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Opioid Use Disorders:

The Female Experience

Ashley Braun-Gabelman, Ph.D.

University Hospitals Case Medical Center

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Ashley Braun-Gabelman, Disclosures

• No disclosures

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Planning Committee, Disclosures

AAAP aims to provide educational information that is balanced, independent, objective and free of bias

and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information

from all planners, faculty and anyone in the position to control content is provided during the planning

process to ensure resolution of any identified conflicts. This disclosure information is listed below:

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD

Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten,

MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, and Justina Andonian.

All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is

accepted within the profession of medicine as adequate justification for their indications and contraindications in the care

of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally

accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been

reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias.

Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of

commercial products.

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Accreditation Statement

• American Academy of Addiction Psychiatry

(AAAP) is accredited by the Accreditation Council

for Continuing Medical Education (ACCME) to

provide continuing medical education for

physicians.

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Designation Statement

• American Academy of Addiction Psychiatry

(AAAP) designates this enduring material for a

maximum of 1 (one) AMA PRA Category 1

Credit™. Physicians should only claim credit

commensurate with the extent of their participation

in the activity.

▪ Date of Release [May 6, 2016]

▪ Date of Expiration [May 6, 2019]

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Target Audience

• The overarching goal of PCSS-O is to offer evidence-based

trainings on the safe and effective prescribing of opioid medications

in the treatment of pain and/or opioid addiction.

• Our focus is to reach providers and/or providers-in-training from

diverse healthcare professions including physicians, nurses,

dentists, physician assistants, pharmacists, and program

administrators.

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System Requirements

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Educational Objectives

• At the conclusion of this activity participants should

be able to:

▪ Identify changing demographics of heroin and

opioid use disorders

▪ Recognize barriers to treatment

▪ Discuss gender-related treatment issues

▪ Describe co-occurring disorders

▪ Identify treatment options for pregnant women

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Outline

• Changing demographics of OUD

• Course of illness

• Treatment issues

▪ Barriers to treatment

• Co-occurring disorders

• Pregnancy

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Case Vignette #1: “Kelly”

• Caucasian, 45 y/o presents with Heroin Use

Disorder, severe

• Childhood sexual abuse, incest, poverty, neglect

• Strong family h/o addiction

• First given tramadol by brother

▪ “Mother’s little helper”

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Case Vignette #1: Kelly

• Now self-described “Soccer Mom”

▪ Married mother of 2 teenage daughters

▪ Manager at work

▪ “I needed to use to be able to get everything

done.”

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Case Vignette #2: Jessica

• 36 y/o, Caucasian, married mother of 3 y/o son

and 8 y/o daughter

• Works as RN

• Nominated for “Nurse of the Year award”

• Diverting Oxycodone from work

• Mother recovering alcoholic

• “The pills made me feel competent, energetic.”

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Introduction

• Important biopsychosocial gender differences in

Opioid Use Disorder (OUD)

• Research suggests that these differences are

important for:

▪ Risk factors for developing an OUD

▪ Trajectory of the disease

▪ Treatment planning, retention and continued

sobriety

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Heroin affects everyone

•Cuyahoga County, Ohio

•2014 - 2015 30%

Fentanyl-related

Overdose deaths were

women

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Changing demographics of opiate users

• Currently, about 1/3 of those with opioid dependence are women of child-bearing age (Unger et al. 2010)

• January 17, 2016 NY Times: The death rates of Caucasians,

especially women, are rising (death rates for black and Hispanics continue to fall)

• Drug overdose • New users predominantly white, living in nonurban

areas • 75% current heroin users began with Rx opioids

first

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Epidemiology

• The demographics of those who abuse heroin and other opiates has changed in recent years (Cicero, 2014)

− 1960s: mostly men abusing heroin

− Now: men and women

Cicero, Ellis, Surratt, Kurtz (2014)

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Prescription Opioids

• Mixed findings

▪ Several large scale studies found women more likely

to use and abuse prescription opioids (CDC, 2016; Green et al., 2009,

Rosenblum et al., 2007; Simoni-Wastila et al., 2000,2004, c.f. Back et al., 2010

▪ In contrast, 2013 and 2014 NSDUH nonmedical use

of pain medication still higher among men

• Rx misuse and overdose among women rapidly rising

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Rx overdose among women

SOURCE: National Vital Statistics System, 1999-2010

(deaths include suicides)

Credit: CDC Vital Signs, Centers for Disease Control

and Prevention

• Prescription

painkiller overdose

deaths among

women increasing

• Up 400% from

1999 – 2010

(CDC, 2013)

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Rx Opioids

• In the past two decades, opioid prescriptions have increased overall

• Women tend to be prescribed medication with abuse potential more often than men (Isacson and Bingefors, 2002; Simoni-Wastila, 2004)

• Women prescribed opiates more often than men (Anthony, 2008; Gu, 2010; McCabe et al., 2005; Parsells, 2008; Roe, 2003; Zhong 2013)

• More chronic pain (Wiesenfeld-Hallin, 2005)

• Lower pain tolerance (Berkley, 1997; Dixon et al., 2004)

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Rx Opioid Abuse

• Immediate release (women) vs. extended release

(men) (Green et al., 2009)

• Among women who died due to unintentional

overdose, prescription opioids found to be most

common cause of death (more than heroin,

alcohol, other drugs) (Shah et al., 2007)

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Heroin

• Men still more likely

to use heroin but

women’s use

rapidly rising o Men and women

equally likely to

inject

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Injection Drug Use

• Injection drug use in particular related to partner

drug use (Powis et al. 1996)

• Women who inject heroin often have partner

who also injects

• Women more likely to be introduced to injection

by male partner

• Women more likely to share needles, leading to

higher risk of infection (Maher et al. 2006)

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Telescoping

• A faster course from commencing substance use

to SUD and treatment onset

• More rapid progression of the disease – more

drug-related problems, sooner

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Telescoping

• Research shows telescoping among women who

use alcohol, compared to men

• Results for opiates are less conclusive, although

several studies indicate

• Shorter duration of illness

• Greater psychiatric, health and family problems (Greenfield et al., 2007; Hernandez-Avila et al., 2004; Unger et al. 2010; c.f. Holscher et al. 2010)

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Treatment

• Women less likely to go to treatment compared to

men

• Gender not predictive of LOS or outcome (Greenfield et al.,

2007)

• Often referred by:

▪ community agencies

▪ welfare

▪ healthcare providers (Greenfield et al., 2010)

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Children: Barrier and motivator

• Women more likely to have children to care for (Bawor et al.,

2015)

• Research shows that mothers who abuse

substances are judged more harshly by the public

and even by healthcare providers (Castillo & Waldorf, 2008)

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Children: Barrier to treatment

• Barriers to treatment

• Who will care for children while mother is in treatment?

• Many worry about custody issues (Greenfield et al., 2010)

• Mothers who are primary caretakers of the children may leave treatment early or not go at all due to childcare restraints (Castillo & Waldorf, 2008)

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Children: Motivator for treatment

• Evidence that women who live with their children

more likely to go to treatment (Greenfield et al., 2010)

• Women who are able to have children with them

in treatment or maintain custody, more likely to

stay in treatment (Greenfield et al., 2010)

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Other Barriers

• Women often caretakers, both at home and in

caretaking professional roles (nurses, social

services, etc.)

• Women in leadership roles at home and at work

• It can be a difficult role-shift to ask for help, accept

help

• Shame

▪ Associated with relapse among women (Wiechelt &

Sales, 2001)

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Treatment Accessibility

• Women with OUD more likely to enter treatment compared to women with other SUD’s (Bernstein et al. 2015)

• Detox more likely than ongoing treatment

▪ Likely having to do with withdrawal profile

▪ Only 15% of women in MAT completed treatment

• Relapse more likely if only detox without continued treatment

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Medication Treatment

• Medication: Methadone, Buprenorphine,

Naltrexone

• Consider gender-specific issues

• Different opioid binding capacity

• Hormone levels

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Psychosocial Treatment

• In early recovery:

▪ Coping skills, problem-solving

▪ Meditation and breathing techniques

▪ Psychoeducation

• Motivational Interviewing

• Cognitive Behavioral Therapy

• Relapse Prevention

• Couples and Family

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Treatment

▪ Female only vs. mixed gender treatment

▪ Women may prefer female-only treatment

▪ Sensitive, gender-specific issues

▪ Intimate partner violence

▪ Sexual trauma

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Co-occurring Conditions

• Compared to men, women with OUD more likely to

have:

▪ More physical health problems

▪ Family history of psychiatric illness

▪ Co-occurring psychological distress compared to

men (Back, 2010; Green et al., 2009)

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Psychiatric Comorbidity

• Anxiety Disorders

▪ PTSD ▪ Women with OUD have higher rates of

trauma and PTSD ▪ Intimate partner violence ▪ Childhood trauma

▪ OCD − Among women with history of childhood

sexual abuse, women with OUD had higher rates of OCD (Peles et al. 2012; 2014)

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Psychiatric Comorbidity

• Mood Disorders

▪ Women with OUD twice as likely as men to

have:

− Major depression

− Dysthymia

− Manic Disorder (Grella et al., 2009)

▪ Depression more common among women with

heroin use disorder vs. men (Ross et al., 2005)

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Psychiatric Comorbidity

• Eating Disorders ▪ Bulimia nervosa

− Opioids – vomiting ▪ Disordered eating – restrict food intake to

enhance the high

• Borderline Personality Disorder ▪ Important to separate addictive behaviors in

active addiction/early recovery from try BPD diagnosis

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Co-Occurring Disorders Treatment

• Many symptoms of acute and post-acute withdrawal

are also common to other mental health conditions:

▪ Anxiety, nervousness

▪ Insomnia

▪ Depressed mood

▪ Difficulty concentrating

• Important for treating clinician to differentiate and treat

appropriately

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Co-Occurring Disorders Treatment

• SSRI’s for anxiety and depressive disorders

• Medications with abuse potential (e.g.,

benzodiazepines) should be avoided

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Co-Occurring Disorders Treatment

• Mixed results as to how co-occurring disorders affect SUD treatment ▪ More receptive to SUD treatment (Zweben, 2003)

▪ Less likely to enter SUD treatment (Bernstein et al. 2015)

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Psychosocial Treatment

• In early recovery: ▪ coping skills, problem-solving ▪ meditation and breathing techniques ▪ psychoeducation

• Seeking Safety: PTSD + SUD

• Motivational Interviewing

• Cognitive Behavioral Therapy

• Relapse Prevention

• Mindfulness

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Pregnancy

• 2012-2013: 5.4% pregnant women age 15 – 44

used illicit drugs (vs. 11.4% in this age group not

pregnant) (SAMHSA, 2014)

• 0.1% pregnant women used heroin

• 1% pregnant women nonmedical use opioids

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Maternal opioid use is increasing

• Opiate use among pregnant women

▪ 1.19 (2000) to 5.63 (2009) per 1000 hospital

births per year

• Neonatal Abstinence Syndrome

▪ 1.20 (2000) to 3.39 (2009) per 1000 hospital

births per year (Patrick et al., 2012)

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Heroin during pregnancy

• Heroin use during pregnancy associated with

many adverse effects on fetus

▪ Short half-life, effects may be due to repeated

withdrawal in the fetus

• Take into account lifestyle effects of some women

actively using heroin

▪ Prostitution, theft, violence, STI’s

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Treatment of pregnant women

• Opioid withdrawal should be avoided in pregnant

women

• Goals of MAT in pregnant women:

▪ Reduce risks of illicit opioid use and withdrawal

▪ Encourage prenatal care and treatment

▪ Reduce criminal activity

▪ Avoid associated risks

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MOTHER study

• Jones et al. 2012

• Methadone vs. buprenorphine in pregnant women

• Outcomes:

▪ Buprenorphine has similar maternal outcomes

to methadone

▪ Buprenorphine resulted in less severe

neonatal abstinence syndrome

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Case Vignette #1: “Kelly”

• Caucasian, 45 y/o presents with Heroin Use Disorder,

severe

• Childhood Sexual Abuse, incest, poverty, neglect

• Strong family h/o addiction

• Now self-described “Soccer Mom”

▪ Married mother of 2 teenage daughters

▪ Manager at work

▪ “I needed to use to be able to get everything done.”

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Case Vignette #1: Questions

• What were some of Kelly’s risk factors for

developing an opioid use disorder?

• What are some of the barriers to treatment?

• Who, aside from Kelly herself, should be involved

in her treatment?

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Case Vignette #2: Jessica

• 36 y/o, Caucasian, married mother of 3 y/o son

and 8 y/o daughter

• Works as RN

• Nominated for “Nurse of the Year award”

• Diverting Oxycodone from work

• Mother recovering alcoholic

• “The pills made me feel competent, energetic.”

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Case Vignette #2: Questions

• What were Jessica’s risk factors?

• Potential barriers to treatment?

• What should be considered as high-risk situations

for relapse?

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Summary

• Women progress from first use to problem use

faster than men

• Women more likely to have co-occurring physical

or mental health condition

• Despite faster course, faster time to develop

problems associated with opioid use, and more

co-occurring disorders, women less likely to enter

treatment compared to men

• Gender is not predictive of LOS or outcome

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Summary

• Must take into account co-occurring disorders

• Special considerations for pregnant women

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References

• Anthony M, Lee KY, Bertram CT, Abarca J, Rehfeld RA, Malone DC, ... Woosley RL (2008). Gender and age differences in medications dispensed from a national chain drugstore. Journal of Women's Health, 17(5): 735-743. • Back SE, Lawson KM, Singleton LM, Brady KT (2011). Characteristics and correlates of men and women with prescription opioid dependence. Addictive Behaviors, 36: 829 – 834. • Back S., Payne RL, Wahlquist AH, Carter RE, Stroud Z, Haynes L., ... Lin W (2011). Comparative profiles of men and women with opioid dependence: results from a national multisite effectiveness trial.The American journal of drug and alcohol abuse, 37(5): 313-323. • Bawor M., Dennis BB, Varenbut M, Daiter J, Marsh DC, Plater C, ... Desai D. (2015). Sex differences in substance use, health, and social functioning among opioid users receiving methadone treatment: a multicenter cohort study. Biology of sex differences, 6(1): 1-11. • Berkley KJ.(1997). Sex differences in pain. Behavioral and Brain Sciences, 20:371–380. • Bernstein J, Derrington TM, Belanoff C, Cabral HJ, Babakhanlou-Chase H, Diop H, ... Kotelchuck M (2015). Treatment outcomes for substance use disorder among women of reproductive age in Massachusetts: A population-based approach. Drug and alcohol dependence, 147: 151-159. • Castillo DT, Waldorf VA (2008). Ethical issues in the treatment of women with substance abuse. The book of ethics: Expert guidance for professionals who treat addiction, 101-114. • Centers for Disease Control and Prevention (CDC). Prescribing Data. (2016, March 16). Retrieved April 10, 2016, from http://www.cdc.gov/drugoverdose/data/prescribing.html • Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses: a growing epidemic, especially among women (2013, July.) Retrieved April 11, 2016 from http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/index.html • Cicero TJ, Ellis MS, Surratt HL, Kurtz, SP (2014). The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA psychiatry, 71(7): 821-826.

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References

• Dixon KE, Thorn BE, Ward LC (2004). An evaluation of sex differences in psychological and physiological responses to experimentally-induced pain: a path analytic description. Pain, 112(1): 188-196. • Green TC, Grimes Serrano JM, Licari A, Budman SH, Butler SF. (2009). Women who abuse prescription opioids: findings from the Addiction Severity Index-Multimedia Version Connect prescription opioid database. Drug and Alcohol Dependence, 102 (1-2): 65 – 73. • Greenfield SF, Back SE, Lawson K, Brady KT (2010). Substance Abuse in Women. Psychiatric Clinics of North America, 33: 339 – 355. • Greenfield SF, Brooks AJ, Gordon SM, Green CA, Kropp F, McHugh RK., ... Miele, G. M. (2007). Substance abuse treatment entry, retention, and outcome in women: A review of the literature. Drug and alcohol dependence, 86(1): 1-21. • Grella CE, Karno MP, Warda US, Niv N, Moore AA (2009). Gender and comorbidity among individuals with opioid use disorders in the NESARC study. Addictive behaviors, 34(6): 498-504. • Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. NCHS Data Brief. 2010:1–8. • Hölscher F, Reissner V, Di Furia L, Room R, Schifano F, Stohler R, ... Scherbaum N (2010). Differences between men and women in the course of opiate dependence: is there a telescoping effect?. European archives of psychiatry and clinical neuroscience, 260(3): 235-241. • Isacson D, Bingefors K. (2002). Epidemiology of analgesic use: a gender perspective. European Journal of Anaesthesiology, 19: 5-15. • Jones HE, Finnegan LP, Kaltenbach K (2012). Methadone and buprenorphine for the management of opioid dependence in pregnancy. Drugs, 72(6): 747-757. • Maher L, Jalaludin B, Chant KG, Jayasuriya R, Sladden T, Kaldor JM, Sargent PL (2006). Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia. Addiction, 101(10): 1499-1508.

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References

• McCabe, S, Knight JR, Teter CJ, Wechsler H. (2005). Non‐medical use of prescription stimulants among US college students: Prevalence and correlates from a national survey. Addiction, 100(1): 96-106. • Parsells KJ, Cook SF, Kaufman DW, Anderson T, Rosenberg L, Mitchell AA. (2008) Prevalence and characteristics of opioid use in the US adult population. Pain, 138: 507–513. • Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. Jama,307(18): 1934-1940. • Peles E, Adelson M, Seligman Z, Bloch M, Potik D, Schreiber S (2014). Psychiatric comorbidity differences between women with history of childhood sexual abuse who are methadone-maintained former opiate addicts and non-addicts. Psychiatry research, 219(1): 191-197. • Peles E, Weinstein A, Sason A, Adelson M, Schreiber S. (2014). Stroop task among patients with obsessive-compulsive disorder (OCD) and pathological gambling (PG) in methadone maintenance treatment (MMT). CNS spectrums, 19(06): 509-518. • Roe CM, McNamara AM, Motheral BR. (2002). Gender- and age-related prescription drug use patterns. Annals of Pharmacotherapy, 36:30–39. • Rosenblum A, Parrino M, Schnoll SH, Fong C, Maxwell C, Cleland CM, ... Haddox JD (2007). Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug and alcohol dependence, 90(1): 64-71. • Ross J, Ross J, Teesson M, Ross J, Teesson M, Darke S, ... Ross J. (2005). The characteristics of heroin users entering treatment: findings from the Australian treatment outcome study (ATOS). Drug and alcohol review, 24(5): 411-418. • Shah NG, Lathrop SL, Reichard RR, Landen MG (2007). Unintentional drug overdose death trends in New Mexico, USA, 1990-2005: Combinations of heroin, cocaine, prescription opioids and alcohol. Addiction, 103: 126 – 136.

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References

• Simoni-Wastila L. (2000). The use of abusable prescription drugs: the role of gender. Journal of women's health & gender-based medicine, 9(3): 289-297. • Simoni-Wastila L., Ritter G., Strickler G. (2004). Gender and other factors associated with the nonmedical use of abusable prescription drugs.Substance use & misuse, 39(1): 1-23. • Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. • Unger A, Jung E, Winklbaur B, Fischer, G. (2010). Gender issues in the pharmacotherapy of opioid-addicted women: buprenorphine. Journal of addictive diseases, 29(2), 217-230. • Wiechelt SA, Sales E. (2001). The role of shame in women's recovery from alcoholism: The impact of childhood sexual abuse. Journal of Social Work Practice in the Addictions, 1(4): 101-116. • Wiesenfeld-Hallin Z. (2005). Sex differences in pain perception. Gender Medicine, 2:137–145 • Zhong W, Maradit-Kremers H, St. Stauver JL, Yawn BP, Ebbert JO, Roger VL (2013). Age and sex patterns of drug prescribing in a defined American population. Mayo Clinic Proceedings, 88: 697 – 707. • Zweben, J. E. (2003). Special issues in treatment: Women. Principles of addiction medicine, 3111: 569-580.

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PCSS-O Colleague Support Program

and Listserv

• PCSS-O Colleague Support Program is designed to offer general information to health

professionals seeking guidance in their clinical practice in prescribing opioid

medications.

• PCSS-O Mentors comprise a national network of trained providers with expertise in

addiction medicine/psychiatry and pain management.

• Our mentoring approach allows every mentor/mentee relationship to be unique and

catered to the specific needs of both parties.

• The mentoring program is available at no cost to providers.

• Listserv: A resource that provides an “Expert of the Month” who will answer questions

about educational content that has been presented through PCSS-O project. To join

email: pcss-o@aaap.org.

For more information on requesting or becoming a mentor visit:

www.pcss-o.org/colleague-support

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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in

partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology

(AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP),

American College of Physicians (ACP), American Dental Association (ADA), American Medical

Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American

Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN),

International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse

Training (SECSAT).

For more information visit: www.pcss-o.org

For questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) from SAMHSA. The

views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department

of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

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