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Substance Abuse in Women: Clinical & Program Issues in the Community & Criminal Justice System Joan E. Zweben, Ph.D. Executive Director, EBCRP Clinical.

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Presentation on theme: "Substance Abuse in Women: Clinical & Program Issues in the Community & Criminal Justice System Joan E. Zweben, Ph.D. Executive Director, EBCRP Clinical."— Presentation transcript:

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 (10 th Special Report to Congress: Alcohol & Health)

19 Psychiatric Comorbidity

20 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;

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.

46 Slides Available at: East-Bay-Community-Recovery- Project/145862318792521 Blog:

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