Women and Addiction

BY MELISSA LEE WARNER AND STEPHANIE LOEBS

Published by ABA COMMISSION ON LAWYER ASSISTANCE PROGRAMS

There are those that say that women are the single minority that has yet to receive sufficient focus in the arena of addiction treatment. Some wonder whether enough is being done regarding the special needs of women in treatment and recovery. The topic of women and addiction is an important one. The role of a woman in today's society is critical, and when affected by addiction the results can be destructive not only to the individual but to the family, the community and society as a whole. The struggles of the addicted mother, sister, aunt, grandmother, niece, friend, tears at the very fabric of our society, leaving in its wake damage, tragedy, loss, and trauma. So
devastating is addiction's effect that it takes generations to heal its wounding.

From the research on women and addiction we know the following:

• There are gender-based differences in alcohol metabolism. Women's bodies contain less water and more fatty tissue then men. The activity of the enzyme known as ADH that breaks down alcohol is decreased in women.

• Women develop alcohol related diseases like cirrhosis and hypertension, brain damage from alcohol abuse, lung cancer, and respiratory diseases like emphysema and chronic bronchitis from smoking, more rapidly than men,

• Women are likelier to develop depression, anxiety, and eating disorders, which are closely linked to nicotine, alcohol, and drug abuse.

• Women who use sedatives, antianxiety drugs, and hypnotics are almost twice as likely as men to become addicted to such drugs.

• A single cigarette smoked by a woman has nearly the same carcinogenic effect as two smoked by a man.

• One drink for a woman commonly has the impact of two drinks for a man.

• Moderate or heavy drinking increases the risk of breast cancer.

• Older women suffer memory loss and mental deterioration after fewer years of drinking than older men.

• Women often differ from men in their response to psychoactive drugs and to drug abuse treatment.

Our experience in the setting of addiction treatment reveals:

• By the time the addiction is intervened upon it is more likely that a woman has reached mid to late stages of the disease.

• Women seeking help from the healthcare system are more likely to be misdiagnosed with a psychiatric condition, and the addictive disorder will often remain undetected.

• Due to the disinhibiting nature of intoxicants, women are at higher risk to become victimized and/or abused while under the influence. In addition, the addicted woman may well have a pattern of toxic relationships involving alcohol and drugs, as well as abuse and neglect for much of her life.

• Tragically, women are more likely to be stigmatized as a result of their addiction. Their shame keeps them "out" longer, and the internalized judgmentalism and denial of those in the helping professions can result in delayed, or non-diagnosis.

• Loss and complicated grief are often present making motivation and engagement difficult.

• We have never met a women addict who did not want to be a good wife, a good mother, a good citizen. Sometimes these very desires make it difficult for women to prioritize addiction treatment for themselves, or result in choices of treatment at an inadequate level of intensity.

All that being said, we know that treatment for addictive disorders works. Care for anybody with an addictive disorder needs to be individualized. Controversy and less than adequate information regarding effective treatment for women with addiction can make this subject seem complicated and confusing.

The idea of getting treatment may seem to generate more questions then it does answers when women consider getting help. Do I really need treatment? What kind of treatment? Who will take care of my family while I am in treatment? How can I afford this? What if it doesn't work? There are no easy answers to these questions. The key here is to make an informed decision. For an individual under the influence this may not be possible. It may be dependent upon a primary caregiver such as spouse, partner, child, friend, or employer to explore and understand what is available; then shepherd the woman into treatment.

The real question is not whether the woman wants treatment, but at what level of intensity will be appropriate. Unlike most other medical conditions we cannot count on the ability to increase the level of intensity when needed. It is best to err on the side of a higher level of intensity of treatment; then let the professionals fully assess all aspects of the case and adjust treatment as indicated.

The myth of someone "wanting treatment" in order for them to benefit is truly irrelevant. Almost all patients with addictive disorders will not recognize that addiction is what they suffer from, until it has been diagnosed. It is an important task of addiction treatment to both diagnose, and then help the individual integrate the diagnosis of addiction for themselves. The myth of "needing to reach a bottom" has no basis in fact; and is a very dangerous concept.

During this phase it is important for those around them to mobilize and help them seek early and immediate intervention to access treatment. Planned interventions work. Do not underestimate the power of fear, inspiration, guilt, hope, and helping relationships.

A woman thinking about change is often profoundly ambivalent. Over-thinking and procrastination may be prevalent. They
develop disgust for the drug they're addicted to; and yet are hopelessly dependent. They are aware of the benefits of changing but powerless to do so; and overwhelmed by the costs (not all of which are financial). There are no choices without consequence. We can assist by helping them to become informed. Develop a plan, move, and support them to be ready. Most individuals are unable to take the initial step into treatment themselves; and all resources should be marshaled to allow this to happen in a safe and compassionate manor.

The woman willing to take action can be integrated into an action-oriented, 12- step recovery based treatment program.

Once successful in taking action, a woman now living a life recovered faces the challenge of maintaining that change. The skills necessary to do that are one of the benefits and results of comprehensive addiction treatment. Maintaining a drugfree lifestyle, returning to work and family, accepting responsibility for one's own actions, and most importantly, preventing relapse is challenging, at times difficult, but not impossible. One of the common reasons for early relapse is that the woman is not well prepared for the prolonged (and profound) effort needed to maintain her changed lifestyle.

So comes the question of treatment. Understanding that treatment is necessary, the issue of what kinds of treatment women require needs to be answered.

Group Therapy

Group therapy is the mainstay of addiction treatmentÐof fering the greatest potency. A combination of different types of group therapies along with the support of individual therapy is optimal. Staff providing such a service need to be well trained and experienced in this milieu. Some patients will require pharmacotherapy as well. The combination of behavioral treatments and medications improve outcomes. Twelvestep programs and group therapies are different in their purpose and structure; 12-step meetings are not group therapy.

Individual Therapy

Individual therapy in the treatment of addictive disorders should never be the sole treatment approach. At a minimum it
should almost always be paired with intensive 12-step recovery program involvement. There is an invaluable benefit to the use of individual therapy in the treatment of addictive disorders in women, concurrent with group therapy, and 12-step meetings. Individual therapy may serve as a point of entry±±assisting the woman in moving into a real plan to treat her addictive disorder. It can help in identifying those high risk environmental factors, or dysfunctional developmental factors that can sabotage any treatment efforts. It can provide a chance for the woman to be heard.

Individual therapy has many roles in the armamentarium of addiction treatment: to serve as initial treatment or as an introduction, to treat early stages of substance abuse/addiction, to serve as the treatment for those who have failed in other modalities, to complement other ongoing treatment modalities, and to help solidify gains after achieving stable abstinence.

Abstinence-Based Treatment

For the woman to recover this is a central issue, and the minimum standard for successful recovery. This is based on many reasons, but primarily to enhance one's recovery, improve one's quality of life, and to prevent relapse. How then does a woman negotiate necessary surgery, child birth, weddings, loss, pain±±life without the use of intoxicants? Courageously and with help and the skills and strategies first learned in an abstinence based treatment program and when necessary, with the consultation of an addiction medicine specialist. With proper, sometimes specialized treatment approaches, sobriety can always be successfully preserved.

Conclusion

Allow this to serve as an introduction to the very complicated topic of addiction treatment for women. If you are, or know, a woman in trouble with drugs and/or alcohol, the help is available. More than likely there has been an awful lot of suffering up to this point. There is probably even some doubt about whether addiction is really the problem. Desperation and confusion may be prevalent; anger and ultimatums arise.

If any of this sounds familiar, you are not alone. Know that the beginning of your, or your loved one's, recovery and healing has already started. Know that recovery is possible and that treatment works. The first step is to simply admit that something is terribly wrong, and then seek the help and expertise of professionals. Answers are available for you, no matter what your struggles.

References

• Jill B. Becker, “Sex differences in Drug Abuse,” Frontiers in Neuroendocrinology 29, no. 1 (Jan. 2008): 36–47.
• CSAT, Tip #2, Pregnant, Substance-Using Women, 1993.
• The Farley Center at Williamsburg Place Patient Handbook, 2009.
• John Gray, Men are from Mars, Women are from Venus (New York: Harper, 2004).
• Charlotte Davis Kasl, Women, Sex, and Addiction: A Search for Love and Power (New York: Harper, 1990).
• The National Center on Addiction and Substance Abuse (CASA), Women Under the Influence (New York: Columbia University, 2005).
• James Prochaska and Carlo DiClemente, Stages of Change Model, University of Rhode Island.
• Richard K. Ries et al., Addiction Medicine, 4th Edition (Philadelphia: Lippincott Williams & Wilkins, 2009).

MELISSA LEE WARNER, MD, is an addiction medicine specialist at The Farley Center at Williamsburg Place in Williamsburg, Virginia.

STEPHANIE LOEBS, BSN, is The Farley Center's executive director and a board member for NACoA (National Association for Children of Alcoholics).