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Women and Prescription 
Opioid Addiction: 
A Growing Epidemic 
Kim Corace, Ph.D., C. Psych, 
Director, Research and Progra...
Learning Objectives 
• The current state of prescription opioid problems in 
Ontario 
• Opioid use, abuse, and addiction a...
Opioids: A growing problem 
• Canada is the world’s second largest per capita 
consumer of opioids. Ontario tops the list ...
The problem in Ontario has grown… 
• 2006: was estimated that there were 30 000 illicit opioid 
users in Ontario and 80 00...
Table 1. Past Year Drug Use (%) for the Total Sample, 
and by Sex and Grade, 2013 OSDUHS (CAMH) 
Total Male Female G7 G8 G...
A Generation Exposed.... 
• Although experimentation with alcohol and other 
drugs is a natural part of adolescence, exper...
What is an opioid? 
• Opioids are depressants-- they slow down certain brain 
functions, act on the mu receptor 
• Opioids...
Prescription Opioids
Commonly abused prescription opioids 
• Oxycodone (Oxycontin, OxyNEO) 
– Oxycontin formerly most popular opioid 
– Replace...
Commonly abused prescription opioids 
• Dilaudid, Hydromorph Contin 
– Usually chewed, snorted or injected 
• Fentanyl “pa...
Risks of Opioid Misuse 
• Overdose (high risk new users, unknown dose, 
combined with alcohol and/or benzodiazepines, afte...
Why Prescription Opioids? Why now? 
• Think it’s safe because it’s a prescription 
• More socially acceptable than heroin ...
Not everyone who takes prescribed opioids 
has a problem.... 
• Prescription opioids are effective pain relievers 
• Some ...
What is addiction? 
• Addiction is a developmental disease 
that starts in adolescence and 
childhood1 
1NESARC , 2003
What is addiction? 
• Primary, chronic disease of brain reward, motivation, 
memory and related circuitry 
• Characterized...
What is addiction? 
• Like other chronic diseases, addiction often involves 
cycles of relapse and remission 
• Addiction ...
Women and Substance Use 
• Substance abuse is more prevalent among men, but 
women are as likely as men to develop substan...
As cited in SAMHSA, 2009
As cited in SAMHSA, 2009
Patients on Methadone in Ontario by Age/Sex (2013)* 
734 
1890 
4000 
3500 
3000 
2500 
2000 
1500 
1000 
500 
*As per the...
Video: Women of Substance 
PLAY 
Women of Substance (2013). South Shore District Health 
Authority
Opioid Misuse: A growing epidemic among 
women 
• Rates of nonmedical prescription drug use is higher 
among women then me...
Source: CDC Vitalsigns, July 2013, as per National Vital Statistics System, 1999-2010
For every woman who dies of prescription opioid overdose, 
30 go to the ER for misuse/abuse 
Source: CDC Vitalsigns, July ...
* Source where pain relievers were obtained for 
most recent nonmedical use among past year 
users aged 12 and older: 2011...
Why are women disproportionately affected? 
• Women are more like to have chronic pain 
• Women are more likely to be pres...
Risk Factors for Substance Use Problems 
ADDICTION 
Vulnerable 
Host 
Environment/ 
Sociocultural 
Context 
Repeated 
subs...
Risk Factors: Relationships 
• Women are more likely to be introduced to and initiate 
drug use through their boyfriends, ...
Risk Factors: Relationships 
• Women may see sharing drug equipment and using drugs 
as emotional intimacy, means of conne...
Risk Factors: Telescoping 
• Telescoping describes an accelerated progression from 
substance use initiation to the onset ...
Risk Factors: Trauma 
• Initiation of substance use and development of substance 
use disorders among women is related to ...
Risk Factors: Trauma 
• Rates of physical or sexual abuse are extremely high 
among women with substance use disorders, ra...
Risk Factors: The Cycle of Trauma 
• Violence is both a risk factor and a consequence of 
substance abuse 
• Substance use...
Risk Factors: Concurrent Disorders 
• Compared to men, women have…. 
– Higher prevalence of concurrent mental health probl...
Risk Factors: Anxiety and Mood Disorders 
• Lifetime prevalence of mood and anxiety disorders are 
higher among women then...
Risk Factors: Eating Disorders 
• 90% of the cases of anorexia nervosa and bulimia 
nervosa are found in women 
• High cor...
Risk Factors: Discrimination 
Race Ethnicity Language 
Culture 
Sexual 
Orienta-tion 
Age SES 
Disability 
Legal 
issues 
...
Substance Use Treatment for Women 
• Women are under-represented in treatment settings 
• Women are less likely to enter t...
Barriers to Treatment 
• According to Health Canada (2001), some of the key 
issues in accessing substance use treatment t...
Barriers to Treatment 
• Opposition for entering treatment from family & friends 
– Partner substance abuse 
• Gender and ...
Barriers to Treatment: Stigma 
• Societal stigma toward women who abuse substances is 
greater than that toward men 
• Sti...
Barriers to treatment: Caregiver role 
• Women are socialized to be other-focused and assume 
caregiver roles
Overcoming treatment barriers 
Understanding how gender-based differences 
affect treatment engagement, internalized 
stig...
Interrelated elements in a 
comprehensive 
treatment model 
Source: Updated 
CSAT, 1994 model 
in SAMHSA, 2009
Core principles for gender-responsive 
treatment1 
• Acknowledge the importance and role of women’s SES 
issues and differ...
Core principles for gender-responsive 
treatment1 
• Recognize that assigned gender roles and expectations 
affect societa...
Factors that encourage treatment retention: 
• A collaborative therapeutic alliance 
• Onsite childcare and children servi...
Women’s Resilience 
• Women and men appear equally likely to complete 
treatment for substance use 
• Men and women have s...
A call to action 
• Women have been largely ignored in addictions research 
• Much-needed research on gender differences i...
You know who I am 
Our Daughters 
Our Mothers 
OOuurr SFirsiteenrds s Our Neighbours 
Our Families
Thank you
How can someone access The Royal’s 
Regional Opioid Intervention Service? 
• Call our addiction counsellor, Leanne, at 613...
References 
• American Society of Addiction Medicine www.asam.org 
• Back, S et al (2011). Comparative profiles of men and...
References 
• Carter et al (2009). Neurobiological Research on Addiction: A Review of the 
Scientific, Public Health and S...
References 
• Greenfield, SF, Back, SE, Lawson, K, & Brady, K (2010). Substance abuse in 
women. Psychiatr Clin North Am, ...
References 
• National Survey on Drug Use and Health (NSDUH) 2012. 
• National Epidemiologic Survey on Alcohol and Related...
References 
• Principles of Addiction Medicine 4th ed. (2009). American Society of Addiction 
Medicine. 
• Public Health A...
References 
• Tjaden, P, & Thoennes, N (2000). Extent, nature, and consequences of intimate 
partner violence: Findings fr...
Pharmacological Interventions for Opioid 
Dependence 
• Methadone: long-acting (>24 hours) synthetic opioid 
agonist 
• Bu...
Maintenance or Detoxification 
• Methadone and Buprenorphine/Naloxone (Suboxone) is 
approved for use in opioid substituti...
Buprenorphine/Naloxone 
• May be safer in overdose than methadone1 
• May be easier to taper off this medication than 
met...
Risk Factors: Sex differences 
• Sex differences in the stress and reward systems which 
increase women’s susceptibility t...
Risk Factors: Menstrual Cycle 
• Substances disrupt menstrual cycle phases 
• Menstrual cycle phases affects substance use...
Risk Factors: Socioeconomic Status (SES) 
• Gender is a risk factor for low SES 
• Women with substance us are more likely...
Issues women face: Sex work involvement 
• Survival sex work is very common among women who 
use drugs 
• Women who use in...
Issues women face: HIV and Hepatitis C 
• Growing number of women are becoming infected with 
HIV1 
• 57% of HIV infection...
Issues women face: HIV and Hepatitis C 
• Although rates of hepatitis C are higher in males then 
females, young females a...
Protective Factors 
• Marriage 
• Parental warmth 
• Partner support 
• Religious and spiritual practices 
• Healthy copin...
Treatment of Opioid Dependence in Pregnancy 
• Methadone maintenance shown to reduce complications 
of pregnancy, childbir...
Neonatal Abstinence Syndrome (NAS) 
• Babies are born with passive dependence on opioids 
used by their mother 
• After um...
Prevalence of NAS 
• In Ontario, has increased from 1.3 cases per 1000 births 
in 2004 to 4.3 cases per 1000 births in 201...
Neonatal Abstinence Syndrome (NAS) 
• Serious medical condition that affects the central 
nervous, autonomic nervous, gast...
Neonatal Abstinence Syndrome (NAS) 
• May cause death due to excess fluid loss, high 
temperatures, seizures, respiratory ...
Treating NAS 
• Challenges: guilt, shame, breastfeeding challenges, 
attachment
Treating NAS 
• Supportive environment: ideally baby and mom 
together 
• Improved outcomes with rooming in1 and 
breastfe...
NAS: Key Messages 
• Detoxification is not recommended during pregnancy 
for women with opioid dependence 
• Methadone is ...
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Conversations at The Royal: Women and Prescription Opioid Addiction - A Growing Epidemic

As presented at The Royal by:
- Dr. Melanie Willows, Clinical Director, SUCD Program, The Royal
- Dr. Kim Corace, Director, Program Development and Research, SUCD Program, The Royal

Opioid addiction is a large and growing problem affecting our community, especially our young people, women and their families. This session addressed:

· The current state of prescription opioid problems

· Opioid use, abuse, and addiction as it relates to women and parenting

· Risk factors for opioid use about women, with a focus on mental health problems

· Treatment options to help women who struggle with opioid problems

· Reducing the stigma and myths regarding women with opioid use problems

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Conversations at The Royal: Women and Prescription Opioid Addiction - A Growing Epidemic

  1. 1. Women and Prescription Opioid Addiction: A Growing Epidemic Kim Corace, Ph.D., C. Psych, Director, Research and Program Development Melanie Willows, B.Sc. M.D. C.C.F.P. C.A.S.A.M. C.C.S.A.M. Clinical Director Substance Use and Concurrent Disorders Program Royal Ottawa Health Care Group October 23, 2014
  2. 2. Learning Objectives • The current state of prescription opioid problems in Ontario • Opioid use, abuse, and addiction as it relates to women and parenting • Risk factors for opioid use in women, with a focus on mental health problems • Treatment options to help women who struggle with opioid problems • Reducing the stigma and myths regarding women with opioid use problems
  3. 3. Opioids: A growing problem • Canada is the world’s second largest per capita consumer of opioids. Ontario tops the list in Canada • Opioid misuse, abuse and dependence is a major public health issue in Ontario and the Ottawa region • Prescription opioids has become the predominant form of illicit opioid use (rather than heroin) • Increase in number of individuals seeking treatment for opioid dependence in the last 10 years • Opioids are a commonly abused substance by youth and young adults
  4. 4. The problem in Ontario has grown… • 2006: was estimated that there were 30 000 illicit opioid users in Ontario and 80 000 in Canada • 2013: there are close to 39 000 individuals being maintained on methadone in Ontario, in addition to individuals maintained on buprenorphine/naloxone (Suboxone) and individuals receiving no treatment
  5. 5. Table 1. Past Year Drug Use (%) for the Total Sample, and by Sex and Grade, 2013 OSDUHS (CAMH) Total Male Female G7 G8 G9 G10 G11 G12 Alcohol 49.5 49.8 49.1 9.9 24.6 37.1 53.5 67.9 74.4 Cannabis 23.0 25.3 20.6 1.7 7.0 14.6 24.5 33.5 39.2 Binge Drinking 19.8 21.3 18.3 3.7 8.5 18.1 29.5 39.2 Opioid Pain Relievers (NM) 12.4 12.8 12.0 8.8 8.9 11.8 13.0 12.1 16.1 Cigarettes 8.5 9.6 7.3 3.3 9.1 12.9 15.4
  6. 6. A Generation Exposed.... • Although experimentation with alcohol and other drugs is a natural part of adolescence, experimentation involving opioids is high risk as addiction occurs much more rapidly than with other drugs » National Institute of Drug Addiction (NIDA)
  7. 7. What is an opioid? • Opioids are depressants-- they slow down certain brain functions, act on the mu receptor • Opioids are also referred to as narcotics • Opioids can be effective painkillers • Some opioids are prescription medications (i.e. oxycontin, fentanyl) and others are not (i.e. heroin)
  8. 8. Prescription Opioids
  9. 9. Commonly abused prescription opioids • Oxycodone (Oxycontin, OxyNEO) – Oxycontin formerly most popular opioid – Replaced by OxyNEO designed to be more difficult to alter – Generic Oxycodone now available but not covered by ODB – Generally chewed, snorted or injected
  10. 10. Commonly abused prescription opioids • Dilaudid, Hydromorph Contin – Usually chewed, snorted or injected • Fentanyl “patch” – Fentanyl is extracted from patches that are designed to be long-acting medication – Fentanyl said to be 80 to 100 times stronger than morphine – Sucked in mouth (strips), smoked, or injected
  11. 11. Risks of Opioid Misuse • Overdose (high risk new users, unknown dose, combined with alcohol and/or benzodiazepines, after a period of stopping opioids) • Death • Accidents • Addiction • Infectious diseases from intravenous use and sharing drug paraphernalia (Hepatitis C, HIV)
  12. 12. Why Prescription Opioids? Why now? • Think it’s safe because it’s a prescription • More socially acceptable than heroin • Purity • Potent opioid (euphoria effects) • Easy access • Possible to alter how you use it: chew, suck, snort, smoke, inject • Inadequate monitoring
  13. 13. Not everyone who takes prescribed opioids has a problem.... • Prescription opioids are effective pain relievers • Some people require long-term prescription opioids for chronic pain • Many people take their opioids as prescribed • Experiencing withdrawal symptoms if you stop your prescription opioids abruptly would be expected
  14. 14. What is addiction? • Addiction is a developmental disease that starts in adolescence and childhood1 1NESARC , 2003
  15. 15. What is addiction? • Primary, chronic disease of brain reward, motivation, memory and related circuitry • Characterized by inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one’s behaviours and interpersonal relationships, and a dysfunctional emotional response ASAM, 2011
  16. 16. What is addiction? • Like other chronic diseases, addiction often involves cycles of relapse and remission • Addiction is progressive and can result in disability or premature death ASAM, 2011
  17. 17. Women and Substance Use • Substance abuse is more prevalent among men, but women are as likely as men to develop substance use disorders after initiation • The gender gap is narrowing1 – In the past, men had higher rates of substance abuse then women – In the last 10 years, young women are more likely to mirror male patterns of drug use then older women – Shrinking gender gap is especially notable for young women 1Grant et al., 2006 as cited in SAMHSA, 2009
  18. 18. As cited in SAMHSA, 2009
  19. 19. As cited in SAMHSA, 2009
  20. 20. Patients on Methadone in Ontario by Age/Sex (2013)* 734 1890 4000 3500 3000 2500 2000 1500 1000 500 *As per the College of Physicians and Surgeons of Ontario 2183 691 2257 3376 0 17-21 22-25 26-29 # of Patients on Methadone Age Group Female Male
  21. 21. Video: Women of Substance PLAY Women of Substance (2013). South Shore District Health Authority
  22. 22. Opioid Misuse: A growing epidemic among women • Rates of nonmedical prescription drug use is higher among women then men, particularly for opioids • Nearly 48,000 women died of prescription opioid overdoses between 1999 to 2010 (5 fold increase) • Female deaths from prescription opioid overdoses have increased more than 400% since 1999, compared to 265% among males • Prescription opioids are involved in 1 in 10 suicides among women * CDC, 2013
  23. 23. Source: CDC Vitalsigns, July 2013, as per National Vital Statistics System, 1999-2010
  24. 24. For every woman who dies of prescription opioid overdose, 30 go to the ER for misuse/abuse Source: CDC Vitalsigns, July 2013, as per Drug Abuse Warning Network, 2010
  25. 25. * Source where pain relievers were obtained for most recent nonmedical use among past year users aged 12 and older: 2011-2012 (NSDUH)
  26. 26. Why are women disproportionately affected? • Women are more like to have chronic pain • Women are more likely to be prescribed prescription painkillers • Women are more likely to be given higher doses • Women are more likely to use prescription opioids for a longer time period than men • Women may become dependent on prescription opioids more quickly then men Source: CDC, 2013
  27. 27. Risk Factors for Substance Use Problems ADDICTION Vulnerable Host Environment/ Sociocultural Context Repeated substance use
  28. 28. Risk Factors: Relationships • Women are more likely to be introduced to and initiate drug use through their boyfriends, partners, spouses, and relatives • Women are also more likely than men to be introduced to IVDU their partners • Even though women are less likely to inject drugs, women accelerate to injecting at a faster rate than men • Women are more likely to inject with and borrow needles and equipment from their partners 1Powis et al., 1996
  29. 29. Risk Factors: Relationships • Women may see sharing drug equipment and using drugs as emotional intimacy, means of connection, or maintaining the relationships • Men are often responsible for obtaining, purchasing, and injecting the drug for women. • There is a power imbalance in these relationships
  30. 30. Risk Factors: Telescoping • Telescoping describes an accelerated progression from substance use initiation to the onset of dependence and first treatment1 • Consistently observed, with studies reporting an accelerated progression among women for opioids. • Women progress faster even when using similar or lesser amounts of substances • When women enter treatment, they have a more severe presentation than men, despite using less and for shorter period of time 1Hernandez-Avila et al., 2004
  31. 31. Risk Factors: Trauma • Initiation of substance use and development of substance use disorders among women is related to traumatic events: – Childhood trauma: physical or sexual abuse – Interpersonal violence: sexual assault, abusive relationships – Domestic violence
  32. 32. Risk Factors: Trauma • Rates of physical or sexual abuse are extremely high among women with substance use disorders, ranging from 55 to 99% • Severity of substance use disorder is related to the number of violent assaults women experience • Among women seeking treatment for substance use, up to 70% report sexual abuse prior to the age of 11 Finnegan, 2013
  33. 33. Risk Factors: The Cycle of Trauma • Violence is both a risk factor and a consequence of substance abuse • Substance use increases women’s vulnerability to re-traumatization and re-victimization
  34. 34. Risk Factors: Concurrent Disorders • Compared to men, women have…. – Higher prevalence of concurrent mental health problems • About 2/3 of women with substance use problems have a co-occurring mental health problem – Higher likelihood of using substances to manage negative affect – Higher likelihood of trauma history and PTSD • Bidirectional influence: Mental illness both a risk factor or a consequence of substance use
  35. 35. Risk Factors: Anxiety and Mood Disorders • Lifetime prevalence of mood and anxiety disorders are higher among women then men, regardless of a substance use disorder (SUD) • 12-month prevalence rates in women with SUD1: – Mood disorder: 29.7% – Anxiety disorders: 26.2% • Anxiety and depression positively associated with substance use, abuse and dependence 1Goldstein, 2009 as cited in Greenfield, 2010
  36. 36. Risk Factors: Eating Disorders • 90% of the cases of anorexia nervosa and bulimia nervosa are found in women • High correlation between eating disorders and substance abuse • Up to 55% of women with bulimia have a substance use problem • 15-40% of women with substance use problems have eating disorders syndromes, in particular purging
  37. 37. Risk Factors: Discrimination Race Ethnicity Language Culture Sexual Orienta-tion Age SES Disability Legal issues Housing Health issues Mental Gender illness
  38. 38. Substance Use Treatment for Women • Women are under-represented in treatment settings • Women are less likely to enter treatment then men • Women tend to seek care in mental health/primary care settings rather then specialized treatment programs • Once initiated, women are as likely as men to stay in treatment • Gender does not appear to predict retention or outcome in substance abuse treatment SAMHSA, 2009; Greenfield, 2010; Green, 2006
  39. 39. Barriers to Treatment • According to Health Canada (2001), some of the key issues in accessing substance use treatment that have a particular impact on women are: – fear of losing children – lack of affordable child care – lack of family support – social stigma – lack of women-centred services – cost of treatment – lack of flexible services
  40. 40. Barriers to Treatment • Opposition for entering treatment from family & friends – Partner substance abuse • Gender and cultural insensitivity • Lower rates for identification and referral for women by care providers • Threat of legal sanction – child custody • Lack of transportation • Caretaker role for dependent family • Economic barriers to entering and staying in treatment *Beckman 1986, Miller, 1993, SAMHSA, 2009
  41. 41. Barriers to Treatment: Stigma • Societal stigma toward women who abuse substances is greater than that toward men • Stigma is a barrier to admission of a problem, asking for help, and seeking and initiating treatment • Stigma, guilt and shame towards drug use and low self-esteem make women feel un-deserving of help • Gender role expectations result in further stigmatization • Compounded stigma
  42. 42. Barriers to treatment: Caregiver role • Women are socialized to be other-focused and assume caregiver roles
  43. 43. Overcoming treatment barriers Understanding how gender-based differences affect treatment engagement, internalized stigma, and treatment outcome will allow for a more responsive, sensitive, and effective approach to treatment
  44. 44. Interrelated elements in a comprehensive treatment model Source: Updated CSAT, 1994 model in SAMHSA, 2009
  45. 45. Core principles for gender-responsive treatment1 • Acknowledge the importance and role of women’s SES issues and difference • Recognize the role and significance of relationships in women’s lives • Address women’s unique physical and mental health concerns • Attend to the relevance and influence of the variety of women’s caregiver roles • Adopt a trauma-informed perspective 1SAMHSA, 2009
  46. 46. Core principles for gender-responsive treatment1 • Recognize that assigned gender roles and expectations affect societal views of women who use substances • Use a strength-based approach to treatment • Incorporate an integrated and multidisciplinary approach to treatment • Maintain a gender responsive treatment environment across settings 1SAMHSA, 2009
  47. 47. Factors that encourage treatment retention: • A collaborative therapeutic alliance • Onsite childcare and children services • Integrated, comprehensive, multimodal treatment – Behavioural, pharmacological, psychological, multimodal systems of care that address complex issues (ie., social services) • Support and participation of significant others • Address pregnancy and parenting skills • Demographics: Being older; High school education Back, 2011; SAMHSA, 2009
  48. 48. Women’s Resilience • Women and men appear equally likely to complete treatment for substance use • Men and women have similar treatment outcomes • Women are less likely then men to relapse while in treatment • Women show better long-term recovery outcomes then men Green, 2006
  49. 49. A call to action • Women have been largely ignored in addictions research • Much-needed research on gender differences in treatment response and gender-specific treatments • Increase efforts to reduce the stigma and discrimination faced by women who use substances • Adopt a multidisciplinary, holistic, comprehensive approach to treatment, prevention, health promotion • Coordinated and integrated systems of care and services with gender and cultural competence SAMHSA, 2009; Finnegan, 2013
  50. 50. You know who I am Our Daughters Our Mothers OOuurr SFirsiteenrds s Our Neighbours Our Families
  51. 51. Thank you
  52. 52. How can someone access The Royal’s Regional Opioid Intervention Service? • Call our addiction counsellor, Leanne, at 613-722- 6521, ext 6224 • Email us at opioidservice@theroyal.ca • Drop by in person • Can connect through our partner agencies
  53. 53. References • American Society of Addiction Medicine www.asam.org • Back, S et al (2011). Comparative profiles of men and women with opioid dependence: Results from a national multisite effectiveness trial. Am J Drug Alcohol Abuse, 37(5), 313-323. • Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice Guideline (2011). Centre for Addiction and Mental Health (CAMH). • Canadian AIDS Treatment Information Exchange (CATIE; 2013). Fact sheet: The epidemiology of hepatitis C in Canada. http://www.catie.ca/fact-sheets/ epidemiology/epidemiology-hepatitis-c-canada • Canadian AIDS Treatment Information Exchange (CATIE; 2012). Gender matters in HIV prevention. Prevention in Focus, Spring 2012. • Canadian AIDS Treatment Information Exchange (CATIE; 2012). Fast Facts: Youth. Prevention in Focus, Summer 2012.
  54. 54. References • Carter et al (2009). Neurobiological Research on Addiction: A Review of the Scientific, Public Health and Social Policy Implications for Australia Final Report January 30, 2009. • CDC (July, 2013). Prescription painkiller overdoses: A growing epidemic, especially among women. CDC Vitalsigns: www.cdc.gov/vitalsigns • Cormier, RA (2000). Predicting treatment outcome in chemically dependent women: A test of Marlatt and Gordon’s relapse model [Unpublished doctoral dissertation]. Windsor, ON: University of Windsor. • Finnegan, L (2013). Substance abuse in Canada: Licit and illicit drug use during pregnancy: Maternal, neonatal, and early childhood consequences. Ottawa, ON. Canadian Centre on Substance Abuse 2013. • Green, C (2006). Gender and use of substance abuse treatment services. NIH National Institute on Alcohol Abuse and Alcoholism.
  55. 55. References • Greenfield, SF, Back, SE, Lawson, K, & Brady, K (2010). Substance abuse in women. Psychiatr Clin North Am, 33(2), 339-355. • Hernandez-Avila, CA, Rounsaville, BJ, & Kranzler, HR (2004). Opioid-, cannabis-and alcohol-dependent women show more rapid progression to substance abuse treatment. Drug and Alcohol Dependence, 74(3), 265–272. • Lowinson & Ruiz’s Substance Abuse: A Comprehensive Textbook Fifth Edition Chapter 57 Adolescent Substance Abuse R. Milin and S. Walker. Editors Pedro Ruiz &Eric Strain. Lippincott Williams & Wilkins, Philadelphia, PA, 2011 • Marchand, K et al (2012). Sex work involvement among women with long-term opioid injection drug dependence who enter opioid agonist treatment. Harm Reduction Journal, 9:8. • Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edition February 2011 CPSO • National Institute on Drug Abuse (NIDA)
  56. 56. References • National Survey on Drug Use and Health (NSDUH) 2012. • National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 2003. • Nicholson D & Saewyc E (2011). Childhood sexual abuse, substance use and substance use-related sexual behaviour in a rural school population. Poster presented at the Issues of Substance national conference. Vancouver, Canada. • Paglia-Boak, A, Mann, RE, Adlaf, EM (2011). Drug use among Ontario students, 1977-2011: OSDUHS highlights. (CAMH Research Document Series No. 32). Toronto, ON: Centre for Addiction and Mental Health. • Poole, N (2000). Evaluation report of the Sheway Project for high-risk pregnant and parenting women. Vancouver: British Columbia Centre of Excellence for Women’s Health. • Powis B, et al. (1996). The differences between male and female drug users: Community samples of heroin and cocaine users compared. Subst Use Misuse, 31(5), 529–43.
  57. 57. References • Principles of Addiction Medicine 4th ed. (2009). American Society of Addiction Medicine. • Public Health Agency of Canada (PHAC; 2010). HIV and AIDS in Canada. Surveillance Report to December 31, 2009. Surveillance and Risk Assessment Division. Centre for Communicable Diseases and Infection Control. PHAC. • Public Health Agency of Canada (PHAC; 2012). Reported cases and rates of hepatitis C by age group and sex, 2005 to 2010. Community Acquired Infections Division, PHAC. • Substance Abuse: A Comprehensive Textbook 4th Ed. Lewinson et al. 2005 • Substance Abuse and Mental Health Services Administration (SAMHSA) (2009). Center for Substance Abuse Treatment. Substance abuse treatment: Addressing the specific needs of women. Treatment Improvement Protocol (TIP) Series 51. Rockville, MD: SAMHSA Administration.
  58. 58. References • Tjaden, P, & Thoennes, N (2000). Extent, nature, and consequences of intimate partner violence: Findings from the National Violence Against Women Survey [Publication No. NCJ 181867]. Washington, DC: Department of Justice. Videos: • Women of Substance (2013). Exec Producer: South Shore District Health Authority. http://www.youtube.com/watch?v=xQZNP3p4k2g • What is it like to be a female addicted to heroin? (2012). http://www.youtube.com/watch?v=RtXJ-iY5TFk
  59. 59. Pharmacological Interventions for Opioid Dependence • Methadone: long-acting (>24 hours) synthetic opioid agonist • Buprenorphine/Naloxone (Suboxone): long acting synthetic partial opioid agonist, naloxone component present to prevent IV abuse
  60. 60. Maintenance or Detoxification • Methadone and Buprenorphine/Naloxone (Suboxone) is approved for use in opioid substitution therapy for maintenance • Buprenorphine/Naloxone (Suboxone) can also be used for detoxification/tapering
  61. 61. Buprenorphine/Naloxone • May be safer in overdose than methadone1 • May be easier to taper off this medication than methadone1 • May be better for youth, young adults and for early intervention2 • High risk of precipitated withdrawal discourages ongoing opioid use 1Methadone Maintenance Treatment Program Standards and Clinical Guidelines, 4th edition February 2011 CPSO 2Buprenorphine/Naloxone for Opioid Dependence: Clinical Practice Guideline CAMH 2011
  62. 62. Risk Factors: Sex differences • Sex differences in the stress and reward systems which increase women’s susceptibility to drug abuse and relapse • Women have a greater biological vulnerability to the adverse consequences of substance use • Women who use substances have poorer health than men as a result of substances
  63. 63. Risk Factors: Menstrual Cycle • Substances disrupt menstrual cycle phases • Menstrual cycle phases affects substance use • Substances can affect fertility • Opioid use can cause amenorrhea and risk of unplanned pregnancy
  64. 64. Risk Factors: Socioeconomic Status (SES) • Gender is a risk factor for low SES • Women with substance us are more likely to have: – Lower incomes – Less education – Less likely to be employed • Among women, lower SES is related to: – Higher substance-use related illness, including HIV/hepatitis C – Higher substance-use related mortality – Difficulties with healthcare service access and uptake – Lack of appropriate nutrition
  65. 65. Issues women face: Sex work involvement • Survival sex work is very common among women who use drugs • Women who use injection drugs are more likely to be involved with sex work then men • These women present with greater vulnerabilities: unstable housing/homelessness, higher rates of incarceration, less education, younger, concurrent mental illness, trauma • High prevalence of HIV and STIs Marchand, 2012
  66. 66. Issues women face: HIV and Hepatitis C • Growing number of women are becoming infected with HIV1 • 57% of HIV infections among women are attributable to use of injection drugs or sexual relations with a person who injects drugs2 • 24% of reported cases of HIV in Canada were among youth in 20093: – 22% males – 30% females 1CATIE, 2012; 2CDC, 2002; 3PHAC, 2010
  67. 67. Issues women face: HIV and Hepatitis C • Although rates of hepatitis C are higher in males then females, young females are at particularly high risk1,2 – Males in the 40 to 59 year age group had the highest rates of reported hepatitis C diagnoses at 78.2 per 100,000 – Females in the 25 to 29 years age group had the highest rates of reported hepatitis C diagnoses at 34.4 per 100,000. 1CATIE, 2013; 2PHAC, 2012
  68. 68. Protective Factors • Marriage • Parental warmth • Partner support • Religious and spiritual practices • Healthy coping skills
  69. 69. Treatment of Opioid Dependence in Pregnancy • Methadone maintenance shown to reduce complications of pregnancy, childbirth and infant development • Methadone and Buprenorphine/Naloxone considered Category C medication (medication should only be used in pregnancy if the potential benefit justifies the potential fetal risk)
  70. 70. Neonatal Abstinence Syndrome (NAS) • Babies are born with passive dependence on opioids used by their mother • After umbilical cord is cut, passive supply of opioids is cut off • Baby potentially develops withdrawal symptoms from opioids
  71. 71. Prevalence of NAS • In Ontario, has increased from 1.3 cases per 1000 births in 2004 to 4.3 cases per 1000 births in 20101 • Occurs in untreated opioid addiction and also as a potential side effect for treatment of opioid dependence with methadone (60% chance of developing NAS)2 1Dow et al., 2010; 2Finnegan & Kandall, 2005
  72. 72. Neonatal Abstinence Syndrome (NAS) • Serious medical condition that affects the central nervous, autonomic nervous, gastrointestinal and respiratory systems • Characterized by signs of: – neurologic excitability (irritability, hyperactivity, sleep disturbance) – gastrointestinal dysfunction (vomiting, diarrhea, uncoordinated sucking and swallowing) – autonomic signs (fever, sweating, nasal stuffiness)
  73. 73. Neonatal Abstinence Syndrome (NAS) • May cause death due to excess fluid loss, high temperatures, seizures, respiratory instability, aspiration of fluid into the lungs or the cessation of breathing if not treated BUT….NAS is TREATABLE
  74. 74. Treating NAS • Challenges: guilt, shame, breastfeeding challenges, attachment
  75. 75. Treating NAS • Supportive environment: ideally baby and mom together • Improved outcomes with rooming in1 and breastfeeding2 1Abrahams et al., 2007; 2Abdel-Latif et al., 2006
  76. 76. NAS: Key Messages • Detoxification is not recommended during pregnancy for women with opioid dependence • Methadone is most extensively studied and standard of care • Buprenorphine is also an option • Women fear stigmatization: Create a safe space • Support woman’s choice of treatment • NAS is common but treatable

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As presented at The Royal by: - Dr. Melanie Willows, Clinical Director, SUCD Program, The Royal - Dr. Kim Corace, Director, Program Development and Research, SUCD Program, The Royal Opioid addiction is a large and growing problem affecting our community, especially our young people, women and their families. This session addressed: · The current state of prescription opioid problems · Opioid use, abuse, and addiction as it relates to women and parenting · Risk factors for opioid use about women, with a focus on mental health problems · Treatment options to help women who struggle with opioid problems · Reducing the stigma and myths regarding women with opioid use problems

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