OUTLINE: ALCOHOL AND WOMEN

Nioaka N Campbell, MD, Univ. of South Carolina SOM

Alcohol Medical Scholars Program, 2006

 

SLIDE 1

I.                    INTRODUCTION

 

SLIDE 2              A.   Alcohol use/Alcohol Use Disorder (AUD): important in women’s health 

 

                        1.  43% of ♀ in 2003 – current drinkers1

                        2.  4.5M ♀  – alcohol abuse 2-4

                        3.  2.5M ♀  – alcohol dependence 5

                                               

B.     Alcohol use and AUDs in women are under-studied

SLIDE 3

1.  Most past AUD research has been on males, only 14% ♀ included

      2.  ↑ Lifetime prevalence of AUDs is: 13% abuse, 20% dependence in ♂ 

           vs. 6% abuse, 8% dependence in ♀ 2,6,7

                        3.  Gender differences in previous research: ? accuracy 4,6,7

                                    a.   Levels of intoxication differ in ♀

i.          ‘At risk’ drinking limit >3 drinks/time vs. 4 

            drinks/time for men

ii.                   Lower body weight, alcohol levels may be 30% higher with same amount

                                                iii.         ↓ gastric alcohol dehydrogenase activity

SLIDE 4                                 4.  Women’s drinking patterns approaching the men 7

                                    a.   Gender gap narrowing: prevalence of >5 drinks/time –

                  23% gap in 1975 ↓ to 12% gap in 2001 

                                    b.   College ♀ adopt patterns of ♂ men in co-ed dorms 8

                                    c.   Rates not significantly different ages 12-17, (17%) 1

                  C.  Women have gender specific sequelae from AUDs

SLIDE 5

                        1.   In one study, showed up to 2X ↑ death rate in ♀ with AUD vs. ♂ 6,4

2.      Third leading cause of death (indirect) in both genders ages 35-55 9

3.      Some consequences we will later discuss10:

                                    a.  ↑ liver disease over shorter time

                        b.  ↑ alcohol induced CNS damage

                        c.  ↑ risk breast cancer  

 

SLIDE 6         D.  Women are less likely to be identified and diagnosed with an AUD:

<50%  ♀ with AUD were identified by primary physician, although ♀ are more often contact primary care doctor 11,12

E.  This lecture reviews alcohol use/AUDs in women. Will cover:

SLIDE 7

1.      Epidemiology

2.      The course of alcoholism in women

3.      Gender specific consequences

4.      Identification and assessment

5.   Thoughts on treatment

II.              EPIDEMIOLOGY

SLIDE 8,9                  A.  Race/Ethnicity comparisons 1,13,14

1.      Caucasian ♀:

a.       Highest prevalence of use vs. other racial groups

b.      55% past month use

c.       87% lifetime use

2.      African American ♀:

a.       37% past month use

b.      73% lifetime use

c.       More likely to abstain: 46% vs Caucasian 34%

SLIDE 10                               3.   Hispanic ♀:

d.      40% past month use

b.   73% lifetime use 

c.   ↑ rates heavy drinking in American born, young ♀

d.  62% of foreign born ♀ abstain

4.   Native American ♀:

            a.  Highest use of ‘heavy drinking’: >5 drinks/time, 30% 

            b.  Past month 36%

c.  Lifetime use 81%

d.  Abstinence in past mo., 65%

 

SLIDE 11                   B.  Abstinence 13,15,16

 1.  Women have ↑ % abstainers

       2.  % current/past yr. abstainers in 2004: 43% ♂, 56% ♀ 

       3.  1997 lifetime data: 22% ♀ abstain, 13% ♂

                   a.  ↓ abstention with increasing education, both sexes

                   b.  ↓ abstention with ↑ salaries,

                        $40,000 or more: <10% ♂, <20% ♀

 

SLIDE 12                   C.  Current alcohol use 1,10,13

                        1.  57% ♂ vs. 44% ♀ current use in 2004

                        2.  Highest use ages 18-24: 76% ♀ vs 80% ♂

                        3.  15% women vs  21% men ‘heavy drinking’:

                 >5 drinks/time, >1x in past mo., ages 18-25            

 

   SLIDE 13                 D.  Defining alcohol use disorders 7,17

1.  Alcohol abuse – clinically significant impairment or distress in ≥1 in a

     12-month period:  

                        a. Failure to fulfill major obligations (e.g. absences/suspensions)

                        b. Physically hazardous (e.g. driving while intoxicated)

                        c. Legal problems (e.g. disorderly conduct, DUIs)

d. Social/interpersonal problems (e.g. arguments, physical fights)

 

                SLIDE 14                           2.  Alcohol dependence – clinically significant impairment or distress in

     ≥ 3 in a 12-mo period:

            a. Tolerance (increased amt needed for effect, diminished effect)

b. Withdrawal (autonomic hyperactivity, tremor)

c. Larger amounts/longer period than intended

d. Persistent desire/unsuccessful attempts to cut down

e. Excessive time spent with or obtaining alcohol

f. Activities given up due to alcohol (social, occupational,   

    recreational activities)

g. Continued use despite problems

   SLIDE 15                            3.  Prevalence of lifetime abuse: 13% ♂ vs 6% ♀

            4.  Prevalence of lifetime dependence: 20% ♂ vs 8% ♀

 

SLIDE 16                   E.  Differences on consequences

                        1.  Alcohol related driving fatalities 1,10

                                 a.  9% women vs. 18% men likely to drive while drinking

                                 b. Women in fatal alcohol related collisions is rising,

                                     12% in 1980 to 16% in 1996    

2.  Victimization 8,18:

a.  Rape, alcohol associated – 70,000 annually in US colleges

                                    b.  College ♀ drinkers 3.5x ↑ nonconsensual sex than nondrinkers

                                    c.  Physical assault, alcohol related – 600,000 in US colleges

3.  Domestic violence: 19

                                  a.  Women victims have 2-3X ­ risk of AUD 1,10      

          b.  67-90% of men/batterers have AUD

SLIDE 17                               4.  Unemployment: 47.6 % ♀ vs 32.7% ♂ with AUD (may be partially

                             accounted for by homemakers) 20

                        5.  Antisocial behavior is correlated with AUD in both genders,

                             but ♂ with AUD have↑ antisocial PD, 15% vs women, 5% 7

                        6.  Health consequences 10

                                  a. Alcohol induced liver disease develops faster, with less alcohol –

              ↑ liver enzymes with 20g/day over a month in ♀ vs 40g/day in ♂  

                      c. CNS damage: 21

i.                     Approximately  55% ♂and ♀ w/AUD have ↑ ventricular size

ii.                   ♀ with AUD had 11% smaller gray matter volume than nonalcoholic ♀

                      d. Hangover: ♂ 18 or older >40% reported, vs. 27% ♀ 22

             

                

 

III.          COURSE OF AUD

 SLIDE 18

   A.  General course of AUD, male and female 15, 23:

1.  First use age 12-14

                        2.  First intoxication age 14-18

                        3.  Alcohol related problems develop age 18-25

                        4.  AUD develops age 23-33

                        5.  Death age 55-60 (15 yrs earlier than avg)

 

   B.  Course specifiers for Women 15, 23:

                        1.  Avg age of first use in ♀ is 14 yrs, tends to be slightly later than ♂, gap

                             narrowing1

                        2.  Age to seek tx for AUD is same, avg 40 4, 24

                        3.  Telescoping effect – only 1-2 yr difference: 6

                                                a. Onset of drinking until the time treatment is sought 

                                                b. Medium interval from 1st drink to onset of alcohol related

                                        problems: 3 yrs ♀ vs. 3.5 yrs in ♂ 6

                                   

SLIDE 19                        C.  Health Problems and AUDs 8, 18, 25

                        1.  DSM-IV Axis I disorders 17, 26:                   

a. Comorbidity: following % do not distinguish independent  

    disorders from substance induced disorders, which are different

    conditions, with different prognosis and treatments

b. 65% rate of comorbidity in ♀ vs 44% in ♂                                

    (DSM-IIIR or DSM-IV Axis I diagnosis + AUD)

c. Major Depression:

i.   Women’s lifetime risk 1.7X > ♂

ii.  ♀ with AUD: have up to 4X risk of depressive D/O 

     vs. other ♀ (includes substance induced D/O) 

                                    d.  Suicide attempts: 40% ♀ with AUD (8% other ♀)  

e.  Anxiety disorders:

                                                i.   ♀ with AUD: odds 3x ↑ than other ♀, includes

                                                     independent anxiety D/O and substance induced

iii. One study found 30% ♀ with AUD met criteria for  

     PTSD

                                    f.  Eating disorders: One study found approx. 28% of ♀ with AUD

                 had an eating disorder, other studies not as high %

                                    g.  Important to assess for psychiatric symptoms versus

                                         independent disorders in comorbidity with AUDs

                        2.  Further gender specific health consequences 27:

                                    a.  Increased risk of breast cancer:

                                    i.   Large study (300,000 ♀, 4 countries)

                 9% ↑ relative risk with each drink/day (10g), linear

                 relationship up to 60g/day (6 drinks)

            ii.  Dose response relationship w/ as low as 1-2 drinks/day

            iii. Proportion of breast CA attributed to alcohol is 2% in

                 U.S., up to 15% in Italy (? alcohol use more prevalent)

                                    b.   Disruption of menstrual cycles, hormonal functioning: 5,26

                                          ↑ in estrogen levels 3X upper limit in postmenopausal ♀, 1-2

      drinks/day may be protective yet further studies are needed

SLIDE 20,21                                      c.   Fetal alcohol syndrome/spectrum (FAS) 28, 29, 30 

i.         Syndrome characterized by varying components: 

- malformations in facial structure

- prenatal and postnatal growth retardation

- functional/structural CNS abnormalities

- spontaneous abortions

- mild to moderate mental retardation

ii.   Affects 1% of US population

iii.  National survey found that 59% of ♀ age 15-44 drank

      alcohol while pregnant

iv.  Cost associated with caring for children with FAS:

      approximately $200M/year in U.S.

v.  Dietary guidelines in US since 1990 advised

     abstention for women pregnant or planning

 

 

 

 

                                               

IV.            IDENTIFICATION AND ASSESSMENT 

SLIDE 22

                 A.  Women do not fit stereotype

                        1.  Often go to primary doctors, who don’t ask (<50% ♀ alcoholics

                             identified) 11, 12

                                                a. ♀ may not have AUD as presenting complaint, have to assess

            b. ↑ stigma and guilt associated, “immoral promiscuous ♀”,

                causing doctors not to ask and ♀ not to tell

            c. Stereotype of a ‘drunk’ does not fit most ♀, grandmas, etc.

2.  History is still the most important tool

            a.   Alcohol problems screening should be part of routine interview  

                 (reduces stigma if every patient is asked)

b.      Avoid asking closed ended questions: minimizes the information given, ex) “you don’t drink, do you?”

c.   Open ended questions increase dialogue, ex) “how much do

      you drink?” 

d.   Follow-up should be specific and direct: frequencies, quantities

      (a drink is different things to different people) 

e.   Addressing alcohol related problems is key to identifying key

      issues and treatment needs – work, school, legal, social

e.       Non-judgmental attitudes increase therapeutic alliance,

      ex) “you drink how much!!?”-not good

 

SLIDE 23                   B.  Psychosocial Factors in ♀ 7, 17

                        1.  Social sanctions: ♀ perceived that 50% of others would disapprove of

                             ♀ drunk vs. 30% would disapprove of a ♂

2.      Women more likely to drink alone, 30% have drinking partner

      (compared to 50% men) 6

                        3.  Protective factors: 4

a. Multiple roles: mother, employed, spouse

b. Married

c. Female athletes

4.  Factors associated with increased risk: 4

a. Divorced, never married or separated

b. Earlyonset drinking: up to 40% later AUD 1, 10

                                    c. History of neglect as a child 31

                                    d. Other psychiatric disorder(s) - see IIIC above

                                    e. ♀ with childhood sexual abuse 18                                                                                           f. Tobacco (61% drinkers use tobacco versus 16% nondrinkers) 1,32

 

SLIDE 24                   C.  Genetic Risk Factors 33, 34, 35

                        1.  50-60% variation of AUD risk in both sexes is genetic

                        2.  Metaanalysis of twin and adoption studies: 40% ↑ risk alcoholism in

                             children of ♀ with alcoholism regardless of environment, (small

                             sample sizes)

                            

            SLIDE 25                   D.  Further challenges in assessment:         

            1.  Lack of practitioner time in taking a thorough history

 2.  Lack of objective assessments specific for women 30

a.  Self report instruments (to identify risk only), developed with ♂

    subjects predominately:

:                        i.   CAGE- “cut down, annoyed, guilty, eye-opener”,

ii.  MAST(Michigan Alcoholism Screening test)- 24 yes/no

iii. AUDIT (Alcohol Use Disorders Identification test) – 10 

     items,  > specificity in ♀ (0.95 with cutoff of 7),

     may need to ↓cutoff to not miss ♀ at risk

b.      Results of these tests may differ not only with gender but race

i.         Study of minority ♀: 23% were above cutoff # with MAST vs 5% with CAGE (would have identified less)

ii.   White ♀ 4X likely to score above cutoff on

      tolerance items vs Black ♀ (difference from the specific

      question or due to ethinicity?)

c.       Screening developed specifically for pregnancy:

i.                     Developed to include with routine exam/screening (again, to reduce stigma)

ii.                   Health Behaviors Questionnaire – 10/15 minutes

iii.                  T-ACE – similar to CAGE yet tolerance replaced guilt as a question, guilt is usually + in this group

 

V.             THOUGHTS ON TREATMENT

SLIDE 26      

            A.  Many women with AUD do not receive treatment: 1, 4, 20

            1. 1 out of 4 ♀ with AUD receive tx

                                    2. Specialty tx facilities: 900,000 ♂  vs 400,000 ♀ (facilities with

                                        primary treatment of AUDs)

3. 2% men received treatment vs 1% women in 2003

4.  ♀ make up 25% of clients in traditional tx centers

 

                        B.  Barriers to treatment 1, 6

            1.   Social stigma

2.      Fear of loss of children or inability to care for them

3.      Lack of child care

4.      Fear of legal sanction 20

a.       14 states consider substance use in pregnancy to be child abuse

b.      9 states require health care professionals to report suspected prenatal substance abuse or dependence

5.      Limited resources 20

a.       In Los Angeles treatment clients, 39 % of ♀ had less than a high school education vs 19% ♂ 

b.      As before, higher rates unemployment in ♀, may be due to homemakers, ?

SLIDE 27

C.  Characteristics of current treatment programs 20, 36

                        1.  38% programs offered womens groups

                        2.  21% pregnant/postpartum groups

                        3.  6% programs are women only

                                    4.  8% programs offer child care services

 

D.  Mixed gender versus women-only programs 4, 20, 37, 38

1.  Women only facilities:

a.  ♀ had 2X rates of program completion vs mixed, with

     reported improved 2yr f/u outcomes (% unknown)

b. Children 5X less likely to be placed in foster care

c.  Historically provide pediatric care, children's activities,

     and housing assistance

d.  Serve higher proportions of minority clients

2.      Mixed gender programs:

a.       Less able to attract/retain vulnerable ♀, history of physical or sexual violence and single parents

b.      Historically less focus on child care, transportation,etc.

 

 

SLIDE 28

E.  Center for substance abuse treatment, DHHS task force guidelines for

      women: 39

           1.  Take thorough intake and assessment

            2.  Offer family services, child care if possible

      3.  Vocational rehabilitation should be consulted when needed

            4.  Legal assistance referrals where appropriate

            5.  Preferred ♀ for first intake or ♂ trained in gender issues

6.      Overview individual strengths and skills of ♀ (empowerment)

7.      Address other general and mental health disorders

 

VI.                        SUMMARY

SLIDE 29

A. Alcohol use and AUDs are significant issues in women’s health

            1.  Affects millions of women

            2.  3rd leading cause of death

            3.  Associated with other medical and mental health disorders

            B. Course of alcohol use and AUD in women is varied and gender specific

                        1.  Women have unique vulnerabilities, risk factors and

                             supportive factors

2.  Consequences from alcohol use and AUDs can differ from men

                        C. Assessment/ Treatment of AUDs in women may need to be specialized

            1.  Screening should be routine and thorough

            2.  Every effort to reduce stigma and empower should be taken

            3.  Specific women-only treatment programs may be of benefit

4.  Treatment should include psychosocial aspects of women,

SLIDE 30                                                childbearing,etc

 

 

 

 

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