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Competency III: Women and Addiction © NORTHEAST REGIONAL FAS EDUCATION AND TRAINING CENTER. 2006.

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Presentation on theme: "Competency III: Women and Addiction © NORTHEAST REGIONAL FAS EDUCATION AND TRAINING CENTER. 2006."— Presentation transcript:

1 Competency III: Women and Addiction © NORTHEAST REGIONAL FAS EDUCATION AND TRAINING CENTER. 2006

2 “ If you have to drink to be social, you are not a social drinker” -Anon

3 Commonly Abused Substances AlcoholTobaccoHeroinMethadoneCocaineMarijuana Prescription Drugs Inhalants

4 Profile of a Woman Most Likely to Drink During Pregnancy Unmarried Unmarried Student or unemployed Student or unemployed Annual income 50,000 Annual income 50,000 College graduated College graduated Smoker Smoker Not receiving prenatal care Not receiving prenatal care In a relationship with a man who is abusive or a substance user himself In a relationship with a man who is abusive or a substance user himself Having a history of physical/sexual abuse Having a history of physical/sexual abuse Previous child with FASD and no intervention Previous child with FASD and no intervention

5 Risk Factors for Substance Use in Women Social History Positive family history of addiction Positive family history of addiction Living with significant other that abuses alcohol or drugs Living with significant other that abuses alcohol or drugs Positive legal history Positive legal history History of domestic violence History of domestic violence History or current physical / sexual abuse History or current physical / sexual abuse

6 Risk Factors (cont) Risk Factors (cont)   Medical History Previous mental health diagnosis Previous mental health diagnosis Previous problem pregnancies Previous problem pregnancies Infections-Hepatitis, HIV, STD’s Infections-Hepatitis, HIV, STD’s Injuries Injuries Gastritis, duodenitis, chemical hepatitis Gastritis, duodenitis, chemical hepatitis Hematologic abnormalities Hematologic abnormalities

7 Pattern of Substance Use in Women Women are more likely to abuse prescription drugs and sedative hypnotics Shorter course of disease-telescoping More likely to use alone or in private Age of first use about the same as for males Certain genetic profiles associated with altered risk

8 Models of Alcohol Addiction Historical models- alcohol-related problems can be defined in many way How we conceptualize a problem influences how we will treat it Models are not mutually exclusive and are still used by some professionals today The current model is a biological one, taking into account predispositions for alcohol use and genetic factors

9 Models (cont) Impaired Model - person is impaired, it is in their nature to drink, they will never change, recovery is temporary only Moral Model - one of the original approaches. Alcoholics are seen as choosing to drink or abstain. They are lacking the moral strength to resist temptation. Sinfulness and punishment are key factors. Management is teaching them to behave properly

10 Models (cont) Psychoanalytical/Characterological Model - Alcoholism is viewed as a symptom of an underlying, hidden psychological disorder, an addictive personality that must be re-structured. Self-awareness is a requirement for this model Conditioning Model - Drinking is a learned habit because it is reinforced. Treatment relies on classical condition- usually aversive therapies in which drinking is punished and abstaining is rewarded

11 Models (cont) Disease/ medical/biological model - Alcoholism is seen as the result of genetic and physiologic processes. Hereditary risk factors and unique biological conditions predispose to alcoholism. Alcoholism now is seen as a chronic disease with progression and warning signs at each stage. It is permanent, treatable, and may relapse and require intermittent treatment (like many other chronic diseases)

12 Extent of Alcohol Use in Pregnancy  20% of pregnant women drink alcohol  3.2% drink 2 or more per day or 5 or more per occasion  52% report alcohol use the month prior to pregnancy  Large majority drank occasionally, but 15% moderate to heavy use  13% report binge drinking

13 Alcohol Comparison-The Standard Drink Alcohol Comparison-The Standard Drink For the unborn child it is the alcohol in the drink that harms.

14 Categories of Alcohol use in Women Abstainers - fewer than 12 drinks per year. Recommended category for pregnant and pre- conceptional women. There is no alcohol use when driving, pregnant, breastfeeding or on certain medications. Low Risk Drinkers - no more than 1 standard drink per day. Alcohol use does not affect health or result in negative consequences.

15 Categories of Alcohol Use  At-Risk Drinking - Defined as drinking at a level that causes or elevates the risk for alcohol related problems or complicates other health problem: Drinking while driving or operating other machinery, pregnant, taking medications Drinking while driving or operating other machinery, pregnant, taking medications For women, this includes 3 or more standard drinks in a day (binge drinking) or 8 or more standard drinks in a week (frequent drinking) For women, this includes 3 or more standard drinks in a day (binge drinking) or 8 or more standard drinks in a week (frequent drinking)

16 Categories of Alcohol Use Heavy Drinking - 2 or more drinks daily Problem Drinking - Defined as more than 21 standard drinks per week. Women may experience negative consequences from drinking with less- behavioral, family, medical, mental health, employment, social, legal.

17 Categories of Alcohol Use: Alcohol Abuse DSM-IV-TR Criteria: Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested within a 12 month period by at least one of the following: Failure to fulfill role obligations at work, school or home Recurrent use in hazardous situations Legal problems related to alcohol Continued use despite alcohol related social or interpersonal problems

18 Categories of Alcohol Use: Alcohol Dependence DSM-IV-TR Criteria: Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested within a twelve month period by at least 3 of the following: Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested within a twelve month period by at least 3 of the following: 1)Tolerance 2)Withdrawal 3)Loss of control over amount of alcohol consumed

19 Categories of Alcohol Use: Alcohol Dependence DSM-IV-TR Criteria (cont) 4) Preoccupation with controlling drinking 5) Preoccupation with drinking activities 6) Impairment of social, occupational, or recreational activities activities 7) Use is continued despite persistent problems related to drinking to drinking DSM-IV-TR=Diagnostic and Statistical Manual of Mental Disorders, 4 th edition,1994

20 Behavioral Indicators of Alcohol/Drug Dependence in a Pregnant Woman  Vague medical history  Missed appointments  Car accidents  Intense daily drama  Family chaos  Depression

21 Medical Indicators of Alcohol/Drug Dependence in the Pregnant Woman Weight Fluctuation EclampsiaIUGR Abruptio Placentae Spontaneous Abortion Breech presentation Preterm labor

22 Possible Nutritional Effects of Alcohol Consumption Decreased dietary intake Impaired metabolism and absorption of nutrients- folate, B6, B1, B3, A Altered nutrient activation and utilization- K, Mg, Ca, Zn, PO4, Glucose Any pregnant woman using alcohol must be assessed for nutritional risk

23 OB/GYN Effects Hormonal changes with irregular menses Fertility problems Changes in preconceptional oocytes Breast cancer Pregnancy birth defects, spontaneous abortions, growth defects, FASDs including FAS

24 Progression of Addiction Convergence of genetics, environmental factors and first time drug use Convergence of genetics, environmental factors and first time drug use Aversive/neutral reaction or first “high” Aversive/neutral reaction or first “high” Continued use Continued use Brain pathway alterations Brain pathway alterations Tolerance/Withdrawal Tolerance/Withdrawal Need for drug becomes primary Need for drug becomes primary Multiple adverse consequences Multiple adverse consequences Drug using person “hits bottom”—continued use or enter stages of change, usually with help Drug using person “hits bottom”—continued use or enter stages of change, usually with help

25 Alcoholism: A Medical Diagnosis Family History Tolerance Physical Dependence Major Organ Damage Secondary Symptoms-craving and loss of control

26 Stages and Progression of Alcohol Use Tolerance-physical adaptation to the intoxicating effects of alcohol. Increasing amounts of alcohol required to achieve desired effect. (Metabolic tolerance-body metabolizes more efficiently) Tolerance-physical adaptation to the intoxicating effects of alcohol. Increasing amounts of alcohol required to achieve desired effect. (Metabolic tolerance-body metabolizes more efficiently) enables user to hide extent of use enables user to hide extent of use user may have hangovers, disrupted sleep and mood, family problems, decreased immune resistance at this stage user may have hangovers, disrupted sleep and mood, family problems, decreased immune resistance at this stage

27 Stages and Progression of Alcohol Use Physical Dependency-Withdrawal symptoms occur when alcohol use is stopped-nausea, tremor, sweating, anxiety. User may drink to avoid or alleviate symptoms Physical Dependency-Withdrawal symptoms occur when alcohol use is stopped-nausea, tremor, sweating, anxiety. User may drink to avoid or alleviate symptoms Pharmacodynamic tolerance-drug is part of the body’s steady state so body responds to absence, not just presence of drug Pharmacodynamic tolerance-drug is part of the body’s steady state so body responds to absence, not just presence of drug Tolerance may increase, may see AM use, sleeplessness, MH diagnoses, craving, school/work problems, legal consequences, medical problems Tolerance may increase, may see AM use, sleeplessness, MH diagnoses, craving, school/work problems, legal consequences, medical problems

28 Stages and Progression of Alcohol Use  Major Organ Changes-measurable damage to body systems and function. There is maintenance use with reduced tolerance and increasing physical, work, school, legal consequences withdrawal symptoms are more severe, including DT’s withdrawal symptoms are more severe, including DT’s major organ damage and suicide ideation or attempts major organ damage and suicide ideation or attempts

29 Risk Factors for Addiction Suspected risk factors: consider gender, age, race/ethnicity, family history, employment status/ occupation, marital status, educational level, mental illness, availability of substances Individuals who begin drinking before age 15 are four times more likely to develop alcohol dependence during their lifetimes than those who begin drinking at age 21. (Grant and Dawson, 1997)

30 Addiction: A Brain Disease Neurological Adaptation Neurological Adaptation Mesolimbic DA System Mesolimbic DA System The VTA-nucleus accumbens pathway is activated by all drugs of dependence, including alcohol The VTA-nucleus accumbens pathway is activated by all drugs of dependence, including alcohol It is also involved in essential physiological behaviors such as eating, drinking, sleeping and sex It is also involved in essential physiological behaviors such as eating, drinking, sleeping and sex “cues” associated with alcohol can activate reward and withdrawal circuits (Messing RO 2001) “cues” associated with alcohol can activate reward and withdrawal circuits (Messing RO 2001)

31 Medical History: Injuries Due To - Fights and Homicide attempts - Auto accidents - Drowning, Falls and other accidents - Suicide attempts Patient neglects injuries until next day

32 Medical History: Infections Heavy Drinkers are more susceptible to pneumonias, especially pneumococcal and gram negative Heavy Drinkers are more susceptible to pneumonias, especially pneumococcal and gram negative Alcohol abuse and dependence may lead to neglect or poor care of wounds Alcohol abuse and dependence may lead to neglect or poor care of wounds Heavy Drinkers may have impaired immunity Heavy Drinkers may have impaired immunity - Increased sequestration of neutrophils - Decreased fixed macrophage phagocytosis - Decreased white blood cell production - Impaired cell mediated immunity

33 Medical History (cont)  Gastritis and Duodenitis Most common symptoms are epigastric pain, morning nausea/ vomiting, melena, coffee ground emesis Most common symptoms are epigastric pain, morning nausea/ vomiting, melena, coffee ground emesis  Hematologic Effects Macrocytosis Macrocytosis Thrombocytopenia Thrombocytopenia Anemia, due to GI bleeding or folic acid deficiency Anemia, due to GI bleeding or folic acid deficiency

34 Medical History (cont)  Early Hepatic Markers Gamma-glutamyl transferase may be up to three times normal Gamma-glutamyl transferase may be up to three times normal Other LFT’s and bilirubin may be abnormal later on Other LFT’s and bilirubin may be abnormal later on  Palpable, nontender fatty liver  Early damage is reversible

35 Effects of Chronic Heavy Drinking HepaticCardiacPancreatic Nervous System Mental Health CancersOb/Gyn

36 Hepatic Effects  Alcoholic Hepatitis-cytokines, free radical formation, acetaldehyde adducts - Increased liver function tests and bilirubin - Enlarged, tender liver - 80% can progress to cirrhosis - 20% result in liver failure  Cirrhosis -40% have 5 year survival with continued use  Liver Cancer

37 Cardiac Effects Increased Blood Pressure- chronic or only during periods of withdrawal Increased Blood Pressure- chronic or only during periods of withdrawal Increased ischemic heart disease Increased ischemic heart disease Cardiomyopathy- direct toxic or nutritional effects Cardiomyopathy- direct toxic or nutritional effects Arrhythmias, especially atrial Arrhythmias, especially atrial Heart failure as a result of above Heart failure as a result of above

38 Pancreatic Effects  Acute pancreatitis- autodigestion and oxidant stress abdominal pain, US, serum amylase 3x nl abdominal pain, US, serum amylase 3x nl  Chronic pancreatitis Diabetes Diabetes Steatorrhea Steatorrhea Pseudocyst Pseudocyst  Major cause of morbidity among alcoholics

39 Nervous System Effects Headaches and sleep disorders Wernicke syndrome Peripheral neuropathy Neuropsychological Disorders-damage to limbic system, diencephalon and frontal cerebral cortex deficits in short-term memory deficits in short-term memory disruption of cognitive and motor function disruption of cognitive and motor function reduced perceptual ability reduced perceptual ability emotional and personality changes emotional and personality changes

40 Cancers Increased incidence of some cancers, especially with concomitant use of alcohol and tobacco Esophageal Esophageal Laryngeal Laryngeal Nasopharyngeal Nasopharyngeal

41 Mental Health Considerations Psychiatric symptoms may be associated with substance use and withdrawal Substance induced mood disorders Withdrawal Syndromes Overlapping symptoms, enmeshed course 86% of female alcoholics have a coexisting lifetime history of a psychiatric disorder in one study ( Kessler RC et al 1997)

42 Co-occurring Addictive and Psychiatric Disorders Wide variation in estimates, but all affective disorders relatively common in substance users Bipolar disorder is the affective disorder most commonly associated with substance use disorder Depression and dysthymia are most commonly seen in alcoholic and opiate-dependent populations Bipolar spectrum disorders are relatively more common in the cocaine dependent population (Brady, Princ Add Med 2003)

43 Treatment Overview  Psychosocial treatments help many alcoholics reduce or stop drinking Cognitive-Behavioral Therapy Cognitive-Behavioral Therapy Motivational Enhancement Therapy Motivational Enhancement Therapy Twelve Step Facilitation Twelve Step Facilitation Project Match  ASAM PPC-R  40-70% may relapse and require additional medical treatment within a year. This is comparable to other chronic diseases (DM, Htn, Asthma) McLellan AT et al., 2001

44 Barriers to Treatment  Access  Cultural  Legal- welfare and criminalization  Social-domestic abuse/violence; stigma; child care for existing children  Financial-insurance, job loss

45 Women’s Issues in Treatment Sexuality Sexuality Biological Differences Biological Differences Menstruation Menstruation Abuse Abuse Substance use during pregnancy and parenting Substance use during pregnancy and parenting Secrets Secrets Desires, dreams, fantasies Desires, dreams, fantasies FASD in self or child FASD in self or child

46 Women’s Issues in Treatment Secrets Secrets guilt, shame, trauma guilt, shame, trauma Parenting Parenting child abuse/neglect, feelings of inadequacy, legal/foster care child abuse/neglect, feelings of inadequacy, legal/foster care Sexuality Sexuality promiscuity, prostitution, rape, fear of sex, incest and/or sexual abuse, loss of orgasm, painful sex, sexual orientation, value conflicts, sexuality as a relapse trigger promiscuity, prostitution, rape, fear of sex, incest and/or sexual abuse, loss of orgasm, painful sex, sexual orientation, value conflicts, sexuality as a relapse trigger

47 Neuropharmacological Strategies for Alcoholism Treatment Medications that reduce craving Meds that reduce the symptoms of acute and protracted withdrawal Meds that reduce impulsivity/attention deficits Meds that reduce bioavailability Meds that treat comorbid psychiatric illness or reduce psychological distress.

48 Medications Currently Approved for Alcohol Dependence DisulfuramNaltrexoneAcamprosate

49 Complementary and Alternative Therapies Accupuncture and electroaccupuncture BiofeedbackHypnosis Transcendental Meditation Relaxation Training Nutrition/ vitamins/ herbal Adjunctive- light, yoga/ tai-chi, EMDR, aromatherapy Culturally specific practices-Native American Spirituality

50 ASAM Patient Placement Criteria  Withdrawal potential  Medical conditions  Psychological conditions  Treatment Acceptance  Relapse potential  Recovery environment  Treatment Options-outpatient, residential, detoxification, opioid maintenance

51 Management: Person Centered Care Education Mental Health Health Care Child Welfare and Family Support Services Criminal and Juvenile Justice Chemical Dependency Developmental Disabilities

52 Women and Treatment Women receive the most benefit from treatment programs that provide comprehensive services: food, clothing, shelter, transportation food, clothing, shelter, transportation employment/vocational counselling employment/vocational counselling literacy training/educational opportunities literacy training/educational opportunities legal assistance legal assistance child care, parenting and social services child care, parenting and social services nutritional guidance nutritional guidance mental health services and followup mental health services and followup

53 STAGING THE DISORDER- Adolescents Stage 1. Experimental Use Stage 1. Experimental Use Stage 2. Recreational Use Stage 2. Recreational Use Stage 3. Problematic Use Stage 3. Problematic Use Stage 4. Addiction and Dependency Stage 4. Addiction and Dependency (Comerci and Macdonald 1990) (Comerci and Macdonald 1990)

54 Epidemiology for FASD FASD occurs in all races and socioeconomic levels Higher rates of FASD are reported among certain ethnic groups Among alcohol abusing women, 10% will deliver a child with FAS 30%-40% will deliver a child with FASD

55 Identifying Individuals with FASD Multiple, “failed” treatments Birth experience, birth weight? Infant/childhood health/nutrition issues? Mom’s use of alcohol? Alcoholic? Foster care? Adopted? Homelessness? Developmental/learning issues? Special ed? Best/worst subject in school? Ever diagnosed with ADD or MH disorder?


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