National Institute on Drug Abuse (NIDA) Substance Use in Women · cues as triggers and greater...
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1 National Institute on Drug Abuse (NIDA) Substance Use in Women Last Updated July 2018 https://www.drugabuse.gov
Transcript of National Institute on Drug Abuse (NIDA) Substance Use in Women · cues as triggers and greater...
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NationalInstituteonDrugAbuse(NIDA)
SubstanceUseinWomen
LastUpdatedJuly2018https://www.drugabuse.gov
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TableofContents
SubstanceUseinWomen
Summary
SexandGenderDifferencesinSubstanceUse
SubstanceUseWhilePregnantandBreastfeeding
SexandGenderDifferencesinSubstanceUseDisorderTreatment
OtherSexandGenderIssuesforWomenRelatedtoSubstanceUse
TheImportanceofIncludingWomeninResearch
WherecanIgetfurtherinformationaboutsubstanceuseinwomen?
References
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Summary
Peoplemayfaceuniqueissueswhenitcomestosubstanceuse,asaresultofbothsexandgender.Sexdifferencesresultfrombiologicalfactors,suchassexchromosomesandhormones,whilegenderdifferencesarebasedonculturallydefinedrolesformenandwomen,aswellasthosewhodonotidentifywitheithercategory.Genderrolesinfluencehowpeopleperceivethemselvesandhowtheyinteractwithothers. Sexandgendercanalsointeractwitheachothertocreateevenmorecomplexdifferencesamongpeople.WhiletheNIHisworkingtostrengthenresearchonsex/genderdifferencesacrossdomainsofhealth,currentevidenceislimited;forthepurposeofthisreport,maleandfemalesubjectsidentifyassuchacrossbothsexandgender.
ExamplesofSexandGenderInfluencesinSmokingCessation
SexDifference:Womenhaveahardertimequittingsmokingthanmendo.Womenmetabolizenicotine,theactiveingredientintobacco,fasterthanmen.Differencesinmetabolismmayhelpexplainwhynicotinereplacementtherapies,likepatchesandgum,workbetterinmenthaninwomen.Menappeartobemoresensitivetonicotine'spharmacologiceffectsrelatedtosubstanceusedisorder.
GenderDifference:Althoughmenaremoresensitivethanwomentonicotine'saddiction-relatedeffects,womenmaybemoresusceptiblethanmentonon-nicotinefactors,suchasthesensoryandsocialstimuliassociatedwithsmoking(e.g.greatersensitivitytovisualandolfactorycuesastriggersandgreaterconcernaboutweightgainwhilequitting).
Sources:ORWH,2015;NIDA,2002
Forexample,womenandmensometimesusedrugsfordifferentreasonsandrespondtothemdifferently.Additionally,substanceusedisorderscanmanifest
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differentlyinwomenthaninmen.Asubstanceusedisorderoccurswhenapersoncontinuestousedrugsoralcoholevenafterexperiencingnegativeconsequences.
Someoftheuniqueissueswomenwhousedrugsfacerelatetotheirreproductivecycles.Somesubstancescanincreasethelikelihoodofinfertilityandearlyonsetofmenopause. Substanceuseisalsofurthercomplicatedduringpregnancyandbreastfeeding.Pregnantwomenusingdrugs,includingtobaccoandalcohol,canpassthosedrugstotheirdevelopingfetusesandcausethemharm.Similarly,newmothersusingdrugscanpassthosetotheirbabiesthroughbreastmilkandcausethemharm.(SeeSubstanceUseWhilePregnantandBreastfeeding)
Unfortunately,itcanbedifficultforapersonwithasubstanceusedisordertoquit,andsomewomenwithsuchdisordersfearthatseekinghelpwhilepregnantorafterwardcouldcausethemlegalorsocialproblems.Communitiescanbuildsupportsystemstohelpwomenaccesstreatmentasearlyaspossible, ideallybeforebecomingpregnant.Ifawomanisunabletoquitbeforebecomingpregnant,treatmentduringpregnancyimprovesthechancesofhavingahealthierbabyatbirth.
Women,pregnantornot,haveuniqueneedsthatshouldbeaddressedduringsubstanceusedisordertreatment.Effectivetreatmentshouldincorporateapproachesthatrecognizesexandgenderdifferences,understandthetypesoftraumawomensometimesface,provideaddedsupportforwomenwithchildcareneeds,anduseevidence-basedapproachesforthetreatmentofpregnantwomen. (SeeSexandGenderDifferencesinSubstanceUseDisorderTreatment)
Despitethemanydifferencesbetweenmenandwomen,formanyyearsmostanimalandhumanresearchhastraditionallyusedmaleparticipants.Tofindoutmoreaboutsexandgenderdifferencestoinformbettertreatmentapproaches,federalagencieshavedevelopedguidelinestopromotetheinclusionofwomenandanalysesofsexandgenderdifferencesinresearch. (SeeTheImportanceofIncludingWomeninResearch)
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SexandGenderDifferencesinSubstanceUse
Menaremorelikelythanwomentousealmostalltypesofillicitdrugs, andillicitdruguseismorelikelytoresultinemergencydepartmentvisitsoroverdosedeathsformenthanforwomen."Illicit"referstouseofillegaldrugs,includingmarijuana(accordingtofederallaw)andmisuseofprescriptiondrugs.Formostagegroups,menhavehigherratesofuseordependenceonillicitdrugsandalcoholthandowomen. However,womenarejustaslikelyasmentodevelopasubstanceusedisorder. Inaddition,womenmaybemoresusceptibletocraving andrelapse, whicharekeyphasesoftheaddictioncycle.
Researchhasshownthatwomenoftenusedrugsdifferently,respondtodrugsdifferently,andcanhaveuniqueobstaclestoeffectivetreatmentassimpleasnotbeingabletofindchildcareorbeingprescribedtreatmentthathasnotbeenadequatelytestedonwomen.
IllegalDrugs
Marijuana(Cannabis)
Similartootheraddictivedrugs,fewerfemalesthanmalesusemarijuana. Forfemaleswhodousemarijuana,however,theeffectscanbedifferentthanformaleusers.Researchindicatesthatmarijuanaimpairsspatialmemoryinwomenmorethanitdoesinmen, whilemalesshowagreatermarijuana-inducedhigh.
Inonestudyspecifictoteenagers,malehighschoolstudentswhosmokemarijuanareportedpoorfamilyrelationshipsandproblemsatschoolmoreoftenthanfemalestudentswhosmokemarijuana. However,afewstudieshavesuggestedthatteenagegirlswhousemarijuanamayhavea
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higherriskofbrainstructuralabnormalitiesassociatedwithregularmarijuanaexposurethanteenageboys.
Animalstudiesshowthatfemaleratsaremoresensitivetotherewarding, pain-relieving, andactivity-altering effectsofmarijuana'smainactiveingredient,delta-9-tetrahydrocannabinol(THC).Manyofthesedifferenceshavebeenattributedtotheeffectsofsexhormones, althoughrodentresearchalsopointstothepossibilitythattherearesexdifferencesinthefunctioningoftheendocannabinoidsystem,thesystemofbrainsignalingwhereTHCandothercannabinoidsexerttheiractions.
MarijuanaUseDisorder
Men Women
Similarities
Atleastoneothermentalhealthdisorder
Lowrateofseekingtreatment
Differences
Othersubstanceusedisorders
Antisocialpersonalitydisorder
Severityofdisorder
Panicattacks
Anxietydisorders
Disorderdevelopsmorequickly
Forbothsexes,marijuanausedisorderisassociatedwithanincreasedriskofatleastoneothermentalhealthcondition,suchasdepressionoranxiety.However,menwhoareaddictedtomarijuanahavehigherratesofothersubstanceuseproblemsaswellasantisocialpersonalitydisorders.Bycontrast,womenwhoareaddictedtomarijuanahavemorepanicattacks andanxietydisorders. Althoughtheseverityofmarijuanausedisordersisgenerallyhigherformen,womentendtodevelopthese
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disordersmorequicklyaftertheirfirstmarijuanause. Ratesofseekingtreatmentformarijuanausedisorderarelowforbothsexes.
Stimulants(CocaineandMethamphetamine)
Researchinbothhumansandanimalssuggeststhatwomenmaybemorevulnerabletothereinforcing(rewarding)effectsofstimulants,withestrogenpossiblybeingonefactorforthisincreasedsensitivity. Inanimalstudies,femalesarequickertostarttakingcocaine—andtakeitinlargeramounts—thanmales.Womenmayalsobemoresensitivethanmentococaine'seffectsontheheartandbloodvessels.Incontrast,femaleandmalecocaineusersshowsimilardeficitsinlearning,concentration,andacademicachievement,evenifwomenhadbeenusingitlonger.Femalecocaineusersarealsolesslikelythanmaleuserstoexhibitabnormalitiesofbloodflowinthebrain'sfrontalregions.Thesefindingssuggestasex-relatedmechanismthatmayprotectwomenfromsomeofthedetrimentaleffectsofcocaineonthebrain.
Asformethamphetamine,womenreportusingthedrugbecausetheybelieveitwillincreaseenergyanddecreaseexhaustionassociatedwithwork,homecare,childcare,andfamilyresponsibilities.Weightlossisanotherincentivewomenciteformethamphetamineuse—andonereportedsignificantlymorebywomenthanbymen. Womenalsoreportusingmethamphetaminebecausetheybelieveitwillincreaseenergyanddecreaseexhaustionassociatedwithwork,homecare,childcare,andfamilyresponsibilities. Womenwhousemethamphetaminealsohavehighratesofco-occurringdepression.
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Womentendtobeginusingmethamphetamineatanearlieragethandomen, withfemaleuserstypicallymoredependentonmethamphetaminecomparedtomaleusers. Womenarealsolesslikelytoswitchtoanotherdrugwhentheylackaccesstomethamphetamine. Inaddition,aswithothersubstances,womentendtobemorereceptivethanmentomethamphetaminetreatment.
Source:Brechtetal.,2004
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MDMA(Ecstasy,Molly)
ResearchsuggeststhatMDMAproducesstrongerhallucinatoryeffectsinwomencomparedtomen,althoughmenshowhigherMDMA-inducedbloodpressureincreases. Thereissomeevidencethat,inoccasionalusers,womenaremorepronethanmentofeelingdepressedafewdaysaftertheylastusedMDMA. BothmenandwomenshowsimilarincreasesinaggressionafewdaysaftertheystopusingMDMA.
MDMAcaninterferewiththebody'sabilitytoeliminatewateranddecreasesodiumlevelsintheblood,causingapersontodrinklargeamountsoffluid.Inrarecases,thiscanleadtoincreasedwaterinthespacesbetweencells,whichmayeventuallyproduceswellingofthebrainandevendeath.Youngwomenaremorelikelythanmentodiefromthisreaction,withalmostallreportedcasesofdeathoccurringinyoungfemalesbetweentheagesof15and30. MDMAcanalsointerferewithtemperatureregulationandcauseacutehyperthermia,leadingtoneurotoxiceffectsandevendeath.
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Heroin
Comparedwithmen,womenwhouseheroinare:younger
likelytousesmalleramountsandforashortertime
lesslikelytoinjectthedrug
moreinfluencedbydrug-usingsexualpartners
Researchsuggeststhatwomentendtousesmalleramountsofheroinandforlesstime,andarelesslikelythanmentoinjectit. Mostwomenwhoinjectheroinpointtosocialpressureandsexualpartnerencouragementasfactors. Onestudyindicatesthatwomenaremoreatriskthanmenforoverdosedeathduringthefirstfewyearsofinjectingheroin,butitisunclearwhythismightbethecase.Onepossibilityisthatwomenwhoinjectheroinaremorelikelythantheirmalecounterpartstoalsouseprescriptiondrugs—adangerouscombination.Womenwhodonotoverdosewithinthesefirstfewyearsaremorelikelythanmentosurviveinthelongterm.Thiscouldbeduetodifferencesintreatmentandotherenvironmentalfactorsthatimpactheroinuse.
PrescriptionDrugs
Prescriptiondrugmisuseistheuseofamedicationwithoutaprescription,inawayotherthanasprescribed,orfortheexperienceorfeelingselicited.Prescriptiondrugmisusecanbedangerousifmixedtogetherwithoutaphysician'sguidance,ormixedwithotherdrugsoralcohol.
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PrescriptionOpioids
Someresearchindicatesthatwomenaremoresensitivetopainthanmen andmorelikelytohavechronicpain, whichcouldcontributetothehighratesofopioidprescriptionsamongwomenofreproductiveage. Inaddition,womenmaybemorelikelytotakeprescriptionopioidswithoutaprescriptiontocopewithpain,evenwhenmenandwomenreportsimilarpainlevels.Researchalsosuggeststhatwomenaremorelikelytomisuseprescriptionopioidstoself-treatforotherproblemssuchasanxietyortension.
Apossibleconsequenceofprescriptionopioidmisuseisfataloverdose,whichcanoccurbecauseopioidssuppressbreathing.In2016,7,109womenand9,978mendiedfromprescriptionopioidoverdose(atotalof17,087)*whichisabout19womenperdaycomparedtoabout27mendyingfromoverdosingonprescriptionopioids.However,from1999to2016,deathsfromprescriptionopioidoverdosesincreasedmorerapidlyforwomen(596percentorsevenfold)thanformen(312percentorfourfold).Womenbetweentheagesof45and54aremorelikelythanwomenofotheragegroupstodiefromaprescriptionopioidoverdose.
*Notethatinthisinstance,“prescriptionopioids”includesotheropioidsandmethadone(ICD-10codesT40.2-T40.3).
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Anti-AnxietyMedicationsandSleepingAids
Womenaremorelikelytoseektreatmentformisuseofcentralnervoussystemdepressants, whichincludesedativessometimesprescribedtotreatseizures,sleepdisorders,andanxiety,andtohelppeoplefallasleeppriortosurgery.Womenarealsomorelikelythanmentodiefromoverdosesinvolvingmedicationsformentalhealthconditions,likeantidepressants.Antidepressantsandbenzodiazepines(anti-anxietyorsleepdrugs)sendmorewomenthanmentoemergencydepartments.Becausewomenarealsomoreatriskthanmenforanxiety andinsomnia, itispossiblethatwomenarebeingprescribedmoreofthesetypesofmedications;greateraccesscanincreasetheriskofmisuseandleadtosubstanceusedisorderoroverdose.
OtherSubstances
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Alcohol
Ingeneral,menhavehigherratesofalcoholuse,includingbingedrinking.However,youngadultsareanexception:girlsages12to20haveslightlyhigherratesofalcoholmisuseandbingedrinkingthantheirmalecounterparts.
Drinkingoverthelongtermismorelikelytodamageawoman'shealththanaman's,evenifthewomanhasbeendrinkinglessalcoholorforashorterlengthoftime. Comparingpeoplewithalcoholusedisorders,womenhavedeathrates50to100percenthigherthandomen,includingdeathsfromsuicides,alcohol-relatedaccidents,heartdisease,stroke,andliverdisease. Inaddition,therearesomehealthrisksthatareuniquetofemaledrinkers.Forexample,heavydrinkingisassociatedwithincreasedriskofhavingunprotectedsex,resultinginpregnancyordisease, andanincreasedriskofbecomingavictimofviolenceandsexualassault.Inaddition,drinkingaslittleasonedrinkperdayisassociatedwithahigherriskofbreastcancerinsomewomen,especiallythosewhoarepostmenopausalorhaveafamilyhistoryofbreastcancer.
Inaddition,menandwomenmetabolizealcoholdifferentlyduetodifferencesingastrictissueactivity.Infact,afterdrinkingcomparableamountsofalcohol,womenhavehigherbloodethanolconcentrations. Asaresult,womenbecomeintoxicatedfromsmallerquantitiesofalcoholthanmen.
MoreinformationonsexandgenderdifferencesinalcoholuseisavailablefromtheNationalInstituteofAlcoholAbuseandAlcoholism(NIAAA).
Nicotine(Tobacco)
Researchindicatesthatmenandwomendifferintheirsmokingbehaviors.Forinstance,womensmokefewercigarettesperday,tendtousecigaretteswithlowernicotinecontent,anddonotinhaleasdeeplyas
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men. Womenalsomaysmokefordifferentreasonsthanmen,includingregulationofmoodandstress. Itisunclearwhetherthesedifferencesinsmokingbehaviorsarebecausewomenaremoresensitivetonicotine,becausetheyfindthesensationsassociatedwithsmokinglessrewarding,orbecauseofsocialfactorscontributingtothedifference;someresearchalsosuggestswomenmayexperiencemorestressandanxietyasaresultofnicotinewithdrawalthanmen.
Riskofdeathfromsmoking-associatedlungcancer,chronicobstructivepulmonarydisease,heartdisease,andstrokecontinuestoincreaseamongwomen—approachingratesformen. Accordingtodatacollectedfrom2005to2009,approximately201,000womendieeachyearduetofactorsrelatedtosmoking—comparedtoabout278,000men. Somedangersassociatedwithsmoking—suchasbloodclots,heartattack,orstroke—increaseinwomenusingoralcontraceptives.
ThenumberofsmokersintheUnitedStatesdeclinedinthe1970sand1980s,remainedrelativelystablethroughoutthe1990s,anddeclinedfurtherthroughtheearly2000s.Becausethisdeclineinsmokingwasgreateramongmenthanwomen,theprevalenceofsmokingisonlyslightlyhigherformentodaythanitisforwomen.Severalfactorsappeartobecontributingtothisnarrowinggendergap,includingwomenbeinglesslikelythanmentoquitandmorelikelytorelapseiftheydoquit.
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SubstanceUseWhilePregnantandBreastfeeding
Researchshowsthatuseoftobacco,alcohol,orillicitdrugsormisuseofprescriptiondrugsbypregnantwomencanhaveseverehealthconsequencesforinfants.Thisisbecausemanysubstancespasseasilythroughtheplacenta,sosubstancesthatapregnantwomantakesalsoreachthefetus. Recentresearchshowsthatsmokingtobaccoormarijuana,takingprescriptionpainrelievers,orusingillegaldrugsduringpregnancyisassociatedwithdoubleoreventripletheriskofstillbirth. Estimatessuggestthatabout5percentofpregnantwomenuseoneormoreaddictivesubstances.
Regularuseofsomedrugscancauseneonatalabstinencesyndrome(NAS),inwhichthebabygoesthroughwithdrawaluponbirth.Mostresearchinthisareahasfocusedontheeffectsofopioids(prescriptionpainrelieversorheroin).However,datahasshownthatuseofalcohol,barbiturates,benzodiazepines,andcaffeineduringpregnancymayalsocausetheinfanttoshowwithdrawalsymptomsatbirth. Thetypeandseverityofaninfant'swithdrawalsymptomsdependonthedrug(s)used,howlongandhowoftenthebirthmotherused,howherbodybreaksthedrugdown,andwhethertheinfantwasbornfulltermorprematurely.
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RisksofStillbirthfromSubstanceUseinPregnancy
Tobaccouse—1.8to2.8timesgreaterriskofstillbirth,withthehighestriskfoundamongtheheaviestsmokers
Marijuanause—2.3timesgreaterriskofstillbirth
Evidenceofanystimulant,marijuana,orprescriptionpainrelieveruse—2.2timesgreaterriskofstillbirth
Passiveexposuretotobacco—2.1timesgreaterriskofstillbirth
Source:Tobacco,druguseinpregnancy,2013
Symptomsofdrugwithdrawalinanewborncandevelopimmediatelyorupto14daysafterbirthandcaninclude :
blotchyskincoloring
diarrhea
excessiveorhigh-pitchedcrying
abnormalsuckingreflex
fever
hyperactivereflexes
increasedmuscletone
irritability
poorfeeding
rapidbreathing
seizures
sleepproblems
slowweightgain
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stuffynoseandsneezing
sweating
trembling
vomiting
Effectsofusingsomedrugscouldbelong-termandpossiblyfataltothebaby:
birthdefects
lowbirthweight
prematurebirth
smallheadcircumference
suddeninfantdeathsyndrome(SIDS)
IllegalDrugs
Marijuana(Cannabis)
Moreresearchneedstobedoneonhowmarijuanauseduringpregnancycouldimpactthehealthanddevelopmentofinfants,givenchangingpoliciesaboutaccesstomarijuana,significantincreasesinthenumberofpregnantwomenseekingsubstanceusedisordertreatmentformarijuanause,andconfoundingeffectsofpolysubstanceuse Unfortunately,giventheunreliablenatureofself-reporteddata,thenumberofwomenwhousemarijuanawhilepregnantisunknown.
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Thereisnohumanresearchconnectingmarijuanausetothechanceofmiscarriage, althoughanimalstudiesindicatethattheriskformiscarriageincreasesifmarijuanaisusedearlyinpregnancy. Someassociationshavebeenfoundbetweenmarijuanauseduringpregnancyandfuturedevelopmentalandhyperactivitydisordersinchildren.Thereissubstantialevidenceofastatisticalassociationbetweenmarijuanasmokingamongpregnantwomenandlowbirthweight.Researcherstheorizethatelevatedlevelsofcarbondioxidemightrestrictfetalgrowthinwomenwhousemarijuanaduringpregnancy. Evidenceismixedrelatedtoprematurebirth, althoughsomeevidencesuggestslong-termusemayelevatetheserisks. Giventhepotentialofmarijuanatonegativelyimpactthedevelopingbrain,theAmericanCollegeofObstetriciansandGynecologistsrecommendsthatobstetrician-gynecologistscounselwomenagainstusingmarijuanawhiletryingtogetpregnant,duringpregnancy,andwhiletheyarebreastfeeding.
Somewomenreportusingmarijuanatotreatseverenauseaassociatedwiththeirpregnancy; however,thereisnoresearchconfirmingthatthisisasafepractice,anditisgenerallynotrecommended.Women
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consideringusingmedicalmarijuanawhilepregnantshouldnotdosowithoutcheckingwiththeirhealthcareprovider.AnimalstudieshaveshownthatmoderateconcentrationsofTHC,whenadministeredtomotherswhilepregnantornursing,couldhavelong-lastingeffectsonthechild,includingincreasingstressresponsivityandabnormalpatternsofsocialinteractions. Animalstudiesalsoshowlearningdeficitsinprenatallyexposedindividuals.
Humanresearchhasshownthatsomebabiesborntowomenwhousedmarijuanaduringtheirpregnanciesdisplayalteredresponsestovisualstimuli,increasedtrembling,andahigh-pitchedcry, whichcouldindicateproblemswithneurologicaldevelopment. Inschool,marijuana-exposedchildrenaremorelikelytoshowgapsinproblem-solvingskills,memory, andtheabilitytoremainattentive. Moreresearchisneeded,however,todisentanglemarijuana-specificeffectsfromthoseofotherenvironmentalfactorsthatcouldbeassociatedwithamother'smarijuanause,suchasanimpoverishedhomeenvironmentorthemother'suseofotherdrugs. Prenatalmarijuanaexposureisalsoassociatedwithanincreasedlikelihoodofapersonusingmarijuanaasayoungadult,evenwhenotherfactorsthatinfluencedruguseareconsidered. MoreinformationonmarijuanauseduringpregnancyinNIDA'sMarijuanaResearchReport.
Thenumberofwomenwhousemarijuanawhilepregnantisunknown.Onestudyfoundthatabout20%ofpregnantwomen24-years-oldandyoungerscreenedpositiveformarijuana.However,thisstudyalsofoundthatwomenwereabouttwiceaslikelytoscreenpositiveformarijuanauseviaadrugtestthantheystateinself-reportedmeasures.Thissuggeststhatself-reportedratesofmarijuanauseinpregnantfemalesisnotanaccuratemeasureofmarijuanauseandmaybeanunderestimation.
Verylittleisknownaboutmarijuanauseandbreastfeeding.OnestudysuggeststhatmoderateamountsofTHCfindtheirwayintobreastmilkwhenanursingmotherusesmarijuana. Someevidenceshowsthat
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exposuretoTHCthroughbreastmilkinthefirstmonthoflifecouldresultindecreasedmotordevelopmentat1yearofage. TherehavebeennostudiestodetermineifexposuretoTHCduringnursingislinkedtoeffectslaterinthechild'slife.Withregularuse,THCcanaccumulateinhumanbreastmilktohighconcentrations. Becauseababy'sbrainisstillforming,THCconsumedinbreastmilkcouldaffectbraindevelopment.Givenalltheseuncertainties,nursingmothersarediscouragedfromusingmarijuana. Newmothersusingmedicalmarijuanashouldbevigilantaboutcoordinatingcarebetweenthedoctorrecommendingtheirmarijuanauseandthepediatriciancaringfortheirbaby.
Stimulants(CocaineandMethamphetamine)
Itisnotcompletelyknownhowapregnantwoman'scocaineuseaffectsherchild,sincecocaine-usingwomenaremorelikelytoalsouseotherdrugssuchasalcohol,tohavepoornutrition,ortonotseekprenatalcare.Allofthesefactorscanaffectadevelopingfetus,makingitdifficulttoisolatetheeffectsofcocaine.
Researchdoesshow,however,thatpregnantwomenwhousecocaineareathigherriskformaternalmigrainesandseizures,prematuremembranerupture,andplacentalabruption(separationoftheplacentalliningfromtheuterus). Pregnancyisaccompaniedbynormalcardiovascularchanges,andcocaineuseexacerbatesthesechanges—sometimesleadingtoseriousproblemswithhighbloodpressure(hypertensivecrisis),spontaneousmiscarriage,pretermlabor,anddifficultdelivery. Babiesborntomotherswhousecocaineduringpregnancymayalsohavelowbirthweightandsmallerheadcircumferences,andareshorterinlengththanbabiesborntomotherswhodonotusecocaine.Theyalsoshowsymptomsofirritability,hyperactivity,tremors,high-pitchedcry,andexcessivesuckingatbirth. Thesesymptomsmaybeduetotheeffectsofcocaineitself,ratherthanwithdrawal,sincecocaineanditsmetabolitesarestillpresentinthebaby'sbodyupto5to7daysafterdelivery.
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Estimatessuggestthatthereareabout750,000cocaine-exposedpregnancieseveryyear.
Pregnantwomenwhousemethamphetaminehaveagreaterriskofpreeclampsia(highbloodpressureandpossibleorgandamage),prematuredelivery,andplacentalabruption.Theirbabiesaremorelikelytobesmallerandtohavelowbirthweight. Inalarge,longitudinalstudyofchildrenprenatallyexposedtomethamphetamine,exposedchildrenhadincreasedemotionalreactivityandanxiety/depression,weremorewithdrawn,hadproblemswithattention,andshowedcognitiveproblemsthatcouldleadtopooreracademicoutcomes.
MDMA(Ecstasy,Molly)
MoreresearchisneededontheeffectsofMDMAuseduringpregnancy.WhatresearchexistssuggeststhatprenatalMDMAexposuremaycauselearning,memory, andmotorproblemsinthebaby.
Heroin
Heroinuseduringpregnancycanresultinneonatalabstinencesyndrome(NAS)specificallyassociatedwithopioiduse.NASoccurswhenheroinpassesthroughtheplacentatothefetusduringpregnancy,causingthebabytobecomedependentonopioids.Symptomsincludeexcessivecrying,high-pitchedcry,irritability,seizures,andgastrointestinalproblems,amongothers.
Medications
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PrescriptionandOver-the-Counter(OTC)Drugs
Pregnancycanbeaconfusingtimeforwomenfacingmanychoicesaboutlegaldrugs,liketobaccoandalcohol,aswellasprescriptionandover-the-counter(OTC)drugsthatmayaffectthedevelopingfetus.Thesearedifficultissuesforresearcherstostudybecausescientistscannotgivepotentiallydangerousdrugstopregnantwomen.Herearesomeoftheknownfactsaboutpopularmedicationsandpregnancy:
Therearemorethan6millionpregnanciesintheUnitedStateseveryyear, andabout9outof10pregnantwomentakemedication. TheU.S.FoodandDrugAdministrationissuedrulesondruglabelingtoprovideclearerinstructionsforpregnantandnursingwomen,includingasummaryoftherisksofuseduringpregnancyandbreastfeeding,adiscussionofthedatasupportingthesummary,andotherinformationtohelpprescribersmakesafedecisions.
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Evenso,weknowlittleabouttheeffectsoftakingmostmedicationsduringpregnancy.Fewerthan10%ofprescriptionshaveenoughinformationtodeterminefetalrisks. Thisisbecausepregnantwomenareoftennotincludedinstudiestodeterminesafetyofnewmedicationsbeforetheycomeonthemarket. Onestudyshowsthatuseofshort-actingprescriptionopioidssuchasoxycodoneduringpregnancy,especiallywhencombinedwithtobaccoand/orcertainantidepressantmedications,isassociatedwithanincreasedlikelihoodofNASintheinfant.
AlthoughsomeprescriptionandOTCmedicationsaresafetotakeduringpregnancy,apregnantwomanshouldtellherdoctoraboutallprescriptionandover-the-countermedications,andherbalordietarysupplementssheistakingorplanningtotake.Thiswillallowherdoctortoweightherisksandbenefitsofamedicationduringpregnancy.Insomecases,thedoctormayrecommendthecontinueduseofspecificmedications,eventhoughtheycouldhavesomeimpactonthefetus.Suddenlystoppingtheuseofamedicationmaybemoreriskyforboththemotherandfetusthancontinuingtousethemedicationwhileunderadoctor'scare. Thiscouldalsoincludemedicationstotreatsubstanceusedisorders—somethingthatisdiscussedinfurtherdetailinthe"SexandGenderDifferencesinSubstanceUseDisorderTreatment."
SomeprescriptionandOTCmedicationsaregenerallycompatiblewithbreastfeeding.Others,suchassomeanti-anxietyandantidepressantmedications,haveunknowneffects, somotherswhoareusingthesemedicationsshouldconsultwiththeirdoctorbeforebreastfeeding.Nursingmothersshouldcontacttheirinfant'shealthcareprovideriftheirinfantsshowanyofthesereactionstothebreastmilk:diarrhea,excessivecrying,vomiting,skinrashes,lossofappetite,orsleepiness.
OtherSubstances
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Alcohol
AlcoholusewhilepregnantcanresultinFetalAlcoholSpectrumDisorders(FASD),ageneraltermthatincludesFetalAlcoholSyndrome,partialFetalAlcoholSyndrome,alcohol-relateddisordersofbraindevelopment,andalcohol-relatedbirthdefects.Theseeffectscanlastthroughoutlife,causingdifficultieswithmotorcoordination,emotionalcontrol,schoolwork,socialization,andholdingajob.MoreinformationcanbefoundontheNIAAAFetalAlcoholExposurewebpage.
Fetalalcoholexposureoccurswhenawomandrinkswhilepregnant.Alcoholcandisruptfetaldevelopmentatanystageduringapregnancy—includingattheearlieststagesbeforeawomanevenknowssheispregnant.
Thereiscurrentlylittleresearchintohowanursingmother'salcoholusemightaffectherbreastfedbaby.Whatsciencesuggestsisthat,contrarytofolklore,alcoholdoesnotincreaseanursingmother'smilkproduction,anditmaydisruptthebreastfedchild'ssleepcycle. TheAmericanAcademyofPediatricsrecommendsthatalcoholdrinkingshouldbeminimizedduringthemonthsawomannursesanddailyintakelimitedtonomorethan2ouncesofliquor,8ouncesofwine,ortwoaveragebeersfora130-poundwoman.Inthiscase,nursingshouldtakeplaceatleast2hoursafterdrinkingtoallowthealcoholtobereducedoreliminatedfromthemother'sbodyandmilk.Thiswillminimizetheamountofalcoholpassedtothebaby.
Nicotine(TobaccoProductsande-Cigarettes)
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Almost10percentofpregnantwomenintheUnitedStateshavesmokedcigarettesinthepastmonth. Carbonmonoxideandnicotinefromtobaccosmokemayinterferewiththeoxygensupplytothefetus.Nicotinealsoreadilycrossestheplacenta,andconcentrationsofthisdruginthebloodofthefetuscanbeasmuchas15percenthigherthaninthemother.Smokingduringpregnancyincreasestheriskforcertainbirthdefects,prematurebirth,miscarriage,andlowbirthweightandisestimatedtohavecausedmorethan1,000infantdeathseachyear. Newbornsofsmokingmothersalsoshowsignsofstressanddrugwithdrawalconsistentwithwhathasbeenreportedininfantsexposedtootherdrugs.Insomecases,smokingduringpregnancymaybeassociatedwithsuddeninfantdeathsyndrome(SIDS),aswellaslearningandbehavioralproblemsandanincreasedriskofobesityinchildren.Inaddition,smokingmorethanonepackadayduringpregnancynearlydoublestheriskthattheaffectedchildwillbecomeaddictedtotobaccoifthatchildstartssmoking. Evenamother'ssecondhandexposuretocigarettesmokecancauseproblems;suchexposureisassociatedwithprematurebirthandlowbirthweight,forexample.
Researchprovidesstrongsupportthatnicotineisagatewaydrug,makingthebrainmoresensitivetotheeffectsofotherdrugssuchascocaine.Thisshowsthatpregnantwomenwhousenicotinemaybeaffectingtheirfetus'sbraininwaystheymaynotanticipate.Additionally,e-cigarettes(ore-vaporizers)sometimescontainnicotine.Therefore,thoseproductsmayalsoposearisktothefetus'shealth.Moreresearchisneeded.
Similartopregnantwomen,nursingmothersarealsoadvisedagainstusingtobacco.Newmotherswhosmokeshouldbeawarethatnicotineispassedthroughbreastmilk, sotobaccousecanimpacttheinfant'sbrainandbodydevelopment—evenifthemotherneversmokesnearthebaby.Thereisalsoevidencethatthemilkofmotherswhosmokesmellsandmaytastelikecigarettes.Itisunclearwhetherthiswillmakeitmorelikelythatexposedchildrenmayfindtobaccoflavors/smellsmoreappealinglaterinlife.
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NewbornsexposedtosecondhandsmokeareatgreaterriskforSIDS,respiratoryillnesses(asthma,respiratoryinfections,andbronchitis),earinfections, cavities, andincreasedmedicalvisitsandhospitalizations. Ifawomansmokesandisplanningapregnancy,theidealtimetoseeksmokingcessationhelpisbeforeshebecomespregnant.
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SexandGenderDifferencesinSubstanceUseDisorderTreatment
Therearemorementhanwomenintreatmentforsubstanceusedisorders.However,womenaremorelikelytoseektreatmentfordependenceonsedativessuchasanti-anxietyandsleepmedications. Inaddition,althoughmenhavehistoricallybeenmorelikelytoseektreatmentforheroinuse,therateofwomenseekingtreatmenthasincreasedinrecentdecades.
Substanceusedisordersmayprogressdifferentlyforwomenthanformen.Womenoftenhaveashorterhistoryofusingcertainsubstancessuchascocaine, opioids, marijuana, oralcohol. However,theytypicallyentersubstanceusedisordertreatmentwithmoreseveremedical,behavioral,psychological,andsocialproblems.Thisisbecausewomenshowaquickerprogressionfromfirstusingthesubstancetodevelopingdependence.
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Manywomenwhoarepregnantorhaveyoungchildrendonotseektreatmentordropoutoftreatmentearlybecausetheyareunabletotakecareoftheirchildren;theymayalsofearthatauthoritieswillremovetheirchildrenfromtheircare.Thecombinedburdensofwork,homecare,childcare,andotherfamilyresponsibilities,plusattendingtreatmentfrequently,canbeoverwhelmingformanywomen.Successfultreatmentmayneedtoprovideanincreasedlevelofsupporttoaddresstheseneeds.
WomenandSmokingCessationTreatment
Researchshowsthatwomenarelesslikelytotrytoquitsmokingandmorelikelytorelapseiftheydoquit. Nicotine-replacementoptions,suchasthepatchorgum,arenotaseffectiveforwomenasformen,andnicotinewithdrawalmaybemoreintenseforwomen. Nicotinecraving andwithdrawal varyacrossthemenstrualcycle,whichmayfurthercomplicateawoman'sattemptstoquit.
Thestressontheheartduetosmokingonepackofcigarettesperdayistheequivalentofbeing90poundsoverweight.
Somewomencontinuetosmokebecausetheyareafraidtheywillgainweight.However,researchshowsonlyamodestweightgainafterquitting.Theaveragesmokergains6to10poundsafterquittingsmoking,butcertaindietandlifestylechangescanreducetheriskofweightgain.Ifapersondoesgainweight,the
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SeeSAMHSA'sBehavioralHealthTreatmentServicesLocatorwebpage
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averagepersonlosesmuchoftheextraweightwithin6months. Infact,long-termquittersgain,onaverage,only2pounds. Mostimportantly,thehealthbenefitsofquittingsmokingfarexceedtherisksofgainingafewpounds.Quittingalsodecreasesrisksforvarioustypesofcancers,heartattack,andlungdisease.
SubstanceUseDisorderTreatmentforMothersandTheirBabiesWhilePregnantorBreastfeeding
Apregnantwomanshouldaskformedicalhelptostopherdruguse.Ifsheattemptstosuddenlywithdrawfromaddictivedrugsandalcoholwithoutmedicalassistance,shecouldbeputtingherfetusatrisk.
Intensiveoutpatienttreatment,whichprovidesahighertreatmentlevelthantraditionaloutpatientprogramsbutdoesnotrequirestructuredresidentialliving,hasproducedpositiveresultsforpregnantwomen.Pregnantwomenaremorelikelytostayinthesetreatmentprogramsiftheyprovideservicessuchaschildcare, parentingclasses,andvocationaltraining.
Federallawrequiresthatpregnantwomenreceivepriorityadmissionintopubliclyfundedsubstanceusedisordertreatmentprograms,allowingthemtobypasswaitinglistsandgainimmediateadmissionwhenabedinaresidentialprogramisavailable.Theprimarytreatmentprovidermustsecureprenatalcareifapregnantwomanisnotalreadyreceivingsuchcare. State-levelcontactsforthisprogramareavailablefromhttps://www.samhsa.gov/sites/default/files/ssadirectory.pdf
Inaddition,itisimportanttomonitornewbornsofsubstance-usingmothersforsymptomsofwithdrawalandprovidepropertreatmentifnecessary.Treatmentofdrugdependencyinnewbornsdependsontheseverityofsymptomsand,whilenonpharmacologicaltreatmentsarepreferred,itsometimesmayincludehospitalizationinordertoreceiveintravenousfluidsandmedications.Thesemedicationsaregraduallytaperedoffuntiltheinfantadaptstobeingdrug-free.
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TreatingOpioidUseDisordersinPregnantWomen
Pregnantwomenwhoareaddictedtoopioidpainrelieversorheroinfacespecialproblemsbecausethebabycanbeborndependent.Currently,theU.S.FoodandDrugAdministrationhasnotapprovedmedicationstotreatopioid-dependentpregnantwomen,butmethadoneorbuprenorphinemaintenancecombinedwithprenatalcareandacomprehensivedrugtreatmentprogramcanimprovemanyoftheadverseoutcomesassociatedwithuntreatedopioidusedisorder. Ingeneral,itisneitherrecommendednornecessaryforpregnantwomentoceasemethadoneorbuprenorphinetreatment.However,newbornsexposedtomethadoneduringpregnancycanrequiretreatmentforwithdrawalsymptoms.
Somestudiessuggestthatbuprenorphine(Suboxone ,Subutex )hassomeadvantagesoversingle-dosemethadoneasatreatmentforopioidusedisorderinpregnantwomen.Infantsborntomotherstreatedwithbuprenorphinehadfewersymptomsofdependenceandreducedlengthofhospitalstaycomparedtothosetreatedwithmethadone.
Pregnantwomenwhotakebuprenorphineforopioidusedisorderduringpregnancyshouldbeawarethattheamountofbuprenorphinepassedthroughbreastmilkmaybeinadequatetopreventopioidwithdrawalintheirinfant.Insomecases,treatmentoftheinfantmayberequired.
Pregnantwomenwhoareaddictedtoopioids,eveniftheyareintreatment,shouldmonitortheirbabiesfordrowsiness,inadequateweightgain,andfailuretomeetdevelopmentalmilestones—especiallyinyounger,exclusivelybreastfedinfants.Althoughunlikely,ifabreastfedbabyofawomanonbuprenorphinetherapyshowssignsofincreasedsleepiness,difficultyfeedingorbreathing,orlimpness,ahealthcareprovidershouldbecontactedimmediately.Infantsshouldbeobservedforwithdrawalsignsifbreastfeedingisabruptlystopped.
AsforinfantsbornwithNASduetoopioids,recoverycanrequirehospitalizationandpossiblytreatmentwithmorphineormethadonetorelievesymptoms;researchershavealsostudiedbuprenorphineforthispurpose. Thereis
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someevidencethatbuprenorphineissuperiortomorphineintreatinginfantswithopioid-relatedNAS.ANIDA-fundedstudypublishedfoundthattreatingNASbabieswithsublingualbuprenorphineresultedinashorterdurationoftreatmentthanoralmorphine.Italsoresultedinashorterlengthofhospitalstay,withsimilarratesofadverseevents.175
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OtherSexandGenderIssuesforWomenRelatedtoSubstanceUse
Co-OccuringMentalHealthDisorders
Manywomenwithsubstanceusedisordersarealsodiagnosedwithothermentaldisorders.Thisisimportantbecauseinteractionsbetweenillnessescanworsenthecourseofboth.Patientswhohavebothasubstanceusedisorderandanothermentalhealthconditionoftenhavesymptomsthataremorepersistent,severe,andresistanttotreatmentcomparedwithpatientswhohaveeitherdisorderalone.Bothdisordersshouldbetreatedatthesametimetoimprovethelikelihoodofsuccess.Althoughmenaremorelikelythanwomentoreportbothamentalhealthandsubstanceusedisorderwithinthepastyear,womenaremorelikelytosufferfromcertainmentalhealthconditions,suchasdepression, anxiety,post-traumaticstressdisorder(PTSD), andeatingdisorders. Somewomenreportusingsubstancestorelievestressornegativeemotions. Inaddition,womenaremorevulnerabletodevelopingsubstanceuseorothermentalhealthdisordersfollowingdivorce,lossofchildcustody,orthedeathofapartnerorchild.
Women,Violence,andSubstanceAbuse
Morethan1in3womenhaveexperiencedphysicalviolenceatthehandsofan
MoreinformationaboutcomorbiditycanbefoundinNIDA'sResearchReport.
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intimatepartner,includingarangeofbehaviorsfromslapping,pushing,orshovingtosevereactssuchasbeingbeaten,burned,raped,orchoked.Victimsofviolenceareatincreasedriskofchronichealthconditions,includingobesity,chronicpain,depression,andsubstanceuse. Inrecognitionoftheseverityofviolenceagainstwomenandtheneedforanationalstrategytoaddressthisissue,in1994CongressenactedtheViolenceAgainstWomenActtoholdoffendersaccountableandtoprovideservicestovictims. In2013,PresidentObamareauthorizedtheActtoexpandprogramsforreachingespeciallyvulnerablepopulations.
TheInstituteofMedicineandtheU.S.PreventiveServicesTaskForce(USPSTF)haverecommendedthatcliniciansscreenandcounselforinterpersonalviolence.Tohelpmeetthatneed,theAffordableCareActof2010(Section2713)requiresthathealthinsuranceproviderscoverallpreventiveservicesrecommendedbytheUSPSTFwithoutcopaysordeductibles.However,improvedpreventionandscreeningguidelinesareneededtohelpcliniciansidentifythosewhoneedhelpandlinkthemtothecaretheyneed.
RaceandEthnicity
Womenofcolormayfaceuniqueissueswithregardtodruguseandtreatmentneeds.Forexample,African-AmericanandAmericanIndian/AlaskaNativewomenaremorelikelythanwomenofotherracialandethnicgroupstobevictimsofrape,physicalviolence,andstalkingbyanintimatepartnerintheirlifetime.Asdiscussedabove,theseissuesareriskfactorsforsubstanceuseandshouldbeaddressedduringtreatment.MoreinformationcanbefoundinWomenofColor:HealthDataBook.
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TheImportanceofIncludingWomeninResearch
Inthepast,womenwerenotincludedinmostclinicalresearch.Thiswasoftenbasedontwonotions:(1)thatwomenaremorebiologicallycomplicatedthanmen;and(2)asprimarycaregiversofyoungchildren,awomanhadtoomanycompetingtimedemandstoparticipateinresearchstudies. Morethantwodecadesago,NIHestablishedtheOfficeofResearchonWomen'sHealth,inrecognitionthatexcludingspecificsubgroupsfromresearchproducesknowledgethatonlyhelpsaportionofthepublic.In1991,theU.S.DepartmentofHealthandHumanServicesestablishedtheOfficeonWomen'sHealthtoensurethatbroaderpublichealthissuesrelatedtosexandgenderwereaddressed.Sincetheseofficeswereestablished,significantprogresshasbeenmadeinseveralmajorareas:
PolicieshavebeenimplementedensuringthatwomenandminoritiesareincludedinNIH-fundedclinicalresearch
Researchonwomen’shealthandsexdifferenceshasexpanded.
Careerdevelopmentandmentoringprogramshaveincreasedthenumbersofwomen’shealthresearchers.
Researchresultshavebeentranslatedintohealthbenefitsforwomen.
Therehasbeengreatercommunicationtoavarietyofpublicaudiencesaboutsexandgenderdifferencesinbasicandbehavioralscience,aswellasinpublichealth.
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"Rememberthefamousstudy,takeanaspirinadaytokeeptheheartattackaway?Thatstudywasdoneon10,000men.Notonewomanwasincluded.Inastudyoftheagingprocess,theytoldmewomenweren’tincludedbecausetherewasn’taladiesroomavailableforstudyparticipants.Yettheresultsofthesestudieswerebeingappliedtomenandwomen.Ivowedtofixthat."
TheHonorableBarbaraMikulski,U.S.Senator,MarylandAugust16,2010MoreinformationaboutcomorbiditycanbefoundinNIDA’sresearchreportoncomorbidity.
Althoughsignificantstrideshavebeenmadetoincludewomeninclinicalresearch,mostanimal-basedresearchstilltendstoover-relyonmales.Becausethesestudiesareimportantinguidingclinicalstudies,NIHannouncedanewpolicyin2014requiringthatbothsexesberepresentedinNIH-fundedresearchinvolvinganimalandcellmodels.
Sinceitsinception,NIDAhassponsoredresearchonissuesrelatedtowomenandsubstanceuse.Beginningwithanearlyfocusontheeffectsofdruguseonpregnantwomenandthechildrentheycarry,NIDAthenexpandeditsinteresttosponsorresearchintowomen'sspecificsubstanceusedisorderriskfactorsandtreatmentneeds.WhentheHIV/AIDSepidemicemergedinthe1980s,NIDArespondedwithfundingforprojectsongender-specificriskfactorsforinfectionandontheimpactofdruguseonHIVtransmissionbetweenmotherandnewbornandthesubsequenthealthofboth.In1995,NIDAformallyestablishedtheWomenandSex/GenderDifferencesResearchProgramtounderstandtheunderlyingcausesofsubstanceusedisordersandthebestwaystopreventandtreattheminbothmenandwomen.
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WherecanIgetfurtherinformationaboutsubstanceuseinwomen?
Tolearnmoreaboutsubstanceuseinwomen,visittheNIDAwebsiteatwww.drugabuse.govorcontactDrugPubsResearchDisseminationCenterat877-NIDA-NIH(877-643-2644)(TTY/TDD:240-645-0228).
NIDA'swebsiteincludes:
Informationondrugsthatpeopleuseandmisuseandrelatedhealthconsequences
NIDApublications,news,andevents
Resourcesforhealthcareprofessionals,educators,andpatientsandfamilies
InformationonNIDAresearchstudiesandclinicaltrials
Fundinginformation(includingprogramannouncementsanddeadlines)
Internationalactivities
Linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsinthefield)
InformationinSpanish(enespañol)
NIDAWebsitesandWebpages
www.drugabuse.gov
www.teens.drugabuse.gov
www.easyread.drugabuse.gov
www.drugabuse.gov/related-topics/women-drugswww.drugabuse.gov/publications/finder/t/160/drugfacts
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www.researchstudies.drugabuse.gov
www.irp.drugabuse.gov
ForPhysicianInformation
NIDAMED:www.drugabuse.gov/nidamed
OtherWebsites
Informationonsubstanceuseinwomenisalsoavailablethrough:
SubstanceAbuseandMentalHealthServicesAdministration:www.samhsa.gov
DrugEnforcementAdministration:www.dea.gov
MonitoringtheFuture:www.monitoringthefuture.org
PartnershipforDrug-FreeKids:www.drugfree.org
TreatmentResources
Findbehavioralhealthtreatment:https://findtreatment.samhsa.gov
FindSmokingcessationprograms.TheU.S.DepartmentofHealthandHumanServiceshasresourcestohelpawomanquitsmokingathttp://women.smokefree.gov/
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