Women and Substance Use: An Overview for Nurses

Substance use is a major health concern among women, as approximately 15.8 million have used an illicit drug in the past year. Another 4.3 million have misused prescription drugs. Men are more likely to engage in illicit drug use than women, however, the gender gap is narrowing. The consequences of substance abuse not only negatively impact women, but may affect the cognitive and physical abilities of their children. For methodology, electronic searches were conducted using scholarly databases with various combinations of keywords related to women, substance abuse, addiction, nursing care, pregnancy, and gender difference. Research trends indicate that women often present with gender-specific needs, including physiologically, socially, and economically. This article gives an overview of some gender differences between men and women and how they influence treatment and outcomes for women. It also discusses special considerations for nurses caring for women with substance use disorders.

Substance use is a health concern in the United States.In 2017, the Center for Behavioral Health Statistics and Quality reported that more than 27 million people in the United States reported current use of an illicit drug or misuse of prescription drugs in the past 30 days (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017a).Another 80 million people are risky substance users, using alcohol and drugs in ways that threaten their health and safety (National Center on Addiction and Substance Abuse at Columbia University [CASA Columbia], 2012).The United States spent $28 billion to treat addiction (CASA Columbia;"author" & Russler, 2014) and research shows that 15.8 million women, ages 18 or older, engaged in illicit drug use in the past year (SAMHSA, 2017b;National Institute on Drug Abuse, 2018).Substance use can lead to adverse outcomes for women and adversely impact their health, families, and socioeconomic status.The complexity of gender presents unique challenges when caring for women with substance use disorders (SAMHSA, 2017a).
Women sometimes encounter negative attitudes and stigma when seeking care for substance use disorders or addictions (Alexander, 2017;Chu & Galang, 2013;Puskar et al., 2013).Healthcare professionals' attitudes toward patients who report substance use directly affect the recovery success and health outcomes (Alexander, 2017).Negative attitudes may influence one's willingness to engage and develop a therapeutic nurse-patient relationship, contributing to suboptimal care.Supportive and positive healthcare experiences can motivate patients to seek ongoing medical care and treatment for their substance use disorders or addictions (Chu & Galang, 2013).Nurses need to understand the disease of addiction and the gender-specific needs of women in order to provide optimal care and improve recovery outcomes.

Epidemiology
Historically, men have had higher rates of substance abuse than women; however, the gap between them has been narrowing worldwide (Grant et al., 2016;Grosso et al., 2013;McHugh, Votawa, Sugarman, & Greenfield, 2017;Sanders," 2014).Internationally, the epidemiology of substance use disorders varies.Policies and culture influence the accessibility and acceptability of substance use.Findings from the World Health Organization (WHO) World Mental Health Survey indicated that less traditional roles correlate with smaller gender gaps.When the gender role was less traditional, women began to "catch up" with men in terms of substance use disorders (Grant et al., 2016;Seedat et al., 2015).
More recently, the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) did a study on drug use disorders and found 4.9% for men and 3.0% for women for any drug use (Grant et al., 2016).The most commonly used drugs were cannabis, opioids, and cocaine (Grant et al., 2016).For stimulants, there were no differences in use between men and women.Several studies indicated that the rates were higher for women than for men, particularly with narcotic analgesics and sedatives (Grant et al., 2016;Grella, 2008).
In the early 1980s, the male to female ratio of alcohol use disorders was estimated to be 5:1.Surveys succeeding this reported the ratio as 3:1 (Greenfield, Back, Lawson, & Brady, 2010).In 2015, an estimated 47.2% of females, 12 and older, reported alcohol use in the past month, compared to 56.2% for males (SAMHSA, 2017b).Women tended to binge less often than men.Usually, adult men showed a greater use of alcohol and more problematic behavior, such as binge drinking and alcohol abuse.Data showed no gender gap among adolescent boys and girls, ages 12-17.Regarding alcohol, the current use has been 9.9% for girls and 9.6% for boys.For binge drinking, the amount has been 5.8% for both genders (CBHSQ, 2016;McHugh et al., 2017).

Gender Differences
Despite using smaller doses in shorter periods of time, when compared to men, women experience more severe clinical complications (McHugh et al., 2017; Office on Women's Health [OWH], 2017).One reason is due to a phenomenon known as telescoping.Telescoping is an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment (McHugh et al., 2017;OWH, 2017).It has been reported that men were 2.2 times more likely than were women to use drugs and 1.9 times more likely to become drug dependent (Greenfield et al., 2010).Biological factors may also increase the adverse effects of substance abuse.Women have lower percentages of total body water, decreased first pass metabolism, and slower rates of alcohol metabolism (National Institute on Drug Abuse [NIDA], 2018, Sanders, 2014).Basic and clinical studies have shown that estrogen increases and progesterone decreases potentiate the effects of stimulants (Greenfield et al., Sanders, 2014).Biological factors adversely influence metabolism, as well as a rapid progression to addiction.
Mortality rates for women who abuse substances are also greater than for men.Women who abuse alcohol are twice as likely to die from abuse-related health problems.Also, women who smoke are three times more likely than men to die of lung cancer.Even more astounding, the number of women dying from addiction related illnesses is four times the number of women who die from breast cancer (Young, 2010).The health impact on women has been significant.
In addition to physiological factors, psychosocial factors differ between men and women.Women are more likely to have relatives with substance use problems, as well as spouses who use drugs.It is more likely that women will initiate hazardous drug use while in intimate partner relationships after being introduced to substances by boyfriends or spouses (OWH, 2017).Additionally, initiation of substance among women has been linked to histories of traumatic childhood events involving physical and sexual abuse, usually by people the women knew and trusted (Cleveland, Bonugli, & McGlothen, 2016;OWH, 2017).

Effects of Children and Parenting
More than 8 million children younger than 18 years have lived with at least one parent who is dependent on drugs and/or alcohol in the past year (Anna, Mericle, Meyers, & Winters, 2012;Sanders & Russler, 2014).Additionally, it is estimated that 50-80% of child welfare system cases involve parents who abuse alcohol or other drugs, with mothers making up the majority of the substance-abusing parents in the child welfare system (Nichols et al., 2012;Sanders & Russler, 2014).Substance abuse impairs parenting skills, which may lead to child maltreatment, insecure attachment, and foster placement (Berlin, Shanahan, & Carmody, 2014;""Sanders & Russler, 2014).
Research links parental substance abuse with an increased risk for children to engage in substance abuse as adults (Anna et al., 2012).Additionally, children whose mothers used alcohol and illicit drugs during pregnancy had increased risks for long term physical, cognitive, behavioral, and academic problems (Muhuri & Gfroerer, 2009;Sanders & Russler, 2014).Mothers with substance abuse issues struggle to provide stable, nurturing environments for their children, and this is compounded by challenging circumstances, including economic and social problems like homelessness and no affordable housing (Nichols et al., 2012;Sanders & Russler, 2014).Also, many mothers have concurrent mental health difficulties, complex trauma histories, experiences of poverty, histories with the criminal justice system, and experiences of abuse and maltreatment from caregivers and/or partners (Naomi et al., 2018;Stone, 2015).It is imperative to screen, counsel, and engage women in treatment due to long-term adverse effects on the lives of mothers and children.

Pregnancy
Among pregnant women aged 15 to 44, 5% were using illicit drugs (SAMHSA, 2017b).More specifically, pregnant women aged 15 to 17, had the highest rates of current illicit drug use, 20.9%.In addition, of pregnant women aged 15 to 17, 9.4% reported current alcohol use and 17.6% had smoked cigarettes in the past month (Stone, 2015;SAMHSA, 2017b).
The number of women of childbearing age, defined as ages 15 -44, who reported past-month heroin use increased to 109,000 in 2013 -2014, an increase of 3% over years 2011-2012(CBHSQ, 2016)).Data vary and are unreliable on the number of infants born annually after prenatal substance exposure.Substance use is one of many factors that place the mother and newborn at risk for adverse outcomes (Lefebvre et al., 2010, Sanders 2014).Research data indicate that drug use during pregnancy is usually poly-drug use and involves other social determinants, such as lack of prenatal care, high rates of violence exposure, co-occurrence of other psychiatric problems, inadequate nutrition, and poverty (Jones, 2006).
Following the birth of a child, continued substance use by parents is harmful in multiple ways, especially to young children (Berlin, Shanahan, & Carmody, 2014).Preterm births were statistically higher among drug-using women (Pinto et al., 2010).The incidence of low birth weight was 30.8% for the substance user, compared to 8% for non-users and the risk of placental abruption was higher.Prevention and intervention of maternal substance use is warranted to significantly reduce the long term, serious consequences to the mother, unborn fetus, and child (Wendell, 2013).Greenfield et al. (2010) suggested that women with substance use disorders are especially vulnerable to health and socioeconomic problems and are less likely than men to seek treatment for addiction.Many women choose not to disclose their drug use, especially during their pregnancies because of shame and embarrassment.In addition, others desire to evade perceived negative judgment for fear of legal and social consequences by delaying or avoiding prenatal care (Stone, 2015;Wendell, 2013).Pregnant women often feel guilty and experience stigma, leading to the expectation of being treated similarly by health care providers (Jones, 2006).It is crucial to encourage women to enter into treatment programs.Mothers who are maintaining recovery through a medically supervised program stay connected to their children.Separation from their children can result in depression, poor recovery outcomes, and diminished senses of identity (Alexander, 2017).

Attitudes and Compassion
Research has found many healthcare professionals who carry negative views and stigmatizing attitudes toward people who misuse drugs or other substances (Alexander, 2017;Chu & Galang, 2013;Puskar et al., 2013).Negative attitudes significantly influence the nurse-patient relationship and adversely affect patient outcomes.Experiencing a positive patient encounter increases the likelihood for continuity in care for medical problems and their drug dependency issues.Receiving ongoing medical care to address multiple medical comorbidities will mitigate further risks and complications.What patients are seeking is nonjudgmental and empathetic care from healthcare professionals (Chu & Galang, 2013).
Nurses sometimes struggle internally with providing optimal care to parenting and pregnant women.Aspects of this conflict include the context of personal biases, mistrust of the patient's shared stories, and views of addiction as a social problem (Painter, 2017;Shaw et al., 2016).Reflection and interaction with the mothers' stories can act as a catalyst for resolving bias.Another is being present to nurture a therapeutic nurse-patient relationship.Sharing and openness creates a positive environment for the relationship to grow.Finally, more experience and exposure with compassion with women experiencing substance use fosters more compassionate healthcare environments (Alexander, 2017).
Nurses interact with patients in diverse settings and play important roles in providing guidance, support, and education for women with substance use disorders.Education on effects of mother and fetus, treatment options, and parenting interventions are most useful.A nonjudgmental approach facilitates more disclosures about drug use and the opportunity to discuss other associated risks (Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2014).Building a trusting relationship that leads to the willing sharing of information may result in proper referral and treatment, resulting in optimal outcomes.

Education
Clinical competencies for working with individuals with substance use disorders or addictions need to be clearly evident in the education of healthcare professionals.Effective integrated care will require a competent workforce capable of addressing mental health needs, including addictions and complex comorbidities, while utilizing a person-centered model (Delaney, Robinson, & Chafetz, 2013).
Data are limited on the amount of education devoted to substance use health care in nursing schools (Institute of Medicine [IOM], 2006).One study found that approximately one to five hours was spent over two to four years.While another study found, again, little content covering psychiatric nursing for undergraduate nursing students (IOM, 2006).It is imperative that nurse educators integrate into nursing curriculum content about addiction prevention, overdose, and screening (Painter, 2017).Additionally, knowledge of mental health disorders and crisis interventions, especially in acute care settings, should be an integral part of nursing education (Dewitt, 2003).Comorbidity of mental illness is common among women with substance use and dependence, particularly major depressive disorders.Coexisting mental illness needs to be addressed to increase the likelihood of a successful recovery (Brandon, 2014).
Another essential component of nursing education is the proper screening for substance use.Screening should occur at the initial contact.Nurses should be sensitive to the pregnancy and parenting issues, as women fear punitive consequences, such as loss of custody, threat of incarceration, and loss of social services (Brandon, 2014).One universal screening and brief intervention tool is the Screening, Brief Intervention, and Referral To Treatment (SBIRTT).It requires only a 3-5 minute intervention to assess for early intervention and treatment for individuals at risk for developing substance use disorders and those who need referral to specialty care for substance use disorders (Puskar et al., 2013).Puskar et al. (2013) conducted an in-class education on addiction training for nurses with SBIRRT for undergraduate students.Nursing students reported that it changed the perception of working with patients who use drugs and alcohol.Also, the nursing students felt that their knowledge and skills increased.

Conclusion
One in five Americans has a diagnosed mental illness and many more suffer from untreated mental illnesses and addictions (National Institute of Mental Health, 2017).Women who are pregnant and/or parenting and misuse substances face unique challenges.The stigma often associated with mental illness must be replaced with an understanding of the disease process and compassionate care through nursing education.Only when a well-informed workforce is treating substance abuse will the journey change for those impacted by addiction.