Misconceptions About Women And Alcohol

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The Presentation for The Neuroscience and Addiction Conference 2009, presented by M. Kotz, DO.

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  • Misconceptions About Women And Alcohol

    1. 1. Misconceptions About Women and Alcohol M. Kotz, DO Associate Professor Case Western Reserve University
    2. 2. Key Points <ul><li>Limited literature; current research shows significant gender differences </li></ul><ul><li>Unique physiological, psychiatric, social impact </li></ul><ul><li>Physiological distinction: rate of metabolism and the effect of given dose of alcohol on total blood level </li></ul><ul><li>More severe medical consequences with accelerated disease progression </li></ul><ul><li>Different cultural and social expectations </li></ul><ul><li>Mediates vulnerability and treatment access </li></ul>
    3. 3. Introduction <ul><li>Sparse information </li></ul><ul><li>First attempt to separately examine alcoholism in women was in 1978 by NIAAA </li></ul><ul><li>Prior research </li></ul><ul><ul><li>Focused on males </li></ul></ul><ul><ul><li>Extrapolated to women </li></ul></ul><ul><ul><li>Assumed gender differences not significant </li></ul></ul><ul><li>Last three decades have shown drastic misconceptions </li></ul><ul><li>Biopsychosocial aspects dramatically different </li></ul><ul><li>Vast evidence: more acute and chronic problems </li></ul><ul><li>Sex bias continues leading to misunderstanding </li></ul>
    4. 4. Prevalence <ul><li>SAMSHA: More males drink than females </li></ul><ul><li>Except 12-17 age group, 17.4 to 17.9 current use </li></ul><ul><li>Increased number of women drinking </li></ul><ul><li>Convergence: men to women about 2:1 </li></ul><ul><li>NSDUH: Gender gap closed youngest age group </li></ul>
    5. 5. Risk for Developing AUD <ul><li>Start drinking before age 15: 40% higher risk </li></ul><ul><li>39% fourteen year old girls report drinking in past month </li></ul><ul><li>Alarming: 21% had five or more, single occasion </li></ul>
    6. 6. Prevalence UK <ul><li>International surveys: Young people among heaviest drinkers in the world </li></ul><ul><li>European School Survey: Age 15-16 </li></ul><ul><ul><li>Sixth for frequent drinking, third for drunkeness, second for binge drinking and for “being drunk before age 13” </li></ul></ul><ul><ul><ul><li>McArdle, Arch Dis Child, April 2008 </li></ul></ul></ul>
    7. 7. UK Undergraduate Female Drinkers <ul><li>Since 1995: significant increase female binge drinking , has been noted in accident and emergency dept reports </li></ul><ul><ul><li>Simpson, International Journal of Drug Policy, 2007 </li></ul></ul><ul><li>40% exceed ‘sensible’ weekly intake of 14 units </li></ul><ul><li>Student binge drinking high - three times normal population </li></ul><ul><li>Female students drinking like male colleagues </li></ul><ul><li>UK initiatives for sensible drinking failing </li></ul><ul><li>Binge drinking within this age group viewed as normal </li></ul><ul><ul><li>Gill, Alcohol and Alcoholism 2001 </li></ul></ul>
    8. 8. Special Risk Factors <ul><li>Alcohol Use Disorders: use, abuse, dependence </li></ul><ul><li>Telescoping: Piazza et al, short interval from initiation to treatment </li></ul><ul><li>Accelerated course: briefer periods between regular drinking and loss of control </li></ul><ul><li>Shortened course: less time for intervention </li></ul><ul><li>Genetic vulnerability: Kendler et al, 50%-60% </li></ul>
    9. 9. Physiological Differences <ul><li>Metabolism: Higher BAC /unit of alcohol </li></ul><ul><li>Frezza,1990,lower levels of alcohol dehydrogenase in gastric mucosa </li></ul><ul><li>Less first-pass metabolism </li></ul><ul><li>Higher alcohol absorption </li></ul><ul><li>Higher BAC </li></ul>
    10. 10. Body Composition Differences <ul><li>Quantity ingested versus BAC explained by </li></ul><ul><li>Women lower proportion of water, higher proportion of fat </li></ul><ul><li>Distributed over smaller volume </li></ul><ul><li>Older women: higher BAC, “goes to head more quickly” </li></ul>
    11. 11. Gender Matters <ul><li>One drink for a man = two for a woman </li></ul><ul><li>Women get high faster and stay high longer than men, matching them drink for drink </li></ul>
    12. 12. Pharmacologic Differences <ul><li>Oral contraceptives: </li></ul><ul><ul><li>Decreased ethanol elimination rate </li></ul></ul><ul><ul><li>Consistent across all three phases of menstrual cycle </li></ul></ul><ul><ul><li>Higher alcohol level </li></ul></ul><ul><ul><li>Harder to predict ….variable BAC </li></ul></ul><ul><ul><li>Jones and Jones, Alcoholism: Clinical and Experimental Research, 2008 </li></ul></ul>
    13. 13. Socio-cultural Factors <ul><li>Female historical and current stereotypes: “party girl, promiscuous, slut, lush, bad mother” </li></ul><ul><li>Men: “macho, boys will be boys” </li></ul><ul><li>Main psychological difference: severe stigma </li></ul><ul><li>Conflicts with society’s view of femininity and roles as wife and mother </li></ul><ul><li>Women internalize this stigma: feel guilt, shame, self-loathing and despair </li></ul>
    14. 14. Socio-cultural Factors <ul><li>Stigma and threat of severe consequences lead women and families to profound denial </li></ul><ul><li>Losing custody, criminal charges </li></ul><ul><li>Paternalism </li></ul><ul><li>Social contagion factor: assume drinking patterns like partner </li></ul><ul><li>Men leave alcoholic wives, wives stay with alcoholic men </li></ul>
    15. 15. Victimization: Sexual Assault <ul><li>Study of 24,000 college women showed correlation to rape and acute intoxication J. Study of Alcohol 2004 </li></ul><ul><li>One in twenty women reported rape, nearly 75% victims reported intoxication at the time </li></ul><ul><li>Adolescent girls use alcohol more than 5 times a month, five times likelier to be sexually active </li></ul><ul><li>One third less likely to use condoms </li></ul>
    16. 16. Societal Stereotyping <ul><li>A woman drinking is sexually available </li></ul><ul><li>Double standard even with assault: </li></ul><ul><li>Blume: “Society considers a rapist less responsible, whereas a female victim who is intoxicated is blamed for the assault” </li></ul><ul><li>Dichotomy of madonna and fallen woman </li></ul>
    17. 17. Gender Gap Closing <ul><li>1978 family analysis: protective factors, deterrents, less social pressure, fewer gender specific situations, different drinking practices </li></ul><ul><li>Gradual changes in social norms </li></ul><ul><li>More women in work force, professions, sports </li></ul><ul><li>Vocational drinking incentives </li></ul><ul><li>Feminist movement and equal rights: drinking with power, “drink like a guy, will be like a guy” </li></ul><ul><li>“ Going toe-to-toe with men is a feminist act” </li></ul><ul><li>Drinking uneasy relationship to women’s freedoms </li></ul>
    18. 18. Drinking Patterns Changed <ul><li>Starting age 14: over one third have drank in past month </li></ul><ul><li>More alarming: one in five had binged, five or more drinks per episode </li></ul><ul><li>Young women in twenties and early thirties more likely to drink - public place </li></ul><ul><li>Middle age and older women: ‘behind closed doors’, solitary drinking, even more stigma </li></ul><ul><li>Women have come out of the closet </li></ul>
    19. 19. Marketing and Media Efforts <ul><li>Liquor Companies mid-’70s : targeted women </li></ul><ul><li>Fashion magazines: splashy ads of women sipping themselves into various states of rapture </li></ul><ul><li>Jim Bean ad: “Get in touch with your masculine side” </li></ul><ul><li>TV “Sex and the City”: tossing down candy-colored cocktails at a bar </li></ul><ul><li>Seductive role models: glamorous fantasies </li></ul><ul><li>Girls today four times more likely than their mothers to begin drinking by age 16 </li></ul><ul><li>NO LONGER A MAN’S DISEASE </li></ul>
    20. 20. Evaluation <ul><li>Needs to be earlier due to telescoping </li></ul><ul><li>Seek help as a consequence of health or family problems </li></ul><ul><li>Seen in primary care physician offices and mental health settings, not alcohol services </li></ul><ul><li>Women less likely to be diagnosed, under-represented in treatment </li></ul>
    21. 21. Delayed Identification <ul><li>Patient denial - more stigma “a lady doesn’t get drunk” </li></ul><ul><li>Physician denial: “she’s too much of a lady to be drunk” </li></ul><ul><li>Probability of missed diagnosis: “pt better educated, higher socio-economic status, privately insured and female” </li></ul><ul><li>Family denial: “not my mother” </li></ul><ul><li>Boss denial: women may get away with more </li></ul><ul><li>Police denial: don’t cite </li></ul><ul><li>Fewer legal and occupational consequences </li></ul><ul><li>Less organized referral programs: EAP’s, drunk driving schools </li></ul>
    22. 22. No Gender Sensitive Tools <ul><li>AUDIT </li></ul><ul><li>TWEAK </li></ul><ul><li>“ Do you sometimes drink alcohol beverages? If you do, please continue.” </li></ul><ul><li>T Tolerance: How man drinks does it take before you begin to feel the first effects of the alcohol? (record number of drinks) </li></ul><ul><li>2 pts for three or more </li></ul><ul><li>W Have close friends or relatives worried or complained about your drinking in the past year? </li></ul><ul><li>2 pts for yes </li></ul><ul><li>E Do you sometimes take a drink in the morning when you first get up? </li></ul><ul><li>1 pt for yes for EAK </li></ul><ul><li>A Amnesia: Are there times when you drink and afterwards you can’t remember what you said or did? </li></ul><ul><li>K Cut-down: Do you sometimes feel the need to cut down on your drinking? </li></ul>
    23. 23. Medical Considerations/Consequences <ul><li>Same health problems: drink less, shorter period of time </li></ul><ul><li>Alcoholic liver disease: more women die from cirrhosis, alcoholic hepatitis </li></ul><ul><li>Estrogen augments alcohol’s toxicity </li></ul><ul><li>Higher at any level of consumption: relative risk 7-13 drinks vs14-27 </li></ul><ul><li>Osteoporosis, cardiovascular and neurological disorders, enhanced brain damage </li></ul><ul><li>Greater toxic effects: brain mass decreased, less exposure, imaging studies grey matter smaller </li></ul><ul><li>If drinking, 75% more likely to smoke; smokers are 86% more likely to drink, greatly compounds osteoporosis risk </li></ul><ul><li>High estrogen phases and elevated levels of acetaldehyde implicated in pathogenesis </li></ul>
    24. 24. Special Teen Risks <ul><li>Prefrontal cortex: still maturing, substantial changes </li></ul><ul><li>Functions to assess situations, make sound decisions </li></ul><ul><li>Increased risk for poor decisions </li></ul><ul><li>Amygdala: emotional reactions, response to stress </li></ul><ul><li>Increased risk-taking behaviors </li></ul><ul><li>Hippocampus: learning and memory </li></ul><ul><li>Decreased volume, decreased learning </li></ul>
    25. 25. Sexual and Reproductive Functioning <ul><li>Increased risk/association: breast ca, PMS </li></ul><ul><li>Sexual arousal: dissociation between greater arousal perceived and decreased physiological/orgasmic response </li></ul><ul><li>Sobriety enhances sexual function </li></ul><ul><li>Teratogenic effects: FAS, mental retardation, spontaneous abortion </li></ul><ul><li>Infertility </li></ul><ul><li>Interferes with puberty </li></ul>
    26. 26. Psychiatric Comorbidities <ul><li>Mood disorders: strong association with depression: relative risk 2.6 higher for heavy drinking </li></ul><ul><li>Bipolar: odds ratio 7.35 for women compared to 2.77 </li></ul><ul><li>Anxiety disorders: higher prevalence </li></ul><ul><li>High rate of sexual and physical abuse </li></ul><ul><li>PTSD greater severity and re-victimized </li></ul><ul><li>High cross addiction to prescription meds </li></ul><ul><li>Alcoholic women attempt suicide 4 times more </li></ul><ul><li>Female alcoholics death rates 50-100 times that of males </li></ul>
    27. 27. Treatment <ul><li>Most efficacious way: no consensus </li></ul><ul><li>Special issues/barriers: child care, transportation, custody concerns,stigmatization and loss of relationships, less access to treatment </li></ul><ul><li>Treat co-morbid conditions: physical and psychiatric </li></ul><ul><li>Addressing sexual abuse improves treatment success </li></ul><ul><li>Same facility: both sexes benefited equally </li></ul><ul><li>Female only: 2 yr follow-up: better outcomes, but had more services </li></ul><ul><li>Like morbidity, mortality greater: Lindberg et at, females five times higher expected rate as compared to 3 times for men </li></ul><ul><li>Most successful treatment starts with early, accurate diagnosis </li></ul>
    28. 28. 12 Step Programs: AA <ul><li>34% Women </li></ul><ul><li>Interpret powerlessness: culturally empowered man versus sexually abused woman </li></ul><ul><li>Treatment goal: learning to take control rather than give it up </li></ul><ul><li>Women for Sobriety </li></ul><ul><li>AA women only groups </li></ul>
    29. 29. Relapse Prevention <ul><li>Women relapse due to negative affect and interpersonal problems, men positive feelings </li></ul><ul><li>Education about effects and risks </li></ul><ul><li>Sexual compulsivity, shopping, eating disorders </li></ul><ul><li>Familial relationships, especially with children </li></ul><ul><li>Safety issues/ family involvement </li></ul><ul><li>Vocational rehab </li></ul><ul><li>Mayo study: “the more depressed, the greater craving for alcohol” </li></ul>
    30. 30. Prevention <ul><li>Address misconceptions: </li></ul><ul><li>“ It won’t happen to me” </li></ul><ul><li>“ I am too young to have a problem” </li></ul><ul><li>“ I need to go out with my colleagues after work and drink, it’s part of my job” </li></ul><ul><li>“ I take medication for my depression, but drink on the week-ends, it’s no big deal” </li></ul><ul><li>“ I drink less than my boyfriend, so I can’t have a problem” </li></ul><ul><li>“ I can drink more than my boyfriend, so I can’t have a problem” </li></ul><ul><li>“ If I have a problem, everybody has a problem”” </li></ul><ul><li>“ I only drink wine or beer” </li></ul>
    31. 31. Education <ul><li>Definition of “a drink” </li></ul><ul><li>One 12-oz bottle of beer or wine cooler </li></ul><ul><li>One five -oz glass of wine </li></ul><ul><li>1.5 oz of 80-proof distilled spirits (hard liquor) </li></ul>
    32. 32. Assess Risk Factors <ul><li>Can’t change genetic liability </li></ul><ul><li>Can change “environment” </li></ul><ul><li>Decrease risk factors: safe exposure for maximum drinking limit </li></ul><ul><li>No more than 3 drinks in a day and </li></ul><ul><li>No more than 7 drinks in a week </li></ul>
    33. 33. Conclusion <ul><li>As prevalence converges, address women’s unique need </li></ul><ul><li>Prevention is critical </li></ul><ul><li>Education about special risks </li></ul><ul><li>Earlier interventions </li></ul><ul><li>Increase access </li></ul><ul><li>Address stigma </li></ul>
    34. 34. <ul><li>What’s a Standard Drink? </li></ul><ul><li>In the U.S., a standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons) . </li></ul>
    35. 44. B
    36. 49. NN
    37. 52. Typical US Patterns of Adult Drinking <ul><li>Never exceed daily or weekly limits </li></ul><ul><ul><li>2/3 have < 12 drinks/yr </li></ul></ul><ul><ul><li>1% have AUD </li></ul></ul><ul><li>Exceed only the daily limit </li></ul><ul><ul><li>20% have AUD </li></ul></ul><ul><li>Exceed both daily and weekly limits </li></ul><ul><ul><li>~50% have AUD </li></ul></ul>72% 16% 10%
    38. 53. Conclusions <ul><li>Women are at special risk for alcohol-related problems </li></ul><ul><li>They are also at special risk for going undiagnosed </li></ul><ul><li>Knowledge is an essential remedy for both issues </li></ul><ul><li>Unwarranted shame and stigma are the enemies of diagnosis and recovery </li></ul><ul><li>When treated, outcomes for women patients are often excellent </li></ul>

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