Women and Prescription Medication Misuse: Trauma informed and gender-informed responses NANCY POOLE, PHD BC CENTRE OF EXCELLENCE FOR WOMEN S HEALTH

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1 Women and Prescription Medication Misuse: Trauma informed and gender-informed responses NANCY POOLE, PHD BC CENTRE OF EXCELLENCE FOR WOMEN S HEALTH

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3 Blog: fasdprevention.wordpress.com

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5 Agenda Background on girls, women, substance use, addiction and prescription pain medication Improving the response re pain medication ideas arising from a small study Trauma informed approaches Gender informed and gender transformative approaches

6 1. Girls, women, substance use BACKGROUND

7 Key issues defining women s experience of addiction Physical health/reproductive health problems Guilt, stigma and shame Experience of violence and abuse Co-occurrence with mental health problems Women as mothers, women as mothers living in poverty Misinformation, denial and lack of effective support on the part of those in a position to help Source: Poole, N. (1997) Alcohol and Drug Problems and BC Women. Government of BC, Ministry of Health

8 Sex and gender matter to health Sex and gender are among the most influential of the determinants of health But the substance use and addiction fields have taken limited action on sex and gender related factors

9 Detailed listing of sex and gender differences in NIH program announcement for research on WOMEN, GENDER DIFFERENCES AND DRUG ABUSE 2003 Source: NIH Program Announcement, June guide/pa-files/pa html Different biological mechanisms Different origins - risk factors, pathways, contexts of use Different courses, consequences, impacts Different access to and responses to treatment

10 Poverty Disability Experience of Grief and Loss Racial Discrimination Substance Use Problems Mothering policy Resilience Trauma Gender based Violence Mental Ill Health Access to health care Punishment/ Incarceration HIV/AIDS Isolation Colonization Social support, Partnership, Friendship

11 Gender and trauma matter Girls who have been physically or sexual abused are twice as likely to smoke, drink or use drugs as those who were not abused also more likely to use substances earlier, more often and in greater quantities

12 Pain medication use prevalence Painkiller use (18.3% vs.15.5%); and sedative use (12.8% vs. 7.5%) are higher among Canadian women aged 15 and older compared to men (CADUMS) Women are more likely to: use any prescription drugs be prescribed opioids and anxiolytics use opioids concurrently with sedatives

13 Particularly vulnerable population groups of women 1. Women with trauma histories 2. Aboriginal women Urban Aboriginal Women 3. Pregnant women 4. Young women 5. Older women 6. Lesbian, bisexual, 2-spirited and transgender individuals 7. Women who experience pain from pelvic operations 8. Rural and Northern women 9. Women who suffer pain as a result of industrial labour accidents 10. Women who experience disaster-related trauma 11. Refugee women

14 Study of 126 young adults (aged years) entering treatment at CAMH Notably, 90% of females and 62% of males endorsed concerns with traumatic distress* Also, 46% of females and 32 % of males report thinking about suicide in the past year Chaim, G., & Henderson, J. (March 17, 2009). From Data to the Right Services. Paper presented at the Looking Back, Thinking Ahead Conference: Using Research to Improve Policy and Practice in Women's Health, Halifax, NS Barbit.* Benzo.* Codeine Opiods Females Males

15 Factors associated with women s misuse of prescription drugs Sex based factors Longer life span = more chronic pain More sensitive to pain Gender related factors More frequent health care visits Social and cultural constructs of pain responses Gendered violence and trauma Patient and physician behaviours Perceived as safer, lower stigma than illicit drugs Women are prescribed higher does of painkillers

16 Current treatment context Many girls and women experience co-occurring or intersecting issues e.g. violence, trauma, substance use/abuse, mental health concerns But treatment systems often deal with one or two of these issues and are rarely offering programming tailored to vulnerable groups However, growing interest in substance use treatment that is: trauma-informed harm reduction oriented gender informed (and gender transformative?)

17 What is wrong with the status quo with respect to sex, gender and health? Gender is a well-recognized determinant of health, but often not applied in research or practice Many programs and policies take a generic and individualistic approach to changing behaviour Do not often account for structural, gendered factors affecting health and power

18 2. Recent study of girls, women and prescription pain medication Hemsing, N., Greaves, L., & Poole, N. (2016). Misuse of prescription opioid medication among women: a scoping review. Pain Research and Management. doi: /2016/

19 The Study Was funded by CIHR, Canadian Research Initiative in Substance Misuse Researchers: Lorraine Greaves, Nancy Poole, Natalie Hemsing Rose Schmidt Objective: To identify research and practice needs and opportunities related to misuse of prescription medications by girls and women in Canada 2 of the activities: Review of literature (scoping) Environmental scan of the needs and opportunities related to misuse of prescription medications by girls and women, to identify priority program, policy issues and/or research questions.

20 Scoping Literature Review

21 Methods Academic, peer reviewed literature (January 1990 to May 2014) N=42 Grey literature Scanned sites related to pain, substance use, and alterative medicine N=24 Google searches N=43

22 Range of recommendations in the literature 1. Additional training and guidelines for service providers 2. Considerations of opioid use and reproduction among women 3. Improving screening practices 4. Multi-component and integrated interventions 5. Including trauma in the course of pain management and addiction 6. Gender-informed and gender-specific services 7. Culturally-informed and specific services for Indigenous communities 8. Generating and using evidence

23 Environmental Scan

24 Participants 64 people invited to participate 37 completing the environmental scan Response rate= 58.7 Province of respondents: Ontario, n= 18 British Columbia, n=13 Saskatchewan, Alberta, New Brunswick, Nova Scotia, Newfoundland, Manitoba, n=1

25 Gaps & Issues with Current System 1. Need for balanced understanding of pain management and addiction 2. Need for treatment and withdrawal management services 3. Need for increased access to non-prescription pain management supports 4. Need for more adequate pain management intervention 5. Need for services designed to address experiences of trauma 6. Need to address stigma 7. Need for services in First Nations and Inuit communities 8. Barriers related to parenting and child protection

26 Recommendations from Participants 1. Improving access and coordination in the system of care 2. Improving access to treatment and withdrawal management 3. Addressing trauma in the course of pain management and addiction 4. Increasing provider education and resources 5. Improving access to other forms of pain management 6. Offering sex/gender informed supports and gender specific treatment 7. Generating and using evidence 8. Identifying and supporting improved prescribing practices 9. Improving screening and monitoring 10. Improving responses to pregnant women and new mothers 11. Collaboration and partnerships with communities 12. Linking to accessible and supportive housing 13. Preventing chronic pain, trauma and prescription drug misuse

27 Recommendations

28 Because it s 2015 Apply a sex, gender and diversity lens in all our work on substance use issues Prime Minister Justin Trudeau responds to media question about why he saw it important to have a cabinet that is gender balanced.

29 Women centered approaches acknowledge prevalence of women s use of painkillers, sex differences in effects of substances on women s health, and the realities of women s lives, including links with mothering and experience of violence Key principles: respect, equity self determination and empowerment partnership

30 Employ integrated, violence- and trauma- informed approaches recognize co-occurring nature of trauma, chronic pain and prescription drug use integrate Indigenous healing practices with trauma informed care holistic approaches that address physical, spiritual, emotional, social and mental wellbeing Interdisciplinary pain management

31 Act to prevent overuse/misuse address prescribing practices assist providers in minimizing, identifying and managing addiction, and offering alternatives identify patients who are not responsive to pain management measures and improve therapeutic response use gender-informed, trauma informed and culturally sensitive screening approaches to understand pain and its context Improve health promotion, social marketing and product information

32 Improve knowledge translation Engage researchers and various knowledge users in synthesizing, exchanging, and applying information related to the treatment of chronic pain Promote understanding of sex and gendered influences and factors related to chronic pain, violence, trauma and prescription drug use

33 Policy & Practice Considerations 1. Apply a sex and gender analysis. 2. Create integrated systems of response from health promotion to treatment. 3. Provide interdisciplinary pain management 4. Meld the response to concurrent pain management and addiction. 5. Provide non-opioid options for pain management.

34 Trauma informed approaches

35 What do we mean by trauma informed practice (TIP)? Trauma-informed practice refers to integrating an understanding of past and current experiences of violence and trauma into all aspects of service delivery. The goal of trauma-informed services and systems is to avoid retraumatizing individuals and support safety, choice, and control in order to promote health and healing. Not treatment, not a technique, instead a paradigm

36 Trauma Informed Practice as a movement Trauma Informed Practice is a movement - it includes changes in the way we think about how we provide social and health care services TIP is built upon contributions and developments from a number of fields public health, women s health, indigenous wellness, neuroscience

37 TIP is a principle based approach 1. Awareness 2. Emphasis on safety, trustworthiness 3. Choice, collaboration, mutuality, connection 4. Empowerment, Skill building, building on strengths

38 Awareness principle Acknowledge common connections between substance use and trauma Recognize range of responses people can have Recognize that because of trauma responses, developing trusting relationships can be difficult Disclosure of trauma is not required Recognize when someone is triggered or experiencing the effects of trauma & support BC TIP Guide, 2013 Gender Matters, 2013

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40 Impact of trauma awareness for women with HIV Randomized control trial of women living with HIV/AIDS and a history of childhood sexual abuse Living in the Face of Trauma (LIFT) group program that focused on coping skills - fifteen 90-minute sessions delivered to same-gender groups (about 6-8 persons per group) Learning about and recognizing how symptoms of sexual trauma had complicated their relationships, affected their ability to cope with HIV, negatively impacted medical and selfcare, and contributed to sexual risk behavior and substance abuse was a new and empowering experience for many women Living in the Face of Trauma (LIFT) Program is considered a CDC HIV prevention best practice program /research/compendium/rr/lift.html Puffer ES, Kochman A, Hansen NB, Sikkema KJ. (2011). An evidence-based group coping intervention for women living with HIV and history of childhood sexual abuse.int J Group Psychother,61(1): [Open Access]

41 TIP in Women s Substance Use Treatment Women identified the RECLAIM principles as important for treatment providers to understand and apply when supporting Aboriginal women s healing from illicit drug abuse. The R of RECLAIM stands for recognition of the impact of trauma in women s healing" (ranging from the intergenerational effects of colonialism through to the disproportionate rates of inter-personal violence faced by Aboriginal women)

42 Trauma informed, gender responsive work with men Fallot, R., & Bebout, R. (2012). Acknowledging and Embracing "the Boy inside the Man": Trauma-informed Work with Men. In N. Poole & L. Greaves (Eds.), Becoming Trauma Informed (pp ). Toronto, ON: Centre for Addiction and Mental Health Safety and trustworthiness - Empathize with the disconnection dilemma, i.e. the conflict between their identity as men and their experience of powerlessness Skill building - A key trauma recovery skill for men is developing a broader range of options for expressing emotions Collaboration and connection Men who have been sensitized to abuse of power in relationships may need to hear offers of collaboration repeatedly. Strengths based acknowledgement of relational strengths may be water in the desert for male survivors

43 Gender informed and gender transformative approaches

44 A Continuum of Approaches

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46 Gender responsive programs are those that consider the needs of women all aspects of their design and delivery, including location, staffing, programme development, programme content and programme materials pdf/report_ _1.pdf (2004)

47 Guiding principles for gender responsive treatment United Nations Office on Drugs and Crime. (August 2004). Substance abuse treatment and care for women: Case studies and lessons learned. odc.org/pdf/r eport_ _1.pdf Environment create an environment based on safety, respect and dignity Relationships develop policies, practices and programmes that are relational and promote health connections to children, family, significant others and community Services Address the issues of substance abuse, trauma and mental health through comprehensive, integrated, culturally relevant services Economic and social status provide women with opportunities to improve their socio-economic conditions Community - Establish as system of community care with comprehensive collaborative services

48 Gender-transformative approaches actively strive to examine, question, and change rigid gender norms and imbalance of power as a means of reaching health as well as gender equity objectives. Source: Elisabeth Rottach, Sidney Ruth Schuler, and Karen Hardee for the IGWG, Gender Perspectives Improve Reproductive Health Outcomes: New Evidence (Washington, DC: PRB for the IGWG, 2009).

49 Promundo (Brazil) Working with youth to redefine gender norms, end violence, promote sexual health and rights, and support diversity In more than 25 countries, Promundo works with youth to question and transform harmful gender norms, support women s empowerment, and promote respect for sexual health and diversity. We create and test new educational tools for gender equality, health promotion, and violence prevention; use sports as an entry point to reach young people and adults; engage teachers and health workers in the discussion; and support online resources to further our mission around the world.

50 True Child (USA)

51 The Fourth R (Canada) Beyond relational skills to gender critique Coming of age in the digital era A school-based presentation and discussion This presentation examines representations of males and females in media and addresses what these images say about gender stereotypes and normative masculinity and femininity. Topics discussed include mixed media messages, violence in media, the hypersexualization of girls, and how social media is impacting on youth perceptions of what type of person they are supposed to be. youthrelationships.org

52 Girls Action Foundation (Canada) Girls Action Foundation empowerment groups addressing: Girls, alcohol and depression Girls, smoking and stress Addressing integrated issues Aimed at shifting gender norms Rebalancing power imbalances Based on research with girls Girls Action Foundation outcome areas: connectedness, self confidence, resilience, critical thinking, communication

53 We have choices regarding the integration of sex and gender in programs, policies and health messaging Move from fix a girl to prepare a girl (Watkins)

54 Blog: fasdprevention.wordpress.com