0% Bradley(1998), Zilberman et al. (2002) Substance Dependent Men Substance Dependent Women Most frequent CODs in women are depression, anxiety, eating disorders and borderline personality disorders (Most frequent COD in men is Antisocial Personality Disorder) (Back, Continii, & Brady 2006) Phobic disorders, major depression, panic disorder, somatization, OCD, co-occurring drug abuse (especially Rx), PTSD, bipolar disorder Suicide attempts more frequent in female alcoholics Adolescent females with ADHD greater risk for substance abuse For women the onset of the psychiatric disorder is more likely to antedate the onset of the substance use disorder. (Back, Continii, & Brady 2006) Zilberman, et al. (2002) Depression and anxiety primary dx for women – predates alcohol abuse Major depression predates alcohol dependence in 2/3 of women; vice versa for men Among depressed alcoholics: depression is more severe in females, alcoholism more severe in males Zilberman, et al. (2002) The induction of negative mood increases alcohol cue-reactivity and craving in women but not in men Craving, withdrawal, and premenstrual symptoms often overlap in female smokers Women with COD more likely to show up in medical or mental health settings, be diagnosed with mental health disorders Zilberman, et al. (2002) Substances may be used for weight control, especially nicotine, cocaine, and other stimulants If try one, likely to try another or two More girls 12-17 use cocaine than boys Disturbed eating usually predates ATOD Sexual abuse linked with earlier onset of cooccurring Substance Use and Emotional Disturbances CASA (2003), Cochrane, Malcolm, & Brewerton (1998), Krahn (1998), Deep, et al. (1999) 30% of SA women have some occurrence of bulimia, only 1-3% of general population Bulimia most common in SA Electrolyte disturbance can worsen withdrawal seizures Food deprivation is a stimulant for drug use in animal and human studies CASA (2003), Cochrane, Malcolm, & Brewerton (1998), Krahn (1998), Deep, et al. (1999) Reasons for using Co-occurring disorder Psychological Victimization Relational Strengths and Risks Compared to women without substance abuse problems, twice as many women with substance abuse problems have a history of sexual abuse Wilsnack and Wilsnack (1994) Sexual assault: 40-65% Physical assault: 32-58% Both physical and sexual assault in childhood increases chance of using illicit drugs One form of violence often co-occurs with other forms Najavits, Weiss, & Shaw (1997) 90% of women in treatment have a history of domestic violence (DV) 75% of DV incidents involve alcohol use by the victim, the perpetrator, or both Crack cocaine use by women on methadone associated with IPV Vicious cycle of increasing domestic violence and substance abuse Wilsnack and Wilsnack (1994), Price and Simmel (2002), El-Bassel, et al.(2004) Quicker onset of substance abuse Higher rate of substance abuse even when controlling for family background Severe trauma can damage brain anatomy, increasing vulnerability to mental health and substance abuse problems CASA (2003) Women in substance abuse treatment have 2 to 4 times the rates of PTSD than men Women in the general population = 11%; women in treatment = 30 to 59% PTSD Rates of victimization (with or without PTSD) = 55 to 99% of women in treatment Najavits, Weiss, & Shaw (1997), Sullivan & Holt (2008) Women’s trauma is from physical and/or sexual assault (sexual assault more prevalent); men’s is from combat, crime victimization, or general disaster Women are twice as likely as men to develop PTSD after trauma Women have high rates of repeated trauma, averaging five traumas each Najavits, Weiss, & Shaw (1997), Sullivan & Holt (2008) Women frequently have family perpetrators Women have more self-blame, suicide attempts, re-victimization, and sexual dysfunction Rape most likely to lead to PTSD for women and men (Lifetime rates: 9.2% of women vs. .7% of men are raped) Najavits, Weiss, & Shaw (1997), Sullivan & Holt (2008) PTSD symptoms can worsen with initial abstinence and with use PTSD symptoms can trigger substance use Traditional models for treating PTSD may not be indicated for substance abuse disorders and vice versa Trauma counseling helps women avoid drug use and relapse Najavits, Weiss, & Shaw (1997), Pride & Simmel (2002) AA may not work for female trauma survivors: men in meetings, not allow discussion of the past, surrendering to a higher power, sharing one’s story publicly Confrontational approaches can re-evoke traumatic experiences Uneasy alliances – trust issues Multiple crises Strong negative counter-transference by therapists Frequent labeling as “poor prognosis” and “treatment failures” Non-compliance with aftercare Less motivation for treatment Najavits, Weiss, & Shaw (1997), Price & Simmel (2002) Reasons for using Co-occurring Disorders Psychological Victimization Relational Strengths and Risks Women are less likely to enter treatment than men possibly due to sociocultural factors Women tend to have better outcomes than men Higher rates of abstinence at 6-month and 5-years follow-up Greater improvements in their domains Shorter relapse episodes Most likely to seek help following a relapse Back, Contini, Brady (2006) If children are doing well, mother tends to drink less Importance of assessing children’s well-being Importance of child care support for women in treatment Zilberman, et al. (2002), Drug-Dependent Mothers More frequently lose children to foster care Perform worse on parenting indices: Sensitivity and responsiveness to children’s emotional cues Understanding of basic child development Reflection on children’s emotion and cognitive experience Ambivalence about having and keeping children Harsh, threatening, overly-involved, authoritarian or permissive, neglectful, poor involvement, low tolerance of children, parent-child role-reversals Suchman, et al., 2004 Women tend to be introduced to drugs by a male partner Heroin: adolescent girls introduced by boyfriend or male friend Women tend to be influenced by the partner’s level of use; men are not Perceived discrepancies = increased use Previous treatment of partner Wilsnack and Wilsnack (1994), Eaves (2004), Logan, et al. (2002), Riehman, et al. (2000), Sack (2012) Women report first narcotic drug was a gift Use because spouse was using Having a spouse who is an addict Being introduced to heroin by an addicted sex partner Unlikely to inject on own, but will with a sex partner Use to self medicate for other mental health problems Sack, 2012 Direct or indirect opposition to recovery efforts (intimidation or threats) Partner resistance Male partners’ attitudes toward treatment Marital instability Economic dependence Bonding mechanism Logan, et al. (2002), Riehman, et al. (2000) Women do less well in mixed-gender groups Don’t talk as much Attend to needs of males in group Less likely to share their needs or feelings Women-focused outpatient or residential treatments often produce higher rates of treatment completion than traditional programs. Back, Contini, Brady (2006) Gender specific: women-only groups Safe: protects women from re-victimization and re-traumatization Gender responsive: addresses women’s issues Holistic: understands the whole woman