Sex & Gender in Acute Care Medicine

Sex & Gender in Acute Care Medicine Chapter 4: Alcohol & Drug Use

Chapter 4: Alcohol & Drug Use Esther K. Choo, Marna Greenberg, and Grace Chang

Case Study • A 34-year-old intoxicated female presents to the ED on a busy Friday evening • A brief screening physical exam reveals no obvious medical problems or injuries • Her vital signs are normal • She is clinically intoxicated and cannot identify a sober caretaker so she is moved to ED observation area for the evening

Case Study • Several hours later, a urine sample reveals that she is pregnant • The patient recalls that her last menstrual period was about 6 weeks earlier • In the morning, nurses notify the incoming clinical team that patient is clinically sober and requesting discharge

Case Study • Patient reports drinking 2-3 beers each evening and as much as 4 drinks on weekends • She expresses an interest in decreasing her alcohol use but denies referral to substance abuse treatment centers

Introduction • Alcohol and drug use are highly prevalent among ED patients • 24 to 45% report high-risk drinking and 5% dependent drinking • Drug use prevalence in the ED is higher than the national average • These behaviors are closely associated with injury, the leading cause of ED visits

Introduction • Substance misuse increases health care costs due to many associated health outcomes • Including neurologic, cardiac, and liver disease • As well as high-risk sexual behaviors, violence involvement, and mental health issues such as depression, anxiety, and suicidality • In this chapter, we explore the vulnerability of women, in particular, to health sequelae of drug and alcohol use

Introduction • The treatment needs of patients with substance misuse account for ~$1500 in excess cost per hospital visit • A study* followed trauma patients from one center over 14 years • Found that 35% of patients with positive alcohol or drugs tests subsequently died of traumatic injury • Compared to 15% of those who tested negative *Dischinger et al.

Introduction • The hope that patients will be connected to substance use treatment through primary care or on their own is overly optimistic • One study found that 27% of ED patients had unmet substance use treatment needs • The ED visit may be the opportune time to reach high-risk populations • Further research is needed on the effectiveness of gender-specific approaches

SBIRT in the ED • ED screening, brief intervention, and referral to treatment (SBIRT) have been studied for over 25 years • Evidence of effectiveness in reducing substance use has been mixed • Possible explanations include “assessment reactivity” as well as the inherent limitations of a one-time ED visit

SBIRT in the ED • The “one size fits all” approach used in many interventions may play a role in SBIRT’s limited success • Interventions could be tailored based on patient characteristics, demographics, or comorbidities • Given the many ways that substance use differs in men and women, gender specificity could improve the effectiveness of ED SBIRT

Gender-Specific Factors – Alcohol Use • While a higher proportion of men than women have substance use problems, recent trends suggest the gender gap is narrowing for risky alcohol use • Research outside the ED suggests gender differences in the course of substance use • Men are more likely to report drinking to escape or cope with stress

Gender-Specific Factors – Alcohol Use • Men have higher “positive expectancies” • More likely to attribute positive qualities to alcohol use – including that it will reduce tension and facilitate social interactions • In contrast, women have been described as having concerns that alcohol will interfere with their ability to handle difficult situations • They may choose to avoid alcohol in times of stress

Gender-Specific Factors – Alcohol Use • Women are more likely than men to use drugs or alcohol to self-treat mental health disorders • Another marked gender difference is the phenomenon of “telescoping” • Rapid progression from initiation to dependence • Some studies suggest that women are more prone to telescoping than men • If true, the ED may be a critical moment to intervene with female high-risk drinkers

Gender-Specific Factors – Drug Use • Women face different sociocultural factors that contribute to drug use compared to men • Physical and sexual abuse and depression are strong correlates of drug use in women • Women are also sensitive to stigmas surrounding drug use (e.g., fear of losing children) • Abusive relationships may keep women from seeking help or changing drug use

Gender-Specific Factors – Drug Use • Although non-medical use of prescription opioids is more common in men, the recent rise in fatal overdoses in women is alarming • Deaths among women have increased 400% since 1999, compared to 265% among men • Men report using opioids more often for recreational reasons, whereas women report using them to help cope with personal stressors

Gender-Specific Factors – Drug Use • Women are more likely than men to be prescribed pain medications, • Are given higher doses, • And use them for longer periods of time than men • These factors may be responsible for the rapid rise of opioid deaths among women

Clinical Consequences • The definition of at-risk alcohol use differs by sex • For men, at-risk use is >4 drinks at one time or >14 drinks in a week • For women, >3 drinks at one time or >7 drinks in a week • These definitions reflect the impact of sex on susceptibility to negative health consequences

Clinical Consequences • At equivalent amounts of consumption, women reach higher serum alcohol concentrations • They are more vulnerable to liver disease, have higher relative risk of fatality in motor vehicle collisions • Prenatal alcohol exposure can lead to Fetal Alcohol Spectrum Disorders (FASD) • Alcohol consumption can also decrease fertility in men, causing low sperm quality and quantity

Clinical Consequences • Sex-related differences have been found at every level of drug ingestion and metabolism • Women have a higher incidence of drug-induced hepatic failure and experience 2/3 of all cases of drug-induced torsades de pointes • Although social and cultural norms affect patterns of consumption, neuroendocrine differences between the sexes likely play a role

Gender Effects on Screening and Treatment • Provider biases may affect identification of substance use problems in women • One study (Beasley et al.) found that women trauma patients were less likely than men to receive blood alcohol or drug screening • Given that women are more sensitive to stigma, they may be less likely to report problems with substance use

Gender Effects on Screening and Treatment • Women are less likely than men to seek substance abuse treatment • Tend to seek treatment later • Have more problems upon entry • Have lower rates of treatment completion • Barriers to treatment include lack of childcare, lack of available treatment spots, and lack of services for pregnant women

Gender Effects on Screening and Treatment • Specific factors appear to impact men’s success with treatment and recovery • Men are more likely than women to have criminal justice involvement in the years following treatment • Men are more likely to transition from recovery to using and are less responsive than women to self-help treatments

Gender Effects on Screening and Treatment • There is some evidence that women and men respond differently to existing brief intervention protocols suitable for ED use • One large multicenter trial of SBIRT in both primary care and hospital settings demonstrated increased abstinence across sites and substance types • However in one of the two sites that included EDs, only men reduced cocaine use

Gender Effects on Screening and Treatment • Since most ED drug interventions are not focused on gender differences they are usually underpowered to examine the role of gender • It remains unclear what effect abstinence or reduced consumption has on patient-centered outcomes by gender

Gender Effects on Screening and Treatment • Further research is needed on how best to address high-risk behaviors or conditions associated with substance use by gender • Gender-sensitive interventions almost universally share certain qualities • Acknowledgement of high prevalence of violence • Consideration of coexisting mental health issues • Consideration of pregnancy and dependent children

Motor Vehicle Collisions • Both alcohol and drug use confer high risk for motor vehicle-related mortality • Men are more likely to drive under the influence of alcohol • However, for a given level of alcohol use, women are at higher risk for injury in MVCs • Men are also at high risk of riding with an intoxicated driver

Violence • In men, alcohol use often precipitates injury from fights or assault • While intimate partner violence (IPV) affects both men and women, women have a higher incidence and are more likely to be injured • ED studies have consistently found rates of substance use among IPV victims that far exceed those of the general population

Violence • In women, there is likely a bidirectional relationship between alcohol use and IPV • With violence leading to increased alcohol use and alcohol use a predisposing factor for violence • Drug use is also closely associated with IPV • Rhodes et al. reported that 13% of partner abuse victims in an urban hospital had used illicit drugs in the past month

Violence • Scant literature on relationships between substance use and non-partner violence • In the ED, women and men report high levels of non-partner violence involvement • Both men and women report victimization and perpetration • Substance use is associated with IPV for both men and women

Sexual Assault • The incidence of sexual assault involving alcohol or drugs is difficult to determine • The data that we have suggest a strong role • Estimates for alcohol use are as high as 74% among perpetrators and 30-79% among victims • Female binge drinkers are 3x more likely to be victims of sexual assault

Elderly Populations • The NIAAA currently defines high-risk drinking in men and women over age 65 at the same level as for women under 65: • >7 drinks per week or >3 drinks per occasion • It is unclear if this is a sufficiently safe parameter or if parameters for the elderly should be stratified by sex • Injury and fatality from falls among the elderly is increased by alcohol and drug use

Elderly Populations • Some elderly patients presenting after falls will have undetected elder abuse • Patients with substance abuse and psychiatric problems are at highest risk for elder abuse • Those whose caregivers abuse substances or have psychiatric disorders are also at high risk • The precise relationship between alcohol use, mental health problems, and elder abuse is poorly defined – but all can potentiate fall risk

Gender Differences in ED Patients • The vast majority of chronic inebriates, who are frequent users of EDs and other medical resources, are men • Suggests a gender component to the health risk factors and social service needs of this population • Care for these “superutilizers” is gaining attention in the context of the need for health care cost-containment strategies

Treatment Implications • A gender-specific approach may increase the specificity of interventions for alcohol and drug use and contribute to the success of treatment outcomes • For women, this means inclusion of childcare or other caretaking needs, acknowledgment of trauma, resources related to IPV and associated risks, and mental health treatment

Treatment Implications • For men, this approach might include screening for specific types of violence and HIV risk behaviors • Such gender-specific treatments have been emerging in the outpatient setting • NIDA’s Drug Abuse Clinical Trials Network has examined gender-specific needs around substance use and eating disorders, PTSD, sexual risk behaviors, and pregnancy

Treatment Implications • Among pregnant patients, ED providers should not assume abstinence and fail to screen • Pregnant substance users often have less prenatal care and require specialized clinical services, including high-risk obstetric care • An ED visit may indicate lack of a primary obstetrician, making screening and active referral even more crucial at this time

Treatment Implications • Until gender-specific programs are readily available, clinicians may focus on a practical approach that accounts for gender differences • Determination of high-risk drinking should use age-correlated gender-specific thresholds • Men and women with substance use problems should be screened for IPV, elder abuse, and mental health problems • All pregnant women should be screened for alcohol and drug use

Treatment Implications • Clinicians should consider gender-specific factors that may effect likelihood of successful follow up • A positive screen should prompt appropriate resources (such as social work counseling) • Barriers to follow up should be considered • Whenever possible, facilities that offer single gender treatment and childcare should be offered

Conclusion • There is strong evidence for gender differences in every aspect of substance use • Researchers are just beginning to understand the relationship between gender and substance use and to use this knowledge to guide clinical care • Clinicians must be aware of gender and sex-specific differences in screening guidelines, treatment oucomes, and barriers to follow up

Clinical Case Follow-Up • The treating provider recognized high-risk alcohol use based on patient’s gender and pregnancy status • Further discussion revealed that she was motivated to stop drinking • Patient feared losing her job should she enter inpatient treatment • She expressed anxiety about the reaction of her live-in boyfriend who is verbally abusive

Clinical Case Follow-Up • Patient did not wish to leave her boyfriend but was receptive to contacting domestic violence agencies for counseling • ED nurse identified a local substance use treatment clinic with free services for pregnant women • Patient expressed interest in attending and was relieved that she would not be admitted

Alcohol & Drug Use Questions 1. A 34-yo intoxicated patient presents to the ED without complaint. After sobering up she reports drinking 3 beers each evening and as much as four-five drinks each night on the weekends. She expresses an interest in decreasing her alcohol use. Which of the following is true? (A) As a woman she is more likely than a man to report drinking to escape or cope with stress. (B) As a woman, she is more likely than a man to have “positive expectancies” about alcohol (such as facilitating social interactions) (C) As a woman she is more likely than a man to use alcohol to self-treat mental health disorders, particularly depression. (D) As a woman she is not as concerned as a man that the alcohol will interfere with her ability to handle difficult situations. (E) As a woman she is less concerned about her own problem drinking than a man. Answer: (C) Reference 1 Other answer explanations: Men are more likely than women to report drinking to escape or cope with stress.2 Men are more likely than women to have “positive expectancies” about alcohol. They may attribute positive qualities to ingestion of alcohol, including that it will reduced tension, increase social or physical pleasure, and facilitate social interactions.3 Women are more concerned than men that drinking alcohol will interfere with their ability to handle difficult situations and more concerned about their problem drinking3 References: 1. Brady KT, Randall CI. Gender differences in substance use disorders. Psychiatric Clinics of North America 1999;22 (2): 241-52. 2. Gregor A, Choo E, Becker B, et al. Sex and Gender in Acute Care Medicine. 2016 Cambridge University Press NY, NY 3. Nolen-Hoeksema S, Hilt I. Possible contributors to the gender differences in alcohol use and problems. Journal of General Psychology 2006;133(4):357-75.

Alcohol & Drug Use Questions 2. According to the National Institute on Alcohol Abuse and Alcoholism a woman has exceeded the lower risk drink limits if she: (A) Has more than 2 drinks on any one occasion (B) Has more than 3 drinks on any one occasion (C) Has more than 7 drinks weekly (D) Has more than 5 drinks weekly (E) Both B and C Answer: (E) A woman exceeds the NIAAA lower risk drink limits if she drinks more than 3 drinks on any one occasion or has more than 7 drinks weekly. Reference: 1. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Moderate and binge drinking.n.d. Available at www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. Accessed June 5, 2013

Alcohol & Drug Use Questions 3. According to the National Institute on Alcohol Abuse and Alcoholism a man ≤ 65 years old has exceeded the lower risk drink limits if he: (A) Has more than 2 drinks on any one occasion (B) Has more than 3 drinks on any one occasion (C) Has more than 14 drinks weekly (D) Has more than 7 drinks weekly (E) Has more than 12 drinks weekly Answer: (C) A man exceeds the NIAAA lower risk drink limits if he drinks more than 4 drinks on any one occasion or has more than 14 drinks weekly. References: 1. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Moderate and binge drinking.n.d. Available at www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. Accessed June 5, 2013

Alcohol & Drug Use Questions 4. Regarding gender differences in drug use, which of the following is false: (A) Women are more sensitive than men about stigmas related to drug use (B) Women are more afraid than men that they will lose their children if they divulge drug use (C) Women are more likely than men to be in abusive relationships that prevent them from seeking help for their substance abuse. (D) Nonmedical use of prescription opioids is more common among women. (E) Men report using opioids more often for recreational reasons than women do. Answer: (D) Reference1 Other answers are all correct. Women are more sensitive than men about stigmas related to drug use, more afraid than men they will lose their children if they divulge drug use and more likely than men to be in abusive relationships that prevent them from seeking help for their substance abuse.2 Men do report using opioids more often for recreational reasons than women do. References: 1. Gregor A, Choo E, Becker B, et al. Sex and Gender in Acute Care Medicine. 2016 Cambridge University Press NY, NY p 51. 2. Coletti S. Service Providers and Treatment Access Issues. Drug Addiction Research and the Health of Women. NIH Publication No 98-4290. Rockville, MD; 1998:236-44. 3. Back SE, Payne RL, Simpson AN, Brady KT. Gender and prescription opioids: Findings from the National Survey on Drug Use and Health. Addictive Behaviors 2010:35(11):100-7.

Alcohol & Drug Use Questions 5. A 36 year old woman in the Emergency Department screens positive for alcohol abuse. Compared to a man she is likely to: (A) Reach higher serum concentrations of alcohol at equivalent amounts of consumption (B) Have less cognitive impairment at equivalent amounts of consumption (C) Be more vulnerable to liver disease at equivalent amounts of consumption (D) A and C (E) All of the above Answer: (D) Women reach higher serum concentrations of alcohol, are more likely to suffer cognitive impairment and are more vulnerable to liver disease at equivalent amounts of ETOH consumption. References: 1. NIAAA, Alcohol Alert: Are women more vulnerable to alcohol’s effects/ 1999. Available at http://pubs.niaaa.nih.gov/publications/aa46.htm. Accessed July 10, 2016

Sex & Gender in Acute Care Medicine