Joan E. Zweben, PhD
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EPIDEMIOLOGY
Several large-scale epidemiologic studies document gender differences in the use of alcohol and almost all other drugs, with higher rates found in men. However, more recent studies are showing a smaller gender difference for all age groups except adolescents aged 12 to 17. With these young people, the gap virtually disappeared for alcohol, marijuana, cocaine, and cigarettes. Stimulants such as cocaine and methamphetamine have a particular appeal for women. Their use is associated with loss of appetite and desirable weight loss, and the stimulating effects are often initially perceived as alerting and beneficial with the many work and household tasks that confront them.
Most adults in treatment for addictive disorders have at least one coexisting psychiatric disorder, but the pattern differs for women. Prominent studies have found that women were more likely to have an affective disorder than were men (with the exception of mania, for which rates were the same). One study showed lifetime prevalence for a major depressive episode of 21.3% and a 12-month prevalence of 12.9% for women, compared with 12.7% and 7.7% for men. Women also had a higher lifetime and 12-month prevalence of three or more disorders.
MEDICAL CONSIDERATIONS
The influence of alcohol on women’s health has been much more carefully studied than has that of other drugs. Although women are less likely than are men to drink heavily or even moderately, when they do so, they are more vulnerable to alcohol-related liver damage, cardiovascular disease, and brain damage. Negative consequences occur at lower levels of consumption and after much shorter periods of drinking. This is referred to as the “telescoped course” in women. Women tend to have lower levels of alcohol dehydrogenase and lower volumes of distribution, leading to an increased effect of alcohol from an equivalent exposure in a man. The relationship between drinking and breast cancer risk has been also studied since the 1980s. Alcohol consumption raises breast cancer risk even after adjustment for age, family history, and other known dietary and reproductive risk factors. The increased risk appears to be modest and dose related, and the form of alcohol appears to be irrelevant.
Drinking during pregnancy remains a serious concern. Fetal alcohol syndrome (FAS) is a set of birth defects considered the single leading nonhereditary cause of mental retardation. These mental impairments include deficits in general intellectual functioning and specific difficulties with learning, memory, attention, and problem solving, in addition to manifestations in psychosocial arenas. The impairments are dose related and may be evident in children without the distinguishing physical features of FAS. Several terms have been developed to describe alcohol-related conditions including alcohol-related birth defects (referring to alcohol-related physical abnormalities of the skeleton and certain organ systems) that occur in the absence of the characteristic growth deficiency and facial characteristics of FAS and alcohol-related neurodevelopmental disorder, referring to the mental impairments in the absence of FAS. The effects of lower levels of alcohol exposure prenatally are still unclear and thus the prevailing view that there is no demonstrated safe level of alcohol consumption during pregnancy.
The evidence of gender differences in the effects of drug use is not as extensive at this time as it is for alcohol. Several studies suggest that some women may have greater vulnerability to the effects of cocaine relative to men. Mechanisms including female steroid hormones, estrogen, menstrual cycle phase, and differences in receptor function have all been suggested.
Methadone is considered the gold standard maintenance treatment for opioid-dependent pregnant women. It is important that the dose be adequate. Higher doses are not associated with increased risks of neonatal abstinence. Likewise, women who are stable on methadone should not be discouraged from breast-feeding. Buprenorphine is now an option for pregnant women. The Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, published in 2010, is a double-blind, double-dummy, flexible-dosing, parallel-group clinical trial that demonstrated that buprenorphine is effective and can be used safely. At this time, follow-up data indicate it does not appear to have negative consequences for the children and may reduce neonatal hospital time.
Women are constituting a larger proportion of AIDS cases than ever before, with 27% of new AIDS cases in girls and women over the age of 13 reported in 2005 (compared to <5% in 1985). HIV/AIDS is the leading cause of death for African American women aged 25 to 34. Latinas are also disproportionally affected. Heterosexual sex with a man with HIV is the most common mode of transmission, followed by sharing injection drug works used by someone with HIV. Similar patterns of increase are also beginning to be apparent in the distribution of reported hepatitis C cases.
PSYCHIATRIC DISORDERS
It is preferable to address multiple disorders with an integrated approach. It has become more widely accepted in the addiction treatment community that psychotropic medications are compatible with recovery, especially when prescribed by physicians knowledgeable about addiction.
As a group, anxiety disorders constitute the most common psychiatric disorders among women, with a total lifetime prevalence of 30.5% and a 12-month prevalence of 22.6%. The experience of anxiety is characterized by sensations of nervousness, tension, apprehension, and the fear that arises from the anticipation of internal or external danger. Women in early recovery will experience heightened distress as they try to cope with situations on which they previously relied on alcohol and other drugs and also as they more clearly see the impact of their self-destructive behaviors. However, overwhelming anxiety is debilitating, it interferes with new learning, and it contributes to relapse. Psychosocial strategies are beneficial for the management of anxiety regardless of whether it is normal or excessive. Fortunately, the first-line medications for anxiety and panic disorders are no longer the benzodiazepines, but the selective serotonin reuptake inhibitors. When anxiety symptoms do not resolve with abstinence, a variety of psychosocial interventions can be used, selected to address the tasks specific to the woman’s stage of recovery.
Benzodiazepines, commonly prescribed for anxiety disorders, can be problematic for those with a personal or family history of addiction. Nonreinforcing alternatives, such as sedating antidepressants or buspirone (BuSpar) for anxiety or trazodone (Desyrel) for insomnia, are recommended. Anticonvulsants, antihypertensives, or the newer atypical neuroleptic medications can also be used.
Of all the anxiety disorders, posttraumatic stress disorder (PTSD) is the most difficult and complex to manage. Participants in addiction treatment have much higher rates of traumatic experiences and PTSD than does the general population. A lifetime history of at least one other disorder was present in 79% of women with PTSD, and more than one third of the women with PTSD failed to recover from their PTSD. Treatment providers must equip themselves to meet these complex needs so as to avoid common outcomes such as early dropout and increased difficulty in obtaining positive outcomes from treatment.
In assessing for depression, it is important to rule out the direct effects of alcohol, illicit drugs, or medications, as well as general medical conditions that can lower mood. This is especially true in the identification of mood disorders in pregnant women, as these women tend to do worse on drug use outcomes than with other disorders.
Negative mood states that are the direct result of alcohol or illicit drugs generally clear within 2 to 3 weeks, with symptoms of longer duration suggesting an independent mood disorder. A sad or depressed mood is only one of many signs and symptoms of a clinically significant depression and may not be the most prominent feature. Other indications include disturbances in emotional, cognitive, behavioral, or somatic regulations.
Eating disorders are more prevalent among substance-abusing women than in the general population, with bulimia being more common than anorexia. Stimulants and over-the-counter diet preparations are particularly appealing to women seeking to lose or control weight.
There are many possible relationships between substance use and eating disorders. Some patients report that heroin is appealing because it facilitates vomiting. Stimulants are attractive because stimulants make women feel capable, energetic, and suppress the appetite. Alcohol can be used to suppress the panic associated with bingeing and vomiting or to quash the shame that follows an episode.
Because secrecy is a feature of both disorders, careful inquiry is important during the initial assessment, and observation by staff members is necessary throughout treatment. A thorough medical evaluation should assess possible problems and be part of a plan for nutritional stabilization, including strategies to stop aberrant eating behaviors, as well as medication planning and discharge planning that actively addresses both disorders. Selective serotonin reuptake inhibitors have been shown to be beneficial in treating bulimia, but not restrictive anorexia. Both cognitive–behavioral approaches and psychotherapy are well supported by evidence to assist in the management of eating disorders.
Misdiagnosis of borderline personality disorder is quite common, because of confusion of borderline characteristics with the behaviors exhibited during active alcohol and drug use and early recovery. Persistent characteristics of borderline personality disorder include unstable mood and self-image; unstable, intense, interpersonal relationships; extremes of overidealization and devaluation; and marked shifts from baseline to impulsive outbursts, anxiety states, or other extreme moods. Women constitute about 75% of those with the diagnosis, which is estimated at 2% of the general population. Literature strongly suggests a relationship between borderline pathology and childhood physical and sexual abuse. Histories of childhood sexual abuse and a family history of substance use disorder are associated with longer time to remission of borderline personality disorder.
According to the large National Epidemiologic Survey on Alcohol and Related Conditions, women are also at greater risk of avoidant, dependent, and paranoid personality disorders. Little focus on specific treatment interventions for this group of women has been undertaken.
SPECIAL POPULATIONS
Variations in cultural groups and sexual orientation play important roles in addiction treatment. The use of alcohol and other drugs may be taboo for women, so recognition of their use or seeking treatment may be impossible. Those from patriarchal cultures can face strong taboos about disclosing family secrets especially around interpersonal violence. Many women also fear institutions such as the police, social services, and mental health agencies. Much more work in the area of cultural sensitivity, education, and prevention need to be done to make an impact on these women’s lives.
Lesbians are another subgroup of women at particular risk. This is, in part, because of the supposed extensive use of alcohol and drugs as part of the culture. Historically, gay bars were seen as gathering places and safe arenas for self-expression. Clearly, socializing patterns built around bars and drug sharing increase the risk of addiction. Even when problems are recognized, gay women can avoid treatment if they fear discrimination.
ADDITIONAL TREATMENT ISSUES
Women tend to seek help in medical or mental health settings; thus, it is important to improve their capacity for diagnosis and referral to treatment of women with substance abuse disorders. At this time, it appears that gender is not a significant predictor of outcomes overall, but specific treatment elements improve outcomes for specific groups. Barriers clearly exist, including lack of pregnancy services, lack of childcare, fears of loss of custody, and inadequate services for women with co-occurring disorders. Treatment retention has been shown to improve with inclusion of children in residential treatment and other key factors.
The finding that women have high rates of three or more disorders has consequences for treatment. Work by Brown and colleagues supports the hypothesis that the most immediate or threatening problems will be what a woman focuses on first, and she selects her treatment modalities accordingly. Thus, women with addictive disorders who are in domestic violence situations are relatively resistant to addressing their alcohol and drug use. They are preoccupied with achieving greater safety and see their alcohol and other drug problems as secondary. Treatment providers need to be willing to start by addressing those problems the woman is most ready to change while cultivating readiness in other areas.
It is generally agreed by providers that women-only programs or activities are an important aspect of effective treatment, particularly those associated with pregnancy and parenting. Women-only programs also were more likely to assist with housing transportation, job training, and practical skills training. These programs also were more likely to be funded through the Medicaid system instead of fees or private insurance.
It appears that gender-specific treatment is also associated with higher rates of continuing care. There is also reason to think that women-only groups tend to foster greater interaction, emotional and behavioral expression, and more variability in style than do mixed-gender groups.
Co-occurring psychopathology typically is associated with less favorable addiction treatment outcomes. Yet abused clients were more likely than were their nonabused counterparts to participate in counseling and just as likely to complete treatment and remain drug-free during and up to 6 months after treatment. Trauma-related difficulties can impair parenting in a variety of ways. Women with histories of childhood trauma can have attachment problems that impact their own parenting. They often lack appropriate role models, leading to reliance on physical punishment, difficulties setting appropriate boundaries, and neglect. Current alcohol and other drug use will exacerbate these vulnerabilities.
Women clients and treatment providers have noted that the male-dominated treatment culture characteristic of some programs is not conducive to meeting women’s needs. An emphasis on harsh confrontation is particularly problematic in populations with a high frequency of traumatic experiences. Women with severe psychiatric disorders can decompensate and leave treatment if confrontation is too intense.
Both the National Institute on Drug Abuse and the Center for Substance Abuse Treatment have funded specialized research and treatment demonstration programs focused on women, and these programs have enhanced the development of provider groups committed to improving women’s treatment. Provider groups serving women also emphasize the importance of female leadership at all levels to serve as role models.
Women constitute the fastest-growing segment of the criminal justice population nationally and yet have the fewest appropriate social services available to them. Women today are more likely than are men to serve time in prison for drug offenses. Half the women reported committing their crimes while under the influence of drugs or alcohol, and about 40% reported using drugs daily before arrest. One third of incarcerated women reported that a parent or guardian had abused drugs or alcohol. Prison-based treatment is growing rapidly, and specialized programs for women are integral to this. Community-based services after treatment in prison significantly increase the percentage of offenders who remain drug free 18 months after release. Drug courts and diversion initiatives have also shown success in reducing recidivism, likely in proportion to their access to psychiatric and social services. There has been excellent recent work on gender-responsive treatment within the criminal justice system.
KEY POINTS
1. There are biomedical and psychosocial gender differences that shape women’s treatment needs.
2. It is necessary to recognize epidemiologic patterns and address co-occurring mental health disorders in an integrated treatment approach.
3. It is important to continue to examine the effective elements in gender-specific and mixed gender programs, including costs.
REVIEW QUESTIONS
1. Recent epidemiologic studies show:
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