CAPTASA Clinical Applications of the Principles in Treatment

CAPTASA Clinical Applications of the Principles in Treatment of Alcoholism and Substance Abuse The 8 th Annual CAPTASA Conference January 25 - 26, 2008 Embassy Suites Lexington, Kentucky 3/1/2021

Gender Differences in Chemical Dependence 2

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Fact Sheet 4

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Fact Sheet n n n Alcoholism is a problem for both men and women. But it is a disease that affects women physically, emotionally, and psychologically differently than men. Women make up one of the fastest growing substanceabuse populations in the united states. Women with alcohol problems are more at risk of heart disease, cancer, liver disorders, loss of personal relationships, abusive relationships, and suicide. Women alcoholics tend to drink to escape feelings of loneliness, to become more comfortable with their sexuality, and because of depression. 6

Fact Sheet n n Studies have shown that 70 percent or more of addicted women have been traumatized by verbal or physical abuse. Substance abuse in women not only has adverse affects on their own lives and health but also on their children, families, and communities. These ties to the family and community are often what keeps women from entering treatment. Aside from the shame many women alcoholics feel for having a drinking problem, often a family is oblivious to the problems of its matriarch. There's no time for mom, sis, or wife to get sick, fall apart, or go into treatment. 7

Alcohol Use • • 77. 6% of women age 12 and older reported ever using alcohol, while 60% reported past year use and 45. 1% reported using alcohol in the past month. 82. 5% of white women reported ever using alcohol, while 65% reported past year use and 49. 7% reported using alcohol in the past month. 67. 9% of black women reported ever using alcohol, while 45. 1% reported past year use and 32. 3% reported using alcohol in the past month. 60. 8% of Hispanic women reported ever using alcohol, while 48. 4% reported past year use and 33. 6% reported using alcohol in the past month. 8

Alcohol Use n n Men and women reported different levels of alcohol involvement. 58. 7% of men age 12 and older reported past month alcohol use compared to 45. 1% of women, while 23. 2% of men age 12 and older reported binge drinking in the past month compared to 8. 6% of women Among current female drinkers, 7. 16% of whites, 10. 22% of blacks, 22. 16% of American Indians/Alaska native, and 9. 03% of Hispanics reported alcohol dependence 9

The disease is often progressive and fatal. 10

What is a Drink? n n n A standard drink is One 12 -ounce beer One 5 -ounce glass of wine 1. 5 ounces of 80 -proof distilled spirits The alcohol content of different types of beer, wine and distilled spirits can vary widely. 11

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Health • • • Women absorb and metabolize alcohol differently than men. Alcohol consumption is associated with a linear increase in breast cancer incidence in women over the range of consumption reported by most women. A pooled analysis of several studies found breast cancer risk was significantly elevated by 9% for each 10 -grams per day increase in alcohol intake for intakes up to 60 grams per day. 1. 5 liters lite beer, . 75 liters beer, . 4 liters wine or. 1 liter distilled spirits equal 30 grams of alcohol. 13

Health • Although the mean lifetime dose of alcohol in female alcoholics is only 60% of that in male alcoholics, one study noted that cardiomyopathy (a degenerative disease of the heart muscle) and myopathy (a degenerative disease of skeletal muscle) was as common in female alcoholics as in males. The study concluded that women are more susceptible than men to the toxic effects of alcohol on the heart muscle. 14

Health • • Brain shrinkage in men and women was found to be similar despite significantly shorter periods of alcohol exposure or drinking histories in women. Women with chronic pancreatitis have shorter drinking histories than that of men. Women with alcoholic hepatitis and cirrhosis were found to have consumed less alcohol per body weight per day than men. These findings indicate that women are more vulnerable to alcoholic liver disease than men. 15

Health • Although alcohol problems are more common in male trauma patients, women with alcohol problems are just as severely impaired, have at least as many adverse consequences of alcohol use, and have more evidence of alcohol-related physical and psychological harm. 16

Suicide • • • One study showed that 40% of alcoholic women attempted to commit suicide, compared to 8. 8% of non-alcoholic women. Younger women who are alcoholics are nearly twice as likely to attempt to commit suicide (50. 5%) than older women who are alcoholics (25. 5%). A study of suicides among females in New Mexico found that 65. 5% of the decedents had alcohol or drugs present in their blood at the time of autopsy. 17

Use During Pregnancy • • • Since 1990 the Dietary Guidelines for Americans have stated that women who are pregnant or planning to become pregnant should not drink alcohol. A national survey found that 58. 8% of women age 15 -44 drank while pregnant. 65. 8% of pregnant women in their first trimester reported using alcohol, while 56. 6% of women in their second trimester and 53. 9% of women in their third trimester reported alcohol use. 18

Victimization • • 57% of female victims of intimate violence (i. e. , current or former spouses, boyfriends, etc. ) reported that the offender had been drinking at the time of the offense. 62% of female victims of alcohol-related violence reported experiencing some form of injury. 19

Criminal Behavior • • An estimated 4 in 10 women committing violence were perceived by the victim as being under the influence of alcohol and/or drugs at the time of the crime. An estimated 25% of women on probation, 29% of women in local jails, 29% of women in state prisons, and 15% of women in federal prisons had been consuming alcohol at the time of the offense. 20

Drinking and Driving • Women are less likely than men to be involved in fatal alcohol-related crashes. However, from 1977 to 1997 the number of male drivers involved in alcohol-related fatal traffic crashes decreased 31%, while the number of females drivers involved in alcohol-related fatal crashes has increased 12%. 21

Moderate Drinking • • Moderation is defined as no more than one drink per day for women. One drink is 12 ounces of regular beer, 5 ounces of wine, and 1. 5 ounces of 80 -proof distilled spirits. 22

Alcohol and Women 23

Alcohol and Women n n Much of our knowledge of alcoholism has been gathered from studies conducted with a predominance of male subjects. Recent studies involving more female subjects reveal that drinking differs between men and women. 24

Alcohol and Women n n Drinking behavior differs with the age, life role, and marital status of women. In general, a woman's drinking resembles that of her husband, siblings, or close friends. Whereas younger women (aged 18 -34) report higher rates of drinking-related problems than do older women. The incidence of alcohol dependence is greater among middle-aged women (aged 35 -49). 25

Alcohol and Women n n Women who have multiple roles (e. g. , married women who work outside the home) may have lower rates of alcohol problems than women who do not have multiple roles. In fact, role deprivation (e. g. , loss of role as wife, mother, or worker) may increase a woman's risk for abusing alcohol. Women who have never married or who are divorced or separated are more likely to drink heavily and experience alcohol-related problems than women who are married or widowed. Unmarried women living with a partner are more likely still to engage in heavy drinking and to develop drinking problems. 26

Greater Physiological Impairment n n Women become intoxicated after drinking smaller quantities of alcohol than are needed to produce intoxication in men. Three possible mechanisms may explain this response. First, women have lower total body water content than men of comparable size. Second, diminished activity of alcohol dehydrogenase (the primary enzyme involved in the metabolism of alcohol) in the stomach. Third, fluctuations in gonadal hormone levels during the menstrual cycle may affect the rate of alcohol metabolism, making a woman more susceptible to elevated blood alcohol concentrations at different points in the cycle. 27

Heightened Vulnerability n n Chronic alcohol abuse exacts a greater physical toll on women than on men. Female alcoholics have death rates 50 to 100 percent higher than those of male alcoholics. Further, a greater percentage of female alcoholics die from suicides, alcohol-related accidents, circulatory disorders, and cirrhosis of the liver. Increasing evidence suggests that the detrimental effects of alcohol on the liver are more severe for women than for men. Women develop alcoholic liver disease, particularly alcoholic cirrhosis and hepatitis, after a comparatively shorter period of heavy drinking and at a lower level of daily drinking than men. Proportionately more alcoholic women die from cirrhosis than do alcoholic men. 28

Heightened Vulnerability n n The exact mechanisms that underlie women's heightened vulnerability to alcohol-induced liver damage are unclear. Drinking also may be associated with an increased risk for breast cancer. After reviewing epidemiological data on alcohol consumption and the incidence of breast cancer, Longnecker and colleagues reported that risk increases when a woman consumes 1 ounce or more of absolute alcohol daily. Increased risk appears to be related directly to the effects of alcohol 29

Heightened Vulnerability n According to the journal of the American medical Association "alcohol consumption is associated with a linear increase in breast cancer incidence in women over the range of consumption reported by most women. Among women who consume alcohol regularly, reducing alcohol consumption is a potential means to reduce breast cancer risk. " 30

Heightened Vulnerability n n Women tend to develop brain "shrinkage" and damage to their memory capabilities much faster than their male counterparts who drink. The researchers found that while male alcoholics, sober for three weeks, showed signs of brain "shrinkage" compared with healthy men, the difference between alcoholic and healthy women was much greater. 31

Heightened Vulnerability n n Brain damage to females occurs much sooner than with men and shows up even in teen-age drinkers. Remembering information, solving spatial problems like working with maps or puzzles, and doing mental arithmetic were less accurate in heavy-drinking youth. 32

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Alcohol Hormones and Women 34

Alcohol Hormones and Women n n Hormones control four major areas of body function: Production, utilization, and storage of energy; Reproduction; Maintenance of the internal environment (e. g. , blood pressure and bone mass); And growth and development. 35

Alcohol Hormones and Women n n By interfering with hormone actions, alcohol can: Alter blood sugar levels and exacerbate or cause diabetes. Impair reproductive functions. Interfere with calcium metabolism and bone structure, increasing the risk of osteoporosis. Conversely, hormones also may affect alcohol consumption by influencing alcoholseeking behavior. 36

Alcohol Impairs Reproductive Functions n n In women, hormones promote the development of secondary sexual characteristics, such as breast development and distribution of body hair; regulate the menstrual cycle; and are necessary to maintain pregnancy chronic heavy drinking can interfere with all these functions. Its most severe consequences in both men and women include inadequate functioning of the testes and ovaries, resulting in hormonal deficiencies, sexual dysfunction, and infertility. 37

Alcohol Impairs Reproductive Functions n n In premenopausal women, chronic heavy drinking can contribute to a multitude of reproductive disorders. These include cessation of menstruation, irregular menstrual cycles, menstrual cycles without ovulation, early menopause, and increased risk of spontaneous abortions These dysfunctions can be caused by alcohol's interfering directly with the hormonal regulation of the reproductive system or indirectly through other disorders associated with alcohol abuse, such as liver disease, pancreatic disease, malnutrition, or fetal abnormalities 38

Alcohol Impairs Calcium Metabolism and Bone Structure n Calcium exists in two forms in the body. The main reservoirs are the bones and teeth, where the calcium content determines the strength and the stiffness of the bones. The rest of the body's calcium is dissolved in the body fluids. Calcium is important for many body functions, including communication between and within cells. The overall calcium levels depend on how much calcium is in the diet, how much is absorbed into the body, and how much is excreted. Calcium absorption, excretion, and distribution between bones and body fluids are regulated by several hormones, namely parathyroid hormone (PTH); Vitamin d-derived hormones; And calcitonin, which is made by specific cells in the thyroid 39

Alcohol Impairs Calcium Metabolism and Bone Structure n n Acute alcohol consumption can lead to a transient PTH deficiency and increased urinary calcium excretion, resulting in loss of calcium from the body Chronic heavy drinking can disturb vitamin D metabolism, resulting in inadequate absorption of dietary calcium 40

Alcohol Impairs Calcium Metabolism and Bone Structure n n n Alcohol is directly toxic to bone-forming cells and inhibits their activity Chronic heavy drinking can adversely affect bone metabolism indirectly, for example by contributing to nutritional deficiencies of calcium or vitamin D Liver disease and altered levels of reproductive hormones, both of which can be caused by alcohol, also affect bone metabolism 41

Osteoporos is Calcium deficiency can lead to bone diseases, such as osteoporosis. Osteoporosis is characterized by a substantial loss of bone mass and, consequently, increased risk of fractures. It affects 4 million to 6 million mainly older Americans, especially women after menopause. In alcoholics, the risk of osteoporosis is increased. Because many falls are related to alcohol use adverse alcohol effects on bone metabolism pose a serious health problem. 42

Hormones May Influence Alcoholseeking Behavior n n The effects of alcohol on different hormonal pathways may in turn influence alcoholseeking behavior. For example, in animals, alcohol-seeking behavior appears to be regulated in part through a system called the renin-angiotensin system, which controls blood pressure and salt concentrations in the blood. In rats, activation of this system through alcohol consumption caused the animals to reduce their alcohol intake. The mechanism and relevance of this effect are currently under investigation. 43

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Treatment Should It Be Different? 45

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Treatment Issues For Women n Researchers have begun to examine whether women and men require distinct treatment approaches. It has been suggested that women alcoholics may encounter different conditions that facilitate or discourage their entry into treatment. 47

Treatment Issues For Women n Women represent 25. 4 percent of alcoholism clients in traditional treatment centers in the United States. Although it appears that they comprise a small proportion of the treatment population (25 percent women compared with 75 percent men), the proportion of female alcoholics to male alcoholics in treatment is similar to the proportion of all female alcoholics to male alcoholics (30 percent women to 70 percent men). 48

Treatment Issues For Women n In addition, women drinkers pursue avenues other than traditional alcoholism programs, such as psychiatric services or personal physicians, for treatment. Women alcoholics may encounter motivators and barriers to seeking treatment that differ from those encountered by men. Women are more likely to seek treatment because of family problems, and they often are encouraged by parents or children to pursue therapy. Men usually are encouraged to pursue therapy by their wives. 49

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Treatment Issues For Women n Fewer women than men reach treatment through the criminal justice system or through employee assistance programs Lack of child care is one of the most frequently reported barriers to treatment for alcoholic women Studies that have attempted to compare treatment outcome between men and women and reported that, among those who completed treatment, abstinence was slightly higher among women than among men. Women had a higher abstinence rate if treated in a medically oriented alcoholism facility, whereas the abstinence rate was higher for men treated in a peer group-oriented facility 51

Treatment Issues For Women n Studies have been done that show men do much better in group therapy with women. They have a tendency to process their feelings more. Women help that. Men do more data processing in groups with only other men. With women in the group, they open up about feelings. Women, however, do much better in groups of only women because it allows them to focus on themselves and their own healing. The focus is no longer about taking care of the men. In addition, women feel safer discussing their abuse or even their hormonal changes in the presence of only women. 52

Treatment Issues For Women n Treatment outcome was better for women treated in a facility with a smaller proportion of female clients and better for men in a facility with a larger proportion of female clients. This study provided preliminary data on gender-specific treatment outcome; However, the trials were not controlled. Although the question of whether women should have separate treatment opportunities is an important one, the supporting evidence still has not been found. 53

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Greater Risks for Women n n Health problems are not the only risks She wakes up groggy with a tremendous hangover, then makes a startling discovery. She is not in her own room, not in her own bed, and not alone. Oh, no! I'm in bed with a man! How did I get here? I don't remember. Did we have sex? We must have! Did he use protection? Could I be pregnant? Could I have a sexually transmitted disease? How did this happen? Everybody else was drinking and apparently having a good time. She was not drinking any more or less than her companion, and he seemed to be in control. How did she get so out of it? 55

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Suggested Readings n n Alcohol: A Women’s Health Issue – U. S. Department of Health and Human Services NIH, NIAAA NIH Publication No. 03 -4956 http: //alcoholism. about. com/msubwomen. htm

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Summarizing n Like men, women have used alcohol throughout history. But alcohol does not affect men and women in the same ways. Recent research shows that women respond to alcohol in many ways differently than men. For example: 59

n n Women experience greater impairment than men with equivalent doses of alcohol. This includes reduced motor coordination, judgment, emotional control and reasoning. Depending on the point in their menstrual cycles, women may get drunk faster and stay drunk longer than men. This is because estrogen causes alcohol to be more quickly absorbed into the bloodstream, but slows down its metabolism from the body. Similarly, women who use oral contraceptives (birth control pills) experience the aforementioned effects of estrogen on alcohol absorption and metabolism. Alcohol can disrupt or change the menstrual cycle and can therefore affect a woman's fertility (ability to conceive). 60

n n Alcohol increases a woman's risk for breast cancer. Women experience the damaging effects of chronic alcohol use more severely and usually more rapidly than men. Alcohol use during pregnancy puts the unborn child at risk of Fetal Alcohol Syndrome or Fetal Alcohol Effects-a collection of damaging and unalterable consequences that may affect physical, emotional, cognitive and social functioning. Alcohol interferes with several processes of aging. For example, alcohol may create more extreme changes during menopause; alcohol also increases risk of osteoporosis because it interferes with absorption of calcium, resulting in greater loss of bone density. 61

Whether or not a woman drinks abusively or is addicted to alcohol, the impairment alcohol causes in the context of a single drinking episode puts her at risk of rape and other acts of violence. Consider the following: 62

n n More than 60% of STDs and unplanned pregnancy among college students result from sexual encounters while one or both partners are drinking-interfering with adequate sexual decision-making and practices of personal protection. More than 75% of acquaintance rape and 60% of stranger rape involve alcohol- either the perpetrator and/or the woman are drinking. Law enforcement agencies associate the majority of domestic violence, including wife battering and child abuse, to alcohol. Alcohol renders a man less capable of suppressing impulses toward violence; it makes women less able to perceive behavioral cues to potential violence and less able to protect themselves from violence in progress. 63

n n Women who are alcoholic frequently have a different experience than male alcoholics. For example: · Alcoholism in women is generally diagnosed at more advanced stages than it is in men, delaying the onset of treatment. This probably occurs because women are more discreet about their abusive drinking than men and tend to be more isolated in their drinking. Women are more likely than men to experience polyaddiction-they are addicted to more than one substance-which complicates treatment. 64

n n Treatment for women is more often complicated by other psychiatric problems such as eating disorders or mood disorders (e. g. , Depression or anxiety). Because of employment, economic and family factors, women have less access to treatment than men. Moreover, there are few treatment programs available for women only, which complicates treatment for those women with sexual abuse in their history. 65

HRT, Drinking and Breast Cancer One Drink a Day Ups Breast Cancer Risk Female Drinking & Brain Damage Dangers Increase for Women Binge Drinkers Women Get Worse Hangovers Than Men Females Become Addicted Quicker, Easier Women Who Drink Heavily More Like to Experience Mental Illness Young Drug Users at Risk for Sexually Transmitted Infections Heart Risk Greater for Women Drinkers Wives of Alcoholics More Likely to Drink 66

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