Gender Differences. Roy E. Smith, MD Addiction Medicine

Transcription

1 Gender Differences Roy E. Smith, MD Addiction Medicine

2 Gender Differences Risk Factors Incidence / Prevalence Insert TEDs slide Mariel Course of Illness Recovery

3 SUD Prevalence Men are more likely than women to become addicts. 11.5% of males ages 12 and older had a substance abuse or dependence problem, compared with 6.4% of females. Men outnumber women in treatment centers at a rate of about 4 to 1 Women who tend to drink more heavily are most often those that believe that alcohol reduces tension. U.S. National Survey on Drug Use and Health, 2008

4 Women are more vulnerable to the damaging effects of alcohol Higher risk for: Cirrhosis Hypertension Damage to brain Damage to pancreas Nerve damage Weakened heart muscle

5 Insert TEDs slides TEDs slides

6 Risk Factors- Increase risk For women, prevalence of AUD x higher if parents abuse substances Take on adult responsibilities as child Women with SUD partners more likely to mood disorder and SUD Female adolescents struggling with sexual orientation concerns History of ACE / other traumas

7 Risk Factors Protective Good Marriage - ê AUD if Fam Hx pos Religious and Spiritual Practices Parental Warmth Coping Skills

8 Gender-specific differences in the onset of alcohol dependence Telescoping effect, where a later onset and a more rapid development of dependence in women were described. Under the assumption of a gradual development of consequential organ damage, brain atrophy seems to develop faster in women. As shown in other organs (i.e., heart, muscle, liver), this may confirm a higher vulnerability to alcohol among women.

9 Course of Addiction in Women Women begin using drugs at lower doses then men Drug use escalates more rapidly into addiction Greater risk of relapse after abstinence Laboratory animals show the same kind of gender differences in addiction. Women tend to enter treatment sooner after becoming addicted Usually have more psychological distress, particularly with mood and anxiety disorders.

10 Co-occurring Disorders % will have a co-occurring mental health disorder Higher risk for relapse Higher risk for suicide Less compliant Worse outcomes PTSD, Eating disorders, depression, anxiety

11 Assessment Bio- Psycho- Social- Cultural- Spiritual-

12 Screening vs Assessment Screening- Self Administered tools more likely honest Face to Face screening not always successful in women- esp if counselor is uncomfortable.. Tools not as sensitive in women for SUD Were the tools developed for men/ women? Screening tool that highlights Consequenceswomen experience greater consequences earlier than men.

13 Trauma Informed Screening Initial questions general and gradual Prepare patient, explain screening- Pace the disclosure- she has more control She can chose not to disclose or delay Some seek relief and disclose too much too soon without.. Establishing Trust Adequate support Coping Strategies

14 Domains for Assessment - Women Substance Abuse Pregnancy considerations Immediate Risks from Intox/ Withdrawal Immediate Risks self harm/ violence. Past and Present MH, PTSD, Anxiety D/O Past / Present Hx violence, trauma Health Needs Pregnancy, HIV, hepatitis, Tb, STDs

15 Physical Effects Women Insert slides

16 Women are more vulnerable to the damaging effects of alcohol Higher risk for: Cirrhosis Hypertension Damage to brain Damage to pancreas Nerve damage Weakened heart muscle

17 Cardiovascular According to current studies, women who drink exhibit a greater propensity to develop alcohol-induced cardiac damage. While light consumption (less than one drink per day) can serve as a protective factor for women who have a risk for coronary artery disease, studies suggest that protection is not evident for younger women, women who drink heavily, and women without risk factors associated with heart disease. Women who are dependent on alcohol or consume heavier amounts are more likely to die prematurely from cardiacrelated conditions (Bradley et al. 1998a; Fernandez-Sola and Nicolas-Arfelis 2002; Hanna et al. 1992).

18 Breast Cancer Many studies report that moderate to heavy alcohol consumption increases the risk for breast cancer although one recent study found no increased breast cancer risk associated with consumption of up to one drink per day, the maximum drinking level reported by most women

19 Breast Cancer postmenopausal women who are moderate alcohol drinkers (one to two drinks a day) and who are using menopausal hormone therapy have an increased risk of breast cancer, with even greater risk at higher rates of alcohol consumption (alcohol - estrogen connection) Dorgan et al. 2001; Onland- Moret et al. 2005).

20 Motor Vehicle Accidents Women are less likely than men to drive after drinking Less likely to be involved in fatal alcoholrelated crashes Women have a higher relative risk of driver fatality than men at similar blood alcohol concentrations Appears to be gender differences in how alcohol affects the performance of driving tasks

21 Drinking can make women less fertile Alcohol causes imbalances in the hormonal system that controls reproduction. Even small amounts of alcohol can affect a woman s menstrual cycle and reduce the chance of conceiving. Long-term heavy drinking can cause women to have irregular periods or stop ovulating. Periods can stop altogether or they can have an early menopause. Heavy drinkers who do become pregnant are more likely to have a miscarriage

22 Heavy drinking now can affect fertility later Many of alcohol s effects on reproduction are temporary, and the reproductive system will return to normal when you stop drinking. But continuing to regularly drink over the government s lower risk guidelines can lead to serious infertility problems for both men and women. This includes heavy drinking in your late teens and early twenties.

23 Fetal Alcohol Spectrum Disorders (FASD), Fetal Alcohol Spectrum Disorders (FASD), An umbrella term for life-long alcoholrelated conditions caused by alcohol exposure before birth. Miscarriage, stillbirth, premature birth and small birth weight are other conditions associated with a mother s binge drinking consuming more than six units on one occasion. Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (DSM-5)

24 Experts estimate that in Western countries, one child in 100 is born with FASD as a result of their mother s heavy drinking while pregnant.

25 Gynecological Amenorrhea Infertility Lower birth weights Premature labor Fetal Alcohol Syndrome ( 1/3 of females drinking more than 6 drinks/day)

26 British Journal of Obstetrics and Gynecology (Kesmodal, et al.) Study followed 1,628 women and their offspring from pregnancy to the time the children were five. They were then categorized as: Abstainers during pregnancy; Light drinkers (one to four drinks a week); Moderate drinkers (five to eight); Heavy drinkers (nine or more). For the purposes of the study, one drink contained 1.5 British units of alcohol - roughly that in a small (125ml) glass of medium-strength white wine.

27 They found that having up to eight small drinks a week had no effect on the fiveyear-olds IQ, attention span, self-control and ability to organize themselves. Only children of women who consumed nine or more such drinks a week were affected, demonstrating lower attention spans.

28 TWEAK TOLERANCE for alcohol WORRY or concern by family or friends about drinking behavior; EYE OPENER, the need to have a drink in the morning; AMNESIA or blackouts while drinking; CUT DOWN the self-perception of the need to cut down on alcohol use A total score of 2 or more on the TWEAK is suggestive of harmful drinking patterns among obstetric patients

29 NIAAA Risk Categories Standard drink 12 g of ETOH(12 oz beer, 5 oz wine, 1.5 oz 80 proof distilled spirit) Moderate low risk: Women: 1 drink/day Men: 2 drinks < age 65, 1 drink > age 65 Heavy at risk: Women >7 drinks/week or 3 per episode Men > 14 drinks/week or 4 per occasion Binge Women > 4, men > 5 in a row

30 If a 140 lb female and a 190 lb male drink exactly the same amount of alcohol over the same amount of time, who will be more intoxicated? Why?

31 Capacity to Dilute Alcohol Different Fluid Volume A woman s body is composed of approximately 45% to 50% water, while a man s body is about 55% to 65% water. The lower fluid volume in women results in higher concentrations of alcohol in the bloodstream compared to men.

32 Body Fat Body fat: The content of body fat is directly related to the rate of absorption and metabolizing of alcohol. Women have a higher concentration of body fat than men. Since fat does not absorb alcohol, the entire alcohol content remains in a highly concentrated form in the bloodstream. Consequently, women experience alcoholinduced intoxication faster than men.

33 Capacity to Metabolize Alcohol Women have lower levels of two enzymes alcohol dehydrogenase and aldehyde dehydrogenase that break alcohol down in the stomach and liver. As a result, women absorb more alcohol into the bloodstream. May increase blood alcohol by 7% compared to male of equal weight One researcher concluded that women s lack of a functional gastric protective barrier means that for an alcoholic woman to drink alcohol is the same as taking the alcohol directly into a vein, contributing to her greater vulnerability to alcohol-related organ damage (Lieber 2000, p. 417).

34 Different Hormone Levels Alcohol interacts with hormone levels. Fluctuations of hormone levels during menstrual cycle result in an elevated intoxication level and prolonged intoxication during the luteal phase. During the week before her period starts a woman will be more intoxicated and stay intoxicated longer. This is also true of women taking oral contraceptives. Oral contraceptives mimic the luteal phase by slowing down the rate at which alcohol is eliminated from the body and therefore tend to make women more sensitive to the effects of alcohol. A woman taking oral contraceptives can expect to feel the sedating effects faster and for a longer length of time than a woman who is not.

35 Treatment Engagement Barriers Individual Relational Structural ( our Programs) SocioCultural Systemic ( Policies, Laws, Large Systems) Retention Planning

36 Treatment Engagement Three Core Strategies Provide Outreach Services Crisis- HIV- Pregnancy- Conduct Pretreatment Intervention Groups Early ID and intervention Personalized Feedback Info about available Services Offer Comprehensive Case Management Women assigned Intensive Case Management Better Initiation; Engagement; Retention

37 Treatment Individual vs Family System Relational System Trauma Informed Care Styles of Engagement Culture in Addiction/ Recovery

38 Treatment Differences Examples Nicotine

39 Sex Differences in Addiction Sex differences are present for all of the phases of drug abuse (initiation, escalation of use, addiction, and relapse following abstinence). While there are some differences among specific classes of abused drugs, the general pattern of sex differences is the same for all drugs of abuse. Females begin regularly self-administering licit and illicit drugs of abuse at lower doses than do males Escalates more rapidly to addiction (telescoping) Greater risk for relapse following abstinence.

40 Nicotine Female smokers may be more likely to develop lung cancer and are twice as likely to have a heart attack. Women find it more difficult than men to quit smoking Women more likely to start smoking again even if they do quit.

41 Nicotine Women report shorter intervals between cigarettes Women tend to have a more difficult time quitting depending on the phase of menstrual cycle Greater craving and dysphoria during the late luteal phase (when estrogen and progesterone are declining)

42 Women and men are equally likely to become addicted to nicotine women typically smoke cigarettes with lower nicotine content than those smoked by men, smoke fewer cigarettes per day, and inhale less deeply than men. Women are less successful than men in quitting smoking and have higher relapse rates after they do quit. Treatment involving nicotine replacement therapynicotine gum or patch-works better for men than for women.

43 Nicotine Replacement Therapy A meta-analysis of 14 placebo-controlled studies concluded that although both women and men were more likely to quit smoking while using a nicotine patch, women were less likely than men to do so. About 20% of men quit for six months using the patch, compared with nearly 15% of women; with a placebo patch, roughly 10% of both sexes quit.

44 Nicotine Cessation Buproprion (Wellbutrin/Zyban) - antidepressant that helps reduce the desire to smoke Varenicline (Chantix)-interacts with nicotine receptors in the brain to reduce craving while also blocking the pleasurable effects of nicotine The limited research available suggests that these medications might be equally effective for both sexes, at least in the short term.

45 Weight Gain About half of female smokers say they are afraid they will gain weight if they stop smoking. Although the usual advice is to exercise or count calories while kicking the habit, this may be impractical and only ensure that the effort to stop smoking will fail. A preliminary study suggests that it may be more productive to help women learn to accept any weight gain as a reasonable trade-off for the improved health that comes from smoking cessation.

46 Nicotine Cessation Kicking the habit is especially tough for women during the menstrual cycle s luteal phase (which begins mid-cycle, just after ovulation). Preliminary research suggests that women who time their quit date to occur during the follicular phase (which begins after menstruation and ends at ovulation) are more likely to abstain from cigarettes for a longer period than women who quit during the luteal phase

47 Men s Specifics Book Game Plan Allen Lyme Being a Man The Culture of Men Helping Men/ Healing Men Resources for Healing

48 Being a Man Environment of Risk Growing up Male Substances of Use Emotions

49 The Culture of Men Relationships Family of Origin Sexuality Male Spiritual Journey Work Money Children

50 Helping Men/ Healing Men Gender Specific Treatment Overcoming Barriers for Men Counseling Men? Expound more on these??

51 Sources of Information TEDS report SAMHSA/ CSAT TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women NIDA Book Game Plan Alan Lyme