Alcoholism And Women: An Epidemiological Perspective
An Interview with Dr. Deidra Roach with the National Institute on Alcohol Abuse and Alcoholism:
I had the honor of meeting Dr. Deidra Roach, M.D. at a panel discussion on the treatment of women coping with harmful drinking last November. The discussion centered around troubling trends in women’s drinking and covered some of the challenges to mount an effective public health response to those trends.
Dr. Roach described yet unpublished studies revealing increases in current drinking that she describes as “troubling.” Examining the reasons for these increases is a complex process that involves understanding some of the cultural and other external influences and pressures on women to drink. According to Roach, women today are more likely to fulfill traditionally male roles in the workplace and are more apt to be expected to drink socially. At the same time, women feel freer than in past decades to drink, and advertisers are increasingly targeting the female demographic on the heels of this trend. As a result, more women are choosing to drink regularly today than only a decade ago.
Roach points to a need for evidence-based treatment to meet the needs of women who are drinking at harmful levels and becoming addicted to alcohol, combined with a need for support that addresses the underlying risks for women who, at harmful levels, are facing addiction. Such risks may include a history of physical and sexual trauma as well as associated emotional trauma that may put women at a greater risk for excessive drinking.
To complicate matters, women are faced with conflicting information about the risks of alcohol, especially while pregnant; certain racial and ethnic disparities exist in health professionals’ screening of women for alcohol and other substance misuse despite similar risks among women from different racial or ethnic backgrounds.
Our phone conversation followed on the heels of a recent article that appeared in Cosmo magazine, which featured a photo of a smiling pregnant woman surrounded by wine glasses. The feature was written, not by a doctor or researcher, but by a woman who touted the anecdotal experience of her pregnancy as proof that drinking during pregnancy is safe, rather than citing scientific evidence supporting her claim that drinking in moderation while pregnant is acceptable.
The article highlighted a false, and all too common belief that affluence and education offer some kind of immunity to the harmful effects of fetal alcohol exposure, collectively known as fetal alcohol spectrum disorders. While most people are aware of fetal alcohol syndrome (FAS), many may not know that FAS is on the most severe end of a wide spectrum of learning and behavioral disorders that may affect children with prenatal alcohol exposure throughout their lifetime.
Said Roach, “The Cosmo article is only one of several recent articles that reflect a common belief that white, middle class, educated women are part of an ‘inner circle’ that can be trusted to drink in moderation during pregnancy, while women of color or less well-educated women are less likely to be in control of their drinking, and thus more likely to injure their developing child.”
She added, “One of the nation’s leading researchers on substance use during pregnancy, Dr. Ira Chasnoff, found in one study of pregnant women in Pinellas County, Florida, that although white women and women of color used substances at similar rates, women of color were 10 times more likely to be screened for substance use by their healthcare provider. Dr. Chasnoff cites this study as evidence that health care providers may be complicit in perpetuating the myth that the harmful use of alcohol and other substances among women is ‘their’ problem; that white women and children are somehow protected from the harmful effects of alcohol and other substance use during pregnancy because they are more likely to use substances responsibly. In fact, this assertion is not supported by the scientific evidence, and all women are strongly encouraged to avoid alcohol and other substances both while pregnant and while trying to become pregnant, as fetal substance exposure may occur before a woman even realizes that she is pregnant.”
Dr. Roach said, more than anything, what is needed is a powerful public awareness campaign to break through some lingering myths about women and alcohol in general, and about pregnant women and alcohol in particular. These types of public initiatives translate into much-needed funding to move forward with evidence-based solutions to combat the very real and growing problem of harmful drinking among women. Dr. Roach said local governments must also assess trends within their own communities to more efficiently target local populations most at risk.
Trends In Drinking
We asked Dr. Roach about patterns emerging in terms of women and alcohol use. She cited a 2009 study from the National Survey on Drug Use and Health (NSDUH) that revealed “a 30 percent increase in binge drinking among women 18 – 23 years between 1979 and 2006.” She went on to say, “ A more recent, yet unpublished, analysis of NSDUH data from the last decade suggests small increases in binge drinking among women 21 and older across racial, ethnic categories and age categories.”
The reasons for these shifts? Roach explains, “In longitudinal studies on women and drinking, women cite many of the same reasons for drinking that are cited by men. One notable difference in women’s drinking today is the dramatic shift in the culture surrounding women’s drinking from one in which public intoxication among women was frowned upon, to one in which public intoxication among women is widely accepted, and in which many younger women expect to drink to intoxication when planning a night out.
“Today, significantly more women want to drink compared with 50 years ago, and shifting norms related to women’s drinking, reflected in dramatic increases in depictions of women drinking in the media and advertising that targets women to a greater degree than at any other time, are encouraging this phenomenon. In some cases, women are drinking more as they move into traditionally male-dominated work environments where drinking is an important part of the work culture. Women also experience more depression and anxiety than men do, and often drink excessively to medicate negative mood states.”
Dr. Roach called the new data “troubling” and explained that complicating matters is that across the board, a 2012 survey on drug use indicated only 15 percent of people receive evidence-based treatment for their harmful substance use.
Are Current Treatment Strategies Falling Short?
We asked whether current or traditional treatment options fall short for women and what sort of developing rehabilitation methods show promise. Roach said there are many more options available for both men and women today, but the most promising for women addresses both the drinking and past trauma that may be fueling the addiction.
“One of the most promising developments has been an increasing focus on trauma-informed treatment that combines treatment for alcohol and other substance use disorders (SUDs) with treatment for trauma-related symptoms, up to and including post-traumatic stress disorder (PTSD),” said Roach.
She went on to explain that these types of integrative treatment programs applying psychotherapy to address trauma-related factors with simultaneous drug and alcohol treatment are showing success.
In 1998 the Substance Abuse and Mental Health Services Administration launched the Women, Co-occurring Disorders, and Violence Study (WCDVS). The WCDVS developed, implemented, and evaluated the outcomes and costs of comprehensive, trauma-informed treatment programs for women with a history of violence and trauma who have substance use and mental health disorders. Results of the WCDVS were modest but promising. The nine WCDVS sites were located across the continental United States, with six sites on the East Coast, two on the West Coast, and one in Colorado. A total of approximately 3000 women (roughly half in the intervention condition and half in the comparison condition) were enrolled over the 13.5-month baseline accrual period (January 2001 through February 2002).
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At six months, women in both the intervention and the comparison groups showed improvement in outcomes in four areas: alcohol use, drug use, mental health, and trauma. Women in the intervention group scored modestly better than women in the usual-care group for outcome measures for drug use, trauma, and mental health. At 12 months women in the intervention group maintained their improvement in drug use outcomes and continued to improve in mental health and trauma outcomes.”
Dr. Roach also said a difference in costs between the two groups was negligible. She outlined some of emerging therapies that show promise, including the Trauma Exposure and Empowerment Model (TREM), which, according to Roach, addresses key differences in how women experience and cope with trauma. “In one study comparing TREM to treatment as usual in women with a trauma history and substance use disorder, women in the intervention group showed significantly greater reductions in drug use and PTSD symptoms at the 12-month follow-up compared with women in usual care.1”
Dr. Roach mentioned other intervention strategies, included Seeking Safety, a “manualized cognitive behavioral intervention,” but said it has shown mixed results when compared with other therapies for co-occurring substance abuse and trauma.
As for other forms of support, said Roach: “Another notable development in the treatment of both women and men with problem drinking is the growing number of online self-help discussion boards, recovery, and support groups for people with drinking problems.” She mentioned the website Women for Sobriety.org, but said these online interventions have not yet been studied thoroughly enough to determine their efficacy.
Simultaneous Treatment Co-occurring Disorders
Comprehensive treatment programs today are beginning to recognize the value of treating co-occurring mental disorders at the time a patient enters a facility to stabilize the patient and improve treatment outcomes. Dr. Roach said traditionally treatment of PTSD followed that of a substance use disorder, but there is a shift today toward simultaneous treatment of these co-occurring disorders.
“There is a growing and compelling body of evidence supporting this model, including several studies showing that improvements in PTSD symptoms have a greater impact on improvements in alcohol dependence symptoms, rather than the other way around.1 One study found that for every unit of PTSD improvement, the odds of being a heavy substance user at follow up decreased more than fourfold.”
Prolonged exposure therapy (PE) is widely used to treat PTSD. Exposure therapy involves engaging an individual directly in the memory of a traumatic event, and working directly with associated triggers that reignite symptoms of PTSD. Most therapies used to treat co-occurring substance use disorder and PTSD are non-exposure based, meaning they instead examine responses to the past trauma rather rather than encouraging patents to re-live it. Dr. Roach said studies of both approaches are still being examined for effectiveness in treating comorbid PTSD and substance use disorders.
The Taboo Of Alcohol Use In Women
Dr. Roach highlighted some of the primary issues women face in seeking help for substance abuse, especially during pregnancy.
“Alcohol and other substance use disorders are particularly stigmatizing for mothers because of the fear and common presumption that these disorders will lead to child neglect and abuse, and, in the case of pregnant women, to fetal harm,” she said. “In recent years, harshly judgmental thinking about mothers with substance use disorders has been most clearly reflected in the increasing criminalization of this group, particularly pregnant women.”
Dr. Roach pointed out that some organizations believe that states issuing “zero tolerance” laws may be causing more harm than good. The National Advocates for Pregnant Women recently observed that, “Beyond increasing Child Protective Services involvement in the state response to maternal substance use, there is an increasing trend toward viewing substance use during pregnancy as a legitimate subject of criminal law.”
“At the forefront of these efforts is Tennessee, which recently passed a law allowing women to be charged with assault, punishable by up to 15 years in prison, for babies born ‘addicted to or harmed by’ a narcotic drug. New York is one of 17 states that specifically address pregnant women’s drug use in civil child neglect laws. In some states, it’s possible to take away a child based on a single positive drug test, regardless of whether the newborn exhibits symptoms of such exposure, whether the mother was using the drug as part of prescribed medical treatment, and absent any other reason to suspect maternal drug addiction or unfitness to parent.”
Dr. Roach said “a growing number of mainstream legal and medical groups, including the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association, object to tactics like those being employed in Tennessee, which they say will deter pregnant women from seeking prenatal care and/or treatment for substance use disorders.”
These groups have pointed out that the punishment of women, rather than rehabilitation, has proven “ineffective in reducing the incidence of alcohol or drug abuse.”
A Move Toward Decriminalizing Women
We asked Dr. Roach about the stigmatization of women abusing alcohol and her response echoed the message that public awareness is a much-needed tool in addressing rising trends of alcohol use among women: “One of the immediate actions that we can take towards de-stigmatizing and decriminalizing women with substance use disorders, including pregnant women, is to begin talking about this issue with our families and friends in our own living rooms; educating ourselves about how common these problems are, why they are occurring, and what we can do collectively and individually to help. We can make this issue a priority topic for discussion in any women’s organizations, health, social policy, and other community organizations we may belong to, and we can move these organizations into dialogue with local and state health officials to learn more about the dimensions of the problem in our own communities.”
Reducing Barriers for Treatment
Dr. Roach also cited motherhood as a major barrier to treatment and touted the benefit of treatment options that address women and their children: “As the prevalence of substance use disorders among women with children has increased over recent decades, so, too, has the number of treatment programs that can accommodate young children. Where such programs are well-resourced, they may offer a range of on-site supportive services to client families, which may include case management services; parenting, financial management, and other life skills training; and health education and screening, among others.”
Despite the promise of family-integrated programs, Dr. Roach said the “relative scarcity of such programs remains a significant barrier to treatment for mothers of young children.” She said without state and local funding, the problem will likely persist. “The need for more programs that can accommodate mothers with young children could be an area of focus for community groups interested in taking action to improve treatment options for women with substance use disorders.”
What Do You Do if Someone Confides in You They’re Struggling with an Alcohol Addiction?
We asked Dr. Roach if she had any advice on how to address someone who confides in you they have a problem with alcohol. She responded:
“In my opinion, a woman who confides that she has a drinking problem is way ahead of the curve and well on her way to healing. As a friend, I can direct her to resources in the community for further evaluation and treatment, and assure her that I will stay with her throughout her journey to recovery. Sadly, a far more common scenario is the girl or woman who is drinking excessively but in denial about having a problem. In my experience, an honest, empathetic, shame and blame-avoidant approach to helping women friends and patients who use alcohol and other substances at harmful levels has worked best.”
What if Your Friend is in Denial of their Addiction to Alcohol?
In response to the friend who is in denial of her excessive drinking, Dr. Roach said it takes courage to be that person who stands up and voices her concerns:
“To say to a friend that you think she may be drinking or using other substances too much takes courage, as her initial response will likely be a defensive one, often manifesting as anger towards and distancing from you. We need to prepare ourselves for this and understand that it is the disease, not our friend, talking. The thing to remember is that by voicing our concern, we have done the very best that we can do by our friend at that moment, and at least cracked open a doorway to recovery. As a friend, my next goal is to remain a constant presence in that barely open door, and, as she is able to listen, to remind my friend that help is available, that treatment works, and that I will help her find a high quality program when she is ready.”
Get Help for Your Addiction to Alcohol
Alcohol addiction affects millions of people. RehabCenter.net is an online resource that will connect you with the professional support and comprehensive, evidence-based treatment options that will work best for you. For women with young children, residential treatment options are available. Contact us and speak with someone in confidence to learn more and take that next step toward a rewarding life in recovery.
Dr. Roach has 26 years of experience in the field of addiction treatment. She currently serves as a medical project officer for the National Institute on Alcohol Abuse and Alcoholism where, among other responsibilities, she manages research portfolios addressing the treatment of co-occurring mental health and alcohol use disorders and alcohol-related HIV/AIDS among women. She also serves on the Interagency Coordinating Committee on Fetal Alcohol Spectrum Disorders (ICCFASD), the National Institutes of Health (NIH) Coordinating Committee for Research on Women’s Health, and the Office of AIDS Research Committee for Research on Racial and Ethnic Minorities. Dr. Roach chairs the Women Drinking, and Pregnancy Work Group of the ICCFASD.