Opioid-, cannabis- and alcohol-dependent women show more rapid progression to substance abuse treatment

Abstract

Alcohol-dependent women progress faster from onset of alcohol drinking to entry into treatment, experiencing an earlier onset (i.e., “telescoping”) of alcohol-related complications. This phenomenon also appears to be evident in drug-dependent women, though the data available to support telescoping in drug dependence is less abundant. Objective: To evaluate gender effects on progression to treatment entry and on the frequency, severity and related complications of DSM-III-R drug and alcohol dependence among 271 substance-dependent patients (mean age: 32.6 years; 156 women). Method: Multivariate and univariate ANCOVA was used to compare age at onset of regular use of cocaine, opioids, cannabis and alcohol and time elapsed between initiation of regular use of each substance and entry into an index or current substance abuse treatment. Scores on the Addiction Severity Index (ASI) were also examined. Results: There was no gender difference among patients in the age at onset of regular use of any substance. Women experienced fewer years of regular use of opioids and cannabis, and fewer years of regular alcohol drinking before entering treatment. Although the severity of drug and alcohol dependence did not differ by gender, women reported more severe psychiatric, medical and employment complications. Conclusions: These findings support the notion of an accelerated progression to treatment entry among opioid-, cannabis- and alcohol-dependent women, and suggest that there exists a gender-based vulnerability to the adverse consequences of these disorders.

Introduction

Although epidemiological studies have shown a greater prevalence of substance use disorders among men, more recent surveys show an increase in prevalence rates of substance use disorders among women, particularly in younger age groups (Substance Abuse and Mental Health Services Administration, 2001). This phenomenon appears related to the fact that, in recent years, availability and opportunities for access to drugs and alcohol have increased among women (Van Etten and Anthony, 1999, Van Etten et al., 1999).

Compared to men, women appear to be more vulnerable to the toxic effects of alcohol (Frezza et al., 1990) manifested by a more rapid progression, or a “telescoped course”, of alcoholism. This telescoped course among women is characterized by a shorter time from the onset of alcohol drinking to entry into alcohol treatment, and by an earlier onset of alcohol-related health and psychosocial complications (Lisansky, 1958, Piazza et al., 1989). Although alcohol-dependent women drink less and experience shorter drinking careers, they are more likely to develop alcoholic liver disease and have a more rapid progression to liver cirrhosis and a greater likelihood of an earlier death than alcoholic men (Ashley et al., 1977, Becker et al., 1996). In addition, alcoholic women appear to be more susceptible to alcohol-induced brain damage, as evidenced by greater widening of the cerebral sulci and fissures in CT scans of the brain, as well as poorer performance on cognitive testing (Jacobson, 1986, Mann et al., 1992).

Although not conclusively demonstrated, several reports also suggest that drug-dependent women experience a greater vulnerability to the deleterious effects of drugs and a faster progression of drug dependence. Women may have a greater subjective response to cocaine (Sofuoglu et al., 1999, Evans et al., 1999; cf. Lukas et al., 1996) and amphetamine (Justice and de Wit, 1999) than do men, especially during the follicular phase of the menstrual cycle. Women appear to be more rapidly addicted to drugs such as cocaine and heroin (Anglin et al., 1987, Haas and Peters, 2000) and to experience fewer years of cocaine (Griffin et al., 1989, White et al., 1996) or heroin use (Longshore et al., 1993) before they enroll in substance abuse treatment. At treatment entry, despite experiencing briefer drug use careers than men, substance-dependent women show comparable or greater severity of drug addiction (Longshore et al., 1993, McCance-Katz et al., 1999), and greater severity of medical problems (Arfken et al., 2001). Women who smoke appear to develop chronic obstructive pulmonary disease and lung cancer at an earlier age than men (Risch et al., 1993, Harris et al., 1993, Baldini and Strauss, 1997, Van Winkle et al., 2002). Similarly, women addicted to cocaine experience a greater risk for cardiovascular complications and other cocaine-related emergencies than do male cocaine abusers (Dudish et al., 1996).

Some studies have also suggested that substance-dependent women experience a greater perceived negative effect of withdrawal from addictive substances and increased withdrawal-related craving. Nicotine-dependent women report more dependence and withdrawal symptoms, despite generally being lighter smokers than men (Bjornson et al., 1995, CDC, 1994). Women smokers also relapse more frequently due to intense withdrawal symptoms and craving and they experience greater relief or reinforcement when they resume smoking (Gunn, 1986).

Societal and cultural factors may contribute to a briefer pretreatment course of drug and alcohol dependence in women than in men. Negative social and familial attitudes toward women’s drug and alcohol use may delay the onset of substance use among women and place greater pressure on substance-dependent women to enroll in treatment (Gomberg, 1988, Blankfield, 1990). Women also utilize health care services more readily than do men (Blume, 1990), thereby increasing their chance of enrolling in treatment. Together, these effects would be expected to reduce the time between the initiation of substance use among women and their first episode of substance abuse treatment, thereby abbreviating their drug and alcohol use careers.

Negative societal attitudes toward women’s substance use have been more pronounced in older cohorts of patients, among whom telescoping was initially described (Lisansky, 1958, Piazza et al., 1989). In contrast, among younger cohorts, permissive attitudes toward women’s substance use appear to be more prevalent (Gomberg, 1988). Consequently, the drug and alcohol careers of younger cohorts of substance-dependent women may more closely resemble those of substance-dependent men. This notion is supported by a report (Randall et al., 1999) that described comparable progression intervals among younger alcoholic women and men, but marked telescoping effects among older alcoholic women. It is noteworthy that the majority of previous reports of telescoping of alcohol and drug dependence among women have failed to address the potential for confounding effects of cohort membership.

Given the paucity of studies examining gender effects on the progression of drug and alcohol dependence, especially those that control for the effects of age cohort, we sought to examine the effects of gender on the progression to treatment entry in a heterogeneous sample of 271 drug- and alcohol-dependent patients seeking substance abuse treatment. In this analysis we use progression to treatment entry as a proxy measure for the overall progression of the disorder. We hypothesized that, after controlling for age and the number of previous treatments, women would show evidence of a faster progression and greater severity of both drug and alcohol problems. The main approach employed was an examination of gender effects on the following landmarks: (1) the age at onset of regular use of drugs and alcohol, (2) the period of time elapsed between time at onset of regular use of substances and time at entry into an index treatment, and (3) the frequency and severity of drug and alcohol dependence at treatment entry.