Substance Use and Abuse in Women
Monica L. Zilberman
Sheila B. Blume
Substance abuse is a major source of health problems worldwide. The National Comorbidity Survey (NCS), a large study of the United States population aged 15 to 54 years conducted at the beginning of the 1990s, suggests that approximately one fourth of Americans had already met criteria for a substance use disorder at the time they were surveyed (1). Although substance use disorders are currently more prevalent in men than in women, this was not always the case. During the nineteenth century, most Americans dependent on opiates were women (male:female ratio close to 1:2). Many of these women started opiate use on the advice of their physicians for a variety of complaints, much like the mother in Eugene O’Neill’s play Long Day’s Journey into Night. Substance use among women, often concealed, was silently accepted and tolerated by close relatives. This changed dramatically in the twentieth century with the advent of antidrug policies (2). The NCS estimates that now 8% of American women between the ages of 15 and 54 have a lifetime diagnosis of alcohol use disorders (male:female ratio of 2.5:1) and 6% have a diagnosis of other drug use disorders (male:female ratio of 1.6:1) (1). Although the current numbers are impressive, reports of abuse of or dependence on substances date back to ancient times. One such example comes from an ancient Egyptian quotation contained in the Anastasi Papyrus IV around 1500 BCE:
Beer makes him cease being a man. It causes your soul to wander, and you are like a crooked steering-oar in a boat that obeys on neither side, you are like a shrine void of its god, like a house void of bread. Now you are seated (still) in the house, and the harlots surround you, now you are standing and bouncing … now you stumble and fall over upon your belly, anointed with dirt. (3)
There is mention of substance abuse in the Hebrew bible, in Samuel, Book I, Chapter 1, where a priest mistakes a woman who is praying for a babbling drunkard and admonishes her to give up drinking.
Throughout history, excessive drinking and its consequences were traditionally attributed to individual choice and blamed on low moral standards. The notion that the desire to drink could be overwhelming and irresistible in some people for physiologic reasons is relatively recent. Dating from the nineteenth century, this notion is central to the modern disease concept of addiction, a term usually used as a synonym for dependence. Substance abuse is defined as the harmful use of a specific psychoactive substance. The next section presents general issues of substance use, abuse, and dependence, paving the path to sections dedicated to specific topics of substance use among women.
OVERVIEW OF SUBSTANCE USE, ABUSE, AND DEPENDENCE
For health professionals, establishing where recreational use of a substance ends and substance abuse starts is a challenge with important preventive and clinical implications. Any substance use pattern involves the complex interaction of pharmacologic, psychological, genetic, and sociocultural factors. Some substances are more liable than others to induce self-administration and thus lead to a pattern of abuse or dependence. (Nicotine, for instance, is associated with fast progression to dependence states, while alcohol dependence usually establishes itself only after several years of continued drinking.) Although initial substance use is often prompted by environmental and psychological factors (curiosity, peer pressure, “self-medication” of uncomfortable affective states), genetic factors have an important role in progression from recreational use to abuse or dependence. The problematic use of a substance represents a continuum from abuse to dependence. (Some prefer the term “substance misuse,” because of the possible pejorative connotations of the term “abuse.”) The continuum starting with substance use may lead to one or more substance-related problems, such as accidents, medical consequences, family and occupational problems, and eventually dependence. Dependence is a behavioral syndrome comprising (a) a strong desire to use the substance; (b) loss of control over substance use, which may be marked by the inability to abstain even in the face of various recurrent health, family, social, or occupational problems; and (c) signs of physiologic adaptation, such as tolerance and withdrawal. Physiologic adaptation (formerly known as physical dependence) is no longer considered a sine qua non criterion for dependence. In fact, substances like cannabis do not seem to be associated with a clear withdrawal syndrome (4), yet they clearly induce abuse and dependence. Further, as scientific knowledge has advanced, substances that were not formerly known to induce abuse have been shown to be strongly associated with dependence (nicotine is an example).
Substances of abuse vary widely in chemical structure but produce common behavioral syndromes. Both licit (often prescribed or even over-the-counter) substances and illicit substances are shown to have addictive properties. They can be
classified for convenience into three groups: (a) central nervous system depressants: alcohol, barbiturates, benzodiazepines, inhalants, and opiates (opiates are sometimes classified in a separate category because their effects involve specific opiate receptors); (b) central nervous system stimulants: amphetamines, caffeine, cocaine, and tobacco (nicotine); (c) hallucinogens: cannabis, LSD, mescaline, psilocybin, and a wide variety of other substances, both natural and synthetic. Although each of these drugs has a different mechanism of action, they all stimulate the limbic system, including the nucleus accumbens and ventral tegmental area, a circuitry thought to be basic to the reinforcement of behavior and a final common pathway for addiction.
classified for convenience into three groups: (a) central nervous system depressants: alcohol, barbiturates, benzodiazepines, inhalants, and opiates (opiates are sometimes classified in a separate category because their effects involve specific opiate receptors); (b) central nervous system stimulants: amphetamines, caffeine, cocaine, and tobacco (nicotine); (c) hallucinogens: cannabis, LSD, mescaline, psilocybin, and a wide variety of other substances, both natural and synthetic. Although each of these drugs has a different mechanism of action, they all stimulate the limbic system, including the nucleus accumbens and ventral tegmental area, a circuitry thought to be basic to the reinforcement of behavior and a final common pathway for addiction.
Knowledge about the neurobiology of addiction has improved dramatically with the use of neuroimaging techniques. Widespread brain structural changes have been associated with stimulant and opiate abuse, while frontal atrophy may appear in alcohol abuse. Functional techniques show altered regional cerebral activity associated with various substances. These techniques further reveal involvement of dopaminergic, serotonergic, opioid, and GABAergic systems in addiction (5).
Substance use and abuse are involved in a variety of problems, affecting directly or indirectly the health of users, family members, and society at large. Driving while intoxicated is one major cause of injuries and fatalities. Similarly, substance abuse is involved in most cases of domestic violence, including emotional, physical, and sexual abuse, affecting domestic partners, children, and the elderly. Legal and occupational problems related to substance use add to the global burden.
In addition to physical consequences, substance abuse is also associated with increased rates of conduct and personality disorders (mainly those characterized by intense impulsivity, such as antisocial and borderline personality disorders) and a number of psychiatric conditions, including affective, anxiety, and psychotic disorders. More than half of all persons with substance use disorders in the general population present at least one other psychiatric disorder (1). The risk of other addictive disorders is also greatly increased (polydrug abuse; eating disorders, particularly bulimia nervosa; and pathologic gambling, for instance). Women are at higher risk for psychiatric comorbidity in general and for developing iatrogenic substance abuse or dependence as well, because they are more likely to be prescribed hypnotics, analgesics, and sedatives by physicians. Worries about body image also put them at risk of abusing cocaine and amphetamines and other diet pills for the purpose of weight control.
SUBSTANCE USE IN WOMEN
Over the past several decades, health professionals and researchers alike have acknowledged that substance use manifests itself differently in women than in men. For many years the study of addiction was focused on men, and clinical approaches to the few women presenting for treatment were derived from what was known to work for men. Since the Second World War, the entry of women into the job market and into professions previously dominated by men, among other societal changes in women’s roles, has very likely contributed to the narrowing of the distinction between women’s and men’s social roles and to broadened opportunities for women to drink and to use drugs. This contributes to the higher prevalence of substance use disorders among women observed in recent epidemiologic surveys (1). Gender differences are reported in a variety of areas, such as physiologic effects of substances, metabolic differences, physical and psychiatric comorbidities, and genetic and sociocultural factors. There are also important
effects on women’s reproductive health, pregnancy, and offspring. This section explores substance use issues that either express differently in women than in men or are unique to women.
effects on women’s reproductive health, pregnancy, and offspring. This section explores substance use issues that either express differently in women than in men or are unique to women.
PATTERNS OF SUBSTANCE USE
In spite of consistent lower levels of use (e.g., drinking or taking drugs less frequently and in lower quantities) compared to men, women develop substance abuse and dependence patterns more rapidly than substance-using men (6). Referred in the specialized literature as a “telescoping” effect, this phenomenon was first observed in the 1950s when it was noticed that women entered treatment with shorter histories of problem drinking than men, although the severity of symptoms was equal. At that point, some professionals found it intriguing that women, although starting to drink much later in life, were entering treatment at the same age as men. The age at which women start to drink has dropped dramatically since that time, being virtually the same for women as men since the 1990s, but the telescoping of alcohol problems among women remains a consistent feature. Women begin treatment for their alcohol disorder two to five years earlier than men, but this period also encompasses time spent dealing with personal feelings of shame and guilt (reinforced by social stigma), opposition of substance-abusing partners, and difficulties in finding treatment programs that can accommodate a woman’s needs (such as child care and flexible hours of operation for women with children). Thus, it is possible that the magnitude of telescoping is underestimated. If it were not for the difficulties encountered by women in accessing addiction treatment, their admission would come earlier, resulting in even greater telescoping (6). A similar telescoping of substance-related problems in women is described for opiates, but data for cocaine are less consistent. Sex-related differences in the metabolism of alcohol and other drugs have been thought responsible, at least in part, for this telescoping effect (see below). However, a similar telescoping has been described for women who seek treatment for pathologic gambling, so that factors other than drug-related physiology must be involved (7).
Women and men also differ in the types of substances they are more likely to use. Although illegal drug use has been more commonly found in men, in recent years women are catching up with men; this is particularly noticeable among young people. The prevalence of prescription drug use (as well as abuse and dependence), however, continues to be higher for women than for men. Women are more likely to use and abuse pain relievers, tranquilizers, stimulants, and sedatives, for instance (8).
PHARMACOLOGIC FACTORS
Blood alcohol concentrations (BAC) are higher in women than in men consuming the same amount of absolute alcohol per unit of body weight. This is explained in part by women’s lower body water content relative to men. Because the ingested alcohol is distributed in total body water and women have proportionately less water in their bodies, the alcohol is less diluted, thus increasing the BAC. As women age, there is a further increase in the body ratio of fat to water, enhancing the increased sensitivity to alcohol. Also, first-pass metabolism of alcohol at the gastric level occurs at lower rates in women. Even women who do not abuse alcohol have lower quantities of the enzyme alcohol dehydrogenase in their gastric mucosa, metabolizing less of the alcohol they ingest, compared to
men. Thus, women’s bodies absorb more of the alcohol they drink than do men’s bodies, which further contributes to the increased BAC in women. In alcoholic women, there is a further decrease in gastric alcohol dehydrogenase, and virtually all of the alcohol ingested is absorbed (9). Whereas a man given a standard amount of absolute alcohol develops the same BAC on each occasion, a woman’s BAC varies from day to day. Some but not all studies have found variation according to the menstrual cycle, with higher BAC in the premenstrual phase. Thus, a given dose of alcohol may produce more unpredictable BAC in a woman compared to a man. Women may also have more intense reactions when drinking the same amount as men, as acute alcohol tolerance is less marked in women (10). As mentioned above, this greater sensitivity to ethanol is thought responsible, at least in part, for the telescoping of the course of alcoholism in women.
men. Thus, women’s bodies absorb more of the alcohol they drink than do men’s bodies, which further contributes to the increased BAC in women. In alcoholic women, there is a further decrease in gastric alcohol dehydrogenase, and virtually all of the alcohol ingested is absorbed (9). Whereas a man given a standard amount of absolute alcohol develops the same BAC on each occasion, a woman’s BAC varies from day to day. Some but not all studies have found variation according to the menstrual cycle, with higher BAC in the premenstrual phase. Thus, a given dose of alcohol may produce more unpredictable BAC in a woman compared to a man. Women may also have more intense reactions when drinking the same amount as men, as acute alcohol tolerance is less marked in women (10). As mentioned above, this greater sensitivity to ethanol is thought responsible, at least in part, for the telescoping of the course of alcoholism in women.
Women also react differently to cocaine than do men, but the direction of the differences and their explanation are not clear. Greater subjective response in women than in men after intranasal cocaine administration has been reported, whereas higher and faster subjective responses, accompanied by higher plasma levels, in men than in women have also been observed. Others have found higher cocaine plasma levels in the follicular than in the luteal phase among women, although these levels were not accompanied by a higher subjective response to cocaine. It is hypothesized that the nasal mucosa of women in the luteal phase is more viscous, leading to decreased cocaine absorption and decreased plasma levels (11).
There has been less research on gender differences in the pharmacologic effects of other drugs, but there is evidence that the intensity of the acute response to cannabis and opiates may be influenced by sex hormones (11). Regarding tobacco, even with similar daily smoking patterns, women exhibit lower nicotine plasma levels, but they inhale more frequently and more intensely to achieve the same nicotine intake (12).
HEALTH CONSEQUENCES
Alcohol abuse is clearly associated with increased morbidity and mortality in women who drink excessively, compared both to women in the general population and to alcohol-abusing men. Women are at increased risk for hypertension, malnutrition, anemia, cardiovascular disease, fatty liver, cirrhosis, gastrointestinal hemorrhage, peptic ulcer, breast cancer, subarachnoid bleeding, decreased brain volume, and poor performance on attention and visuospatial tasks, to name a few conditions. Several of these problems develop faster and with lower total alcohol intake in women compared to men. It is possible that women’s greater sensitivity to alcohol effects plays a role in the increased morbidity and mortality observed in women who abuse alcohol compared to men who abuse alcohol (13).
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