Substance Abuse in Women: Clinical & Program Issues in the Community & Criminal Justice System

1. Substance Abuse in Women: Clinical & Program Issues in the Community & Criminal Justice System Joan E. Zweben, Ph.D. Executive Director, EBCRP Clinical Professor of Psychiatry; UCSF ADP Conference October 13, 2010

2. Introduction • 1970’s – first focus on gender disparities and women’s issues • 90% of articles on gender published since 1990 (Back, 2007) • 24% of substance abuse treatment facilities now provide specific programs or groups for women (SAMHSA Facility Locator, 2007)

3. Epidemiology • Prevalence of AOD disorders greater in men • Gender differential is higher for alcohol use disorders than drug use disorders • Prescription drug abuse and tobacco use in women only slightly less than men • For adolescents, the gap disappeared for alcohol, marijuana, cocaine and cigarettes

4. Minority Women and Alcohol Use Drinking patterns influenced by: • Religious activity • Genetic risk/protective factors • Level of acculturation to U.S. society • Historical, social and policy variables (Collins & McNair, 2002)

5. African American Women • Relatively high rates of abstention and low rates of heavy drinking among black women • Most over 40 did not consume alcohol • High participation in religious activities is a protective factor (Collins & McNair, 2002)

6. Asian American Women • Regardless of national origin, Asian American women have low rates of alcohol use and problem drinking • Facial flushing response (occurring in 47-85% of Asians) is a protective factor • ALDH2-2 leads to perspiration, headaches, palpitations, nausea, tachycardia, and facial flushing • Women report being more embarrassed than the men do • Acculturation promotes increased drinking (e.g., Japanese women) (Collins & McNair, 2002)

7. Native American Women • Availability of distilled spirits, its use outside specific cultural contexts, and modeling of heavy drinking by Europeans promoted binge drinking • Tribal policies about drinking on the reservation are influential • High density of alcohol outlets in poor urban communities • Marketing of high alcohol content to Native Americans (Crazy Horse) (Collins & McNair, 2002)

8. Latinas • Often did not drink, or drank small amounts in country of origin, but drinking patterns changed more dramatically than male counterparts • More research on Mexicans than Puerto Ricans or Cubans • After three generations, the drinking patterns of Mexican-American women are similar to other U.S. women (Collins & McNair, 2002)

9. Older Women Risk Factors: • Longer life expectancies • Many losses • Live alone longer • Less likely to be financially independent • More susceptible to the effects of alcohol, particularly as they age (Blow & Barry, 2002)

10. Women in the Military Women Veterans of Iraq & Afghanistan: • Review of records from Defense Medical Surveillance System indicated 17.4% received specific mental health diagnosis (overall rate, 12%) • 22% suffered from military sexual trauma, compared with 1% of men (Susan Storti, NIDA Conference 2010)

11. Diagnostic & Screening Issues • Women tend to seek treatment at mental health or primary care clinics • Both substance abuse and psychiatric conditions are often undetected • A single question about last episode of drinking can increase detection in primary care settings

12. Psychosocial Influences • Women more likely to have role models in nuclear families and/or spouses who are alcohol dependent • Weight control is important factor in tobacco smoking • Relapse factors: women more likely to cite interpersonal and other stressors; men more likely to report external temptations

13. Medical Comorbidity

14. Biological Factors • Alcohol • Enzymes – lower concentration of gastric dehydrogenase • Higher fat/water ratio • Drugs • Hormone fluctuation during menstrual cycle • Gender differential in brain activation by stress and drug cues

15. Alcohol

16. Course of Illness • Increased vulnerability to adverse consequences • “Telescoped” course • Females advance more rapidly from use to regular use to first treatment episode • Severity generally equivalent to males despite fewer years and smaller quantities • Biological and psychosocial factors contribute to this outcome

17. Biological Factors • Alcohol: differences in bioavailability • Enzymes – lower concentration of gastric alcohol dehydrogenase (enzyme that degrades alcohol in the stomach) • Higher fat/water ratio (smaller volume of total body water so alcohol is more concentrated)

18. Breast Cancer • Moderate consumption elevates the risk (linear relationship between #drinks and risk) • Occurs with all forms of alcohol • Does alcohol raise estrogen levels? • Metabolism of ethanol leads to the generation of acetaldehyde (AA) and free radicals. Acetaldehyde is carcinogenic (e.g., GI tract cancers) • Research areas: specific drinking patterns, body mass index, dietary factors, family hx breast cancer, use of HRT, tumor hormone receptor status, immune function status (10th Special Report to Congress: Alcohol & Health)

19. Psychiatric Comorbidity

20. Psychiatric Comorbidity • More likely in girls and women: • Anxiety disorders (especially PTSD) • Depression • Eating disorders • Borderline personality disorders • Onset more likely to precede the onset of the substance use disorder • More likely in boys and men: • Antisocial personality disorder • Conduct disorder

21. PTSD • Convergence of trauma, PTSD and SUDS particularly important • Early life stress, esp sexual abuse, more common in girls • Higher risk of alcohol dependence in women exposed to violence in adulthood • AOD use elevates risk for victimization • Uncontrollable stress increases drug self-administration in animals

22. Treatment Issues

23. Gender Differences in Treatment I • Women less likely to enter treatment • Sociocultural: stigma, lack of partner/family support • Socioeconomic: child care, pregnancy, fears about child custody • Children are a big motivator to enter treatment or avoid it • Availability of appropriate treatment for co-occurring disorders is important

24. Gender Differences II • Few differences in retention, outcome, or relapse rates • If there are differences, women have better outcomes • Show greater improvement in other domains (e.g., medical), shorter relapse episodes, more likely to seek help following a relapse

25. Gender Differences III • No strong evidence that gender-specific treatments are more effective, but there are few controlled trials • Residential programs that include children have better retention rates • Gender is not a specific predictor overall, but specific treatment elements improve outcomes for various subgroups (Greenfield et al 1006)

26. Key Services to Improve Outcomes for Women • Child care • Prenatal care • Supplemental services addressing women-focused topics (e.g., trauma history) • Mental health services; psychotropic meds • Transportation • Women-only groups • Employment services (jobs with decent pay)

27. Documented Improvements • Length of stay; treatment completion • Decreased use of substances • Reduced mental health symptoms • Improved birth outcomes • Employment • Self-reported health status • HIV risk reduction (Ashley et al 2003; Greenfield et al, 2007)

28. Readiness to Change: Start Where the Woman Is • Domestic violence • Emotional problems • Substance abuse • HIV risk behaviors Rapidly address what the woman indicates as high priority, and build a bridge to the other problems (Brown et al, 2000)

29. Treatment Culture • Female role models at all levels of hierarchy • Positive male role models available • Forthright feedback but not aggressive confrontation • Monitor the intensity, especially for women who are more disturbed • Sexual boundary issues

30. Women-Only vs Mixed Gender Programs • Most consistent difference: provision of services related to pregnancy and parenting • Parenting classes • Children’s activities • Pediatric, prenatal, post-partum services • Also more likely to assist with housing, transportation, job training, practical skills training (Grella et al, 1999)

31. Women-Only Groups • Foster greater interaction, emotional and behavioral expression • More variability in interpersonal style • Women in mixed groups engage in a more restrictive type of behavior; men show wider variability (and interrupt women more). (Hodgkins et al, 1997)

32. Relapse Issues for Women • Untreated psychiatric disorders, especially depression and trauma sequelae (PTSD) • Intimate partner • Underestimating the stress of reunification or ongoing parenting • Isolation; poor social support • High level of burden

33. Seeking Safety:Early Treatment Stabilization • 25 sessions, group or individual format • Safety is the priority of this first stage tx • Treatment of PTSD and substance abuse are integrated, not separate • Restore ideals that have been lost • Denial, lying, false self – to honesty • Irresponsibility, impulsivity – to commitment

34. Seeking Safety: (2) • Four areas of focus: • Cognitive • Behavioral • Interpersonal • Case management • Grounding exercise to detach from emotional pain • Attention to therapist processes: balance praise and accountability; notice therapists’ reactions

35. Seeking Safety (3):Goals • Achieve abstinence from substances • Eliminate self-harm • Acquire trustworthy relationships • Gain control over overwhelming symptoms • Attain healthy self-care • Remove self from dangerous situations (e.g., domestic abuse, unsafe sex) (Najavits, 2002; www.seekingsafety.org)

36. Women in the Criminal Justice System

37. Epidemiology • Women are the fastest growing segment of the CJ population in all components since 1990s • Majority are nonviolent offenders • Most are minority, esp black and Hispanic • Variety of medical problems, more severe than age matched counterparts

38. Children at High Risk • Most women offenders have children • Disproportionately linked to race • Family disorganization, financial hardship, exposure to abuse and trauma often predated incarceration • No reliable research to support the view that these children are more likely to be incarcerated as adults • Did have problematic school behavior and deviant peer influences

39. Family Contact • Family contact in prison is associated with lower rates of post release recidivism • Telephone restrictions significantly reduce family contact • Budget cuts have led to reduced visiting hours

40. Criminogenic Factors Targeted to Improve Outcomes • Antisocial values • Criminal peers • Dysfunctional families • Substance abuse • Criminal personality • Low self-control Substance abuse treatment alone is not enough.

41. Treatment In Custody • S. Covington manuals specific for this population • Gender-responsive treatment showed better outcomes (Messina et al, JSAT 2010) • Community based continuing care improves outcomes • Safety issues: women victimized by other inmates and custodial staff

42. Treatment in the Community • Re-entry courts as an alternative sanction • Second Chance, PROTOTYPES, intensive tx that addresses COD • Complex problems of women parolees often not addressed

43. Barriers to Effective Treatment in the Community • Laws and regulations are designed for high risk inmates • Difficult to get approval for educational activities outside the program • Computer access restricted • Exploitative requirements for telephone access • Prohibitions/restrictions on medications

44. Recommendations • Select appropriate evidence-based practices; avoid “pick from this list” approach • Beware of rigid adherence to a model or EBP at the expense of individualized treatment planning • Carefully investigate whether appropriate services are available • Eliminate barriers to medication use for psychiatric or addictive disorders • Acknowledge that tx requires building capacity for independence; avoid excess restrictions not required for public safety

45. References • Covington, S. (1999). Helping Women Recover. San Francisco: Jossey Bass. • Covington, S. (2000). Helping women to recover: Creating gender-specific treatment for substance-abusing women and girls in correctional settings. In M. McMahon (Ed.), Assessment to Assistance: Programs for Women in Community Corrections (pp. 171-233). Latham, Maryland: American Correctional Association. • Messina, N., Grella, C. E., Cartier, J., & Torres, S. (2010). A Randomized Experimental Study of Gender-Responsive Substance Abuse Treatment for Women in Prison. Journal of Substance Abuse Treatment, 38(2), 97-107. • Zweben, J. E. (2011). Women's Treatment in Criminal Justice Settings. In C. Leukefeld, J. Gregrich & T. P. Gullotta (Eds.), Handbook on Evidence-Based Substance Abuse Treatment Practice in Criminal Justice Settings. New York, NY: Springer.

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