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Women and Substance Abuse            Elena Volfson, MD, MPH             Addiction Psychiatrist   Clinical Assistant Profes...
Disclosure• Dr. Volfson has no financial interest  to disclose
Outline• Updates in general addiction neurobiology• Gender differences in epidemiology and  neurobiology• Hormones and sub...
Quoted from multiple sourcesWHO 2002
Model of Addiction             Emotion                                      ControlTemporal - Parietal                    ...
Model of Addiction            Emotion                                     ControlAntidepressants                          ...
Addiction is a Compulsive Relapsing                DisorderTwo essential features:• impaired ability to regulate the drive...
Vulnerabilities in Development of                   Addiction•   Genetic•   Developmental•   Social•   Drug-induced brain ...
Core Addiction Syndrome• Common neuroplastic changes in  response to chronic administration of  different substances of ab...
Core Addiction Syndrome• Hypofrontality- subcortical glutamatergic  connections assume primacy and reduce  cortical contro...
Staged Neuroplasticity of Addiction•   Abstinence•   Social Use•   Chronic Use•   Regulated relapse – conscious choice•   ...
Neurobiological Changes with        Chronic Substance Use•   Motivation/reward system DA/endorphine•   Glutamate/GABA dysr...
Pharmacologic Strategies to Treat              Addiction•   Dopaminergic (D1-D5)•   Glutamatergic (NMDA, AMPA, KA, metabot...
Complexity of Gender Research         Apples to Apples?•   Menstrual cycle: 2-6 phases vs none•   Hormones <> substance us...
Gender Differences in Brain       • Structural       • Functional
Why Are Male and Female Brains            Different?• Chromosomal sex determines gonadal sex;  gonadal hormones influence ...
Epidemiology
Substance Dependence or Abuse in the Past  Year, by Age and Gender: NSDUH 2010
NSDUH 2010: Alcohol Use by Gender
SUBSTANCE USE BY WOMEN, 2008                                                       Past year Past monthCigarettes         ...
NSDUH 2010: Tobacco Use by Pregnancy Status in        Women of Reproductive Age
Substance Use by Pregnant Women• Of women in their first trimester, 19% used  alcohol, 22% used cigarettes, and 5% used ma...
Substance Use by Lesbian/Bisexual Women• Higher and riskier alcohol use• Spend more time socializing in bars and party set...
Initiation of Drug Use by Substance NSDUH 2010
Multiple studies demonstrate higher   rates of substance abuse anddependence in males as compared            to females…
Are females less vulnerable to     substance abuse than males?If given the opportunity, females are at least aslikely as m...
Opportunity to Use Drugs          70          60                                       Male          50                   ...
Percent Use Given an Opportunity          80                                                                         Male ...
Males And Females Are Equally Likely    To Become Dependent On •   Cocaine        •   Inhalants •   Tobacco        •   Hal...
Gender Differences in Dependence             PotentialMales are more likely to    Females are more likelybecome dependent ...
Telescoping: Risk of Dependence is          Greater for Females• Westermeyer et al, 2000 has demonstrated  telescoping phe...
Animal Models Confirm Greater       Female Vulnerability• Females compared to males, self-administer more alcohol  ( Hill,...
Gender Differences in Animal Models• Due to circulating estrogens and  progesterones?• But gonadectomized female rats cont...
Menstrual Cycle                  34
Estrogen Effects on the Brain   • Estrogen enhances cholinergic and     glutamatergic systems leading to brain     activat...
Estrogen Effects on the Brain• Estradiol enhances dopamine (DA) release  through several mechanisms:1. Enhances DA recepto...
Progesterone Effects on the Brain• Progesterone and its metabolite,  allopregnanolone (ALLO), produces a sedating,  calmin...
Estrogens and Substance Abuse                Vulnerability• Enhanced drug seeking and subjective effects  of substances in...
Effects of Estradiol on Substance Use            in Animal Models• Estradiol enhances and tamoxifen (estradiol  antagonist...
Differences in BehavioralResponse in Males and Females i                              Hu and Becker, 2008
Progesterone and Substance Abuse            Vulnerability• Progesterone attenuates dopamine release and  responses to drug...
Menstrual Cycle and Substances Of               Abuse• Women reported higher enjoyment of cocaine  during follicular phase...
Gender Differences in Response to                 Stress• Uncontrollable stress increases drug self-  administration in an...
Mood Changes Across the Menstrual             Cycle                                44
Brain Function Variability in Normal Women    is Controlled by Ovarian Hormones •   Mood: 20% •   Verbal performance: 25% ...
PMDD• Normal levels of estrogen, progesterone,  gonadotropins, prolactin, cortisol and thyroid• Women with PMDD react abno...
Disorders with Premenstrual    Exacerbation (Catamenial Disorders)•   Mood              •   Seizures•   Anxiety           ...
PMDD and Substance Use• GABA A and endorphine withdrawal state –  self medication• Women with PMDD drink more heavily than...
Gender Differences in Brain Imaging• In response to cues more areas are activated  in females• Substance-induced brain shr...
Female smokers are much more sensitive to cigarette cues than male smokers                                                ...
Differences in Initiation and UseAlcohol         Women drink to cope with stress, negative emotions; men                 ...
Differences in RelapseWomen relapse for different reasons than men  • Stress, weight gain, negative emotions  • Untreated ...
Gender Differences in Medical    Consequences of Substance Use• Females have higher rates of liver problems  including cir...
Gender Differences in Co-Occurring              Disorders• Women with substance abuse show higher rates of  major depressi...
Mood Disorders: Gender Differences   • 2 : 1 ratio female to male   • In 165 cultures, it varies (1.7-2.2) : 1   • Remarka...
Gender Differences in Co-Occurring              Disorders• Women have a primary mental health disorder that  antedates the...
Gender Differences in History of       Victimization and Violence• Early life stress, childhood sexual abuse are more  com...
Gender Differences in Nicotine            Metabolism• Faster in women than men• Equal in men and post-menopausal women• Fa...
Women and Tobacco• Tobacco plays greater role in progression to illicit  drugs use in women than in men (Tuchman, 2010)• W...
Treatment of Tobacco Dependence• Combination nicotine replacement (patch and  losenges; patch and gum) is the most effecti...
Women and Alcohol• Lower content of body water (51% vs 65% in  men)• Lower levels of gastric ADH (25% of men’s)• Menstrual...
Women and Alcohol• Women start drinking later in life than men  and consume less alcohol• Due to societal stigma, many wom...
Treatment for Alcohol Dependence•   Disulfiram (Antabuse)•   Naltrexone oral (Revia) or injectable (Vivitrol)•   Acamprosa...
Gender Differences InPharmacotherapy of Substance Abuse• Disulfiram for cocaine dependence effective only  in males, not f...
Gender Differences In Pharmacological   Treatment of Substance Abuse•   Buprenorphine•   Methadone•   Acamprosate ( no dif...
Gender Differences in Treatment Entry,     Retention and Completion• Women are less likely than men to enter  substance ab...
Substance Abuse Treatment: Women of childbearing age                                                  NSDUH 2006
Reasons for Not Receiving Treatment in Past Year                                           NSDUH 2006
Characteristics of Women Entering Treatment,              Compared to Men • Younger • Less educated • Less likely to be em...
Gender-Sensitive Treatment Availability      Facilities accepting women: 2005                               SAMHSA. Nation...
Why Gender-Sensitive Programs?  Ancillary clinical/social               Child care, transportation  services  Special nee...
Self-Help Support GroupsWomen-only and   •Alcoholics Anonymousmixed gender     •Narcotics Anonymous“12-step”        •Cocai...
Gender Differences in Treatment     Entry, Retention and Completion• Treatment outcomes are comparable with  men in retent...
Psychosocial Substance Abuse Interventions for        Women with Trauma History• The Addiction and Trauma Recovery Integra...
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Pm 4.10 volfson

  1. 1. Women and Substance Abuse Elena Volfson, MD, MPH Addiction Psychiatrist Clinical Assistant Professor of Psychiatry Perelman School of Medicine University of Pennsylvania 03/16/2012
  2. 2. Disclosure• Dr. Volfson has no financial interest to disclose
  3. 3. Outline• Updates in general addiction neurobiology• Gender differences in epidemiology and neurobiology• Hormones and substance abuse• Gender differences acquisition, escalation, dependence, withdraw al, relapse and treatment• Gender differences in pharmacotherapy of substance use
  4. 4. Quoted from multiple sourcesWHO 2002
  5. 5. Model of Addiction Emotion ControlTemporal - Parietal Orbital Prefrontal Cortex Reward / Craving Euphoria Ventral Tegmentum Nucleus Accumbens Memory Hippocampus 5 Used with permission from David Oslin, 2012
  6. 6. Model of Addiction Emotion ControlAntidepressants 12 Step / CBTMood StabilizersTherapy Reward / Craving Euphoria Naltrexone Naltrexone Acamprosate Acamprosate Memory 6 Used with permission from David Oslin, 2012
  7. 7. Addiction is a Compulsive Relapsing DisorderTwo essential features:• impaired ability to regulate the drive to obtain and use substances• reduced drive to obtain natural rewardsChange in the reward circuitry : substances usurp normal learning circuitry to create the pathology of addiction Kalivas and O’Brien, 2008
  8. 8. Vulnerabilities in Development of Addiction• Genetic• Developmental• Social• Drug-induced brain plasticity
  9. 9. Core Addiction Syndrome• Common neuroplastic changes in response to chronic administration of different substances of abuse• Addiction is “overlearned “ with repeated associations between substances and life events mediated by dopamine release• Addictive behaviors and chronic relapse vulnerability are maintained by glutamatergic neurotransmission Kalivas and O’Brien, 2008
  10. 10. Core Addiction Syndrome• Hypofrontality- subcortical glutamatergic connections assume primacy and reduce cortical control over drug-seeking (automatic behavior)• Drug-associated stimuli activate PFC excessively, whereas natural reinforcers (sex, food, danger etc.) elicit poor response - maladaptive process
  11. 11. Staged Neuroplasticity of Addiction• Abstinence• Social Use• Chronic Use• Regulated relapse – conscious choice• Compulsive relapse- inability to make a conscious choice (Kalivas and O’Brien 2008)
  12. 12. Neurobiological Changes with Chronic Substance Use• Motivation/reward system DA/endorphine• Glutamate/GABA dysregulation• HPA axis dysregulation• Hypofrontality• Sex hormones dysregulation• Cravings• Relapse
  13. 13. Pharmacologic Strategies to Treat Addiction• Dopaminergic (D1-D5)• Glutamatergic (NMDA, AMPA, KA, metabotropic)• GABA ergic (GABA A and B)• Cholinergic (Ach M and N)• Noradrenergic (Alpha and beta)• Serotonergic (14 subtypes)• Endogenous opioids (mu, delta, kappa, OFQ-N)• Endogenous cannabinoids (CB1 and CB2)• Many others (NPY, DARPP-32, galanin, orexin, CRF, substance P, melanocortins, leptin, BDNF etc.)
  14. 14. Complexity of Gender Research Apples to Apples?• Menstrual cycle: 2-6 phases vs none• Hormones <> substance use• Stress <> substance use• Multiple stages of substance use from recreational to dependence
  15. 15. Gender Differences in Brain • Structural • Functional
  16. 16. Why Are Male and Female Brains Different?• Chromosomal sex determines gonadal sex; gonadal hormones influence brain development• Hormones released are different between males and females• Hormone-Environment Interactions: developmental and adult differences
  17. 17. Epidemiology
  18. 18. Substance Dependence or Abuse in the Past Year, by Age and Gender: NSDUH 2010
  19. 19. NSDUH 2010: Alcohol Use by Gender
  20. 20. SUBSTANCE USE BY WOMEN, 2008 Past year Past monthCigarettes 25.3% 21.7%Alcohol 62.3% 45.9% Binge (5+ drinks/day >1 day per month) -- 15.4 Heavy use (binge drinking >5 days per month) -- 3.4Illicit Drugs 12.2% 6.3% Marijuana & hashish 8.3 4.4Prescription Drug Misuse 5.8% 2.4% Pain relievers 4.3 1.8 Tranquilizers 2.2 0.8 SAMHSA. National Survey on Drug Use and Health, 2008. 20
  21. 21. NSDUH 2010: Tobacco Use by Pregnancy Status in Women of Reproductive Age
  22. 22. Substance Use by Pregnant Women• Of women in their first trimester, 19% used alcohol, 22% used cigarettes, and 5% used marijuana in the past month• Of women in their second or third trimester, 1 in 7 used cigarettes• Stimulants are primary drug for which pregnant women seek treatment• 65% of women relapse within 6 months of deliveryGreenfield et al. Psychiatr Clin North Am. 2010;33:339-55; SAMHSA. Substance Use amongWomen During Pregnancy and Following Childbirth, 2009. 22
  23. 23. Substance Use by Lesbian/Bisexual Women• Higher and riskier alcohol use• Spend more time socializing in bars and party settings, and drink more in these settings• More IV drug use among bisexual women• Mental health and substance use disorders may result, in part, from stress related to sexual minority status• Good news: – Lesbian and bisexual women are twice as likely as heterosexual women to receive treatment for mental health or substance use disorders Grella et al. BMC Psychiatry2009;9:52. 23
  24. 24. Initiation of Drug Use by Substance NSDUH 2010
  25. 25. Multiple studies demonstrate higher rates of substance abuse anddependence in males as compared to females…
  26. 26. Are females less vulnerable to substance abuse than males?If given the opportunity, females are at least aslikely as males • to use drugs and alcohol • to become dependentLower prevalence of substance abuse in femalesis explained by less exposure and feweropportunities
  27. 27. Opportunity to Use Drugs 70 60 Male 50 Female 40Percent 30 20 10 0 Marijuana Cocaine Hallucinogens Heroin Van Etten et al. (1999) -- 1993 NHSDA
  28. 28. Percent Use Given an Opportunity 80 Male 70 Female 60 50Percent 40 30 20 10 0 Marijuana Cocaine Hallucinogens Heroin Van Etten et al. (1999) -- 1993 NHSDA
  29. 29. Males And Females Are Equally Likely To Become Dependent On • Cocaine • Inhalants • Tobacco • Hallucinogens • Opioid Analgesics • Heroin Anthony et al. (1994)
  30. 30. Gender Differences in Dependence PotentialMales are more likely to Females are more likelybecome dependent on to become dependent on • Marijuana • Anxiolytics • Alcohol • Sedatives • Hypnotics Anthony et al. (1994)
  31. 31. Telescoping: Risk of Dependence is Greater for Females• Westermeyer et al, 2000 has demonstrated telescoping phenomenon in females for tobacco, caffeine, alcohol, cannabis, opiate, sedative, cocaine, inhalant, amphetamine, hallucinogen and PCP• Rate of escalation and rate of consumption are greater, more severe dependence• Within 24 months of cocaine use females were 3-4 times more likely than males to become dependent (O’Brien and Anthony, 2005)• Girls develop tobacco dependence symptoms faster than boys (DiFranza et al, 2002)
  32. 32. Animal Models Confirm Greater Female Vulnerability• Females compared to males, self-administer more alcohol ( Hill, 1978; Lancaster & Spiegel, 1992); caffeine (Heppner et al., 1986), cocaine(Morse et al., 1993; Matthews et al., 1999; Lynch & Carroll,1999; Hu et al., 2004), fentanyl(Klein et al., 1997), heroin (Carroll et al., 2001), morphine(Alexander et al, 1978; Hill, 1978; Cicero et al, 2000), nicotine (Donny et al., 2000), cannabinoids (Fattore, 2007)• Females acquire stronger cocaine-induced conditioned place preference quicker and at lower doses (Russo et al., 2003a; Russo et al., 2003b)• Females acquire self-administration faster than males (Lynch & Carroll, 1999; Donny et al., 2000)
  33. 33. Gender Differences in Animal Models• Due to circulating estrogens and progesterones?• But gonadectomized female rats continued to acquire self-administration faster and used more cocaine than both intact and castrated males (Hu et al, 2004; 2008)• Sexual dimorphism in brain organization during early development due to chromosomal sex and gonadal hormones (Reisert et al, 1990; Kolbinger et al, 1991; Carruth et al, 2002)
  34. 34. Menstrual Cycle 34
  35. 35. Estrogen Effects on the Brain • Estrogen enhances cholinergic and glutamatergic systems leading to brain activation in both male and female brains • Memory, learning, cognitive function • MRI shows increase blood flow to the brain in response to estrogenLeBlanc ES. JAMA 2001;285:1489-99; Resnick SM. J Clin Endocrinol Metab 2006;9:1802-10. 35
  36. 36. Estrogen Effects on the Brain• Estradiol enhances dopamine (DA) release through several mechanisms:1. Enhances DA receptors activity2. Potassium – induced mechanisms3. GABAergic neurons inhibitionBecker and Hu, 2008• Activation of HPA axis
  37. 37. Progesterone Effects on the Brain• Progesterone and its metabolite, allopregnanolone (ALLO), produces a sedating, calming effect via GABA A receptors• ALLO is anxiolytic, anticonvulsant, and anesthetic• Serotonine facilitates the metabolism of progesterone into ALLO• HPA axis deactivation 37
  38. 38. Estrogens and Substance Abuse Vulnerability• Enhanced drug seeking and subjective effects of substances in women are associated with higher levels of endogenous estrogens (Evans 2007, Terner and De Wit 2006)• Greater increase in dopamine induced by substances of abuse in females results in more robust ‘down-stream’ changes in the brain, and greater liability for addiction (Hu and Becker, 2008)• Telescoping phenomenon
  39. 39. Effects of Estradiol on Substance Use in Animal Models• Estradiol enhances and tamoxifen (estradiol antagonist) inhibits acquisition of cocaine self- administration in female rats, but not in male rats (Becker, 2005)• Pretreatment with estradiol changes behavioral sensitization to cocaine (Hu and Becker, 2003)
  40. 40. Differences in BehavioralResponse in Males and Females i Hu and Becker, 2008
  41. 41. Progesterone and Substance Abuse Vulnerability• Progesterone attenuates dopamine release and responses to drugs of abuse• Progesterone inhibits cocaine self-administration (Jackson et al, 2006)• Women treated with progesterone showed a decrease in the positive subjective effects of cocaine ( Evens, 2006, Sofuoglu, 2004)• High circulating plasma levels of progesterone are associated with decreased cravings following drug and stress-related cues (Sinha, 2007)
  42. 42. Menstrual Cycle and Substances Of Abuse• Women reported higher enjoyment of cocaine during follicular phase vs. luteal phase (Evans et al, 2002) and lower ratings of “feeling high” during the luteal phase (Sofuoglu et al, 1999)• Women reported more positive subjective effects of oral D-amphetamine during follicular vs. luteal phase (Justice & de Wit, 1999)• Women may be more vulnerable to relapse during the follicular as compared with luteal phase (Wilcox and Brizendine, 2006)
  43. 43. Gender Differences in Response to Stress• Uncontrollable stress increases drug self- administration in animals and humans (Stewart et al, 2000; Kosten et al, 2000; Koob et al, 2001; Sinha, 2001; de Wit et al, 2003)• Gender differences in the neurobiological response to stress (Fox and Sinha, 2009)• Stress (high cortisol level) sensitizes the reward circuitry to the pleasurable effects of the substances and increases cravings (Sinha et al, 2006; Sinha, 2007; Shalev et al, 2002; Stewart, 2000)• Cortisol level varies across the menstrual cycle ( Nepomnaschy et al, 2011)
  44. 44. Mood Changes Across the Menstrual Cycle 44
  45. 45. Brain Function Variability in Normal Women is Controlled by Ovarian Hormones • Mood: 20% • Verbal performance: 25% • Sexual interest: 30% • Visual-spatial performance: 20% Research and treatment studies have to control for days of the menstrual cycle !!! Brizendine L. The Female Brain. Morgan Road/Broadway Books 2006. 45
  46. 46. PMDD• Normal levels of estrogen, progesterone, gonadotropins, prolactin, cortisol and thyroid• Women with PMDD react abnormally to normal hormone levels due to dysfunctions in serotonergic and GABAergic systems• Seasonal variation in symptom severity due to lower serotonin levels in fall and winter Maskall et al. Am J Psychiatry 1997;154:1436-41. Praschak-Rieder et al. Arch Gen Psychiatry 2008;65:1072-8. 46
  47. 47. Disorders with Premenstrual Exacerbation (Catamenial Disorders)• Mood • Seizures• Anxiety • Allergies• Psychosis • Asthma• Migraines • Sleep• Substance Use • Pain
  48. 48. PMDD and Substance Use• GABA A and endorphine withdrawal state – self medication• Women with PMDD drink more heavily than controls and have higher rates of alcohol abuse and dependence (Tobin et al, 1994; Halliday et al, 1986; Mello et al, 1990; Allen, 1996; Sutker et al, 1983; Russel et al, 1986; Svikis et al,2006)• Benzodiazepines, opioids, barbiturates
  49. 49. Gender Differences in Brain Imaging• In response to cues more areas are activated in females• Substance-induced brain shrinkage may be greater in females• Substance-induced perfusion deficits are greater in males• More neuronal damage and white matter changes in males
  50. 50. Female smokers are much more sensitive to cigarette cues than male smokers 3.5 3.0Females 2.5 2.0 1.5 N = 5 Female Smokers - 6 NonSmoking Females 1.0 .5 Males 0 T Value N = 6 Male Smokers - 5 NonSmoking Males T. Franklin, 2010
  51. 51. Differences in Initiation and UseAlcohol  Women drink to cope with stress, negative emotions; men drink to enhance positive emotions or conform to a groupStimulants  Women are attracted to meth for weight loss, increased energy & control of depressive symptoms  Over 70% of meth-dependent women report hx of abuseOpiates  Women more likely to hoard unused meds and use additional drugs (e.g., sedatives) to enhance Rx opioidsHeroin /  Women likely to be introduced to substance by a partnerIV drugs  Use less for shorter periods of time than men  Less likely to inject; more likely to share preparation equipmentTobacco  Women have more difficulty quitting  More susceptible to proximal cues paired with smoking  Worry 2x as much about weight gain; relapse 3x more often than menGreenfield et al. Psychiatr Clin North Am. 2010;33(2):339-55; UCLA Integrated Substance 51Abuse Programs. Methamphetamine.org. 2006-2010.
  52. 52. Differences in RelapseWomen relapse for different reasons than men • Stress, weight gain, negative emotions • Untreated psychiatric disorders, especially depression and trauma-related symptoms (PTSD) • Intimate partner issues • Issues with children or ongoing parenting • Isolation and poor social support Greenfield et al. Psychiatr Clin North Am. 2010;33(2):339-55. 52
  53. 53. Gender Differences in Medical Consequences of Substance Use• Females have higher rates of liver problems including cirrhosis, HTN, anemia, GI problems• Higher rates of HIV and STDs• Higher risk of breast cancer and heart disease• Higher risk of lung cancer and COPD• Higher rates of infertility, repeat miscarriages and premature delivery
  54. 54. Gender Differences in Co-Occurring Disorders• Women with substance abuse show higher rates of major depression, social phobia, post-traumatic stress disorders, and eating disorders compared to men (Denier etal, 1991; Fornari et al, 1994; Grealla et al, 1996, Merikangas et al,1998; Najavits et al,1997, Sonne et al, 2003; Westermeyer et al,1996)• Lifetime eating disorders co-occur with substance abuse disorders in up to 40% of women (Godfrey et al, 2007; Greenfield et al, 2010)• Alcohol dependent women show higher comorbidity in all diagnoses except for antisocial personality and pathological gambling (higher in alcoholic men)
  55. 55. Mood Disorders: Gender Differences • 2 : 1 ratio female to male • In 165 cultures, it varies (1.7-2.2) : 1 • Remarkably stable across cultures • Ratio in childhood is 1 : 1 • 2 : 1 with onset of puberty and continues to be that way throughout life 55
  56. 56. Gender Differences in Co-Occurring Disorders• Women have a primary mental health disorder that antedates the onset of substance abuse disorder more often than men(Kessler, 2004)• Women with depression were more than seven times as likely as women without depression to have alcohol dependence at 2-year follow up. In men, there was no difference (Gilman and Abraham,2001)• Women with a hx of MDD were twice as likely to relapse to smoking at 1 year follow up as compared to women without depression (Oncken et al, 2007)
  57. 57. Gender Differences in History of Victimization and Violence• Early life stress, childhood sexual abuse are more common in girls than boys (Kendler et al, 2000)• Prevalence rates of intimate partner violence among women in drug treatment ranges 25-57% in contrast with non-drug using women’s 1.5-16% (El-Bassel et al,2000; Caetano et al, 2001; Tjaden et al, 1998)• Lifetime rates of physical (71.3%) and sexual abuse (44.5%) and PTSD (19%) are often found in drug- dependent pregnant women (Moylan et al, 2001; Velez et al, 2006)
  58. 58. Gender Differences in Nicotine Metabolism• Faster in women than men• Equal in men and post-menopausal women• Faster in women on oral contraceptives (OC) than not on OC (Benowitz et al, 2006)• Faster in pregnant women than non-pregnant women (Dempsey et al, 2002)
  59. 59. Women and Tobacco• Tobacco plays greater role in progression to illicit drugs use in women than in men (Tuchman, 2010)• Women are less likely to quit initially (Killen et al, 1997) or to remain abstinent at follow-up (Killen et al, 1994; Kabat et al, 1987)• Females report positive mood increases to a greater extent after smoking and show a greater decline in positive mood during abstinence than men (Perkins, 1996)• Faster nicotine metabolizers have poorer smoking cessation outcomes from NRT (Lerman et al, 2006)
  60. 60. Treatment of Tobacco Dependence• Combination nicotine replacement (patch and losenges; patch and gum) is the most effective• 2-4 mg of nicotine per cigarette• 20 cig a day = 60-80 mg of nicotine• Varenicline• Bupropion SR or XL
  61. 61. Women and Alcohol• Lower content of body water (51% vs 65% in men)• Lower levels of gastric ADH (25% of men’s)• Menstrual cycle-related variability in peak BAC• Safe level of drinking for non-pregnant healthy females <65: no more than three standard drinks per day and no more than 7 per week
  62. 62. Women and Alcohol• Women start drinking later in life than men and consume less alcohol• Due to societal stigma, many women tend to drink alone (married, employed, upper socioeconomic strata)• Somatization of alcohol problems is often unrecognized by providers and medicated by sedatives and tranquilizers
  63. 63. Treatment for Alcohol Dependence• Disulfiram (Antabuse)• Naltrexone oral (Revia) or injectable (Vivitrol)• Acamprosate ( Campral)• Topiramate (Topamax)• Ondansetron (Zofran)
  64. 64. Gender Differences InPharmacotherapy of Substance Abuse• Disulfiram for cocaine dependence effective only in males, not females (Nich et al, 2004)• NRT was more effective in males than females (Cepeda-Benito, 2004)• In a study of sertraline treatment of non- depressed, alcohol-dependent individuals, sertraline reduced drinking in males, but not females (Pettinati et al, 2004)• Response to oral naltrexone is similar in males and females; however injectable Vivitrol was less effective in women (Greenfileld et al, 2010; Garbutt et al, 2005; Kranzler et al, 2004)
  65. 65. Gender Differences In Pharmacological Treatment of Substance Abuse• Buprenorphine• Methadone• Acamprosate ( no difference)• Anticonvulsants (gabapentine and lamotrigine)• Baclofen• Varenicline (no difference)• Ondansetrone• Progesterone
  66. 66. Gender Differences in Treatment Entry, Retention and Completion• Women are less likely than men to enter substance abuse treatment (Greenfield et al, 2007)• Reasons include sociocultural, socioeconomic factors, child custody issues, availability of gender-specific treatment programs etc. (Canterbury 2002; Greenfield, 2007)• Women are more likely to seek treatment in other settings (Weisner et al, 1992)
  67. 67. Substance Abuse Treatment: Women of childbearing age NSDUH 2006
  68. 68. Reasons for Not Receiving Treatment in Past Year NSDUH 2006
  69. 69. Characteristics of Women Entering Treatment, Compared to Men • Younger • Less educated • Less likely to be employed • More likely to have physical/mental health problems • More likely to have exchanged sex for substances • Greater exposure to physical and sexual abuse • Greater concerns about issues related to children Kaskutas et al. Addiction 2005;100:60.
  70. 70. Gender-Sensitive Treatment Availability Facilities accepting women: 2005 SAMHSA. National Survey of Substance Abuse Treatment Services (N-SSATS), 2005. 70
  71. 71. Why Gender-Sensitive Programs? Ancillary clinical/social  Child care, transportation services Special needs services  Prenatal care, HIV prevention Tailored to women’s  Interpersonal focus, nurturing special needs and supportive, empowering May provide programs for  Pediatric, prenatal, post-partum pregnancy and parenting services  Parenting classes, child activities More likely to assist  Housing, job training, practical patients with: skills trainingGodfrey. J Womens Health 2007;16:163-7; Grella et al. J Subst Abuse Treat 1999;17:37–44.
  72. 72. Self-Help Support GroupsWomen-only and •Alcoholics Anonymousmixed gender •Narcotics Anonymous“12-step” •Cocaine Anonymousprograms •Crystal Meth Anonymous •Al-Anon, Al-AteenLifeRing •No reference to “higher power”Women for •Empowering approach… “My name is ___Sobriety and I am a competent woman.” •Can be adjunct or independent of AASMART Recovery •Cognitive behavior therapy approachModeration •Harm reduction approachManagement •For problem drinkers who have experienced mild to moderate alcohol-related problems
  73. 73. Gender Differences in Treatment Entry, Retention and Completion• Treatment outcomes are comparable with men in retention rates, relapse rates (Greenfield et al, 2007; Hser et al, 2001; Mangrum et al, 2006)• Women have been shown to have greater improvement in medical problems and more likely to seek assistance after relapse (Hser et al, 2005; McKay et al, 1996)
  74. 74. Psychosocial Substance Abuse Interventions for Women with Trauma History• The Addiction and Trauma Recovery Integration Model (ATRIUM; Miller and Guidry 2001)• Beyond Trauma: A Healing Journey for Women and A Healing Journey: A Workbook for Women (Covington 2003)• Helping Women Recover: A Program for Treating Addiction (Covington 2008)• Seeking Safety (Najavits 2000)• Trauma Adaptive Recovery Group Education and Therapy (TARGET; Ford et al. 2000)• Trauma Recovery and Empowerment Model (TREM; Harris and The Community Connections Trauma Work Group 1998)• Treating Addicted Survivors of Trauma (Evans and Sullivan 1995)
  75. 75. Questions?Comments?Thank you!

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