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Women and Substance Abuse

Women and Substance Abuse. Dr. Cynthia Kuhn Department of Pharmacology and Cancer Biology Duke University Medical Center. Definitions. Addiction: Out of control, compulsive use of addictive drug Abuse: Use with negative consequences. How Do Women Use Drugs?.

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Women and Substance Abuse

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  1. Women and Substance Abuse Dr. Cynthia Kuhn Department of Pharmacology and Cancer Biology Duke University Medical Center

  2. Definitions Addiction: Out of control, compulsive use of addictive drug Abuse: Use with negative consequences

  3. How Do Women Use Drugs?

  4. Women Use Addictive Drugs Less than Men NHSDUH 2008

  5. Teenage Women and Men Use Addictive Drugs Equally NHSDUH 2008

  6. Addictive Drug Use Peaks During Young Adulthood

  7. Substance Dependence in Women and Men

  8. Alcohol Dependence in Women and Men

  9. What is Different About Women and Drug Use?

  10. Women’s Issues in Drug Use Epidemiology • Use is becoming equal for many drugs • Female adolescents higher than males for several drugs • Pregnancy: special risk for children

  11. Illicit Drug Use by Pregnant Women

  12. Binge Alcohol Use by Pregnant Women

  13. Addiction is The Result of a Brain Process Is this Biology Different in Women?

  14. Addiction Is a Process of Brain Adaptation Drug use: Reward ADDICTION Withdrawal, Craving Reward Circuit Adapts Need Drug to Feel Good at all

  15. Addiction is NOT just Dopamine • Components of Addiction • Rewarding effects of the drugs – dopamine • Tolerance and dependence- withdrawal • Impaired priority setting/decision making – craving, compulsive use

  16. Dopamine Neural Basis of Addiction

  17. Cocaine DA Alcohol Heroin Nicotine All Addictive Drugs Activate This Circuit

  18. All Addictive Drugs Increase Dopamine Levels

  19. Addiction Is a Process of Brain Adaptation Drug use: Reward ADDICTION Withdrawal, Craving Reward Circuit Adapts Need Drug to Feel Good at all

  20. Reward System Adaptations in Addiction DA Target Neuron DA Receptors Constant DA Release Dopamine Neuron

  21. Dopamine Receptors Are Decreased in Addicts

  22. Addictive Drugs Cause Long Lasting Changes in the Brain Kalivas and Volkow, Arch Gen Psy. 162: 1403

  23. Addiction Is a Process of Brain Adaptation Drug use: Reward ADDICTION Withdrawal, Craving Reward Circuit Adapts Need Drug to Feel Good at all

  24. Executive Function Changes in Addiction: Drugs Become Priority • Increased impulsivity: Do things without considering the outcome • Impaired memory- Can’t keep things in mind while considering a decision • Difficulty shifting priorities • Risky decision making Berridge et al, Phil Trans. R. Soc B. 363:3257 (2008)

  25. Addicts Can’t Change Losing Strategies A B Win Big, Lose Overall C D Win Small, Win Overall . J. Math. Psychol 54:28 (2010)

  26. Addiction Is a Process of Brain Adaptation Drug use: Reward ADDICTION Withdrawal, Craving Reward Circuit Adapts Need Drug to Feel Good at all

  27. Craving and Misery of Withdrawal: From Activation of Stress Axis • Chronic drug exposure triggers stress axis • Involves stress peptide CRF • Amygdala sends messages to cortex – motivates more drug taking Chronic Addictive Drugs Activate the Stress Axis in the Brain

  28. Summary: Key Processes in Addiction • Rewarding effects of drugs • Adaptation to drugs – brain biochemistry and structure changes • Disturbed decision making • Craving associated with Withdrawal – activation of stress axis

  29. You meet your clients at the withdrawal phase when they: Can’t feel pleasure Feel miserable - going through withdrawal Have poor decision making Want drug more than anything

  30. Gender Differences in Addiction???

  31. Do Women Respond to Addictive Drugs Differently? Not really • Subjective effects (high) not significantly different from men • Sedatives • Nicotine • Marijuana • Alcohol • Stimulants

  32. Do hormones affect biological response to psychoactive drugs? • Yes: • Stimulants • No: • Ethanol • Nicotine • Marijuana • Heroin

  33. Hormones may actually help! Progesterone suppresses drug taking

  34. Addiction in Women??? Addiction develops more quickly Shorter window between initiating use and entering therapy Women show stronger craving

  35. Long Term Effects? • Alcohol: women experience more toxicities at lower doses • Cirrhosis • Heart disease • Stroke • Osteoporosis • Stimulants: Men have more CNS damage

  36. What We Don’t Know about Women and Addiction • Are brain changes different? • Is decision making changed in the same way? • Is withdrawal worse?

  37. Addiction is not just Brain Biology Which of these influences are important for women?

  38. Vulnerability Factors in Addiction Individual Environment Genetics Psychiatric illness Drug using family Abuse Education Poverty Low access to services Drug using area Family history

  39. Women and Men Substance Abusers have Different Psychopathology • Common in men • ADHD • Conduct disorder • Common in women • Major depressive disorders • Anxiety disorders Latimer et al., 2002

  40. Women: Special Risk from Psychiatric Co-Morbidity Depression is risk Factor for substance abuse More women have depression

  41. Family History • Women more likely to have experienced physical and/or sexual abuse • Women more likely to have less education than drug using men

  42. Environment • Women are more likely to be poor (especially if they are mothers) • If they have a partner, he/she is more likely to be a drug user • Women’s profession more likely to be linked to drug use (sex work)

  43. Treatment

  44. Treatment of Addiction • Multiple approaches are necessary • Needs to be long enough- brain changes slowly • Cognitive behavioral therapy a valuable adjunct for impaired decision making • Drugs can contribute • Substitution therapies • Antagonist strategies • Engagement as a result of criminal justice (YOU!) increases success

  45. Heroin Nicotine Most Drug Treatments Replace Drug at Site of Action Methadone Nicotine Patch

  46. Treatment Works! Efficacy of Methadone Treatment One example of many

  47. Gender Effects in Treatment • Women less likely to get therapy • Low expectations • Don’t perceive need • Most therapies effective in women and men • Gender-specific approaches little tested • Special needs must be addressed- children! Greenfield et al, Drug and Alcohol Dep. 86: 1 (2007)

  48. Summary: Women’s Issues in Substance Abuse • Women are losing the protection they had from historic social roles • Their brains respond to addictive drugs like those of mens • Addiction may “telescope,” develop faster • Treatment likely to be successful but there are barriers to entry • Special needs due to pregnancy and children must be addressed

  49. Practical Advice • Addiction: Treat! Just like anybody else • Underlying psychiatric illness must be treated • Physical/sexual abuse history will be a factor in engagement in treatment • Treatment is more likely to be successful if women can be with their children • Pregnant women: most likely to engage in treatment

  50. Dr. Cynthia Kuhn ckuhn@duke.edu

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