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Diagnosis and treatment of drug and alcohol abuse in women
PRIMARY CARE Diagnosis and treatment of drug and alcohol abuse in women Ed Kaufman, MD Dana Point, California The major reasons why women abuse drugs and alcohol are presented with a focus on societal and psychologic bases. A structured format is provided for eticiting a history while motivating the patient to obtain adequate treatment. A workable treatment contract is presented. A three-stage method of treatment is described, which focuses on the following: (1) achieving abstinence, (2) maintaining abstinence, and (3) achieving sobriety (advanced recovery). (AM J OSSTETGYNECOL1996;174:21-7.)
Key words: Women; d r u g abuse, understand, assess, treat Substance abuse by w o m e n is very m u c h related to the p r o b l e m s of w o m e n in c o n t e m p o r a r y society. Issues such as age, social class, ethnicity, environment, state of substance abuse consumption, and social changes such as feminism atl have p r o f o u n d effects on substance abuse problems in women. Lack of social power and external pressure to c o n f o r m to sex-role stereotypes create intolerable stress that drives some w o m e n to substance abuse. These w o m e n are o v e r w h e l m e d by the message many of t h e m have b e e n subjected to t h r o u g h o u t their lives: that they are less worthy because they are women. Far from protecting them, the culturally defined behavior dem a n d e d of w o m e n actually contributes to m u c h of the pain and conflict that leads t h e m to substance abuse. Those who b e c o m e addicts or alcoholics are further insuited because they are stigmatized as female substance abusers, which only increases their difficulties. 1 W o m e n use m o r e prescribed abusable drugs than m e n do. T h e most c o m m o n prescription drugs abused by w o m e n are the benzodiazepines, Vicodin ( h y d r o c o d o n e bitartrate and a c e t a m i n o p h e n ) , and Fiorinal (butalbital, a rapid-acting barbiturate, and caffeine and aspirin). They also turn to prescribed and o v e r - t h e - c o u n t e r stimulants or illegal drugs such as cocaine and a m p h e t a m i n e s to lose weight or o v e r c o m e depression. An essential feature of substance abuse in w o m e n is a p r e o c c u p a t i o n with what the w o m e n perceive as their inadequacy, ineptness, and inability to establish themselves in their environment. Female alcoholics feel less socially c o m p e t e n t and less effective in goal a c h i e v e m e n t than nonalcoholics do. They have m o r e covert and overt anxiety and often feel unworthy and dissatisfied with their purpose in life. 2 W o m e n are m o r e likely than m e n to begin p r o b l e m
From the ChemicalDependency Services, Capistrano by the Sea Hospital. Receivedfor publication May 15, 1995; accepted Septembo"28, 1995. Reprint requests: Ed Kaufman, MD, Chemical Dependency Services, Capistrano by the Sea Hospital, 34000 Capistrano by the Sea Dr., Dana Point, CA 92629. Copyright © 1996 by Mosby-YearBook, inc. 00020378/96 $5.00+ 0 6/1/69634
drinking in response to a specific trauma, even with no prior history of alcohol abuse. These traumas most often involve losses that threaten their sense of self, such as divorce, desertion, infidelity, death of a family member, children leaving h o m e , or health problems, especially gynecologic or menopausal. 1' s Many w o m e n begin abusing alcohol during a crisis in middle age, w h e n they fear they can never fulfill the dreams of their y o u t h ? Greater social stigma is still attached to drinking and d r u g abuse by w o m e n c o m p a r e d with men. As a result, many w o m e n react with shame and attempt concealment. Many female alcoholics frequently drink early in the day and then nap. T h e i r ability to conceal their drinking habits may account for part of the telescoping (shorter duration between onset of drinking and alcoholism) described in w o m e n alcoholics. ~ This denial of w o m e n ' s drinking continues because its feared consequences, such as overt sexuality and family neglect, violate traditional female taboos.' A w o m a n who abuses drugs or alcohol may a b a n d o n her responsibility as a wife but cling desperately to h e r role as mother, with this a c h i e v e m e n t minimizing the attention paid to h e r drinking. 2 Alcohol use by the spouse is also an i m p o r t a n t factor in female drinking patterns. If both s p o u s e s d r i n k heavily, they tend to support each o t h e r in c o n t i n u e d alcoholism. W o m e n frequently are i n t r o d u c e d to alcohol and drugs by men, 4 and alcoholic w o m e n are m o r e likely to be m a r r i e d to an alcoholic spouse? W o m e n frequently state that p r o b l e m s in the marriage are reasons they drink. ~ Alcoholic w o m e n have a high divorce rate and are left by their spouses m o r e frequently than are alcoholic men. ~ Sexual dysfunction in alcoholic w o m e n is c o m m o n . 6 T h e majority of w o m e n addicted to cocaine were introd u c e d to it by men. Cocaine's capacity for increasing self-confidence and providing a sense of control would seem to e a r m a r k it for use by women, many of w h o m have low self-esteem and whose lives are controlled by outside forces. In addition, climbing the corporate ladder in what has always b e e n considered as a m a l e - d o m i n a t e d environm e n t with its attendant long hours and stress puts w o m e n 21
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in positions of substantially increased risk for addiction and d r u g abuse. T h e additional bonus of weight loss for w o m e n obsessed with body image also provides a stimulus for c o n t i n u e d stimulant d r u g use.
Psychopathologic mechanisms in female substance abusers A wide variety of psychopathologic features, personality styles, and personality disorders are seen a m o n g w o m e n who abuse drugs and alcohol. Not only do these w o m e n face society's c o n d e m n a t i o n , they frequently c o n d e m n themselves. This cycle lowers their self-esteem, which drives t h e m further into substance abuse. The high incidence of depression in female alcoholics has b e e n well d o c u m e n t e d . Winokur and Pills 7 (1965) were a m o n g the first authors to link alcoholism in w o m e n to affective illness. Schuckit et al.8 (1969) f o u n d that 27% of 70 female alcoholics had severe depression before their alcoholism (these are called secondary alcoholics). More recently, in a study analyzing data f r o m the Epidemiologic C a t c h m e n t Area Study focusing on alcoholism and major depression, Helzer and Pryzbeck 9 (1988) f o u n d in 78% of the male subjects with both disorders that alcoholism was primary and depression secondary. An analysis of w o m e n subjects revealed a striking reversal of this relation: in 66% of the female subjects depression was primary and alcoholism was secondary. I advocate the establishment and continuation of abstin e n c e as a prerequisite for c o n t i n u i n g treatment. Those rare instances where addicts or alcoholics are " c u r e d " while they continue to drink or use drugs are w o m e n whose use of abusable substances is defintely the result of underlying psychopathologic disorders or who were n o t truly addicted over substantial periods of time. Early intervention and t r e a t m e n t of w o m e n with addictive disorders consist of assessment, motivation, detoxification, abstinence, and establishment of a t r e a t m e n t contract.
Assessment Assessment of a substance abuser must of necessity be m o r e t h o r o u g h and detailed than with o t h e r types of patients. This is so because substances of abuse have such pervasive effects on psyche and soma. Substance abuse and addiction can be dangerous, if not fatal, in early phases. In addition, over time they substantially shorten a w o m a n ' s life span. Assessment is only one of several key aspects of the initial interview. T h e major goal of the initial evaluation is for the patient to end up c o m m i t t e d to appropriate, workable treatment. O t h e r functions of evaluation include initiating a workable t r e a t m e n t partnership and developing the c o m p o n e n t s of an individualized program. Assessment is the b e g i n n i n g of treatment, and most patients will b o n d
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strongly to the first person who takes a detailed, sensitive history of the addiction problem. Assessment is always a continuing process t h r o u g h o u t treatment, but it is even m o r e relevant to substance abusers because we constantly reevaluate their c o m m i t m e n t to abstinence and their psychologic state. In the early phases of t r e a t m e n t o t h e r critical information is often revealed that appreciably alters our assessment of the patient (for example, previously withheld facts such as loss o f j o b or spouse or legal or financial crises)) ° During this phase it is essential that the physician be exploratory without being j u d g m e n t a l . 11 T h e first step of this phase is to assess the extent of substance abuse and its physical, vocational, and familial consequences. A medical examination that delineates the specific physical effects of the substance(s) involved and a detailed psychosocial evaluation are important. 12T h e pattern of use of every type of abusable substance is determined. Many individuals will minimize the i m p o r t a n c e of their abuse of a secondary d r u g that is not their d r u g of choice, such as alcohol or marijuana use by cocaine addicts or prescription d r u g abuse by alcoholics. D o c u m e n t a t i o n of use of these secondary drugs is i m p o r t a n t because their c o n t i n u e d use predisposes the addict to r e t u r n to his or her d r u g of choice. Some impor{ant specifics are quantity, quality, duration, expense, how intake was s u p p o r t e d and prevented, physical effects, tolerance, withdrawal, and any drug-related complications. T h e circumstances u n d e r which the patient began to use and abuse drugs or alcohol and their current drugs of choice are reviewed for their psychosocial and psychodynamic significance. Direct and indirect psychosocial sequelae, particularly psychotic disruptions, paranoid or suicidal ideation, and violence are assessed. Early effort is devoted to why the patient is entering t r e a t m e n t at this specific time. Is the significant o t h e r so fed up or e m p o w e r e d that he is clearly c o m m u n i cating his readiness to leave? Is the prospective patient there because an employer is m a n d a t i n g it as a condition of c o n t i n u e d e m p l o y m e n t or is she attempting to obtain leniency in a p e n d i n g court case? T h e u n d e r s t a n d i n g of i m m e d i a t e motivation tells us a great deal about true treatm e n t needs and sincerity of c o m m i t m e n t . Working with the judicial system can provide necessary leverage to motivate a difficult patient to enter and stay in appropriate treatment.I° T h e history of t r e a t m e n t is reviewed during the initial interview. What was helpful and what was not? How long did she stay sober? Did she work a 12-step p r o g r a m and with what level of c o m m i t m e n t ? Was she receiving psychotherapy, and what orientation did the therapist have? Did she lie to " c o n " the therapist? What precipitated relapse? Is she willing to sign a consent so that you can c o m m u n i c a t e with her prior t r e a t m e n t team, hospital, or therapist? How aware is she of earlier signs of
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relapse that preceded the major precipitant? Other important indicators of potential relapse include continued related nonchemical compulsive (addictive) behaviors such as gambling, promiscuous sexuality including perversions and high-risk behaviors, binge eating, extreme exercising, food restriction, frequent rage, violence, loss of temper, and self-mutilation. Exploration of how the patient obtained the money for the drugs and alcohol is often quite revealing. To what extent were these activities indicative of an underlying antisocial personality? How self-destructive, risky, or sensation seeking were these activities? The family history of substance dependence is gathered early because such a history conveys a powerful risk for substance dependence and greater severity of illness.13 The family and other collaterals are also interviewed in family sessions to provide their view of substance abuse and related behaviors. Many substance abusers will minimize the extent of their abuse of drugs and alcohol until confronted by their families. Others will be more honest in individual sessions and later use family visits to share their substance abuse history with their families in an open way, which opens up communication about other issues. Peer relationships are also explored. Do most or all of the patient's friends, relatives, fellow employees, or supervisors use or abuse drugs and alcohol? To what extent does a supportive network of nonabusing or sober associates exist? The psychologic aspects of substance use are explored by asking what the patient is like while abusing drugs or alcohol; what happens u n d e r the influence; what effects are soughtl~; what are fantasies before, during, and after drug use; and what are its effects on family, friendship, work, and recreational performance? What feelings are stimulated by drugs and alcohol? Which feelings are relieved or soothed by these substances? The consequences of substance abuse pervade all biopsychosociaI spheres and include unemployment, violence, divorce, and financial, tax, family, and legal difficulties. Assessment should include the specific events and situations that are consequences of the problem (which, when, and if the substance-dependent person recognizes and accepts that she has the disease) are identified and labeled as part of the disease. The clinician begins with questions such as, "How do you use alcohol?" or "How does your use of drugs affect you and those who are close to you?" As assessment progresses and it becomes apparent that the patient is resistant to workable treatment, the physician may need to become confrontive or use the intervention (defined below) or other similar techniques. However, some patients may need to demonstrate the ability t O abstain from alcohol and drugs "just one time" before they are motivated to accept a comprehensive workable program. Phy-
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sicians should be flexible but not enablers as they decide how many "one more times" to permit, l° A difficult aspect of evaluation for many clinicians is the patient in whom substance abuse is initially unrecognized. This may occur for a n u m b e r of reasons, including patients who minimize or deny substance abuse or who escalate from controlled use to abuse or dependence over their years of contact. While one continues to treat patients in whom the problem is denied or ignored, it becomes progressively more difficult to confront the substance abuse and even more problematic to require abstinence. It then requires considerable therapeutic objectivity or outside consultation to step back from the physician-patient relationship and require the patient to deal with substance abuse before treatment can continue. If this confrontation is done with empathic concern, the patient's active participation in the shift of emphasis can occur.
Another important aspect of assessment is laboratory testing: liver enzyme levels (aspartate aminotransferase, ~lanine aminotransferase, and y-glutamyl transpeptidase) or complete blood cell count (macrocytic anemia) are helpful in confirming the diagnosis of alcoholism and the extent of liver and hematopoietic damage. Many patients who are questioning the diagnosis or need for intensive treatment may be persuaded to accept diagnosis and treatment when they are confronted with this definitive laboratory confirmation of disease. However, we should not rely on these tests because many alcohol-dependent persons may have normal or near-normal values. Urine drug screens for drugs of abuse may also be helpful in resistant patients, particularly adolescents, to diagnose substance abuse. These must be obtained u n d e r monitored conditions and carefully assessed for contaminants that can interfere with testing. Medical sequelae and related complications are evaluated and these are also used to confront resistant patients of the need for treatment. The patient is asked to accept appropriate medical treatment for complications such as hypertension, anemia, infertility, syphilis, hepatitis, acquired immunodeficiency syndrome, etc. During the evaluation I convey to the patient that I feel that for treatment to be successful she must choose a method to reinforce abstinence. I inform her that, although medications such as disulfiram (Antabuse) or methadone maintenance may provide that method, the best method in my experience is a 12-step program. I also emphasize that, because addiction has destroyed so many aspects of her life, a holistic approach that develops the whole person-is most helpful.
Motivation Some patients will refuse to enter treatment, particularly if abstinence is required. Several techniques that the
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physician can use to motivate such patients have been described above (gradual persuasion, confrontation, laboratory tests). The patient's network provides many important sources of motivation for treatment. Spouses, parents, children, and work-related persons such as employers, supervisors, peers, and employment assistance persons may individuallyor in concert motivate an unwilling patient for treatment. Attorneys, judges, and probation officers also carry considerable weight in motivating patients. One difficulty here is balancing the need for treatment with laws about confidentiality. If the family or significant other is seen in the initial interview, then a clear, mutually agreed on contract about what will be shared can be clarified, At that time the iZamilycan be worked with to support or demand necessary treatment, as appropriate. Employment assistance persons and supervisory personnel are often well educated about substance abuse and can be strong motivators for treatment without any urging from the therapist. Experience has shown that substance abusers who are motivated externally do as well as or better than those who profess only internal motivation.5 This is an important contradiction to those physicians who tell substance abusers and their families that they are unable to treat the substance abuser unless he or she is personally motivated. Resistant patients in whom the above methods have failed, particularly if they are involved with their families and are employed, may be good candidates for an intervention. This technique, developed for treatment of alcoholism at the Johnson Institute in Minneapolis, is readily adapted for use with all addictions. In this technique all available family members and the most meaningful support network members, such as employer, neighbors, friends, and clergy, are coached to confront the addicted person with the facts of the substance use and related behaviors. This confrontation is done with deep concern and without hostility. The participants list specific incidents and behaviors consequential to drug use and present them in a nonjudgmental fashion once the intervention meeting is arranged. Family members may be immobilized by fear or love and may find the idea of an intervention intimidating. They need to be educated about the deadly consequences of their inaction, and they need instruction on how to say, "We love yon and because we love you, we will not continue to live with you while yon abuse alcohol and drugs. If you accept the treatment being offered and continue to work at recovery, we will renew our lifetime commitment to you." The family needs to agree in advance about what treatment is necessary, insist on it in a firm, consistent manner, and follow through with. the limits set, including the consequences of return to substance use or refusal to enter treatment. As many family members as possible are included. In-
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volvement of the employer is often crucial, and in some cases sufficient of itself to motivate the addicted individual to seek treatment. The employer who clearly makes treatment a precondition for employment, who supports time off for treatment, and who agrees to continue support for the patient in aftercare offers a helpful model for the family and is a valuable ally.
Early issues in treatment After the confrontive phase of motivating the patient for treatment, the therapist shifts to providing support, direct assistance, and information. When the patient is involved with a therapeutic team, manipulative and splitting activity must be kept to a m i n i m u m so that the patient learns newer and more adaptive ways to get needs met. A split treatment team undoubtedly replicates the patient's divided or disorganized parents. This should not be interpreted at this point, but rather the team should understand the patient's projective identifications or splitting and work together to present a unified approach. The treatment team must be consistent and cohesive while providing a safe environment that is neither too giving nor too withholding. 14
Detoxification Detoxification will not be described in detail; the reader is referred to several excellent references 1~19 for this process. Previously I have written about the difficulties in outpatient detoxification and the need to use a comprehensive program that reaches into the patient's home, network, physicians, and pharmacies when attempting this. Recently I have encountered several case managers who have only been willing to approve outpatient detoxification in certain patients. If the patient is addicted to sedative drugs or alcohol and inpatient detoxification is not available, I only perform the detoxification in a highly structured intensive outpatient setting (partial hospital program) in which the patient's vital signs and activities can be monitored for up to 14 hours daily if necessary. Urine drug screens and blood alcohol levels can also be monitored daily and can provide immediate feedback about nonprescribed substance use. If potentially abusable drugs (benzodiazepines, opiates, sedative hypnotics) are prescribed without adequate monitoring as described above, they are often abused along with the primary substance of abuse. Although stimulant addicts require little medical detoxification and Washton 2° has described excellent intensive outpatient programs, I prefer initial inpatient detoxifications and stabilization for at least several days. This is particularly true with heavy cocaine users (>5 gm weekly) and even more so in those who primarily smoke it. In these patients there is often a prolonged sleep of up
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to 3 or 4 days that is interrupted by bizarre, paranoid impulsive behavior and followed by powerful cravings. Hospitalization accomplishes containment from drug use and other destructive behaviors and nurtures motivation during periods of wakefulness.
Pharmacologic adjuncts to treatment This article will not deal with pharmacologic adjuncts to treatment in detail, but the reader is referred to several excellent tests and articles in this area. 2>2a Many pharmacologic adjuncts have been recommended for cocaine addicts. In the first few days after drug cessation the patient may require neuroleptics for extreme paranoia or destructive behaviors. 21 Note that neuroleptics are contraindicated in acute cocaine overdoses in which there is agitation and hyperthermia because these drugs may worsen the latter symptom, Oxazepam or other benzodiazepines may provide active relief of agitation, irritability, and anxiety in structured treatment settings, which will help motivate the cocaine addict to become engaged in treatment. A group ofdopaminergic agents has been suggested to alleviate early cravings and withdrawal. These include amantadine, bromocirptine, >dopa, methylphenidate,2 and carbamazepine, z* >Tyrosine and other amino acids have been used to enhance new dopamine production. Buprenorphine has been found to diminish cravings for cocaine and opiates. 2~ Desipramine has been advocated as reducing longer-term craving by reducing dopaminergic receptor sensitivity. 25In spite of studies that show little if any benefit from Antabuse in large treatment groups, 2~I have found it helpful in individuals who must leave hospital treatment early or who have otherwise tenuous sobriety. 22 After detoxification it is necessary to develop a method that enables the substance abuser to stay offof drugs and alcohol. The specific methods may vary according to the extent of use, abuse, and dependence. Effective parental expectations and limit setting may be sufficient to stop adolescent drug abuse. Awareness through education about the physical and psychosocial consequences of substance abuse may motivate some abusers to stop. Individuals with moderately severe or intermittent substance abuse may need brief hospitalization to initiate a drugfree state. This should be followed up by a variety of individualized approaches, including traditional 28-day inpatient stay, 5- to 7-day-per-week evening, partial-day hospital, intensive 20-hour week outpatient settings, or recovery homes. If the abuse pattern is severe, that is, if intake is excessive, social or vocational functioning grossly impaired, or physical dependence present, hospitalization may be set as a requirement early in therapy. Other criteria for inpatient initiation of treatment includes low internal or external motivation, inability to abstain particularly during therapy or other outpatient
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failure, heavy peer and family substance abuse, potential for serious withdrawal, severe toxic overdose, severe comorbid medical or psychiatric condition, and presence of severe violence, suicidality, or other self-destructiveness. Relative conditions for outpatient t r e a t m e n t include, in addition to the opposite of the above, absence of child care, potential devastating loss of employment from absence from work, and other financial factors. Wellmotivated patients who require inpatient treatment and cannot afford it should receive this treatment from the onset and be permitted to pay for care through a payment plan. Comorbid disorders that require hospital initiation of treatment may even include axis II disorders such as antisocial personality and borderline personality and major psychoses. Inpatient treatment provides an intensive orientation and stabilization that may provide the impetus for abstinence, particularly if effective, comprehensive aftercare programs are initiated. Most patients who are seriously addicted to drugs or alcoholic will require intensive, high-impact programs at the onset of therapy, either in hospital or daily outpatient. A therapeutic milieu that is supportive of recovery can motivate resistant substance abusers. The patient is asked to choose a method to reinforce staying off all substances of abuse; thus patients will select one or more of the following: Alcoholics Anonymous, Cocaine Anonymous, Antabuse, methadone maintenance, or naltrexone. (Acupuncture has been used for detoxification and abstinence.2a) A lifetime commitment to abstinence is not required. Rather the 1-day-at-a-time approach is recommended: the patient establishes a method of maintaining abstinence to commit to for only 1 day at a time that is renewed daily with the basic principles of 12-step programs such as Alcoholics Anonymous, Cocaine Anonymous, and Narcotics Anonymous. Many women with underlying gynecologic problems or chronic pain seek treatment to deal with associated depression or drug and alcohol dependence. Those who have prior histories of substance abuse or who currently abuse pain medications or alcohol need to be dealt with initially as any other addicted patient. That is, they need to be detoxified an d given a thorough medical evaluation with appropriate multimodality referral for pain management. This would include appropriate treatment of medical problems such as adhesions or chronic pelvic inflammatory disease with an emphasis on treatments for pain such as nonsteroidal antiinflammatory drugs, transcutaneous electrical nerve stimulation for pain relief, physical therapy and massage, acupuncture, and relation and imaging techniques. When a prescription drug-abusing patient with chronic pain is detoxified, she generally finds that the pain is less than when she was using narcotics. With the drug-free state as a baseline, the patient's pain can be relieved with the safer modalities described above.
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As a therapist I often meet with the sponsor at this phase, to facilitate our working together as a treatment team rather than be split into "good" and "bad" objects by the substance abuser. Many patients will elect to not work with a 12-step program, particularly during their early attempts at sobriety. Thus it is often helpful to provide a variety of choices from which to select a method or methods to maintain abstinence. For the 19-step-resistant patient other secular groups such as Women for Sobriety, Recovery, Inc., or Secular Organization for Sobriety can be helpful, but they are much less available than Alcoholics Anonymous, Narcotics Anonymous, or Cocaine Anonymous. My preference with this type of resistant patient is to have her participate in group psychotherapy one to three times weekly. The next step is to diagnose and treat any underlying primary psychiatric disorder and to assess acute and chronic cognitive deficits.
Specific issues in the treatment of female substance abusers The degree of stress, estrangement, threatened loss, and enmeshment reported in the families of chemically dependent women suggests that family involvement in assessment and treatment is essential. Because substance abuse in women is often precipitated by loss, therapists should be sensitive to these issues and emphatic, understanding of these losses should be a focus of treatment. Likewise, the commonality of sexual abuse in their histories mandates that this be worked through. Inpatient and residential settings are excellent for processing sexual abuse because these provide structure and support during the difficult release of these painful feelings that could easily lead to relapse without protection. Thus I advocate processing these issues either during the early residential phase of treatment or later when sobriety is solidifed. Former perpetrators can be brought into treatment and confronted by their female victims in the presence of a therapist who has sensitivity for all parties. Child care is another critical issue. A major reason that women fail to avail themselves of appropriate treatment is the lack of child care. Another problem is the lack of parenting skills. These issues simultaneously can be worked on if the facility can accommodate the women and their children. If this is not possible, then guided visiting should be part of the program. Female substance abusers have more problems with employment than males do. Treatment for women who do not live with family should focus on vocational training and socialization with family and non-drug-using friends. Treatment for single women with children should emphasize child care and parenting skills, whereas women
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with spouses could learn how to better balance employment and child care. In working with the families and networks of chemically dependent women, therapists must remember that drug and alcohol treatment programs have for the most part been organized for Chemically dependent men. Thus programs should be sought out that are sensitive to if not specifically designed for the needs of female substance abusers. Although it is not my style to use a written contract, a verbal contract is developed at the end of the evaluation or detoxification period. Every attempt should be made to obtain the patient's and family's active participation in creating and agreeing to the elements of the contract. The contract deals with the following elements: 1. Agreement as to where, when, and how detoxification will take place 2. Agreement as to what method of maintaining abstinence the patient will choose and related specifics (e.g., n u m b e r and type of 12-step meetings, monitoring of Antabuse or Naltrexone, etc.). This component may be postponed until after detoxification. Agreement to monitoring of substance abuse with random urine drug screens is obtained. 3. Agreement as to therapy for axis I psychiatric or axis II medical disorders (e.g., taking of lithium, plan for treatment Of epilepsy or diabetes, antibiotics for pelvic inflammatory disease, etc.). Appropriate treatment with nonnarcotic drugs and drug-free modalities for chronic pain. 4. Family participation in patient's treatment, family's participation in own psychotherapy; treatment for own substance abuse or n u m b e r of Manon, CoAnon, or significant other groups weekly for each family member. 5. Patient and family's participation in a comprehensive program of education about the psychologic, familial, and physical effects of alcohol and other drugs. This should include education about key issues such as the disease concept, cross-addiction, codependency, and enabling the prolonged abstinence syndrome, relapse prevention, etc. 6. A beginning commitment to a drug and alcoholfree environment. The family agrees to eliminate all abusable drugs and alcohol from the house. The patient agrees to not associate with known substance users and "pushers" and to build a sober network of associates. Phase I ends for outpatients after they have been off drugs and alcohol for a week or two, have had the opportunity to put the treatment contract into effect, and there is agreement between patient and therapist as to how the contract will be workable at that point in the therapy. Patients who have been in hospital, residential, partial
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hospital, or intensive o u t p a t i e n t p r o g r a m s
(20 h o u r s
weekly) generally e n d p h a s e I w h e n they g r a d u a t e f r o m these s t r u c t u r e d p r o g r a m s . This usually involves a b o u t ! m o n t h o f a b s t i n e n c e f r o m d r u g s a n d alcohol. P h a s e II involves t h e m a i n t e n a n c e o f sobriety t h r o u g h cognitive b e h a v i o r a l therapy, relapse p r e v e n t i o n training, a n d a focus o n safety a n d control. In p h a s e III the focus is o n m o r e t r a d i t i o n a l p s y c h o t h e r a p y a i m e d at a c h i e v i n g i n t i m a t e r e l a t i o n s h i p s a n d b u i l d i n g a sense o f a n i n d e p e n d e n t self while m a i n t a i n i n g a s o b e r core. Most obstetricians a n d gynecologists will n o t focus o n these latter p h a s e s o f t r e a t m e n t unless they are also addictionists.
Key points 1. T h e cuhurally d e f i n e d b e h a v i o r d e m a n d e d of w o m e n c o n t r i b u t e s to m u c h of t h e p a i n a n d conflict t h a t leads t h e m to s u b s t a n c e abuse. 2. W o m e n use m o r e legal d r u g s t h a n m e n do, m o s t of w h i c h are p r e s c r i b e d by m a l e physicians. 3. W o m e n are m o r e likely t h a n m e n to b e g i n p r o b l e m d r i n k i n g in r e s p o n s e to a specific t r a u m a . 4. T h e clinician b e g i n s with q u e s t i o n s such as, " H o w do you. use a l c o h o l ? " or " H o w does your use o f d r u g s affect you a n d those w h o are close to you?" 5. T h e p a t i e n t ' s n e t w o r k provides m a n y i m p o r t a n t sources o f m o t i v a t i o n for t r e a t m e n t . 6. S u b s t a n c e abusers c a n b e t r e a t e d successfully even w h e n initial m o t i v a t i o n is only e x t e r n a l . 7. After detoxification it is necessary to develop a m e t h o d t h a t e n a b l e s the s u b s t a n c e a b u s e r to stay off d r u g s a n d alcohol. 8. W h e n a p r e s c r i p t i o n d r u g - a b u s i n g p a t i e n t with c h r o n i c p a i n is detoxified, h e or she generally finds t h a t t h e p a i n is m u c h less t h a n w h e n h e or she was u s i n g narcotics. 9. Because s u b s t a n c e a b u s e in w o m e n is o f t e n prec i p i t a t e d by loss, therapists s h o u l d b e sensitive to these issues, a n d e m p a t h i c u n d e r s t a n d i n g of these losses s h o u l d b e a focus o f t r e a t m e n t . 10. T h e c o m m o n a l i t y o f sexual a b u s e in the history of f e m a l e s u b s t a n c e abusers m a n d a t e s t h a t this b e worked through.
REFERENCES 1. Sandmaier M. The invisible alcoholics: women and alcohol abuse in America. New York: McGraw-Hill, 1980. 2. Corrigan EM. Alcoholic women in treatment. New York: Oxford Press, 1980. 3. Beckman LJ. Women alcoholics: a review of social and psychological studies. J Stud Alcohol 1975;36:797-824. 4. Reed BG. Drug misuse and dependency in women: the
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meaning and implications of being considered a special population or minority group. Int J Addict 1985;20:1362. 5. Liepman MR, Nirenberg TD, Begin AM. Evaluation of a program designed to help family and significant others to motivate resistant alcoholics into recovery. Am J Drug Alcohol Abuse 1989;15:209-21. 6. Forrest CG. Alcoholism and human sexuality. Springfield, Illinois: Charles C Thomas, 1982. 7. Winokur G, Pitts FN. Affective disordm; VI: a family history study of prevalences, sex differences and possible genetic factors. J Psychiatr Res 1965;3:113-23. 8. Schuckit MA, Pitts FN, Reich T, King LJ, Winokur G. Alcoholism, I: two types of alcoholism in women. Arch Gen Psychiatry 1969;20:301-6. 9. Helzer JE, Pryzbeck TR. The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment. J Stud Alcohol 1988;49:219-24. 10. Kaufman E. Psychotherapy of addicted persons. New York: Guilford Press, 1994. 11. Dodes LM, Khantzian EJ. Individual psychodynamic psychotherapy. In: Frances RJ, Miller SI, eds. Clinical textbook of addictive disorders. New York: Guilford Press, 1991:391-405. 12. Pattison EM. Clinical approaches to the alcoholic patient. Psychosomatics 1986;27:762-70. 13. Kaufman E, ReouxJ. Guidelines for the successful psychotherapy of substance abusers. Am J Drug Alcohol Abuse 1988;14:199-209. 14. Khantzian EJ, Schneider RJ. Treatment implications of psychodynamic understanding of opioid addicts. In: Meyer RE, ed. Psychopathology and addictive disorders. New York: Guilford Press, 1986. 15. Gessner PK. Treatment of the alcohol withdrawal syndrome. Substance Abuse 1979;1:2-5. 16. Greenblatt DJ, Shader RI. Treatment of the alcohol withdrawal syndrome. In: Shader RI, ed. Manual of psychiatric therapeutics. Boston: Little Brown, 1975:211-35. 17. LiskowV, Goodwin D. Pharmacological treatment of alcohol intoxication withdrawal and dependence: a critical review. J Stud Alcohol 1987;48:356-70. 18. O'Connor PG, Waugh ME, Schottenfeld RS, et al. Ambulatory opiate detoxification and primary care: a role of the primary care physician. J Gen Intern Med 1992;7:532-4. 19. Rosenbloom A. Emerging treatment options in the alcohol withdrawal syndrome. J Clin Psychiatry 1988;49:28-31. 20. Washton A. Cocaine addiction, treatment recovery and relapse prevention. New York: V~¢~r Norton, 1989. 21. Kosten T. Pharmacotherapeutic interventions for cocaine abuse: matching patients to treatment. J Nerv Ment Dis 1989;177:379-89. 22. Banys R The clinical use of disulfiram (Antabuse): a review. J Psychoactive Drugs 1988;20:243-6. 23. Jaffee JH, Ciraulo DA. Drugs used in treatment of alcoholism. In: Mendelson JH, Mello NIL, eds. Diagnosis and treatment of alcoholism. New York: McGraw-Hill, 1985. 24. Halikas JA, Crosby RD, Carlson GA, Crea F, Graves NM, Bowers LD. Cocaine reduction in unmotivated crack users using carbamazepine versus placebo in a short-term doubleblind crossover design. Clin Pharmacol Ther 1991;50:81-95. 25. J. Kosten TR, Kleber HD, Morgan C. Treatment of cocaine abuse with buprenorphine. Biol Psychiatry 1989;26:170-2. 26. Fuller RF, Roth HR Disulfiram for the treatment of alcoholism: an evaluation of 128 men. Ann Intern Med 1979;90:9014. 27. Whitehead PC. Acupuncture in the treatment of addiction: a review and analysis; IntJ Addict 1978;13:1-16.
Key words: Women; d r u g abuse, understand, assess, treat Substance abuse by w o m e n is very m u c h related to the p r o b l e m s of w o m e n in c o n t e m p o r a r y society. Issues such as age, social class, ethnicity, environment, state of substance abuse consumption, and social changes such as feminism atl have p r o f o u n d effects on substance abuse problems in women. Lack of social power and external pressure to c o n f o r m to sex-role stereotypes create intolerable stress that drives some w o m e n to substance abuse. These w o m e n are o v e r w h e l m e d by the message many of t h e m have b e e n subjected to t h r o u g h o u t their lives: that they are less worthy because they are women. Far from protecting them, the culturally defined behavior dem a n d e d of w o m e n actually contributes to m u c h of the pain and conflict that leads t h e m to substance abuse. Those who b e c o m e addicts or alcoholics are further insuited because they are stigmatized as female substance abusers, which only increases their difficulties. 1 W o m e n use m o r e prescribed abusable drugs than m e n do. T h e most c o m m o n prescription drugs abused by w o m e n are the benzodiazepines, Vicodin ( h y d r o c o d o n e bitartrate and a c e t a m i n o p h e n ) , and Fiorinal (butalbital, a rapid-acting barbiturate, and caffeine and aspirin). They also turn to prescribed and o v e r - t h e - c o u n t e r stimulants or illegal drugs such as cocaine and a m p h e t a m i n e s to lose weight or o v e r c o m e depression. An essential feature of substance abuse in w o m e n is a p r e o c c u p a t i o n with what the w o m e n perceive as their inadequacy, ineptness, and inability to establish themselves in their environment. Female alcoholics feel less socially c o m p e t e n t and less effective in goal a c h i e v e m e n t than nonalcoholics do. They have m o r e covert and overt anxiety and often feel unworthy and dissatisfied with their purpose in life. 2 W o m e n are m o r e likely than m e n to begin p r o b l e m
From the ChemicalDependency Services, Capistrano by the Sea Hospital. Receivedfor publication May 15, 1995; accepted Septembo"28, 1995. Reprint requests: Ed Kaufman, MD, Chemical Dependency Services, Capistrano by the Sea Hospital, 34000 Capistrano by the Sea Dr., Dana Point, CA 92629. Copyright © 1996 by Mosby-YearBook, inc. 00020378/96 $5.00+ 0 6/1/69634
drinking in response to a specific trauma, even with no prior history of alcohol abuse. These traumas most often involve losses that threaten their sense of self, such as divorce, desertion, infidelity, death of a family member, children leaving h o m e , or health problems, especially gynecologic or menopausal. 1' s Many w o m e n begin abusing alcohol during a crisis in middle age, w h e n they fear they can never fulfill the dreams of their y o u t h ? Greater social stigma is still attached to drinking and d r u g abuse by w o m e n c o m p a r e d with men. As a result, many w o m e n react with shame and attempt concealment. Many female alcoholics frequently drink early in the day and then nap. T h e i r ability to conceal their drinking habits may account for part of the telescoping (shorter duration between onset of drinking and alcoholism) described in w o m e n alcoholics. ~ This denial of w o m e n ' s drinking continues because its feared consequences, such as overt sexuality and family neglect, violate traditional female taboos.' A w o m a n who abuses drugs or alcohol may a b a n d o n her responsibility as a wife but cling desperately to h e r role as mother, with this a c h i e v e m e n t minimizing the attention paid to h e r drinking. 2 Alcohol use by the spouse is also an i m p o r t a n t factor in female drinking patterns. If both s p o u s e s d r i n k heavily, they tend to support each o t h e r in c o n t i n u e d alcoholism. W o m e n frequently are i n t r o d u c e d to alcohol and drugs by men, 4 and alcoholic w o m e n are m o r e likely to be m a r r i e d to an alcoholic spouse? W o m e n frequently state that p r o b l e m s in the marriage are reasons they drink. ~ Alcoholic w o m e n have a high divorce rate and are left by their spouses m o r e frequently than are alcoholic men. ~ Sexual dysfunction in alcoholic w o m e n is c o m m o n . 6 T h e majority of w o m e n addicted to cocaine were introd u c e d to it by men. Cocaine's capacity for increasing self-confidence and providing a sense of control would seem to e a r m a r k it for use by women, many of w h o m have low self-esteem and whose lives are controlled by outside forces. In addition, climbing the corporate ladder in what has always b e e n considered as a m a l e - d o m i n a t e d environm e n t with its attendant long hours and stress puts w o m e n 21
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in positions of substantially increased risk for addiction and d r u g abuse. T h e additional bonus of weight loss for w o m e n obsessed with body image also provides a stimulus for c o n t i n u e d stimulant d r u g use.
Psychopathologic mechanisms in female substance abusers A wide variety of psychopathologic features, personality styles, and personality disorders are seen a m o n g w o m e n who abuse drugs and alcohol. Not only do these w o m e n face society's c o n d e m n a t i o n , they frequently c o n d e m n themselves. This cycle lowers their self-esteem, which drives t h e m further into substance abuse. The high incidence of depression in female alcoholics has b e e n well d o c u m e n t e d . Winokur and Pills 7 (1965) were a m o n g the first authors to link alcoholism in w o m e n to affective illness. Schuckit et al.8 (1969) f o u n d that 27% of 70 female alcoholics had severe depression before their alcoholism (these are called secondary alcoholics). More recently, in a study analyzing data f r o m the Epidemiologic C a t c h m e n t Area Study focusing on alcoholism and major depression, Helzer and Pryzbeck 9 (1988) f o u n d in 78% of the male subjects with both disorders that alcoholism was primary and depression secondary. An analysis of w o m e n subjects revealed a striking reversal of this relation: in 66% of the female subjects depression was primary and alcoholism was secondary. I advocate the establishment and continuation of abstin e n c e as a prerequisite for c o n t i n u i n g treatment. Those rare instances where addicts or alcoholics are " c u r e d " while they continue to drink or use drugs are w o m e n whose use of abusable substances is defintely the result of underlying psychopathologic disorders or who were n o t truly addicted over substantial periods of time. Early intervention and t r e a t m e n t of w o m e n with addictive disorders consist of assessment, motivation, detoxification, abstinence, and establishment of a t r e a t m e n t contract.
Assessment Assessment of a substance abuser must of necessity be m o r e t h o r o u g h and detailed than with o t h e r types of patients. This is so because substances of abuse have such pervasive effects on psyche and soma. Substance abuse and addiction can be dangerous, if not fatal, in early phases. In addition, over time they substantially shorten a w o m a n ' s life span. Assessment is only one of several key aspects of the initial interview. T h e major goal of the initial evaluation is for the patient to end up c o m m i t t e d to appropriate, workable treatment. O t h e r functions of evaluation include initiating a workable t r e a t m e n t partnership and developing the c o m p o n e n t s of an individualized program. Assessment is the b e g i n n i n g of treatment, and most patients will b o n d
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strongly to the first person who takes a detailed, sensitive history of the addiction problem. Assessment is always a continuing process t h r o u g h o u t treatment, but it is even m o r e relevant to substance abusers because we constantly reevaluate their c o m m i t m e n t to abstinence and their psychologic state. In the early phases of t r e a t m e n t o t h e r critical information is often revealed that appreciably alters our assessment of the patient (for example, previously withheld facts such as loss o f j o b or spouse or legal or financial crises)) ° During this phase it is essential that the physician be exploratory without being j u d g m e n t a l . 11 T h e first step of this phase is to assess the extent of substance abuse and its physical, vocational, and familial consequences. A medical examination that delineates the specific physical effects of the substance(s) involved and a detailed psychosocial evaluation are important. 12T h e pattern of use of every type of abusable substance is determined. Many individuals will minimize the i m p o r t a n c e of their abuse of a secondary d r u g that is not their d r u g of choice, such as alcohol or marijuana use by cocaine addicts or prescription d r u g abuse by alcoholics. D o c u m e n t a t i o n of use of these secondary drugs is i m p o r t a n t because their c o n t i n u e d use predisposes the addict to r e t u r n to his or her d r u g of choice. Some impor{ant specifics are quantity, quality, duration, expense, how intake was s u p p o r t e d and prevented, physical effects, tolerance, withdrawal, and any drug-related complications. T h e circumstances u n d e r which the patient began to use and abuse drugs or alcohol and their current drugs of choice are reviewed for their psychosocial and psychodynamic significance. Direct and indirect psychosocial sequelae, particularly psychotic disruptions, paranoid or suicidal ideation, and violence are assessed. Early effort is devoted to why the patient is entering t r e a t m e n t at this specific time. Is the significant o t h e r so fed up or e m p o w e r e d that he is clearly c o m m u n i cating his readiness to leave? Is the prospective patient there because an employer is m a n d a t i n g it as a condition of c o n t i n u e d e m p l o y m e n t or is she attempting to obtain leniency in a p e n d i n g court case? T h e u n d e r s t a n d i n g of i m m e d i a t e motivation tells us a great deal about true treatm e n t needs and sincerity of c o m m i t m e n t . Working with the judicial system can provide necessary leverage to motivate a difficult patient to enter and stay in appropriate treatment.I° T h e history of t r e a t m e n t is reviewed during the initial interview. What was helpful and what was not? How long did she stay sober? Did she work a 12-step p r o g r a m and with what level of c o m m i t m e n t ? Was she receiving psychotherapy, and what orientation did the therapist have? Did she lie to " c o n " the therapist? What precipitated relapse? Is she willing to sign a consent so that you can c o m m u n i c a t e with her prior t r e a t m e n t team, hospital, or therapist? How aware is she of earlier signs of
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relapse that preceded the major precipitant? Other important indicators of potential relapse include continued related nonchemical compulsive (addictive) behaviors such as gambling, promiscuous sexuality including perversions and high-risk behaviors, binge eating, extreme exercising, food restriction, frequent rage, violence, loss of temper, and self-mutilation. Exploration of how the patient obtained the money for the drugs and alcohol is often quite revealing. To what extent were these activities indicative of an underlying antisocial personality? How self-destructive, risky, or sensation seeking were these activities? The family history of substance dependence is gathered early because such a history conveys a powerful risk for substance dependence and greater severity of illness.13 The family and other collaterals are also interviewed in family sessions to provide their view of substance abuse and related behaviors. Many substance abusers will minimize the extent of their abuse of drugs and alcohol until confronted by their families. Others will be more honest in individual sessions and later use family visits to share their substance abuse history with their families in an open way, which opens up communication about other issues. Peer relationships are also explored. Do most or all of the patient's friends, relatives, fellow employees, or supervisors use or abuse drugs and alcohol? To what extent does a supportive network of nonabusing or sober associates exist? The psychologic aspects of substance use are explored by asking what the patient is like while abusing drugs or alcohol; what happens u n d e r the influence; what effects are soughtl~; what are fantasies before, during, and after drug use; and what are its effects on family, friendship, work, and recreational performance? What feelings are stimulated by drugs and alcohol? Which feelings are relieved or soothed by these substances? The consequences of substance abuse pervade all biopsychosociaI spheres and include unemployment, violence, divorce, and financial, tax, family, and legal difficulties. Assessment should include the specific events and situations that are consequences of the problem (which, when, and if the substance-dependent person recognizes and accepts that she has the disease) are identified and labeled as part of the disease. The clinician begins with questions such as, "How do you use alcohol?" or "How does your use of drugs affect you and those who are close to you?" As assessment progresses and it becomes apparent that the patient is resistant to workable treatment, the physician may need to become confrontive or use the intervention (defined below) or other similar techniques. However, some patients may need to demonstrate the ability t O abstain from alcohol and drugs "just one time" before they are motivated to accept a comprehensive workable program. Phy-
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sicians should be flexible but not enablers as they decide how many "one more times" to permit, l° A difficult aspect of evaluation for many clinicians is the patient in whom substance abuse is initially unrecognized. This may occur for a n u m b e r of reasons, including patients who minimize or deny substance abuse or who escalate from controlled use to abuse or dependence over their years of contact. While one continues to treat patients in whom the problem is denied or ignored, it becomes progressively more difficult to confront the substance abuse and even more problematic to require abstinence. It then requires considerable therapeutic objectivity or outside consultation to step back from the physician-patient relationship and require the patient to deal with substance abuse before treatment can continue. If this confrontation is done with empathic concern, the patient's active participation in the shift of emphasis can occur.
Another important aspect of assessment is laboratory testing: liver enzyme levels (aspartate aminotransferase, ~lanine aminotransferase, and y-glutamyl transpeptidase) or complete blood cell count (macrocytic anemia) are helpful in confirming the diagnosis of alcoholism and the extent of liver and hematopoietic damage. Many patients who are questioning the diagnosis or need for intensive treatment may be persuaded to accept diagnosis and treatment when they are confronted with this definitive laboratory confirmation of disease. However, we should not rely on these tests because many alcohol-dependent persons may have normal or near-normal values. Urine drug screens for drugs of abuse may also be helpful in resistant patients, particularly adolescents, to diagnose substance abuse. These must be obtained u n d e r monitored conditions and carefully assessed for contaminants that can interfere with testing. Medical sequelae and related complications are evaluated and these are also used to confront resistant patients of the need for treatment. The patient is asked to accept appropriate medical treatment for complications such as hypertension, anemia, infertility, syphilis, hepatitis, acquired immunodeficiency syndrome, etc. During the evaluation I convey to the patient that I feel that for treatment to be successful she must choose a method to reinforce abstinence. I inform her that, although medications such as disulfiram (Antabuse) or methadone maintenance may provide that method, the best method in my experience is a 12-step program. I also emphasize that, because addiction has destroyed so many aspects of her life, a holistic approach that develops the whole person-is most helpful.
Motivation Some patients will refuse to enter treatment, particularly if abstinence is required. Several techniques that the
24 Kaufman
physician can use to motivate such patients have been described above (gradual persuasion, confrontation, laboratory tests). The patient's network provides many important sources of motivation for treatment. Spouses, parents, children, and work-related persons such as employers, supervisors, peers, and employment assistance persons may individuallyor in concert motivate an unwilling patient for treatment. Attorneys, judges, and probation officers also carry considerable weight in motivating patients. One difficulty here is balancing the need for treatment with laws about confidentiality. If the family or significant other is seen in the initial interview, then a clear, mutually agreed on contract about what will be shared can be clarified, At that time the iZamilycan be worked with to support or demand necessary treatment, as appropriate. Employment assistance persons and supervisory personnel are often well educated about substance abuse and can be strong motivators for treatment without any urging from the therapist. Experience has shown that substance abusers who are motivated externally do as well as or better than those who profess only internal motivation.5 This is an important contradiction to those physicians who tell substance abusers and their families that they are unable to treat the substance abuser unless he or she is personally motivated. Resistant patients in whom the above methods have failed, particularly if they are involved with their families and are employed, may be good candidates for an intervention. This technique, developed for treatment of alcoholism at the Johnson Institute in Minneapolis, is readily adapted for use with all addictions. In this technique all available family members and the most meaningful support network members, such as employer, neighbors, friends, and clergy, are coached to confront the addicted person with the facts of the substance use and related behaviors. This confrontation is done with deep concern and without hostility. The participants list specific incidents and behaviors consequential to drug use and present them in a nonjudgmental fashion once the intervention meeting is arranged. Family members may be immobilized by fear or love and may find the idea of an intervention intimidating. They need to be educated about the deadly consequences of their inaction, and they need instruction on how to say, "We love yon and because we love you, we will not continue to live with you while yon abuse alcohol and drugs. If you accept the treatment being offered and continue to work at recovery, we will renew our lifetime commitment to you." The family needs to agree in advance about what treatment is necessary, insist on it in a firm, consistent manner, and follow through with. the limits set, including the consequences of return to substance use or refusal to enter treatment. As many family members as possible are included. In-
January 1996 AmJ ObstetGynecol
volvement of the employer is often crucial, and in some cases sufficient of itself to motivate the addicted individual to seek treatment. The employer who clearly makes treatment a precondition for employment, who supports time off for treatment, and who agrees to continue support for the patient in aftercare offers a helpful model for the family and is a valuable ally.
Early issues in treatment After the confrontive phase of motivating the patient for treatment, the therapist shifts to providing support, direct assistance, and information. When the patient is involved with a therapeutic team, manipulative and splitting activity must be kept to a m i n i m u m so that the patient learns newer and more adaptive ways to get needs met. A split treatment team undoubtedly replicates the patient's divided or disorganized parents. This should not be interpreted at this point, but rather the team should understand the patient's projective identifications or splitting and work together to present a unified approach. The treatment team must be consistent and cohesive while providing a safe environment that is neither too giving nor too withholding. 14
Detoxification Detoxification will not be described in detail; the reader is referred to several excellent references 1~19 for this process. Previously I have written about the difficulties in outpatient detoxification and the need to use a comprehensive program that reaches into the patient's home, network, physicians, and pharmacies when attempting this. Recently I have encountered several case managers who have only been willing to approve outpatient detoxification in certain patients. If the patient is addicted to sedative drugs or alcohol and inpatient detoxification is not available, I only perform the detoxification in a highly structured intensive outpatient setting (partial hospital program) in which the patient's vital signs and activities can be monitored for up to 14 hours daily if necessary. Urine drug screens and blood alcohol levels can also be monitored daily and can provide immediate feedback about nonprescribed substance use. If potentially abusable drugs (benzodiazepines, opiates, sedative hypnotics) are prescribed without adequate monitoring as described above, they are often abused along with the primary substance of abuse. Although stimulant addicts require little medical detoxification and Washton 2° has described excellent intensive outpatient programs, I prefer initial inpatient detoxifications and stabilization for at least several days. This is particularly true with heavy cocaine users (>5 gm weekly) and even more so in those who primarily smoke it. In these patients there is often a prolonged sleep of up
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to 3 or 4 days that is interrupted by bizarre, paranoid impulsive behavior and followed by powerful cravings. Hospitalization accomplishes containment from drug use and other destructive behaviors and nurtures motivation during periods of wakefulness.
Pharmacologic adjuncts to treatment This article will not deal with pharmacologic adjuncts to treatment in detail, but the reader is referred to several excellent tests and articles in this area. 2>2a Many pharmacologic adjuncts have been recommended for cocaine addicts. In the first few days after drug cessation the patient may require neuroleptics for extreme paranoia or destructive behaviors. 21 Note that neuroleptics are contraindicated in acute cocaine overdoses in which there is agitation and hyperthermia because these drugs may worsen the latter symptom, Oxazepam or other benzodiazepines may provide active relief of agitation, irritability, and anxiety in structured treatment settings, which will help motivate the cocaine addict to become engaged in treatment. A group ofdopaminergic agents has been suggested to alleviate early cravings and withdrawal. These include amantadine, bromocirptine, >dopa, methylphenidate,2 and carbamazepine, z* >Tyrosine and other amino acids have been used to enhance new dopamine production. Buprenorphine has been found to diminish cravings for cocaine and opiates. 2~ Desipramine has been advocated as reducing longer-term craving by reducing dopaminergic receptor sensitivity. 25In spite of studies that show little if any benefit from Antabuse in large treatment groups, 2~I have found it helpful in individuals who must leave hospital treatment early or who have otherwise tenuous sobriety. 22 After detoxification it is necessary to develop a method that enables the substance abuser to stay offof drugs and alcohol. The specific methods may vary according to the extent of use, abuse, and dependence. Effective parental expectations and limit setting may be sufficient to stop adolescent drug abuse. Awareness through education about the physical and psychosocial consequences of substance abuse may motivate some abusers to stop. Individuals with moderately severe or intermittent substance abuse may need brief hospitalization to initiate a drugfree state. This should be followed up by a variety of individualized approaches, including traditional 28-day inpatient stay, 5- to 7-day-per-week evening, partial-day hospital, intensive 20-hour week outpatient settings, or recovery homes. If the abuse pattern is severe, that is, if intake is excessive, social or vocational functioning grossly impaired, or physical dependence present, hospitalization may be set as a requirement early in therapy. Other criteria for inpatient initiation of treatment includes low internal or external motivation, inability to abstain particularly during therapy or other outpatient
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failure, heavy peer and family substance abuse, potential for serious withdrawal, severe toxic overdose, severe comorbid medical or psychiatric condition, and presence of severe violence, suicidality, or other self-destructiveness. Relative conditions for outpatient t r e a t m e n t include, in addition to the opposite of the above, absence of child care, potential devastating loss of employment from absence from work, and other financial factors. Wellmotivated patients who require inpatient treatment and cannot afford it should receive this treatment from the onset and be permitted to pay for care through a payment plan. Comorbid disorders that require hospital initiation of treatment may even include axis II disorders such as antisocial personality and borderline personality and major psychoses. Inpatient treatment provides an intensive orientation and stabilization that may provide the impetus for abstinence, particularly if effective, comprehensive aftercare programs are initiated. Most patients who are seriously addicted to drugs or alcoholic will require intensive, high-impact programs at the onset of therapy, either in hospital or daily outpatient. A therapeutic milieu that is supportive of recovery can motivate resistant substance abusers. The patient is asked to choose a method to reinforce staying off all substances of abuse; thus patients will select one or more of the following: Alcoholics Anonymous, Cocaine Anonymous, Antabuse, methadone maintenance, or naltrexone. (Acupuncture has been used for detoxification and abstinence.2a) A lifetime commitment to abstinence is not required. Rather the 1-day-at-a-time approach is recommended: the patient establishes a method of maintaining abstinence to commit to for only 1 day at a time that is renewed daily with the basic principles of 12-step programs such as Alcoholics Anonymous, Cocaine Anonymous, and Narcotics Anonymous. Many women with underlying gynecologic problems or chronic pain seek treatment to deal with associated depression or drug and alcohol dependence. Those who have prior histories of substance abuse or who currently abuse pain medications or alcohol need to be dealt with initially as any other addicted patient. That is, they need to be detoxified an d given a thorough medical evaluation with appropriate multimodality referral for pain management. This would include appropriate treatment of medical problems such as adhesions or chronic pelvic inflammatory disease with an emphasis on treatments for pain such as nonsteroidal antiinflammatory drugs, transcutaneous electrical nerve stimulation for pain relief, physical therapy and massage, acupuncture, and relation and imaging techniques. When a prescription drug-abusing patient with chronic pain is detoxified, she generally finds that the pain is less than when she was using narcotics. With the drug-free state as a baseline, the patient's pain can be relieved with the safer modalities described above.
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As a therapist I often meet with the sponsor at this phase, to facilitate our working together as a treatment team rather than be split into "good" and "bad" objects by the substance abuser. Many patients will elect to not work with a 12-step program, particularly during their early attempts at sobriety. Thus it is often helpful to provide a variety of choices from which to select a method or methods to maintain abstinence. For the 19-step-resistant patient other secular groups such as Women for Sobriety, Recovery, Inc., or Secular Organization for Sobriety can be helpful, but they are much less available than Alcoholics Anonymous, Narcotics Anonymous, or Cocaine Anonymous. My preference with this type of resistant patient is to have her participate in group psychotherapy one to three times weekly. The next step is to diagnose and treat any underlying primary psychiatric disorder and to assess acute and chronic cognitive deficits.
Specific issues in the treatment of female substance abusers The degree of stress, estrangement, threatened loss, and enmeshment reported in the families of chemically dependent women suggests that family involvement in assessment and treatment is essential. Because substance abuse in women is often precipitated by loss, therapists should be sensitive to these issues and emphatic, understanding of these losses should be a focus of treatment. Likewise, the commonality of sexual abuse in their histories mandates that this be worked through. Inpatient and residential settings are excellent for processing sexual abuse because these provide structure and support during the difficult release of these painful feelings that could easily lead to relapse without protection. Thus I advocate processing these issues either during the early residential phase of treatment or later when sobriety is solidifed. Former perpetrators can be brought into treatment and confronted by their female victims in the presence of a therapist who has sensitivity for all parties. Child care is another critical issue. A major reason that women fail to avail themselves of appropriate treatment is the lack of child care. Another problem is the lack of parenting skills. These issues simultaneously can be worked on if the facility can accommodate the women and their children. If this is not possible, then guided visiting should be part of the program. Female substance abusers have more problems with employment than males do. Treatment for women who do not live with family should focus on vocational training and socialization with family and non-drug-using friends. Treatment for single women with children should emphasize child care and parenting skills, whereas women
January 1996 AmJ Obstet Gynecol
with spouses could learn how to better balance employment and child care. In working with the families and networks of chemically dependent women, therapists must remember that drug and alcohol treatment programs have for the most part been organized for Chemically dependent men. Thus programs should be sought out that are sensitive to if not specifically designed for the needs of female substance abusers. Although it is not my style to use a written contract, a verbal contract is developed at the end of the evaluation or detoxification period. Every attempt should be made to obtain the patient's and family's active participation in creating and agreeing to the elements of the contract. The contract deals with the following elements: 1. Agreement as to where, when, and how detoxification will take place 2. Agreement as to what method of maintaining abstinence the patient will choose and related specifics (e.g., n u m b e r and type of 12-step meetings, monitoring of Antabuse or Naltrexone, etc.). This component may be postponed until after detoxification. Agreement to monitoring of substance abuse with random urine drug screens is obtained. 3. Agreement as to therapy for axis I psychiatric or axis II medical disorders (e.g., taking of lithium, plan for treatment Of epilepsy or diabetes, antibiotics for pelvic inflammatory disease, etc.). Appropriate treatment with nonnarcotic drugs and drug-free modalities for chronic pain. 4. Family participation in patient's treatment, family's participation in own psychotherapy; treatment for own substance abuse or n u m b e r of Manon, CoAnon, or significant other groups weekly for each family member. 5. Patient and family's participation in a comprehensive program of education about the psychologic, familial, and physical effects of alcohol and other drugs. This should include education about key issues such as the disease concept, cross-addiction, codependency, and enabling the prolonged abstinence syndrome, relapse prevention, etc. 6. A beginning commitment to a drug and alcoholfree environment. The family agrees to eliminate all abusable drugs and alcohol from the house. The patient agrees to not associate with known substance users and "pushers" and to build a sober network of associates. Phase I ends for outpatients after they have been off drugs and alcohol for a week or two, have had the opportunity to put the treatment contract into effect, and there is agreement between patient and therapist as to how the contract will be workable at that point in the therapy. Patients who have been in hospital, residential, partial
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Volume 174, Number 1. Part 1 Am J Obstet Gynecol
hospital, or intensive o u t p a t i e n t p r o g r a m s
(20 h o u r s
weekly) generally e n d p h a s e I w h e n they g r a d u a t e f r o m these s t r u c t u r e d p r o g r a m s . This usually involves a b o u t ! m o n t h o f a b s t i n e n c e f r o m d r u g s a n d alcohol. P h a s e II involves t h e m a i n t e n a n c e o f sobriety t h r o u g h cognitive b e h a v i o r a l therapy, relapse p r e v e n t i o n training, a n d a focus o n safety a n d control. In p h a s e III the focus is o n m o r e t r a d i t i o n a l p s y c h o t h e r a p y a i m e d at a c h i e v i n g i n t i m a t e r e l a t i o n s h i p s a n d b u i l d i n g a sense o f a n i n d e p e n d e n t self while m a i n t a i n i n g a s o b e r core. Most obstetricians a n d gynecologists will n o t focus o n these latter p h a s e s o f t r e a t m e n t unless they are also addictionists.
Key points 1. T h e cuhurally d e f i n e d b e h a v i o r d e m a n d e d of w o m e n c o n t r i b u t e s to m u c h of t h e p a i n a n d conflict t h a t leads t h e m to s u b s t a n c e abuse. 2. W o m e n use m o r e legal d r u g s t h a n m e n do, m o s t of w h i c h are p r e s c r i b e d by m a l e physicians. 3. W o m e n are m o r e likely t h a n m e n to b e g i n p r o b l e m d r i n k i n g in r e s p o n s e to a specific t r a u m a . 4. T h e clinician b e g i n s with q u e s t i o n s such as, " H o w do you. use a l c o h o l ? " or " H o w does your use o f d r u g s affect you a n d those w h o are close to you?" 5. T h e p a t i e n t ' s n e t w o r k provides m a n y i m p o r t a n t sources o f m o t i v a t i o n for t r e a t m e n t . 6. S u b s t a n c e abusers c a n b e t r e a t e d successfully even w h e n initial m o t i v a t i o n is only e x t e r n a l . 7. After detoxification it is necessary to develop a m e t h o d t h a t e n a b l e s the s u b s t a n c e a b u s e r to stay off d r u g s a n d alcohol. 8. W h e n a p r e s c r i p t i o n d r u g - a b u s i n g p a t i e n t with c h r o n i c p a i n is detoxified, h e or she generally finds t h a t t h e p a i n is m u c h less t h a n w h e n h e or she was u s i n g narcotics. 9. Because s u b s t a n c e a b u s e in w o m e n is o f t e n prec i p i t a t e d by loss, therapists s h o u l d b e sensitive to these issues, a n d e m p a t h i c u n d e r s t a n d i n g of these losses s h o u l d b e a focus o f t r e a t m e n t . 10. T h e c o m m o n a l i t y o f sexual a b u s e in the history of f e m a l e s u b s t a n c e abusers m a n d a t e s t h a t this b e worked through.
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