Women and substance abuse

DEFINITION: The risk factors for substance abuse in women are different from those in men, and women often face unique barriers to receiving treatment. The health effects of substance abuse also are worse for women who abuse alcohol, illicit drugs, or prescription medication. Understanding these gender differences is of paramount importance for proper prevention and treatment.

Risk Factors

Men were once the only persons studied and treated for substance abuse. However, the Substance Abuse and Mental Health Services Administration (SAMHSA) survey reported that in 2020, 13.2 percent of the surveyed women aged eighteen and older had past-year substance dependence or abuse, indicating the need for studies of women and substance abuse. By 2022, this number decreased to 8.4 percent. In addition, women account for a growing percentage of persons seeking treatment, making them the fastest-growing population of substance abusers in the United States.

Women generally turn to substance abuse for different reasons than men. Women often seek the comfort of a substance to help deal with a psychological diagnosis, such as anxiety, depression, post-traumatic stress disorder, an eating disorder, or postpartum depression. Men typically abuse substances secondary to impulsive or aggressive behavior problems. Women also abuse more frequently than men to deal with social concerns and pressures, such as family stressors or a traumatic event, including physical, sexual, and emotional abuse. Women who abuse substances are more likely to be in a relationship with an individual who abuses substances or in a relationship in which their partner is in control.

The female body reacts differently to substances than the male body. Women typically report more cravings and have a higher rate of relapse in the first two years of recovery. Men are more likely to try drugs than women, but when women use drugs, they are just as likely as men to develop a dependence or addiction. Women who become addicted do so faster and develop medical concerns more rapidly and more severely than do men, particularly to prescription opioids. Women do not present for treatment as frequently as men because of gender-related barriers. Women who use substances are more likely than men to have children, to be unemployed, and to receive medical assistance. Other risk factors for substance abuse are young age and lower educational status. These differences lead to unique barriers to treatment, including financial concerns, fear of being stigmatized by society as weak or helpless, feeling guilt or shame, and concerns of losing child custody.

Alcohol Abuse

In comparison to men, women drink alcohol less frequently. When women drink, they are more likely to engage in binge drinking, defined as five or more drinks on one occasion, than to engage in heavy constant alcohol consumption, defined as five drinks per day over several days. Alcoholism is underdiagnosed in women because of the public perception that most individuals addicted to alcohol are men.

Women who abuse alcohol have more health concerns related to its use than do men because of the way a woman’s body processes alcohol. A woman absorbs and metabolizes alcohol differently because she has a higher concentration of alcohol in the blood; has less of the enzyme called alcohol dehydrogenase, which metabolizes alcohol; and has larger amounts of estrogen, which may increase the risk for liver disease. These factors cause higher levels of alcoholic hepatitis after a shorter duration of drinking and a greater proportion of deaths from cirrhosis of the liver. Women are twice as likely as men to develop alcoholic hepatitis. Women who abuse alcohol also have an increased risk for heart disease, breast cancer, osteoporosis, gastric ulcers, and neurological complications.

Teenage girls are particularly sensitive to the effects of alcohol because alcohol decreases levels of hormones, including estrogen. Normal growth and timing of puberty might be delayed by alcohol abuse during these formative years.

Another significant health issue is alcohol consumption during pregnancy, whereby the fetus becomes at risk for developing fetal alcohol spectrum disorders (FASD) fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND), alcohol-related birth defects (ARBD), and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE). No safe level of alcohol consumption has been determined for pregnancy, and all women are discouraged from drinking any form of alcohol through gestation.

Fetal alcohol spectrum disorders compromise a constellation of symptoms, such as life-long learning disabilities, hyperactive behavior, difficulty focusing, speech and language delays, intellectual disabilities, and congenial abnormalities that include congenital heart problems, hearing and vision problems, and characteristic facial features. The greatest risk for the fetus occurs when there is heavy alcohol consumption throughout the entire pregnancy. About one in twenty Americans are impacted by these disorders.

Fetal alcohol effects generally occur when there have been lower levels of alcohol consumption; these effects may include some findings of fetal alcohol syndrome. Women who are older, educated, and in better economic standing are at the greatest risk for increasing alcohol consumption during pregnancy. Teenagers who drink before pregnancy are most likely to continue drinking during pregnancy.

Postpartum depression is common among women following pregnancy, and women with a substance use disorder are at an increased risk of self-medicating with drugs or alcohol. Women who use substances during pregnancy are often filled with guilt, which increases their chances of experiencing depression and their desire to use. To prevent substance abuse among women experiencing postpartum depression, family support, education, and eliminating the stigma surrounding the condition are critical.

Drug Abuse

Females who abuse substances and enter treatment are more likely to use drugs than partake in heavy alcohol consumption. Methadone, the primary abused drug for which women seek treatment, may be categorized as an illicit substance or as an abused medication (such as a psychotropic prescription). Women are more likely than men to be prescribed psychotropic medications for an underlying mental condition, and they are more likely to be prescribed pain relievers and at higher doses.

Women metabolize a drug’s components at a slower rate than do men. Prolonged exposure to these toxic ingredients leads to an increased risk for health concerns. Women who abuse drugs often experience irregular menstrual cycles and decreased fertility because of the suppression of endocrine and sex hormones. Although both men and women who use drugs are at risk for contracting an infectious disease from shared needles, women infected with the human immunodeficiency virus show a more rapid progression to acquired immunodeficiency syndrome than do men. Drug use also suppresses the immune system and allows for more rapid viral replication.

As with alcohol abuse, drug use in pregnancy is of utmost concern because of the risk for congenital anomalies and disorders and adverse pregnancy outcomes. The primary substances reported to be used during pregnancy include heroin, cocaine, crack cocaine, marijuana, and amphetamine. Abuse of these substances leads to pregnancy complications that include miscarriage, low birth weight, premature delivery, intrauterine fetal demise, and stillbirth. These substances also can lead to neonatal dependence, meaning the baby is born addicted to the substance the mother used during pregnancy, from which the newborn must endure medical detoxification and remain in the hospital for an extended time because of withdrawal. Social services will often remove the newborn from the mother's home because of this exposure. Newer research suggests an increased risk for the child to have developmental delays, both motor and cognitive.

Prevention and Treatment

Women’s risk factors must be addressed to successfully target the specific needs of women in treating substance abuse. Even though women and men do similarly well in completing treatment, the challenge is women’s access to treatment and their susceptibility to relapse.

Often, women underestimate the role alcohol or drug abuse plays in contributing to their illness, and they overestimate the contribution of mental illness to their medical and emotional concerns. It is important to address both the substance abuse and the additional comorbid psychological diagnoses. This may be accomplished by a combination of psychotherapy, pharmacotherapy, and medication. Pregnant women benefit most from buprenorphine rather than naltrexone or methadone, and it causes the least harm to the fetus.

Women often feel uncomfortable sharing their experiences in the company of men; therefore, many treatment centers offer gender-specific and gender-separate programs. Women are also more likely to have a negative perception of treatment, and specific centers have specially trained therapists and physicians who are sensitive to and aware of the unique challenges in treating females with substance abuse disorders. These facilities also have accommodations for increased access to care. For example, the provision of childcare at the site of treatment relieves the financial burden of paying for this service and the worry of caring for children while in recovery.

Transportation services to and from the treatment facility also increase the likelihood of arrival for routine appointments, as it alleviates the individual's financial and logistical burden of travel. As part of the treatment process, education about substance abuse in pregnancy should be provided for current or future mothers, and education should include a discussion of the risks for congenital abnormalities, disorders, and other adverse pregnancy outcomes.

Data indicate that while the aforementioned services would benefit women in treatment, only a minority of treatment centers actually have these accommodations. Because of the psychological and emotional risk factors, the significant and life-threatening health effects, and the barriers to treatment, further research is needed to better understand the implications of substance abuse in women and the best methods for treatment and prevention.

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