Women and Substance Abuse

Dr. Cynthia Kuhn

Department of Pharmacology and Cancer Biology

Duke University Medical Center

Definitions

Addiction: Out of control, compulsive use of addictive drug

Abuse: Use with negative consequences

How Do Women Use Drugs?

Women Use Addictive Drugs Less than Men

NHSDUH 2008

Teenage Women and Men Use Addictive Drugs Equally

NHSDUH 2008

Addictive Drug Use Peaks During Young Adulthood

Substance Dependence in Women and Men

Alcohol Dependence in Women and Men

What is Different About Women and Drug Use?

Women’s Issues in Drug Use Epidemiology

• Use is becoming equal for many drugs

• Female adolescents higher than males for several drugs

• Pregnancy: special risk for children

Illicit Drug Use by Pregnant Women

Binge Alcohol Use by Pregnant Women

Addiction is The Result of a Brain Process

Is this Biology Different in Women?

Addiction Is a Process of Brain Adaptation

Drug use: Reward

Reward CircuitAdapts

Need Drug to Feel Good at all

ADDICTIONWithdrawal,Craving

Addiction is NOT just Dopamine

• Components of Addiction

• Rewarding effects of the drugs – dopamine

• Tolerance and dependence- withdrawal

• Impaired priority setting/decision making – craving, compulsive use

Neural Basis of Addiction

Dopamine

All Addictive Drugs Activate This Circuit

DA

Cocaine

Alcohol

Heroin

Nicotine

All Addictive Drugs Increase Dopamine Levels

0102030405060708090

100

10 30 60 90 120

Time (minutes)

Dop

amin

e CocaineHeroinAlcoholMarijuanaNicotine

Addiction Is a Process of Brain Adaptation

Drug use: Reward

Reward CircuitAdapts

Need Drug to Feel Good at all

ADDICTIONWithdrawal,Craving

Reward System Adaptations in Addiction

Dopamine Neuron

DA Target Neuron

DA Receptors

Constant DA Release

Dopamine Receptors Are Decreased in Addicts

Addictive Drugs Cause Long Lasting Changes in

the Brain

Kalivas and Volkow, Arch Gen Psy. 162: 1403

Addiction Is a Process of Brain Adaptation

Drug use: Reward

Reward CircuitAdapts

Need Drug to Feel Good at all

ADDICTIONWithdrawal,Craving

Executive Function Changes in Addiction: Drugs Become Priority

• Increased impulsivity: Do things without considering the outcome

• Impaired memory- Can’t keep things in mind while considering a decision

• Difficulty shifting priorities

• Risky decision making

Berridge et al, Phil Trans. R. Soc B. 363:3257 (2008)

Addicts Can’t Change Losing Strategies

A B

C D

Win Big, Lose Overall

Win Small, Win Overall

. J. Math. Psychol 54:28 (2010)

Addiction Is a Process of Brain Adaptation

Drug use: Reward

Reward CircuitAdapts

Need Drug to Feel Good at all

ADDICTIONWithdrawal,Craving

Craving and Misery of Withdrawal: From Activation of Stress Axis

• Chronic drug exposure triggers stress axis

• Involves stress peptide CRF

• Amygdala sends messages to cortex – motivates more drug taking

Chronic Addictive Drugs Activate the Stress Axis in the Brain

Summary: Key Processes in Addiction

• Rewarding effects of drugs• Adaptation to drugs – brain biochemistry

and structure changes• Disturbed decision making• Craving associated with Withdrawal –

activation of stress axis

You meet your clients at the withdrawal phase when they:

Can’t feel pleasure

Feel miserable - going through withdrawal

Have poor decision making

Want drug more than anything

Gender Differences in Addiction???

Do Women Respond to Addictive Drugs Differently? Not really

• Subjective effects (high) not significantly different from men– Sedatives– Nicotine– Marijuana– Alcohol– Stimulants

Do hormones affect biological response to psychoactive drugs?

• Yes:– Stimulants

• No:– Ethanol

– Nicotine

– Marijuana

– Heroin

Hormones may actually help! Progesterone suppresses drug taking

Addiction in Women???

Addiction develops more quicklyShorter window between initiating use

and entering therapyWomen show stronger craving

Long Term Effects?

• Alcohol: women experience more toxicities at lower doses– Cirrhosis– Heart disease– Stroke– Osteoporosis

• Stimulants: Men have more CNS damage

What We Don’t Know about Women and Addiction

• Are brain changes different?

• Is decision making changed in the same way?

• Is withdrawal worse?

Addiction is not just Brain Biology

Which of these influences are important for women?

Vulnerability Factors in Addiction

Individual Family history

GeneticsPsychiatric illness

Environment

PovertyLow access to services

Drug using area

Drug using familyAbuse

Education

Women and Men Substance Abusers have Different Psychopathology

• Common in men– ADHD– Conduct disorder

• Common in women– Major depressive disorders– Anxiety disorders

Latimer et al., 2002

Women: Special Risk from Psychiatric Co-Morbidity

More women havedepression

Depression is risk Factor for substance

abuse

Family History

• Women more likely to have experienced physical and/or sexual abuse

• Women more likely to have less education than drug using men

Environment

• Women are more likely to be poor (especially if they are mothers)

• If they have a partner, he/she is more likely to be a drug user

• Women’s profession more likely to be linked to drug use (sex work)

Treatment

Treatment of Addiction

• Multiple approaches are necessary– Needs to be long enough- brain changes slowly– Cognitive behavioral therapy a valuable adjunct

for impaired decision making

• Drugs can contribute– Substitution therapies– Antagonist strategies

• Engagement as a result of criminal justice (YOU!) increases success

Heroin

Nicotine

Most Drug Treatments Replace Drug at Site of Action

Methadone

Nicotine Patch

Treatment Works! Efficacy of Methadone Treatment

0

10

20

30

40

50

60

70

80

90

100

Per

cent

Usi

ng

Start of methadoneOne year

One example of many

Gender Effects in Treatment• Women less likely to get therapy

– Low expectations– Don’t perceive need

• Most therapies effective in women and men

• Gender-specific approaches little tested– Special needs must be addressed- children!

Greenfield et al, Drug and Alcohol Dep. 86: 1 (2007)

Summary: Women’s Issues in Substance Abuse

• Women are losing the protection they had from historic social roles

• Their brains respond to addictive drugs like those of mens

• Addiction may “telescope,” develop faster• Treatment likely to be successful but there

are barriers to entry• Special needs due to pregnancy and

children must be addressed

Practical Advice

• Addiction: Treat! Just like anybody else• Underlying psychiatric illness must be treated• Physical/sexual abuse history will be a factor

in engagement in treatment• Treatment is more likely to be successful if

women can be with their children• Pregnant women: most likely to engage in

treatment

Dr. Cynthia Kuhn

ckuhn@duke.edu