Transcript The Evolution of Substance Use Disorder Treatment for Women

The Evolution of Substance
Use Disorder Treatment for
Women
Joan E. Zweben, Ph.D.
Executive Director, East Bay Community Recovery Project
Clinical Professor of Psychiatry, UCSF
SARC Conferences - June 4 & 6, 2012
OVERVIEW



Contributions of NIDA, CSAT, NIAAA
Distinctive characteristics: some key
findings
Treatment Issues – research findings,
ingredients of gender responsive
treatment
NIDA’s Contribution




1974 – research demos on opioid
addicted pregnant women
Loretta Finnegan, MD – developed first
measure of NAS; promoted
comprehensive care
Karol Kaltenbach, Ph.D. - longitudinal
studies of kids 0-5 yrs
Satellite sessions at CPDD
NIDA: Perinatal 20



Cocaine epidemic required shift in target
population
Launched in 1989 & 1990; lasted until 1995
Goals:



Conduct treatment research
Create many new treatment slots for women and
their children
Design: experimental, quasi-experimental,
correlational
Perinatal 20 Research
Questions




Differential effectiveness of residential vs
oupatient tx
Differential effectiveness of TAU vs TAU +
enhancement
Determine effectiveness using common set of
intake and outcome measures
Improve research methodologies
Rahdert, E.R.(Ed.). (1996). Treatment for drug-exposed women and their children:
advances in research methodology. NIDA Monograph #166; Rockville, Md.
CSAT Discretionary Funding
for Women & Children






1989 to 1995: Anti-Drug Abuse Act 1988--Pregnant Post-Partum
Women and their Infants Demonstration Project (PPWI) results
in 147 grants
1993 to 1995: ADAMHA Reorganization--Comprehensive, longterm (5 year), residential treatment for Pregnant Post-Partum
Women (PPW) and Residential Women with Children (RWC)
Demonstration Programs results in 70 programs.
1994: Developed and disseminated the “Comprehensive
Treatment Model for Alcohol and Other Drug-Abusing Women
and Their Children”
1995: National PPW/RWC Cross-Site Demonstration study
begins
1998- 2003: Women, Co-occurring Disorders and Violence
Study. 2000, Children’s subset study
2006 to 2007: Funding for women in 8 different CSAT grant
programs (30% of budget) including 23 PPW programs
(CSAT – Sharon Amitetti)
Women’s Alcohol Problems



Women’s movement, FAS, and
perception of increased drinking in
women stimulated attention in mid
1970’s
NIAAA working conference – 1978
New federal initiative (1979) gave
special attention to women’s issues
(Wilsnack, S. C., & Beckman, L. J. (Eds.). (1984). Alcohol
Problems in Women. New York: The Guilford Press.)
Distinctive Characteristics &
Findings
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
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)
Psychiatric Disorders


Women have high rates of 3 or more
disorders
Common disorders:




Anxiety disorders (especially PTSD)
Mood disorders
Eating disorders
Borderline personality disorders
Special Issues & Populations






Domestic violence
HIV/AIDS
Lesbian, bisexual, transgendered
Ethnic differences
Military Sexual Trauma (MST)
Criminal justice populations
Treatment Issues
Research Findings
Elements of Gender Responsive
Treatment
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 cooccurring disorders is important
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
Gender Differences III



No strong evidence that gender-specific
treatments are more effective, but there are
few controlled trials.
Gender is not a specific predictor overall, but
specific treatment elements improve
outcomes for various subgroups
Residential programs that include children
have better retention rates
(Greenfield et al 2006)
Key Services to Improve
Outcomes for Women







Child care
Prenatal care
Supplemental services addressing womenfocused topics (e.g., trauma history)
Mental health services; psychotropic meds
Transportation
Women-only groups
Employment services (jobs with decent pay)
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)
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)
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
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)
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)
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
Current Research Issues

Development and testing of effective tx for
subpopulations





Prescription SUDS
Eating disorders & SUDS
Gender and ethnicity
RCTs: gender specific & mixed gender
programs; effective elements (including
costs)
Characteristics of women who can benefit
from mixed vs single gender programs
(Greenfield 2007)
Acknowledgements




Karol Kaltenbach, Ph.D.
Sharon Amitetti, CSAT
SAMHSA/CSAT – supporting Project
Pride (EBCRP)
NIDA/CTN
Slides: www.ebcrp.org