

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