Meth and Women: Treatment Best Practices and Effects on Family

1. Meth and Women: Treatment Best Practices and Effects on Family Alison Hamilton, Ph.D. UCLA Integrated Substance Abuse Programs Department of Psychiatry Los Angeles County Annual Drug Court Conference May 15, 2009

2. Outline of today’s presentation Overview of statistics for women in treatment in Los Angeles County: overall and for methamphetamine specifically Treatment for meth users: what current research says about women Effects of women’s meth use on families Findings from an in-depth study in Los Angeles County Wrap-up & discussion

3. Methamphetamine (meth) in CA & Los Angeles County California is one of only 5 states that had over 200,000 treatment admissions for meth in 2003 By 2004-2005, meth was the main reason for treatment admission throughout California In 2007-2008, meth remained the main reason for treatment admission in Los Angeles County (28% of admissions; cocaine 2nd at 22% of admissions) In 2007-8 in Los Angeles County-funded treatment programs, 40% of those seeking treatment for meth were women

4. Women in treatment inLos Angeles County Among the 11,255 women in treatment in LAC in 2007-8, meth was the primary drug of choice (32%), followed by cocaine/crack (22%) and alcohol (20%) Among ALL women in treatment: 33% Latina, 32% white, 28% African American 90% were unemployed 5% were pregnant at admission 29% had a mental illness diagnosis 25% were homeless 58% had children < 18 years 43% had children < 5 years 25% had open cases with Child Protective Services 21% had a child protection court order

5. Women meth users in treatment in LAC 3,610 women in treatment in 2007-8 for primary meth use Most were Latina (54%) or white (35%) Approximately ½ of women meth users were receiving outpatient treatment, and 1/3 were in residential treatment Among women meth users (vs. among all women in treatment) 88% were unemployed (90%) 8% were pregnant at admission (5%) 20% had a mental illness diagnosis (29%) 27% were homeless (25%) 73% had children < 18 years (58%) 58% had children < 5 years (43%) 39% had an open case with CPS (25%) 32% had a child protection court order (21%)

6. Substance abuse treatment for meth users Center for Substance Abuse Treatment Methamphetamine Treatment Project (MTP) 1,016 participants in a randomized, controlled trial in eight substance abuse treatment programs in California, Montana, and Hawaii 55% female, 45% were male; mean age 32.8 years 60% white, 18% Hispanic, 17% Asian Pacific Islander, 3% Native American, 2% African American 23% unemployed; 12 mean years of education used meth for a mean of 11 years; 5 years of frequent or problematic use use of both marijuana and MA tripled the odds ratio of a sexual abuse history, doubled the odds ratio of a history of suicide attempt

7. Substance abuse treatment for meth users 20% had history of child sexual abuse, 52% physical abuse 60% had depression at some point, 34% had thoughts of suicide, 21% had made a suicide attempt within their lifetime; 56% reported significant symptoms of anxiety 58% of women reported having been forced to have sex Outcomes of psychosocial outpatient treatment: Matrix Model produced better in-treatment performance than treatment-as-usual, but difference did not persist at discharge or follow-up Both Matrix and TAU produced fewer days of meth use at follow-up

8. Substance abuse treatment for meth users • Trends in treatment admissions for meth abuse from 1992 to 2002 in California (124,289 episodes) • % female admitted to treatment stable around 50% through late 1990s, down to 43% in 2002 (due to SACPA admissions of males) • From 2000-2002, 47% of women completed residential treatment (vs. 52% men) and 31% completed outpatient (vs. 30% men) • Women were more likely than men to drop out of residential treatment but women in outpatient treatment were less likely to drop out and had longer retention than men • Issue of coordinating child care etc. • Improved outcomes when those needs are addressed

9. Substance abuse treatment for meth users • Treatment outcomes among 1,073 methamphetamine-abusing patients (567 women, 506 men) from 32 community-based outpatient and residential programs in 13 California counties • More women than men reported that their children were living with someone else by child protection court order, and that their parental rights had been terminated • Women were also more likely to have a family member who abused alcohol or drugs and to report being physically or sexually abused in the past 30 days • More women than men had serious thoughts of suicide and had been prescribed medication for their psychological problems • About 13% of women and 10% men also reported trouble controlling violent behaviors • Women demonstrated greater improvement in family relationships and medical problems • Summary: women appeared to have greater problem severity, but they also seemed to show greater improvement in many areas

10. Substance abuse treatment for women meth users Very little research on treatment outcomes for women meth users; no best practices yet specific to women meth users Women in treatment tend to have more psychological symptoms (e.g., heightened anxiety, depression), lower self-esteem, and higher rates of childhood sexual abuse than men in treatment. Women also face problems related to child-rearing and to limited incomes, education, and job skills Some evidence that residential treatment is more effective than other forms of treatment, and that women have more success with treatment than men

11. Special considerations Route of administration Young age of initiation: pre-adolescent & adolescent girls Relationship between meth use and sexuality: implications for HIV and other STD risk, intimate partner violence, relapse Unintended pregnancies; use during pregnancy Efforts to keep women with their children Violence: victimization & perpetration History of trauma Polydrug use Comorbid psychiatric conditions (e.g., depression) Comorbid physical health conditions (e.g., STDs, dental problems, skin problems) Criminal justice involvement (probation, parole) Intergenerational drug use (family not always a source of support)

12. Interventions for HIV risk behaviors among meth users One study used motivational interviewing and social cognitive theory to increase safer sex behaviors among 451 HIV-negative, heterosexual active meth users in San Diego Participants in the intervention conditions: significantly increased protected sex acts and decreased unprotected sex demonstrated significant improvements in self-efficacy for negotiating safer sex behavioral intervention was effective, likely due to increased self-efficacy for negotiating safer sex

13. Psychiatric comorbidity among women In a study of 146 meth-using women in San Diego: 60% met criteria for moderate to severe depressive symptoms (i.e., higher levels of depressive symptoms) 40% had minimal to mild depressive symptoms (i.e., lower levels of depressive symptoms) Women with higher levels of depressive symptoms were: less likely to be employed more likely to use meth to cope with mood using more grams of meth in a 30-day period using meth more times per day on a greater number of consecutive days more likely to be binge users of meth lower on a measure of self-esteem and higher on measures of impulsivity, social stigma, and social network members' use of meth

14. Effects of women’s meth use on families Many women come from homes where meth and/or other drugs were being used, manufactured, and/or distributed Issue of environmental exposure for those living in/near meth labs Many women come from homes where they experienced and/or witnessed violence, abuse, and/or neglect Many women have unintended pregnancies, high rates of miscarriage & abortion Many women engage in crimes to support their meth habits Some are picked up, others are not Many become incarcerated or otherwise involved with the criminal justice system Crimes can be of a violent nature, against family members, friends, acquaintances, strangers, intimate partners Many women continue to use while pregnant, give birth to babies who test positive, lose their babies to the foster care system Many women engage in high-risk sexual behaviors that have implications for their sexual partners and their reproductive health

15. From seventeen to twenty is when I was just running around, you know, just doing whatever. And then I got pregnant when I was nineteen - I had him when I was twenty and, and then every two years for the next eight years - I had a kid. And just - by that time my mom had the kids full-time, you know? And I was just running around doing whatever. With my second one, I didn’t really use - just a little bit. With my third one, I used a little bit more. By the time I had my fourth one…I used every day of my pregnancy with that one. [And did he test positive when he was born?] Yeah, yeah, and the state took him. (39-year-old Latina)

16. Women, Methamphetamine, & Sex Study In-depth qualitative study of 30 women in women-only residential treatment for 6+ months All participants identified meth as their primary drug of choice Focus of study on relationship between meth and sexual experiences and behaviors Interviews took place at the treatment facilities between September 2006-February 2007 Follow-up interviews scheduled to begin June 2009

17. Sample characteristics Average age: 28.5 years (range 18-45 years) Self-Reported Race/Ethnicity: Latina: 56% (n=17) White: 30% (n=9) Native American: 7% (n=2) Mixed: 7% (n=2) Education: Less than HS: 57% HS degree or GED: 33% Some college: 10% Employment status: Unemployed & receiving public assistance: 97% (n=29)

18. Sample characteristics Marital status: Never been married: 77% Married: 13% Divorced/separated: 10% Children: 97% (n=29) have children 9 women have one child each; 6 women have 2 children each; 6 women have 3 children each; 6 women have 4 children each; 1 woman has 5 children; and 1 woman has 6 children Women were an average age of 20 years when they had their first child Criminal justice status: 37% were on probation or parole or both Substance use history in past year: 67% had used other drugs in addition to meth in the past year (typically alcohol & marijuana)

19. Sample characteristics History of child sexual abuse: 12/30 described early childhood abuse/molestation Several definitively said they were not abused Parental drug use: 11/30 had at least one parent who was an addict Route of administration: Most progressed from snorting to smoking 4/30 had tried needles but either didn’t like the feeling or liked the feeling “too much” 6/30 were chronic IV drug users

20. Sample characteristics Introduction to meth: Most had already used other drugs before using meth. Participants were an average age of 15 when they started using meth. Two started using when they were 9; 8 started using between the ages of 11-13. Most were introduced to meth by family members or friends.

21. Women who injected meth 5/6 (83%) women were introduced to injecting by their boyfriends or started injecting because their boyfriends were; 1 woman was introduced to injecting meth by her mother Several described high-risk sexual behaviors (e.g., unprotected vaginal and anal sex, multiple partners, sex with strangers) and drug-use behaviors (e.g., sharing needles), but participants did not use any form of protection against sexually transmitted diseases and needle sharing often commenced when addiction was at peak. No one reported being HIV+, though several reported having STDs (25% of sample). Many women reported continuing to use while pregnant, including the injectors.

22. A closer look at an issue of concern: use during pregnancy 22/29 women discussed using while pregnant 7 women said they stopped when they learned they were pregnant Dominant themes: I couldn’t stop using. I stopped at first but started using again later in the pregnancy. I didn’t use during earlier pregnancies but I did during later pregnancies I don’t know why I did it when I was pregnant. I stopped when I found out I was pregnant. Pregnancy problems

23. I couldn’t stop using. I couldn’t stop. I tried, but I couldn’t. So I used through my whole pregnancy. He was due on the 18th and I stopped on the 11th and had him on the 14th…It really got worse when he was getting bigger and he started moving and, you know, me being high and I wouldn’t eat for days at a time and I knew I was starving my baby, but I just couldn’t stop.

24. Effect on child development “I mean, in all three of my pregnancies, I used, and I just couldn’t stop - even being pregnant, even feeling my baby move, I still, you know, did dope. [Did you have any complications?] No, both my, all of my kids, all my kids - perfectly fine. But yet, you know, my son’s only three, you know, and we don’t know whether he is level headed, you know, yeah, but - so I’m sure they affected him some way, somehow, you know?”

25. Impact on children “My children are a direct result of, of me - you know what I mean? My three older kids all--my seventeen year old now, actually has a year and a half sober. But my other two still battle with it, you know? And it’s because it’s what I taught them, you know? My fourteen year old, he, he hasn’t done any drugs yet, you know? But me and his dad both are drug addicts, you know? [And he was the one that tested positive?] Uh huh (yes), um hmm. [And do you see any like effects of…] Not now, but him and my oldest one, like with one…they don’t have no patience or tolerance for crowds, you know? So, yeah, that’s probably all that I’ve ever noticed in them…”

26. Take-home points Women meth users often have severe dependence but do seek treatment and can be treated effectively Women meth users might seek help through avenues other than drug treatment (e.g., prenatal care, criminal justice system) and systems need to be prepared for women meth users who present with other issues Drug treatment can be an avenue for addressing other issues such as HIV risk behaviors Women’s meth use has tremendous effects on families in terms of the woman’s health and role in her family, her behaviors with her family, her children and their custodial status and well-being, her reproductive legacy

27. Acknowledgements • Special thanks to Desirée A. Crèvecoeur-MacPhail, Ph.D. for LACES data • Women, Methamphetamine, and Sex study funded by NIH NIDA K01-DA017647

28. Contact information Alison Hamilton alisonh@ucla.edu