Women and Addiction
Presented by Erica Ghignone, MD
Transcript of Presentation:
Today I’m going to talk about women and addiction, and some of the unique features of substance use disorders in the female population. It wasn’t until the mid 1990’s, actually, that women and minorities were even included in research studies on substance use disorders, so relatively new, we’ve learned a lot in the last few decades. But I think it is a very important topic, especially as clinicians, for us to be able to treat our female patients.
So, as Dr. Angres mentioned, a lot of my experiences in fellowship actually got me interested in this topic, at the Jesse Brown VA, my women’s only recovery group as well as being over at the Asher center, and dealing with women and peripartum issues. And also being here, it’s been wonderful to be here and see a lot of these issues play out in women across the board.
So, to start . . . our objectives. We’re going to summarize the prevalence of substance use disorders in women. Also talk about co-morbid illnesses and treatment. Highlight some of the gender differences between men and women in the course of illness and substance use disorders. And then briefly touch on pregnancy and what we can do in that population.
So, I do have some questions, and we’ll cover the answers during the presentation. But I’ll just read through them.
- During which phase of the menstrual cycle are women thought to be more vulnerable to relapse as a result of low progesterone levels? The luteal phase, the follicular phase, ovulation, or menstruation? Any thoughts? [Laughs] We’ll get to it.
- Which of the following co-morbid psychiatric disorders is found more commonly in addicted women compared to me? Bipolar disorder, ADHD, PTSD, or antisocial personality disorder?
And then a couple of true or false questions.
- Women are less likely than men to enter substance treatment. True or false?
- In the MOTHER study, buprenorphine was found to be as effective as methadone for treating mothers with opiate use disorders, however infants of mothers on buprenorphine experienced more severe symptoms of NAS. True or false?
Like I said, we will get to all of these.
I did want to start with a case study presentation. This was a patient that I saw at the Jesse Brown VA, which is a predominantly male population. And I think her case really encompasses a lot of the features that I’m going to talk about for women and addiction. I’m going to present it, and then we’ll come back to it at the end and kind of tie everything together.
Nicole, she’s a 28 year old African-American female veteran. She was divorced, had one son, had recently lost her job, and came to us at the Jesse Brown VA after she had had a DUI.
At that time, she’d been drinking about a fifth of vodka a day, and smoking a joint of marijuana daily for the last year. She was meeting criteria for substance use disorder, she had loss of control, tolerance, adverse consequences including the DUI, lost her job, and really was having a hard time taking care of her son. And during this last year of heavy use, she’d also been engaging in risky sexual behavior, having unprotected sex with multiple partners.
As far as her past medical history goes, she was overall healthy. She’d had one past pregnancy. She did have a history of PTSD and depression. She wasn’t currently in any treatment. No history of hospitalizations or suicidality. As far as her substance history, she really started drinking alcohol when she joined the military around age 18 but it didn’t become problematic until after her trauma, which I’ll talk about in a little bit. She had no prior history of treatment, no history of alcohol withdrawal, and had no other substance use outside of the marijuana and alcohol.
She was living in Chicago with her son and her brother, but really felt like she had limited social support. Her ex-husband had moved to Texas after their divorce. Her mom was around but they kind of had a contentious relationship. And her brother, the one she was living with, was an active alcoholic. Her father was an active alcoholic as well.
As for her trauma history, she’d experienced military sexual trauma during her time in the army, and also as the victim of domestic violence. Her husband had been violent with her multiple times. No charges for that, but she did have this pending DUI.
And when she came for her initial treatment evaluation, she found out that she was 12 weeks pregnant, which she had up to that point not known, and in addition to her substance use, which was concerning, she also had not really been taking care of herself, wasn’t eating properly, and had had no pre-natal care up to that point.
I’m going to switch now and talk about epidemiology and other topics related to women, and then we’ll come back to Nicole.
It starts kind of just generally.
- Men tend to use more substances than women do, but this gender gap is narrowing and we’re not seeing that in adolescents.
- But when women do start using, they’re just as likely as men to get addicted.
- The lifetime prevalence of alcohol use disorder in women is 19.5%, drug use disorders is 7.1%.
- A study done in 2011 showed that the prevalence of substance use disorders was almost double in men as compared to women.
- In a different study, done in 2012, looking at how many people in the US were reporting illicit drug use, about 42% of those were women. Of all people who were using tobacco, 40% were women, and alcohol was almost 50-50.
So despite the fact that women actually tend to use fewer substances than men, when they do use their consequences tend to be more severe, and this includes medical, psychiatric, social consequences. And some of this is due to biological influences which I’ll get into. There was actually a term that was coined for this, the telescoping of substance use disorders in women, which essentially means that even though women will use for a shorter period of time and use less substances, their severity of illness progresses much more quickly and gets to a much severe point, much faster. And it’s been shown in multiple substances, so opiates, alcohol, cannabis, and cocaine.
Women appear to be particularly vulnerable to cravings and relapse in response to stress. Stress reactivity is regulated by the HPA axis, so that’s the hypothalamus, the Pituitary, the Adrenal glands. So kind of a normal response, when there is a stress, our body will release cortisol and glucose kind of to prepare for this fight-or-flight response.
For substance-dependent women though, this actually is found to be decreased: less cortisol is released in response to stress. And it’s thought that this blunted hormonal response is actually what increases vulnerability to relapse. And so women tend to have greater emotional intensity at lower levels of HPA arousal.
The menstrual cycle is obviously pretty unique to women. And gonadal steroid hormones are thought to affect responses to substances. This chart kind of shows the different phases of the menstrual cycle.
The first phase, right after menstruation, is the follicular phase and during this phase the uteral wall is starting to build, estrogen is high and progesterone is low. In this phase, women report a higher subjective response to stimulus.
Whereas during the next phase, the luteal phase, estrogenic drops, progesterone rises, and in this phase women actually report feeling less high than they did in the previous phase, and also less high than men.
When substance-dependent women were given exogenous progesterone, so the same hormone, they’re actually reporting, again, a less subjective high. But men did not have the same response. Nicotine’s another substance that responds to hormones, so during the luteal phase, women actually experience greater feelings of cravings and dysphoria if they tried to quit during that phase, because it’s thought that nicotine has more saliency at that time.
It’s estimated that one in three women have experienced physical violence at the hands of an intimate partner, which not only makes them more likely to use substances and have depression, but similarly using substances puts them at higher risk of having partner violence and sexual victimization. A lot of women who have addiction do have a history of childhood sexual trauma, so the two are very related.
Similarly, with STDs, when women use substances they’re at higher risk for having STDs developing. If they’re binging on alcohol or other substances, they’re engaging in higher risk sexual behavior, sometimes they’re being victimized at the hands of others. Binge drinking’s associated with unintended pregnancies, risk of infection from IV drug use, and women, more so than men, are more likely to use sex as a transactional object, to get money or drugs.
I want to talk about some of the psychiatric comorbidities, and most of these can occur in men and women, but the ones I’m going to mention are more likely to occur in women.
Women are more likely to have PTSD, depression–depression’s 2:1, women to men– anxiety, borderline personality disorder, eating disorders. Men, on the other hand, are more likely to have antisocial personality disorder, ADHD or other substance use disorders. Bipolar disorder is pretty equal in both. It’s also important to note that women, when expose to trauma, are more likely to develop PTSD than men are.
For eating disorders, they do co-occur frequently with substance use disorders, up to 40%. 30-50% of those with bulimia, and 12-18% with anorexia have a comorbid substance use disorder. And the purging subtype of bulimia’s the most common seen with substance use disorders. And also, physical or sexual trauma is associated with greater rates of substance use with binge eating disorder. And women who have binge eating disorder plus PTSD plus a substance use disorder actually do worse in treatment than women who just have PTSD and a substance use disorder.
And although men and women may have the same comorbidities, they’re actually thought to have a different ideology in that there’s a temporal difference in which one comes first, whether it’s the affective disorder or the substance disorder.
So for men, they tend to develop the substance use disorder first, and then later the affective disorder will come. Whereas for women, most of the time what happens is that they start off with either depression, anxiety, PTSD, and then later develop the substance use disorder. And this, in part, may be explained by the fact that women are more likely to use substances to manage stress and negative affect, and they have more cravings in response to these negative cues, whereas men respond more to drug-related cues.
Borderline personality disorder: Up to 50% of patients with BPD also have a co-occurring substance use disorder. And as we know, in these patients there’s already a higher risk of suicidality and suicide attempts. Adding in a substance use disorder makes them more impulsive; the rate of suicide attempts do increase, there is an increased vulnerability to relapse, and it is a predictor of substance use disorder persistence overtime. So if you have a patient that has both of these and you’re just trying to treat the substance use disorder, it may be a little bit futile, and treatment should also be targeting the personality disorder.
I’m going to talk about the main substances just briefly and how they relate to women. So, alcohol is a big one. The 12-month prevalence of alcohol use disorder is 4.9% compared to 12.4% in men. Women experience more blackouts, more passing out; men tend to be involved in more violent acts. And, again, women are using alcohol to get away from negative stressors, whereas men are using alcohol for others reasons: to moderate the effect of another drug, or for sleep.
And we talked a little bit about telescoping . . . When women use alcohol, they’re more likely to develop cirrhosis, have brain atrophy much more quickly, and also develop cognitive deficits. Women reach higher blood alcohol levels when consuming the same amount of alcohol as men, and part of this is due to their size, metabolism, body composition, so having more fatty tissue, less body water, as well as having lower levels of the enzyme alcohol dehydrogenase, which breaks down alcohol in their stomach. And because of this, less alcohol’s broken down and more goes directly into the bloodstream.
And this is also part of the reason that the guidelines for recommendations for drinks is different for men and women. Men can have up to 14 drinks per week, whereas women can have 7, and those are kind of the numbers at which we start to see more of these physical consequences.
For opiates, use in women is increasing and when women do use heroin, it’s associated with higher impairment, more psychiatric illness, more physical impairment. Prescription opiates are a little bit different in that women are using about the same, not more, than men are.
For marijuana, again, there’s a telescoping effect; rates in general are increasing with everyone, but women in particular. And using marijuana does put women at higher risk for risky sexual behavior, STDs, and then pelvic inflammatory disease as a result.
Amphetamines, we talked a little bit about this, that women might be more vulnerable to the reinforcing effects of stimulants, they crave more in response to cocaine. But interestingly, women actually have fewer perfusion and abnormalities in the cortex and less neurotoxicity when compared to men, and it’s thought that estrogen is actually neuro-protective in this regard.
Tobacco. Nicotine’s metabolized by the P450 enzymes, which are upregulated in females. So women metabolize nicotine much faster, making it harder for them to quit smoking, especially as we talked about earlier, when they’re in the luteal phase of their menstrual cycle. One thing when it comes to smoking cessation that women express much more so than men is a concern for weight gain, and also women who are smoking, using tobacco in general, have more physical consequences including heart attacks, lung disease, COPD and cancer.
Substance use in pregnancy is a really important topic. About one in four pregnant women report using substances, and it’s important not just for the mom but also for the fetus, because anything the mom uses will pass through the placenta and affect the fetus.
The national survey on drug use and health estimated that 19% of pregnant women use tobacco, 10% alcohol, 4% marijuana. In another study that looked at pregnant women and alcohol use, 8.5% reported using alcohol, 2.7% reported binge drinking, 3.6% met criteria for an alcohol use disorder. It is important to note that women, a lot of times, are motivated during their pregnancies to have more positive health behaviors for their baby, for themselves, so substance use actually decreases throughout pregnancy.
Women who are more likely to use substances during pregnancy include: single, unmarried, unemployed women who have psychiatric comorbidity. One might think that poor women and minorities are more likely to use substances; studies show that white women are four times as likely to report substance use than non-whites and they’re more likely to use alcohol, which is actually the one that we know the most about. Black women and poor women report higher use of illicit substances, particularly cocaine. Another thing that’s important to know and may reflect some of the genetic and environmental factors is that women who use substances during pregnancy are more likely to have been raised by substance abusers, in particular alcoholics.
Screening in pregnant women: It’s really important to screen women, not just for the teratogenicity of substances, but also just for general health behaviors of mom that can affect her and the baby. This includes nutrition and access to prenatal care. There are some screening tools that have been validated specifically in pregnant women, that include the TWEAK and the T-ACE. So the TWEAK is Tolerance, Worried, Eye-opener, Amnesia, and Cut-down. The T-ACE is Tolerance, Annoyed, Cut-down, Eye-opener, and it specifically looks at the quantities of alcohol being used.
And as much as it’s important to screen pregnant women, it may be even more important to screen women before they get pregnant, because that’s a place we can really have an effect.
Alcohol use in pregnancy: A lot of times women get pregnant during a time that they’ve been drinking heavily, binge drinking, they may not even know that they’re pregnant initially, so they continue to drink into the first trimester. Imaging studies have shown that prenatal alcohol exposure can disrupt the development of grey and white matter, can lead to alterations in cerebral blood flow, neurotransmitters.
The most common effect of alcohol in pregnancy that most people have probably heard of is Fetal Alcohol Syndrome. And the classic version of it comes with a very distinctive facial dysmorphology, so it’s smooth philtrum, thin upper lip, small eyes. But it can occur with or without this. It’s more of a spectrum disorder. The prevalence is estimated to be in 2-5% of births. Usually in small babies as well.
But, importantly, alcohol during pregnancy is the most common cause of non-genetic mental retardation which we can help to prevent.
For breast feeding, some of the alcohol that the mom consumes is excreted into breast milk, which will be passed onto the infant during breast feeding, and this can actually negatively impact motor development and early learning. And if the mom is drinking a lot of alcohol as well, that can inhibit lactation, so they won’t be able to provide enough food for their baby.
As far as opiates and pregnancy go, I’m mainly just going to talk about heroin. Heroin crosses the placenta very readily, within about an hour of mom’s use, the fetus is already exposed to the substance. And using heroin in pregnancy comes with a lot of issues, including the fact that heroin’s illegal, so there’s criminal behavior associated with it. A lot of times, a mom may not know when she’s going to get the next dose, and is kind of going through a lot of these highs and lows, intoxication and then withdrawal, and when mom goes through withdrawal, so does the fetus.
And there’s fetus abstinence syndrome which increases the risk of premature delivery, stillbirth, low birth weight, sudden infant death syndrome . . . As well as that, there’s a risk for infection if mom’s using IV, risk of overdose, and we don’t even know what’s in the heroin that’s out there these days, so it could be heroin or not at all, or heroin plus a lot of other things that may actually be teratogenic.
When moms are really using heavily and there’s a lot of risk, it is important to consider opiate replacement strategies. Methadone’s been the standard of care and SAMHSA does not recommend stopping this for pregnant women. The benefits tend to outweigh this cycle of high, low, withdrawal, intoxication. Some of the benefits are stabilizing the opiate level, the dose, knowing what the mom and baby are getting, reducing illegal activity, reducing withdrawal, increasing woman’s participation in pre-natal care and just general positive health behaviors.
Methadone’s also associated with lower risk of infection, fewer pregnancy complications, increased birth weight, better development in general. And methadone, like any other substance, does cross the placenta so while we’re kind of regulating how much the fetus is getting, the fetus will still be dependent on this medication.
At the time of birth when there is a separation from the placental circulation, the baby will then most likely go through withdrawal and this is called Neonatal Abstinence Syndrome. It can occur in 50-95% of infants that are exposed to heroin, or another opiate. And they’re essentially going through their own form of withdrawal now that they’re no longer connected to mom, and this can look like very irritable, poor sleep, vomiting, respiratory issues, potentially even seizures. Treatment is generally supportive, hospitalization, and a low dose morphine taper usually, to help with the symptoms.
This is a really important study, the MOTHER study aka The Maternal Opioid Treatment: Human Experimental Research study. Which was double-blind, double-dummy, randomized, and it compared two groups of pregnant women who had opiate use disorders, one of which received methadone, and the other buprenorphine during pregnancy.
It found buprenorphine to be a safe and effective alternative to methadone, which has been the standard of care. The two groups were really similar in terms of outcomes from mom and baby in terms of pregnancy complications, neonatal health, weight gain, positive drug screens and any delivery complications. The one place that they differed was in the neonatal abstinence syndrome. The infants that were born to the women who had received the buprenorphine had much milder symptoms than those who had been getting the methadone. Similarly, those infants who’d gotten buprenorphine needed less morphine to manage their symptoms, they finished their taper in much less time and had shorter hospital stays. Part of what might explain is that buprenorphine is a partial agonist rather than a full opioid agonist, so there might be less severe fetal opioid dependence than with methadone.
Opioids are still excreted into the breast milk, in very small amounts, and it may help with some of the neonatal abstinence syndrome, but overall it’s thought to have a fairly minimal effect on the newborn, although the mom should be watching for signs of intoxication, like sedation and respiratory difficulties.
Tobacco use in pregnancy: It’s actually pretty common; 15.9% of pregnant women reported smoking in the past month. And nicotine is not the only thing that’s in cigarettes, so nicotine plus whatever else is in there is getting transferred to the baby across the placenta. That can result in impaired oxygen delivery, carbon monoxide exposure, increased risk of spontaneous abortion, general effects like small birth weight, small gestational age, preterm birth, and potentially even long-term effects on cognition. So it is important to encouraging smoking cessation, it’s good for mom and baby, especially the earlier that it’s done in pregnancy. Unfortunately, among those who do quit, there’s a 50-90% relapse in the first year after delivery.
There is an increased risk of stillbirth with most of these things, but I thought it was interesting . . . there’s about two times the risk for the general population in moms who are using tobacco, including passive tobacco exposure. The risk actually increases with the level of use, so the greatest risk was in those who were smoking the heaviest.
As far as treatment goes . . . Generally, women are less likely than men to engage in treatment, and they tend to be under-represented in treatment programs. They have some unique barriers to care, one of them being childcare, and this one can kind of go either way. For some women, if they’re single moms, they’re the only one taking care of their kids; they feel like they have to be home; they can’t afford to go to treatment; it’s just not possible. They’re worried DCFS may take their kids, so they kind of neglect themselves in trying to take care of their kids.
Some other studies have shown that women are really motivated by having children in wanting to get treatment for themselves. But definitely something we need to be aware of and considering. Women have a lot of fear around divorce if they go to treatment, family instability. Sometimes they’re reliant on someone else for finances and so that is another barrier. And there is a lot of stigma towards women in general having addiction, but pregnant women in particular.
The good news is that once women do engage in treatment, they tend to do just as well as men do. One thing that we do need to pay attention to is that if women do have co-occurring psychiatric disorders or a history of trauma this can negatively impact treatment, so we really want to be addressing these to improve treatment response. And there have been studies that show that adding a trauma-focused approach to women who have PTSD do better in treatment, and when there are fewer PTSD symptoms, substance use decreases as well.
Whether women would do better in women-only treatments or mixed gender treatments . . . there aren’t a lot of randomized control trials on this, but some studies do indicate that women-only programs may address more of these issues specific to women—the trauma, stigma, pregnancy, maybe even apply some assertiveness training for women and help around self-esteem issues.
Potentially women, when they’re surrounded by a group of just other women, feel more comfortable communicating how they’ve been feeling, past experiences, etc. It does minimize the risk of further sexual victimization while in treatment. Some studies have shown better retention rates for women-only programs, improved aftercare attendance, less criminal activity. One study in particular compared a women-only recovery group to a mixed gender group and they didn’t find any differences at 12 weeks, but further out in 6 months the women-only group actually had a greater reduction in substance use.
Okay, so I do want to get back to Nicole and kind of tie a lot of this stuff in. Because of her pregnancy, we felt she needed the highest level of care, we wanted to get her in immediately, and we got her into the residential unit over at Jesse Brown where she was detoxed and was able to stay there for 60 days.
As far as her childcare issues, her ex-husband had moved to Texas and she was able to send her son to live with him, so she could feel that he was in a safe place which allowed her to get treatment for herself.
I think Nicole represents a lot of the topics that we talked about, with her history of trauma, military sexual trauma, domestic violence, her unintended pregnancy as a result of alcohol use, engaging in this risky sexual behavior. And really, she hadn’t been getting any pre-natal care because she didn’t know she was pregnant. But after she came to treatment, she was able to be tested for STDs and got prenatal care. Her nutrition improved, the fetus’s health improved, and she felt really motivated during her pregnancy to stay sober, although she expressed a lot of concern about relapse after delivery.
The veteran population, the Jesse Brown VA, is a primarily male population. She was the only female in the unit for most of the time she was in treatment, and she did report being stigmatized. She felt like they kind of looked down on her, not just for being female but also for being pregnant. Also she reported being sexually harassed by the male patients while on the unit. And as I mentioned before, her alcohol use really picked up after her trauma, so that’s that temporal relationship that we talked about where she first had trauma, PTSD, and then was using substances to cope with that.
So, during residential, she felt like she’d kinda worked up to being able to address her trauma, and following residential treatment, she went to a two-week intensive outpatient treatment that was women-only and focused on sexual trauma and PTSD. She continued to be engaged in outpatient treatment after that, and through to the end of her pregnancy, including attending the women’s therapy group, which she felt was one of the best things that she’d done for her recovery.
And that’s it.