Young women and substance
use: Understanding
vulnerabilities and building on
strengths
Kim Corace, Ph.D., C. Psych,
Clinic...
Learning objectives:
1. Identify current patterns of substance use among
young women
2. Review risk factors for substance ...
What is addiction?
• Primary, chronic disease of brain reward, motivation,
memory and related circuitry
• Characterized by...
What is addiction?
• Like other chronic diseases, addiction often involves
cycles of relapse and remission
• Addiction is ...
What is addiction?

• Addiction is a developmental disease
that starts in adolescence and
childhood1

1NESARC

, 2003
Table 1. Past Year Drug Use (%) for the Total Sample,
and by Sex and Grade, 2011 OSDUHS (CAMH)
Total

Male

Female

G7

G8...
Opioids: A growing problem
• Canada is the world’s second largest per capita
consumer of opioids. Ontario tops the list in...
A Generation Exposed....
• Although experimentation with alcohol and other
drugs is a natural part of adolescence, experim...
What is an opioid?
• Opioids are depressants-- they slow down certain brain
functions, act on the mu receptor
• Opioids ar...
Prescription Opioids
Commonly abused prescription opioids
• Oxycodone (Oxycontin, OxyNEO)
–
–
–
–

Oxycontin formerly most popular opioid
Repla...
Commonly abused prescription opioids
• Dilaudid, Hydromorph Contin
– Usually chewed, snorted or injected

• Fentanyl “patc...
Risks of Opioid Misuse
• Overdose (high risk new users, unknown dose,
combined with alcohol and/or benzodiazepines, after
...
Why Prescription Opioids? Why now?
•
•
•
•
•
•

Think it’s safe because it’s a prescription
More socially acceptable than ...
Women and Substance Use
• Substance abuse is more prevalent among men, but
women are as likely as men to develop substance...
As cited in SAMHSA, 2009
As cited in SAMHSA, 2009
Video: Women of Substance

PLAY

Women of Substance (2013). South Shore District Health
Authority
Opioid Misuse: A growing epidemic among
women
• Rates of nonmedical prescription drug use is higher
among women then men, ...
Source: CDC Vitalsigns, July 2013, as per National Vital Statistics System, 1999-2010
For every woman who dies of prescription opioid overdose,
30 go to the ER for misuse/abuse

Source: CDC Vitalsigns, July 2...
* Source where pain relievers were obtained for
most recent nonmedical use among past year
users aged 12 and older: 2011-2...
Why are women disproportionately affected?
• Women are more like to have chronic pain
• Women are more likely to be prescr...
Risk Factors for Substance Use Problems
Environment/
Sociocultural
Context
Vulnerable
Host

Repeated
substance use

ADDICT...
Risk Factors: Relationships
• Women are more likely to be introduced to and initiate
drug use through their boyfriends, pa...
Risk Factors: Relationships
• Women are also more likely than men to be introduced
to IVDU their sexual partners1
– 51% of...
Risk Factors: Relationships
• Women may see sharing drug equipment and using drugs
as emotional intimacy, means of connect...
Risk Factors: Telescoping
• Telescoping describes an accelerated progression from
substance use initiation to the onset of...
Risk Factors: Sex differences
• Sex differences in the stress and reward systems which
increase women’s susceptibility to ...
Risk Factors: Menstrual Cycle
•
•
•
•

Substances disrupt menstrual cycle phases
Menstrual cycle phases affects substance ...
Risk Factors: Trauma
• The prevalence of PTSD is 1.4 to 5 times higher among
those with concurrent SUD1
• Initiation of su...
Risk Factors: Trauma
Rural school
youth in
Western
Canada
(N=3781)1

1Nicholson

& Saewyc, 2011
Risk Factors: Trauma
• Rates of physical or sexual abuse are extremely high
among women with SUD, ranging from 55 to 99%
•...
Risk Factors: Trauma
• Survey of women from substance use treatment centers
in Ontario, 85.7% of these women were victimiz...
Risk Factors: Trauma
• Women who have been abused are more likely to suffer
other adverse outcomes, including depression, ...
Risk Factors: The cycle of trauma
• Violence is both a risk factor and a consequence of
substance abuse
• Substance use in...
Risk Factors: Concurrent Disorders
• Compared to men, women have….
– Higher prevalence of concurrent mental health problem...
Risk Factors: Anxiety and Mood Disorders
• Lifetime prevalence of mood and anxiety disorders are
higher among women then m...
Risk Factors: Eating Disorders
• 90% of the cases of anorexia nervosa and bulimia
nervosa are found in women
• High correl...
Risk Factors: Eating Disorders
• Co-morbidity with other mental health disorders,
personality disorders (borderline person...
Risk Factors: Discrimination
Race

Culture

Legal
issues

Health
issues
Sexual
Orientation

Ethnicity

Gender

Language

M...
Risk Factors: Socioeconomic Status (SES)
• Gender is a risk factor for low SES
• Women with SUD are more likely to have:
–...
Video: What is it like to be a female addicted to
heroin?

PLAY

Published on July 2012
Issues women face: Sex work involvement
• Survival sex work is very common among women who
use drugs
• Women who use injec...
Issues women face: HIV and Hepatitis C
• Growing number of women are becoming infected with
HIV1
• 57% of HIV infections a...
Issues women face: HIV and Hepatitis C
• Although rates of hepatitis C are higher in males then
females, young females are...
Protective Factors
•
•
•
•
•

Marriage
Parental warmth
Partner support
Religious and spiritual practices
Healthy coping sk...
Substance Use Treatment for Women
• Women are under-represented in treatment settings
• Women are less likely to enter tre...
Women Face Barriers to Treatment on Many
Levels
•
•
•
•
•

Intrapersonal
Interpersonal
Sociocultural
Structural
Systemic
Barriers to Treatment
• According to Health Canada (2001), some of the key
issues in accessing substance use treatment tha...
Barriers to Treatment
• Opposition for entering treatment from family & friends
– Partner substance abuse

• Gender and cu...
Barriers to Treatment: Stigma
• Societal stigma toward women who abuse substances is
greater than that toward men
• Stigma...
Barriers to treatment: Caregiver role
• Women are socialized to be other-focused and assume
caregiver roles
Overcoming treatment barriers
Understanding how gender-based differences
affect treatment engagement, internalized
stigma ...
Interrelated elements in a
comprehensive
treatment model

Source: Updated
CSAT, 1994 model
in SAMHSA, 2009
Core principles for gender-responsive
treatment1

• Acknowledge the importance and role of women’s SES
issues and differen...
Core principles for gender-responsive
treatment1
• Recognize that assigned gender roles and expectations
affect societal v...
Factors that encourage treatment retention:
• A collaborative therapeutic alliance
• Onsite childcare and children service...
Pharmacological Interventions for Opioid
Dependence
• Methadone: long-acting (>24 hours) synthetic opioid
agonist
• Bupren...
Maintenance or Detoxification
• Methadone and Buprenorphine/Naloxone (Suboxone) is
approved for use in opioid substitution...
Buprenorphine/Naloxone
• May be safer in overdose than methadone1
• May be easier to taper off this medication than
methad...
Treatment of Opioid Dependence in Pregnancy
• Methadone maintenance shown to reduce complications
of pregnancy, childbirth...
Neonatal Abstinence Syndrome (NAS)
• Babies are born with passive dependence on opioids
used by their mother
• After umbil...
Prevalence of NAS
• In Ontario, has increased from 1.3 cases per 1000 births
in 2004 to 4.3 cases per 1000 births in 20101...
Neonatal Abstinence Syndrome (NAS)
• Serious medical condition that affects the central
nervous, autonomic nervous, gastro...
Neonatal Abstinence Syndrome (NAS)
• May cause death due to excess fluid loss, high
temperatures, seizures, respiratory in...
Treating NAS
• Challenges: guilt, shame, breastfeeding challenges,
attachment
Treating NAS
• Supportive environment: ideally baby and mom
together

• Improved outcomes with rooming in1 and
breastfeedi...
Women’s Resilience
• Women and men appear equally likely to complete
treatment for substance use
• Men and women have simi...
A call to action
• Women have been largely ignored in addictions research
• Much-needed research on gender differences in
...
Thank you
References
• American Society of Addiction Medicine www.asam.org
• Back, S et al (2011). Comparative profiles of men and w...
References
• Carter et al (2009). Neurobiological Research on Addiction: A Review of the
Scientific, Public Health and Soc...
References
• Greenfield, SF, Back, SE, Lawson, K, & Brady, K (2010). Substance abuse in
women. Psychiatr Clin North Am, 33...
References
• National Survey on Drug Use and Health (NSDUH) 2012.
• National Epidemiologic Survey on Alcohol and Related C...
References
• Principles of Addiction Medicine 4th ed. (2009). American Society of Addiction
Medicine.
• Public Health Agen...
References
• Tjaden, P, & Thoennes, N (2000). Extent, nature, and consequences of intimate
partner violence: Findings from...
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WOMEN IN MIND: Young women and substance abuse: Understanding vulnerabilities and building on strengths

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Presented at our annual Women in Mind conference by The Royal's Dr. Melanie Willows and Dr. Kim Corace.

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  • Potent opioid (euphoria effects)High dosePurityMore socially acceptable than heroinPossible to circumvent delivery system: chew, snort, injectEasy accessInadequate monitoring
  • http://www.youtube.com/watch?v=xQZNP3p4k2g
  • Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2011-2012 (NSDUH)
  • 2. People of Introduction and Relationship Status: Women are more likely to be introducedto and initiate alcohol and drug use through significant relationships including boyfriends,spouses, partners, and relatives. According to the National Center on Addiction and SubstanceAbuse and Columbia University (CASA) research report, females are often introduced tosubstances in a more private setting (2003). In addition, marital status plays an important roleas a protective factor in the development of substance use disorders.3. Drug Injection and Relationships: Even though women are less likely to inject drugs thanmen, research suggests that women accelerate to injecting at a faster rate than men (Bryantand Treloar 2007). When women inject drugs for the first time, they are more likely than menwho are first-time injectors to be introduced to this form of administration by a sexual partner(Frajzyngier et al. 2007). Women are more likely to be involved with a sexual partner who alsoinjects. While various personality and interpersonal factors influence needle sharing amongwomen (Brook et al. 2000), women are more likely to inject with and borrow needles andequipment from their partner, spouse, or boyfriend. Among women who use with their sexualpartners, Bryant and Treloar (2007) highlight a division of labor where men are responsible forobtaining, purchasing, and injecting the drug for them. Thus, needle sharing and drug usingwith a sexual partner may engender a sense of emotional intimacy among women or refl ectinequity of power in the relationship. Other “people of introduction” besides sexual partnersare groups that are predominantly female. While women may initiate drug injection throughrelational means, it is important to recognize that some women are as likely to initiate druginjection on their own.
  • 2. People of Introduction and Relationship Status: Women are more likely to be introducedto and initiate alcohol and drug use through significant relationships including boyfriends,spouses, partners, and relatives. According to the National Center on Addiction and SubstanceAbuse and Columbia University (CASA) research report, females are often introduced tosubstances in a more private setting (2003). In addition, marital status plays an important roleas a protective factor in the development of substance use disorders.3. Drug Injection and Relationships: Even though women are less likely to inject drugs thanmen, research suggests that women accelerate to injecting at a faster rate than men (Bryantand Treloar 2007). When women inject drugs for the first time, they are more likely than menwho are first-time injectors to be introduced to this form of administration by a sexual partner(Frajzyngier et al. 2007). Women are more likely to be involved with a sexual partner who alsoinjects. While various personality and interpersonal factors influence needle sharing amongwomen (Brook et al. 2000), women are more likely to inject with and borrow needles andequipment from their partner, spouse, or boyfriend. Among women who use with their sexualpartners, Bryant and Treloar (2007) highlight a division of labor where men are responsible forobtaining, purchasing, and injecting the drug for them. Thus, needle sharing and drug usingwith a sexual partner may engender a sense of emotional intimacy among women or refl ectinequity of power in the relationship. Other “people of introduction” besides sexual partnersare groups that are predominantly female. While women may initiate drug injection throughrelational means, it is important to recognize that some women are as likely to initiate druginjection on their own.
  • 2. People of Introduction and Relationship Status: Women are more likely to be introducedto and initiate alcohol and drug use through significant relationships including boyfriends,spouses, partners, and relatives. According to the National Center on Addiction and SubstanceAbuse and Columbia University (CASA) research report, females are often introduced tosubstances in a more private setting (2003). In addition, marital status plays an important roleas a protective factor in the development of substance use disorders.
  • progress faster than men from initial use to alcohol anddrug-related consequences even when using a similar or lesser amount of substances
  • Sex Differences in Stress Reactivity and Relapse to Substance AbuseSex differences in neuroendocrine adaptations to stress and reward systems may mediate women’s susceptibility to drug abuse and relapse.18 Several studies have examined sex differences in stress response (eg, subjective, autonomic) and relapse.18,19 Among substance-dependent subjects, attenuated neuroendocrine stress response in women (ie, blunted adrenocorticotropic hormone and cortisol) has been shown following exposure to stress and drug cues.20 This hypothalamic-pituitary-adrenocortical (HPA) dysregulation in women may be one key to enhanced vulnerability to relapse in response to negative affect, as it may be associated with greater emotional intensity at lower levels of HPA arousal.21
  • Menstrual Cycle (Check Greenfield paper)Substances disrupt menstrual cycle phases menstrual cycle phases affect substances Fertility Substances can effect fertility Cocaine & Opioids  secondary amenorrhea & risk of unplanned pregnancies Prenatal care may be delayed as woman does not know she’s conceived (Shimi Kang)
  • 75% of women in treatment for alcohol dependence report childhood sexual abuse Severity of SUD directly related to # of violent assaults a women has experienced* Substance use may  vulnerability of women to re-traumatization and re-victimization*Jacobsen 2001; Chandler & McCaul 2003 , UN 2004 (Shimi Kang)
  • Women use substances as a means of coping (self-medication) or to increase social desirability (low self-esteem)
  • Childhood trauma sexual abuse physical abuseAdolescence/Young Adulthood rape abusive relationships75% of women in treatment for alcohol dependence report childhood sexual abuse Severity of SUD directly related to # of violent assaults a women has experienced* Substance use may  vulnerability of women to re-traumatization and re-victimization*Jacobsen 2001; Chandler & McCaul 2003 , UN 2004 (Shimi Kang)
  • Childhood trauma sexual abuse physical abuseAdolescence/Young Adulthood rape abusive relationships75% of women in treatment for alcohol dependence report childhood sexual abuse Severity of SUD directly related to # of violent assaults a women has experienced* Substance use may  vulnerability of women to re-traumatization and re-victimization*Jacobsen 2001; Chandler & McCaul 2003 , UN 2004 (Shimi Kang)
  • Childhood trauma sexual abuse physical abuseAdolescence/Young Adulthood rape abusive relationships75% of women in treatment for alcohol dependence report childhood sexual abuse Severity of SUD directly related to # of violent assaults a women has experienced* Substance use may  vulnerability of women to re-traumatization and re-victimization*Jacobsen 2001; Chandler & McCaul 2003 , UN 2004 (Shimi Kang)
  • Greater rates of concurrent Axis I & SUD1 More likely to have suffered from trauma1 Anxiety more of a factor for women2 Women with dual diagnosis have less access to treatment3 1 UN 2004, 2ICPE, 3Baker 2001
  • Estimates of rates of occurrence in womenCo-morbidity with substance use disorders?increased rate of opioid use disorders ?medicating anxiety and depression
  • Discriminatory acts range from mundane slights to devastating violent actsWomen may experience varied levels of discrimination that affect their substance use and their recoverySubstance use may become a way of coping with the additional stresses of discriminationWhen women experience more than one type of discrimination the effect can be compoundedDiscrimination can result in fewer educational and employment opportunities, lower SES, fewer housing choices and poorer health outcomeLess access to health care and difficulty in getting to treatmentLeads to negative health consequences and psychological distress
  • http://www.youtube.com/watch?v=RtXJ-iY5TFk
  • If I have hepatitis C and get pregnant, can I pass it on to my baby?The risk of HCV transmission to the baby is low compared to other viruses such as hepatitis B or HIV. Approximately 5 out of 100 mothers who have HCV might pass it to their babies before or at the time of birth.If a mother has both hepatitis C and HIV, the risk of the baby getting hepatitis C is much higher than when the mother is infected with hepatitis C alone. Anywhere from 22 to 36 out of 100 babies born to hepatitis C and HIV positive mothers will become infected with hepatitis C.Can I do anything to reduce the risk of passing it to my baby?Unfortunately, there is currently no effective way to prevent or reduce the risk of hepatitis C transmission to the baby.The mode of delivery (caesarian or vaginal) does not seem to affect the rate of transmission but firm evidence is lacking.However, for mothers infected with both hepatitis C and HIV, there are medications that can significantly reduce the risk of passing HIV to the baby.
  • Parental warmth: Agrawal et al., 2005: Tip Manual p. 20Marriage appears to be protective whereas separated never married or divorced are at great risk for addictionParental warmth: High parental warmth = less likely to initiate use, abuse substances, and become dependent on substancesPartner support: Key motivator that brings women to treatment; more likely to accept helpReligious and spiritual practices: Associated with reduced risk for substance use, relapse preventionHealthy coping skills
  • Women who present to opioid treatment have a broader range of collateral symptomatology such as greater psychiatric comorbidity, medical problems, employment and family/social impairmentWomen seeking treatment have more severe problems, are younger, have lower education levels, and lower incomes then men seeking treatment
  • Barriers to treatment are: Intrapersonal, interpersonal, sociocultural, structural, and systemicIntrapersonal: Individual factors including health problems, psychological issues, cognitive functioning, readiness/motivationInterpersonal: Relational issues including significant relationships, family dynamics, support systemsSociocultural: Stigma, bias, racism, inequity in health services, attitudes of health care providers towards womenStructural: Program characteristics, design, restrictionsSystemic: Larger systems including country, province, local agencies that generate polices and laws, health insurance and drug coverage, economy
  • Assuming that a woman is resistant to treatment because she is other-focused in the program is a form of gender biasUse their ability to be other-focused as a tool for motivation for recovery
  • Another off label use…taper off for individuals physically dependent but not addicted
  • Few studies on women so inconclusive evidence on treatment outcomes, but current research suggests that:Women and men are equally likely to complete treatmentTreatment outcomes as good as men’sWomen less likely to relapse then men in treatment. When they relapse it’s due to substance abusing romantic partners, or personal problems before relapseBetter long-term recovery outcomes then men
  • WOMEN IN MIND: Young women and substance abuse: Understanding vulnerabilities and building on strengths

    1. 1. Young women and substance use: Understanding vulnerabilities and building on strengths Kim Corace, Ph.D., C. Psych, Clinical Psychologist; Director, Research and Program Development Melanie Willows, B.Sc. M.D. C.C.F.P. C.A.S.A.M. C.C.S.A.M. Clinical Director Substance Use and Concurrent Disorders Program Royal Ottawa Health Care Group November 15, 2013
    2. 2. Learning objectives: 1. Identify current patterns of substance use among young women 2. Review risk factors for substance use problems among young women 3. Discuss promising interventions to address substance use problems in young women
    3. 3. What is addiction? • Primary, chronic disease of brain reward, motivation, memory and related circuitry • Characterized by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response ASAM, 2011
    4. 4. What is addiction? • Like other chronic diseases, addiction often involves cycles of relapse and remission • Addiction is progressive and can result in disability or premature death ASAM, 2011
    5. 5. What is addiction? • Addiction is a developmental disease that starts in adolescence and childhood1 1NESARC , 2003
    6. 6. Table 1. Past Year Drug Use (%) for the Total Sample, and by Sex and Grade, 2011 OSDUHS (CAMH) Total Male Female G7 G8 G9 G10 G11 G12 Alcohol 54.9 54.6 55.1 17.4 26.4 50.5 59.6 75.5 78.4 Cannabis 22.0 23.0 21.0 2.4 5.9 11.9 23.5 36.8 36.4 Binge Drinking 22.3 22.7 21.8 1.1 4.1 13.7 24.4 35.3 39.7 Opioid Pain Relievers (NM) 14.0 12.9 15.2 8.5 10.9 13.0 14.9 18.0 16.0 Cigarettes 8.7 9.3 8.2 2.8 3.7 10.3 14.5 14.4
    7. 7. Opioids: A growing problem • Canada is the world’s second largest per capita consumer of opioids. Ontario tops the list in Canada • Opioid misuse, abuse and dependence is a major public health issue in Ontario and the Ottawa region • Prescription opioids has become the predominant form of illicit opioid use (rather than heroin) • Increase in number of individuals seeking treatment for opioid dependence in the last 10 years • Opioids are a commonly abused substance by youth and young adults
    8. 8. A Generation Exposed.... • Although experimentation with alcohol and other drugs is a natural part of adolescence, experimentation involving opioids is high risk as addiction occurs much more rapidly than with other drugs » National Institute of Drug Addiction (NIDA)
    9. 9. What is an opioid? • Opioids are depressants-- they slow down certain brain functions, act on the mu receptor • Opioids are also referred to as narcotics • Opioids can be effective painkillers • Some opioids are prescription medications (i.e. oxycontin, fentanyl) and others are not (i.e. heroin)
    10. 10. Prescription Opioids
    11. 11. Commonly abused prescription opioids • Oxycodone (Oxycontin, OxyNEO) – – – – Oxycontin formerly most popular opioid Replaced by OxyNEO designed to be more difficult to alter Generic Oxycodone now available but not covered by ODB Generally chewed, snorted or injected
    12. 12. Commonly abused prescription opioids • Dilaudid, Hydromorph Contin – Usually chewed, snorted or injected • Fentanyl “patch” – Fentanyl is extracted from patches that are designed to be longacting medication – Fentanyl said to be 80 to 100 times stronger than morphine – Sucked in mouth (strips), smoked, or injected – Cost varies: 25mcg patch (approx $60 - $100)
    13. 13. Risks of Opioid Misuse • Overdose (high risk new users, unknown dose, combined with alcohol and/or benzodiazepines, after a period of stopping opioids) • Death • Accidents • Addiction • Infectious diseases from intravenous use and sharing drug paraphernalia (Hepatitis C, HIV)
    14. 14. Why Prescription Opioids? Why now? • • • • • • Think it’s safe because it’s a prescription More socially acceptable than heroin Purity Potent opioid (euphoria effects) Easy access Possible to alter how you use it: chew, suck, snort, smoke, inject • Inadequate monitoring
    15. 15. Women and Substance Use • Substance abuse is more prevalent among men, but women are as likely as men to develop substance use disorders after initiation • The gender gap is narrowing1 – In the past, men had higher rates of substance abuse then women – In the last 10 years, young women are more likely to mirror male patterns of drug use then older women – Shrinking gender gap is especially notable for young 1Grant et al., 2006 as cited in SAMHSA, 2009 women
    16. 16. As cited in SAMHSA, 2009
    17. 17. As cited in SAMHSA, 2009
    18. 18. Video: Women of Substance PLAY Women of Substance (2013). South Shore District Health Authority
    19. 19. Opioid Misuse: A growing epidemic among women • Rates of nonmedical prescription drug use is higher among women then men, particularly for opioids • Nearly 48,000 women died of prescription opioid overdoses between 1999 to 2010 (5 fold increase) • Female deaths from prescription opioid overdoses have increased more than 400% since 1999, compared to 265% among males • Prescription opioids are involved in 1 in 10 suicides * CDC, 2013 among women
    20. 20. Source: CDC Vitalsigns, July 2013, as per National Vital Statistics System, 1999-2010
    21. 21. For every woman who dies of prescription opioid overdose, 30 go to the ER for misuse/abuse Source: CDC Vitalsigns, July 2013, as per Drug Abuse Warning Network, 2010
    22. 22. * Source where pain relievers were obtained for most recent nonmedical use among past year users aged 12 and older: 2011-2012 (NSDUH)
    23. 23. Why are women disproportionately affected? • Women are more like to have chronic pain • Women are more likely to be prescribed prescription painkillers • Women are more likely to be given higher doses • Women are more likely to use prescription opioids for a longer time period than men • Women may become dependent on prescription opioids more quickly then men Source: CDC, 2013
    24. 24. Risk Factors for Substance Use Problems Environment/ Sociocultural Context Vulnerable Host Repeated substance use ADDICTION
    25. 25. Risk Factors: Relationships • Women are more likely to be introduced to and initiate drug use through their boyfriends, partners, spouses, and relatives • Even though women are less likely to inject drugs, women accelerate to injecting at a faster rate than men. • Women’s IVDU is influenced by their sexual partner’s injection risk behaviour • Compared to men, women are more likely to be involved with a sexual partner who also injects drugs
    26. 26. Risk Factors: Relationships • Women are also more likely than men to be introduced to IVDU their sexual partners1 – 51% of female heroin users first injected by their male partner – 90% of men injected by a friend • Compared to men IVDU, women report being more influenced by social pressure and by sexual partner encouragement • Women are more likely to inject with and borrow needles and equipment from their partners 1Powis et al., 1996
    27. 27. Risk Factors: Relationships • Women may see sharing drug equipment and using drugs as emotional intimacy, means of connection, or maintaining the relationships • Men are often responsible for obtaining, purchasing, and injecting the drug for women. • There is a power imbalance in these relationships
    28. 28. Risk Factors: Telescoping • Telescoping describes an accelerated progression from substance use initiation to the onset of dependence and first treatment1 • Consistently observed, with studies reporting an accelerated progression among women for opioids. • Women progress faster even when using similar or lesser amounts of substances • When women enter treatment, they have a more severe presentation than men, despite using less and for shorter 1Hernandez-Avila et al., 2004 period of time
    29. 29. Risk Factors: Sex differences • Sex differences in the stress and reward systems which increase women’s susceptibility to drug abuse and relapse • Women have a greater biological vulnerability to the adverse consequences of substance use • Women who use substances have poorer health than men as a result of substances
    30. 30. Risk Factors: Menstrual Cycle • • • • Substances disrupt menstrual cycle phases Menstrual cycle phases affects substance use Substances can affect fertility Opioid use can cause amenorrhea and risk of unplanned pregnancy
    31. 31. Risk Factors: Trauma • The prevalence of PTSD is 1.4 to 5 times higher among those with concurrent SUD1 • Initiation of substance use and development of substance use disorders among women is related to traumatic events: – Childhood trauma: physical or sexual abuse – Interpersonal violence: sexual assault, abusive relationships – Domestic violence 1Greenfield, 2010
    32. 32. Risk Factors: Trauma Rural school youth in Western Canada (N=3781)1 1Nicholson & Saewyc, 2011
    33. 33. Risk Factors: Trauma • Rates of physical or sexual abuse are extremely high among women with SUD, ranging from 55 to 99% • Female crime victims with PTSD are 17 times more likely to have a SUD than the general population1 • Severity of SUD related to the number of violent assaults women experience • Among women seeking treatment for substance use, up to 70% report sexual abuse prior to the age of 112 1US National Violence Against Women Survey; Tjaden & Thoennes, 2000; 2Finnegan, 2013
    34. 34. Risk Factors: Trauma • Survey of women from substance use treatment centers in Ontario, 85.7% of these women were victimized1 – – – – 56.1% reported current physical abuse 45.4% reported current sexual abuse 56.1% reported childhood physical abuse 56.3% reported childhood sexual abuse • Vancouver treatment facility survey of women2: – 65% physically assaulted; 38% sexually assaulted as adults – 47% childhood physical abuse; 53% childhood sexual abuse 1 Cormier, 2000; 2 Poole, 2000
    35. 35. Risk Factors: Trauma • Women who have been abused are more likely to suffer other adverse outcomes, including depression, anxiety, personality disorders, eating disorders, suicidal behavior, and low self-esteem
    36. 36. Risk Factors: The cycle of trauma • Violence is both a risk factor and a consequence of substance abuse • Substance use increases women’s vulnerability to retraumatization and re-victimization
    37. 37. Risk Factors: Concurrent Disorders • Compared to men, women have…. – Higher prevalence of concurrent mental health problems • About 2/3 of women with substance use problems have a co-occurring mental health problem – Higher prevalence of multiple comorbidities – Higher likelihood of using substances to manage negative affect – Higher likelihood of trauma history and PTSD • Less access to treatment with a concurrent disorder • Bidirectional influence: Mental illness both a risk factor or a consequence of substance use
    38. 38. Risk Factors: Anxiety and Mood Disorders • Lifetime prevalence of mood and anxiety disorders are higher among women then men, regardless of a SUD • 12-month prevalence rates in women with SUD1: – Mood disorder: 29.7% – Anxiety disorders: 26.2% • Anxiety and depression positively associated with substance use, abuse and dependence 1Goldstein, 2009 as cited in Greenfield, 2010
    39. 39. Risk Factors: Eating Disorders • 90% of the cases of anorexia nervosa and bulimia nervosa are found in women • High correlation between eating disorders and substance abuse • Up to 55% of women with bulimia have a substance use problem • 15-40% of women with substance use problems have eating disorders syndromes, in particular purging
    40. 40. Risk Factors: Eating Disorders • Co-morbidity with other mental health disorders, personality disorders (borderline personality disorder), and trauma • Among women with eating disorders, rates of SUD are greater for those with a history of sexual and physical abuse
    41. 41. Risk Factors: Discrimination Race Culture Legal issues Health issues Sexual Orientation Ethnicity Gender Language Mental illness Disability Housing Age SES
    42. 42. Risk Factors: Socioeconomic Status (SES) • Gender is a risk factor for low SES • Women with SUD are more likely to have: – Lower incomes – Less education – Less likely to be employed • Among women, lower SES is related to: – – – – Higher substance-use related illness, including HIV/hepatitis C Higher substance-use related mortality Difficulties with healthcare service access and uptake Lack of appropriate nutrition
    43. 43. Video: What is it like to be a female addicted to heroin? PLAY Published on July 2012
    44. 44. Issues women face: Sex work involvement • Survival sex work is very common among women who use drugs • Women who use injection drugs are more likely to be involved with sex work then men • These women present with greater vulnerabilities: unstable housing/homelessness, higher rates of incarceration, less education, younger, concurrent mental illness, trauma • High prevalence of HIV and STIs Marchand, 2012
    45. 45. Issues women face: HIV and Hepatitis C • Growing number of women are becoming infected with HIV1 • 57% of HIV infections among women are attributable to use of injection drugs or sexual relations with a person who injects drugs2 • 24% of reported cases of HIV in Canada were among youth in 20093: – 22% males – 30% females 1CATIE, 2012; 2CDC, 2002; 3PHAC, 2010
    46. 46. Issues women face: HIV and Hepatitis C • Although rates of hepatitis C are higher in males then females, young females are at particularly high risk1,2 – Males in the 40 to 59 year age group had the highest rates of reported hepatitis C diagnoses at 78.2 per 100,000 – Females in the 25 to 29 years age group had the highest rates of reported hepatitis C diagnoses at 34.4 per 100,000. 1CATIE, 2013; 2PHAC, 2012
    47. 47. Protective Factors • • • • • Marriage Parental warmth Partner support Religious and spiritual practices Healthy coping skills
    48. 48. Substance Use Treatment for Women • Women are under-represented in treatment settings • Women are less likely to enter treatment then men • Women tend to seek care in mental health/primary care settings rather then specialized treatment programs • Once initiated, women are as likely as men to stay in treatment • Gender does not appear to predict retention or outcome in substance abuse treatment SAMHSA, 2009; Greenfield, 2010; Green, 2006
    49. 49. Women Face Barriers to Treatment on Many Levels • • • • • Intrapersonal Interpersonal Sociocultural Structural Systemic
    50. 50. Barriers to Treatment • According to Health Canada (2001), some of the key issues in accessing substance use treatment that have a particular impact on women are: – – – – – – – fear of losing children lack of affordable child care lack of family support social stigma lack of women-centred services cost of treatment lack of flexible services
    51. 51. Barriers to Treatment • Opposition for entering treatment from family & friends – Partner substance abuse • Gender and cultural insensitivity • Lower rates for identification and referral for women by care providers • Threat of legal sanction – child custody • Lack of transportation • Caretaker role for dependent family • Economic barriers to entering and staying in treatment *Beckman 1986, Miller, 1993, SAMHSA, 2009
    52. 52. Barriers to Treatment: Stigma • Societal stigma toward women who abuse substances is greater than that toward men • Stigma is a barrier to admission of a problem, asking for help, and seeking and initiating treatment • Stigma, guilt and shame towards drug use and low selfesteem make women feel un-deserving of help • Gender role expectations result in further stigmatization • Compounded stigma
    53. 53. Barriers to treatment: Caregiver role • Women are socialized to be other-focused and assume caregiver roles
    54. 54. Overcoming treatment barriers Understanding how gender-based differences affect treatment engagement, internalized stigma and treatment outcome will allow for a more responsive, sensitive, and effective approach to treatment
    55. 55. Interrelated elements in a comprehensive treatment model Source: Updated CSAT, 1994 model in SAMHSA, 2009
    56. 56. Core principles for gender-responsive treatment1 • Acknowledge the importance and role of women’s SES issues and difference • Recognize the role and significance of relationships in women’s lives • Address women’s unique physical and mental health concerns • Attend to the relevance and influence of the variety of women’s caregiver roles • Adopt a trauma-informed perspective 1SAMHSA, 2009
    57. 57. Core principles for gender-responsive treatment1 • Recognize that assigned gender roles and expectations affect societal views of women who use substances • Use a strength-based approach to treatment • Incorporate an integrated and multidisciplinary approach to treatment • Maintain a gender responsive treatment environment across settings 1SAMHSA, 2009
    58. 58. Factors that encourage treatment retention: • A collaborative therapeutic alliance • Onsite childcare and children services • Integrated, comprehensive, multimodal treatment – Behavioural, pharmacological, psychological, multimodal systems of care that address complex issues (ie., social services) • Support and participation of significant others • Address pregnancy and parenting skills • Demographics: Being older; High school education Back, 2011; SAMHSA, 2009
    59. 59. Pharmacological Interventions for Opioid Dependence • Methadone: long-acting (>24 hours) synthetic opioid agonist • Buprenorphine/Naloxone (Suboxone): long acting synthetic partial opioid agonist, naloxone component present to prevent IV abuse
    60. 60. Maintenance or Detoxification • Methadone and Buprenorphine/Naloxone (Suboxone) is approved for use in opioid substitution therapy for maintenance • Buprenorphine/Naloxone (Suboxone) can also be used for detoxification/tapering
    61. 61. Buprenorphine/Naloxone • May be safer in overdose than methadone1 • May be easier to taper off this medication than methadone1 • May be better for youth, young adults and for early intervention2 • High risk of precipitated withdrawal discourages ongoing opioid use 1Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edition February 2011 CPSO 2Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice Guideline CAMH 2011
    62. 62. Treatment of Opioid Dependence in Pregnancy • Methadone maintenance shown to reduce complications of pregnancy, childbirth and infant development • Methadone and Buprenorphine/Naloxone considered Category C medication (medication should only be used in pregnancy if the potential benefit justifies the potential fetal risk)
    63. 63. Neonatal Abstinence Syndrome (NAS) • Babies are born with passive dependence on opioids used by their mother • After umbilical cord is cut, passive supply of opioids is cut off • Baby potentially develops withdrawal symptoms from opioids
    64. 64. Prevalence of NAS • In Ontario, has increased from 1.3 cases per 1000 births in 2004 to 4.3 cases per 1000 births in 20101 • Occurs in untreated opioid addiction and also as a potential side effect for treatment of opioid dependence with methadone (60% chance of developing NAS)2 1Dow et al., 2010; 2Finnegan & Kandall, 2005
    65. 65. Neonatal Abstinence Syndrome (NAS) • Serious medical condition that affects the central nervous, autonomic nervous, gastrointestinal and respiratory systems • Characterized by signs of: – neurologic excitability (irritability, hyperactivity, sleep disturbance) – gastrointestinal dysfunction (vomiting, diarrhea, uncoordinated sucking and swallowing) – autonomic signs (fever, sweating, nasal stuffiness)
    66. 66. Neonatal Abstinence Syndrome (NAS) • May cause death due to excess fluid loss, high temperatures, seizures, respiratory instability, aspiration of fluid into the lungs or the cessation of breathing if not treated BUT….NAS is TREATABLE
    67. 67. Treating NAS • Challenges: guilt, shame, breastfeeding challenges, attachment
    68. 68. Treating NAS • Supportive environment: ideally baby and mom together • Improved outcomes with rooming in1 and breastfeeding2 1Abrahams et al., 2007; 2Abdel-Latif et al., 2006
    69. 69. Women’s Resilience • Women and men appear equally likely to complete treatment for substance use • Men and women have similar treatment outcomes • Women are less likely then men to relapse while in treatment • Women show better long-term recovery outcomes then men Green, 2006
    70. 70. A call to action • Women have been largely ignored in addictions research • Much-needed research on gender differences in treatment response and gender-specific treatments • Increase efforts to reduce the stigma and discrimination faced by women who use substances • Adopt a multidisciplinary, holistic, comprehensive approach to treatment, prevention, health promotion • Coordinated and integrated systems of care and services with gender and cultural competence SAMHSA, 2009; Finnegan, 2013
    71. 71. Thank you
    72. 72. References • American Society of Addiction Medicine www.asam.org • Back, S et al (2011). Comparative profiles of men and women with opioid dependence: Results from a national multisite effectiveness trial. Am J Drug Alcohol Abuse, 37(5), 313-323. • Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice Guideline (2011). Centre for Addiction and Mental Health (CAMH). • Canadian AIDS Treatment Information Exchange (CATIE; 2013). Fact sheet: The epidemiology of hepatitis C in Canada. http://www.catie.ca/factsheets/epidemiology/epidemiology-hepatitis-c-canada • Canadian AIDS Treatment Information Exchange (CATIE; 2012). Gender matters in HIV prevention. Prevention in Focus, Spring 2012. • Canadian AIDS Treatment Information Exchange (CATIE; 2012). Fast Facts: Youth. Prevention in Focus, Summer 2012.
    73. 73. References • Carter et al (2009). Neurobiological Research on Addiction: A Review of the Scientific, Public Health and Social Policy Implications for Australia Final Report January 30, 2009. • CDC (July, 2013). Prescription painkiller overdoses: A growing epidemic, especially among women. CDC Vitalsigns: www.cdc.gov/vitalsigns • Cormier, RA (2000). Predicting treatment outcome in chemically dependent women: A test of Marlatt and Gordon’s relapse model [Unpublished doctoral dissertation]. Windsor, ON: University of Windsor. • Finnegan, L (2013). Substance abuse in Canada: Licit and illicit drug use during pregnancy: Maternal, neonatal, and early childhood consequences. Ottawa, ON. Canadian Centre on Substance Abuse 2013. • Green, C (2006). Gender and use of substance abuse treatment services. NIH National Institute on Alcohol Abuse and Alcoholism.
    74. 74. References • Greenfield, SF, Back, SE, Lawson, K, & Brady, K (2010). Substance abuse in women. Psychiatr Clin North Am, 33(2), 339-355. • Hernandez-Avila, CA, Rounsaville, BJ, & Kranzler, HR (2004). Opioid-, cannabisand alcohol-dependent women show more rapid progression to substance abuse treatment. Drug and Alcohol Dependence, 74(3), 265–272. • Lowinson & Ruiz’s Substance Abuse: A Comprehensive Textbook Fifth Edition Chapter 57 Adolescent Substance Abuse R. Milin and S. Walker. Editors Pedro Ruiz &Eric Strain. Lippincott Williams & Wilkins, Philadelphia, PA, 2011 • Marchand, K et al (2012). Sex work involvement among women with long-term opioid injection drug dependence who enter opioid agonist treatment. Harm Reduction Journal, 9:8. • Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edition February 2011 CPSO • National Institute on Drug Abuse (NIDA)
    75. 75. References • National Survey on Drug Use and Health (NSDUH) 2012. • National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 2003. • Nicholson D & Saewyc E (2011). Childhood sexual abuse, substance use and substance use-related sexual behaviour in a rural school population. Poster presented at the Issues of Substance national conference. Vancouver, Canada. • Paglia-Boak, A, Mann, RE, Adlaf, EM (2011). Drug use among Ontario students, 1977-2011: OSDUHS highlights. (CAMH Research Document Series No. 32). Toronto, ON: Centre for Addiction and Mental Health. • Poole, N (2000). Evaluation report of the Sheway Project for high-risk pregnant and parenting women. Vancouver: British Columbia Centre of Excellence for Women’s Health. • Powis B, et al. (1996). The differences between male and female drug users: Community samples of heroin and cocaine users compared. Subst Use Misuse, 31(5), 529–43.
    76. 76. References • Principles of Addiction Medicine 4th ed. (2009). American Society of Addiction Medicine. • Public Health Agency of Canada (PHAC; 2010). HIV and AIDS in Canada. Surveillance Report to December 31, 2009. Surveillance and Risk Assessment Division. Centre for Communicable Diseases and Infection Control. PHAC. • Public Health Agency of Canada (PHAC; 2012). Reported cases and rates of hepatitis C by age group and sex, 2005 to 2010. Community Acquired Infections Division, PHAC. • Substance Abuse: A Comprehensive Textbook 4th Ed. Lewinson et al. 2005 • Substance Abuse and Mental Health Services Administration (SAMHSA) (2009). Center for Substance Abuse Treatment. Substance abuse treatment: Addressing the specific needs of women. Treatment Improvement Protocol (TIP) Series 51. Rockville, MD: SAMHSA Administration.
    77. 77. References • Tjaden, P, & Thoennes, N (2000). Extent, nature, and consequences of intimate partner violence: Findings from the National Violence Against Women Survey [Publication No. NCJ 181867]. Washington, DC: Department of Justice. Videos: • Women of Substance (2013). Exec Producer: South Shore District Health Authority. http://www.youtube.com/watch?v=xQZNP3p4k2g • What is it like to be a female addicted to heroin? (2012). http://www.youtube.com/watch?v=RtXJ-iY5TFk

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