Substance Abuse in Women: Clinical & Program Issues in the Community & Criminal Justice System

Joan E. Zweben, Ph.D.

Executive Director, EBCRPClinical Professor of Psychiatry;

UCSFADP Conference October 13,

2010

Introduction 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)

Epidemiology 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 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 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 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 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)

Latinas 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 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)

Women in the MilitaryWomen Veterans of Iraq & Afghanistan: Review of records from Defense Medical Surveillance System indicated 17.4% received specific mental health diagnosis (overall rate, 12%)

22% suffered from military sexual trauma, compared with 1% of men(Susan Storti, NIDA Conference 2010)

Diagnostic & 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

Psychosocial 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

Medical Comorbidity

Biological 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

Alcohol

Course 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 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 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 Comorbidity

Psychiatric 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

PTSD 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

Treatment Issues

Gender 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 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 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 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 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 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 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 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 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 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

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) 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):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)

Women in the Criminal Justice System

Epidemiology Women are the fastest growing segment of the CJ population in all components since 1990s

Majority are nonviolent offenders Most are minority, esp black and Hispanic

Variety of medical problems, more severe than age matched counterparts

Children at High Risk Most women offenders have children Disproportionately linked to race Family disorganization, financial hardship, exposure to abuse and trauma often predated incarceration

No reliable research to support the view that these children are more likely to be incarcerated as adults

Did have problematic school behavior and deviant peer influences

Family Contact Family contact in prison is associated with lower rates of post release recidivism

Telephone restrictions significantly reduce family contact

Budget cuts have led to reduced visiting hours

Criminogenic Factors Targeted to Improve Outcomes Antisocial values Criminal peers Dysfunctional families Substance abuse Criminal personality Low self-controlSubstance abuse treatment alone is not enough.

Treatment In Custody S. Covington manuals specific for this population

Gender-responsive treatment showed better outcomes (Messina et al, JSAT 2010)

Community based continuing care improves outcomes

Safety issues: women victimized by other inmates and custodial staff

Treatment in the Community Re-entry courts as an alternative sanction

Second Chance, PROTOTYPES, intensive tx that addresses COD

Complex problems of women parolees often not addressed

Barriers to Effective Treatment in the Community Laws and regulations are designed for high risk inmates

Difficult to get approval for educational activities outside the program

Computer access restricted Exploitative requirements for telephone access

Prohibitions/restrictions on medications

Recommendations Select appropriate evidence-based practices; avoid “pick from this list” approach

Beware of rigid adherence to a model or EBP at the expense of individualized treatment planning

Carefully investigate whether appropriate services are available

Eliminate barriers to medication use for psychiatric or addictive disorders

Acknowledge that tx requires building capacity for independence; avoid excess restrictions not required for public safety

References Covington, S. (1999). Helping Women Recover. San

Francisco: Jossey Bass. Covington, S. (2000). Helping women to recover:

Creating gender-specific treatment for substance-abusing women and girls in correctional settings. In M. McMahon (Ed.), Assessment to Assistance: Programs for Women in Community Corrections (pp. 171-233). Latham, Maryland: American Correctional Association.

Messina, N., Grella, C. E., Cartier, J., & Torres, S. (2010). A Randomized Experimental Study of Gender-Responsive Substance Abuse Treatment for Women in Prison. Journal of Substance Abuse Treatment, 38(2), 97-107.

Zweben, J. E. (2011). Women's Treatment in Criminal Justice Settings. In C. Leukefeld, J. Gregrich & T. P. Gullotta (Eds.), Handbook on Evidence-Based Substance Abuse Treatment Practice in Criminal Justice Settings. New York, NY: Springer.

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