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

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. 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. 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. 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. 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. 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. 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. Prescription Opioids

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. 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. 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. 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. 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. What is addiction?
• Addiction is a developmental disease
that starts in adolescence and
childhood1
1NESARC , 2003

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. 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. 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. As cited in SAMHSA, 2009

19. As cited in SAMHSA, 2009

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. Video: Women of Substance
PLAY
Women of Substance (2013). South Shore District Health
Authority

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. Source: CDC Vitalsigns, July 2013, as per National Vital Statistics System, 1999-2010

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. * Source where pain relievers were obtained for
most recent nonmedical use among past year
users aged 12 and older: 2011-2012 (NSDUH)

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. Risk Factors for Substance Use Problems
ADDICTION
Vulnerable
Host
Environment/
Sociocultural
Context
Repeated
substance use

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. 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. 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. 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. 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. 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. 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. 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. 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. Risk Factors: Discrimination
Race Ethnicity Language
Culture
Sexual
Orienta-tion
Age SES
Disability
Legal
issues
Housing
Health
issues
Mental
Gender illness

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. 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. 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. 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. Barriers to treatment: Caregiver role
• Women are socialized to be other-focused and assume
caregiver roles

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. Interrelated elements in a
comprehensive
treatment model
Source: Updated
CSAT, 1994 model
in SAMHSA, 2009

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. 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. 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. 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. 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. You know who I am
Our Daughters
Our Mothers
OOuurr SFirsiteenrds s Our Neighbours
Our Families

51. Thank you

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Protective Factors
• Marriage
• Parental warmth
• Partner support
• Religious and spiritual practices
• Healthy coping skills

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. 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. 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. 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. 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. Treating NAS
• Challenges: guilt, shame, breastfeeding challenges,
attachment

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. 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