Competency III: Women and Addiction “If you have to drink to be social, you are not a social drinker” -Anon Commonly Abused Substances * Alcohol * Tobacco * Heroin * Methadone * Cocaine * Marijuana * Prescription Drugs * Inhalants Profile of a Woman Most Likely to Drink During Pregnancy * Unmarried * Student or unemployed * Annual income<10,000 or >50,000 * College graduated * Smoker * Not receiving prenatal care * In a relationship with a man who is abusive or a substance user himself * Having a history of physical/sexual abuse * Previous child with FASD and no intervention Risk Factors for Substance Use in Women > Social History * Positive family history of addiction * Living with significant other that abuses alcohol or drugs * Positive legal history * History of domestic violence * History or current physical / sexual abuse Risk Factors (cont) > Medical History * Previous mental health diagnosis * Previous problem pregnancies * Infections-Hepatitis, HIV, STD’s * Injuries * Gastritis, duodenitis, chemical hepatitis * Hematologic abnormalities 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 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 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 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 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) 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 Alcohol Comparison-The Standard Drink 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. 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 * 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) 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. 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 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: • Tolerance • Withdrawal • Loss of control over amount of alcohol consumed 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 7) Use is continued despite persistent problems related to drinking DSM-IV-TR=Diagnostic and Statistical Manual of Mental Disorders, 4th edition,1994 Behavioral Indicators of Alcohol/Drug Dependence in a Pregnant Woman * Vague medical history * Missed appointments * Car accidents * Intense daily drama * Family chaos * Depression Medical Indicators of Alcohol/Drug Dependence in the Pregnant Woman > Weight Fluctuation > Eclampsia > IUGR > Abruptio Placentae > Spontaneous Abortion Breech presentation > Preterm labor 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 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 Progression of Addiction * Convergence of genetics, environmental factors and first time drug use * Aversive/neutral reaction or first “high” * Continued use * Brain pathway alterations * Tolerance/Withdrawal * Need for drug becomes primary * Multiple adverse consequences * Drug using person “hits bottom”—continued use or enter stages of change, usually with help Alcoholism: A Medical Diagnosis > Family History > Tolerance > Physical Dependence > Major Organ Damage > Secondary Symptoms-craving and loss of control 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) * enables user to hide extent of use * user may have hangovers, disrupted sleep and mood, family problems, decreased immune resistance at this stage 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 * 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 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 * major organ damage and suicide ideation or attempts 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) Addiction: A Brain Disease * Neurological Adaptation * Mesolimbic DA System * 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 * “cues” associated with alcohol can activate reward and withdrawal circuits (Messing RO 2001) Medical History: Injuries > Due To - Fights and Homicide attempts - Auto accidents - Drowning, Falls and other accidents - Suicide attempts > Patient neglects injuries until next day Medical History: Infections * 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 * Heavy Drinkers may have impaired immunity - Increased sequestration of neutrophils - Decreased fixed macrophage phagocytosis - Decreased white blood cell production - Impaired cell mediated immunity Medical History (cont) * Gastritis and Duodenitis * Most common symptoms are epigastric pain, morning nausea/ vomiting, melena, coffee ground emesis * Hematologic Effects * Macrocytosis * Thrombocytopenia * Anemia, due to GI bleeding or folic acid deficiency Medical History (cont) > Early Hepatic Markers * Gamma-glutamyl transferase may be up to three times normal * Other LFT’s and bilirubin may be abnormal later on > Palpable, nontender fatty liver > Early damage is reversible Effects of Chronic Heavy Drinking * Hepatic * Cardiac * Pancreatic * Nervous System * Mental Health * Cancers * Ob/Gyn 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 Cardiac Effects * Increased Blood Pressure- chronic or only during periods of withdrawal * Increased ischemic heart disease * Cardiomyopathy- direct toxic or nutritional effects * Arrhythmias, especially atrial * Heart failure as a result of above Pancreatic Effects > Acute pancreatitis- autodigestion and oxidant stress * abdominal pain, US, serum amylase 3x nl > Chronic pancreatitis * Diabetes * Steatorrhea * Pseudocyst > Major cause of morbidity among alcoholics 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 * disruption of cognitive and motor function * reduced perceptual ability * emotional and personality changes Cancers > Increased incidence of some cancers, especially with concomitant use of alcohol and tobacco * Esophageal * Laryngeal * Nasopharyngeal 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) 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) Treatment Overview > Psychosocial treatments help many alcoholics reduce or stop drinking * Cognitive-Behavioral Therapy * Motivational Enhancement Therapy * 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 Barriers to Treatment * Access * Cultural * Legal- welfare and criminalization * Social-domestic abuse/violence; stigma; child care for existing children * Financial-insurance, job loss Women’s Issues in Treatment * Sexuality * Biological Differences * Menstruation * Abuse * Substance use during pregnancy and parenting * Secrets * Desires, dreams, fantasies * FASD in self or child Women’s Issues in Treatment • Secrets * guilt, shame, trauma • Parenting * child abuse/neglect, feelings of inadequacy, legal/foster care • 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 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. Medications Currently Approved for Alcohol Dependence > Disulfuram > Naltrexone > Acamprosate Complementary and Alternative Therapies > Accupuncture and electroaccupuncture > Biofeedback > Hypnosis > Transcendental Meditation > Relaxation Training > Nutrition/ vitamins/ herbal > Adjunctive- light, yoga/ tai-chi, EMDR, aromatherapy > Culturally specific practices-Native American > Spirituality ASAM Patient Placement Criteria > Withdrawal potential > Medical conditions > Psychological conditions > Treatment Acceptance > Relapse potential > Recovery environment > Treatment Options-outpatient, residential, detoxification, opioid maintenance Management: Person Centered Care > Education > Mental Health > Health Care > Child Welfare and Family Support Services > Criminal and Juvenile Justice > Chemical Dependency > Developmental Disabilities Women and Treatment > Women receive the most benefit from treatment programs that provide comprehensive services: * food, clothing, shelter, transportation * employment/vocational counselling * literacy training/educational opportunities * legal assistance * child care, parenting and social services * nutritional guidance * mental health services and followup STAGING THE DISORDER- Adolescents * Stage 1. Experimental Use * Stage 2. Recreational Use * Stage 3. Problematic Use * Stage 4. Addiction and Dependency (Comerci and Macdonald 1990) 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 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?