i

Drug Addiction Research

and the Health of Women

Executive Summary

Editors:

Cora Lee Wetherington, Ph.D., Women’s Health Coordinator

Adele B. Roman, M.S.N., R.N., Deputy Women’s Health Coordinator

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20857
NIDA Conference Planning Committee

Loretta P. Finnegan, M.D., Chair, Office of the Director1

Lula Beatty, Ph.D., Chief, Special Populations Office

J.C. Comolli, R.N., M.B.A., Office on AIDS

Katherine Davenny, M.P.H., Clinical Medicine Branch,

Division of Clinical and Services Research

Ronald I. Herning, Ph.D., Neuroscience Branch,

Division of Intramural Research

Coryl Jones, Ph.D., Epidemiology Research Branch,

Division of Epidemiology and Prevention Research

Sheryl Massaro, M.F.A., Public Information Branch,

Office of Science Policy and Communications

Ann Montgomery, R.N., M.A., Clinical Trials Branch,

Medications Development Division

Lisa Onken, Ph.D., Treatment Research Branch,

Division of Clinical and Services Research

Elizabeth R. Rahdert, Ph.D., Treatment Research Branch,

Division of Clinical and Services Research

Adele B. Roman, M.S.N., R.N., Office of the Director

Zili Sloboda, Sc.D., Director, Division of Epidemiology and

Prevention Research

Pushpa V. Thadani, Ph.D., Basic Neurobiology and Biological

Systems Research Branch, Division of Basic Research

Linda B. Thomas, B.S., Office of the Director

Cora Lee Wetherington, Ph.D., Women’s Health Coordinator

1 Dr. Finnegan is now Director, Women's Health Initiative, Office of the Director,

National Institutes of Health.
ii

Two publications have been produced based on the scientific

research conference “Drug Addiction Research and the Health of

Women,” which was held on September 12-14, 1994, in Tysons Corner,

VA, and was sponsored by the National Institute on Drug Abuse. This

volume, Drug Addiction Research and the Health of Women: Executive

Summary, contains condensed versions of the conference presentations

as well as the ensuing discussion sessions. A companion volume, Drug

Addiction Research and the Health of Women, builds on the conference

presentations and provides greatly expanded reviews of research in this

field.

To obtain copies of either publication contact the National

Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box

2345, Rockville, MD 20847-2345, 1-800-NCADI-64 (622-3464) or see

its World Wide Web site: http://www.health.org.

COPYRIGHT STATUS

All material in this volume is in the public domain and may be

used or reproduced without permission from the Institute or the authors.

Citation of the source is appreciated.

DISCLAIMER

Opinions expressed in this volume are those of the presenters and

do not necessarily reflect the opinions or official policy of the National

Institute on Drug Abuse or any other part of the U.S. Department of

Health and Human Services.

The U.S. Government does not endorse or favor any specific

commercial product or company. Trade, proprietary, or company names

appearing in this publication are used only because they are considered

essential in the context of the studies reported herein.

National Institute on Drug Abuse

NIH Publication No. 98-4289

Printed April 1998
iii

Foreword

Alan I. Leshner, Ph.D.

Drug abuse and addiction are among the most pressing health and

social issues facing our Nation, posing serious health risks and often

tragic consequences for those who are afflicted and for their families

and communities. Although extraordinary progress has been made in

understanding these disorders and in finding the best ways to prevent

and treat them, unfortunately, research on drug abuse and addiction

related to women has, until relatively recently, been sorely neglected.

Most drug abuse interventions developed to date, including prevention

and treatment programs, have largely been shaped by men’s characteristics and needs. Because women traditionally have been underrepresented in research studies and drug abuse treatment groups, the effects

of drug abuse are far less understood for women than for men. But the

scientific evidence generated thus far suggests that drug abuse and

addiction present different challenges to women’s health, progress

differently in females than in males, and may require different treatment

approaches and strategies. Moreover, the rapid increase in AIDS cases

among women in recent years makes it all the more critical to address

gender differences as they relate to drug problems.

In an effort to assess and begin to fill the gaps that exist in knowledge about drug abuse and women’s health, the National Institute on

Drug Abuse (NIDA), the Federal agency leading the Nation’s research

efforts on drug abuse and addiction, sponsored a national conference

in September 1994 titled “Drug Addiction Research and the Health

of Women.” This 2-day meeting brought together leading researchers

to present state-of-the-science findings, discuss research issues and

challenges confronting the field, and lay the framework for NIDA’s

research agenda in this important area.

This volume contains condensed versions of the conference presentations as well as the ensuing discussion sessions. These summaries and

discussions emphasize the gaps in knowledge regarding women and drug

abuse that existed then and that, unfortunately, continue to exist today.
iv

A companion volume, Drug Addiction Research and the Health of Women,

contains greatly expanded reviews of research in this field.

Alan I. Leshner, Ph.D.

Director

National Institute on Drug Abuse

Parklawn Building, Room 10-05

5600 Fishers Lane

Rockville, MD 20857
v

Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Opening Session

Welcome and Opening Remarks

Loretta P. Finnegan, M.D.

Senior Adviser on Women’s Issues

Office of the Director, National Institute on Drug Abuse . . . . . . . . 1

Welcome From the Office of Research on Women’s Health

Vivian W. Pinn, M.D.

Associate Director for Research on Women’s Health

Office of Research on Women’s Health . . . . . . . . . . . . . . . . . . . 1

Welcome From the National Institute on Drug Abuse

Alan I. Leshner, Ph.D.

Director, National Institute on Drug Abuse . . . . . . . . . . . . . . . . 3

Welcome From the U.S. Public Health Service

Susan J. Blumenthal, M.D., M.P.A.

Deputy Assistant Secretary for Health (Women’s Health)

Assistant Surgeon General

Office on Women’s Health, U.S. Public Health Service . . . . . . . . 4

The History of Drug Abuse and Women in the United States

Stephen R. Kandall, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Keynote Address: Neurobiological Correlates of the Addictions:

Findings From Basic and Treatment Research

Mary Jeanne Kreek, M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Epidemiology

Epidemiology of Drug Use and Abuse Among Women

Denise B. Kandel, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
vi

Biological/Behavioral Mechanisms

Drug Abuse and Reproduction in Women

Nancy K. Mello, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Sex Differences, Drugs, and Defensive Behavior

D. Caroline Blanchard, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Biological/Behavioral Mechanisms Panel

Sex Differences and Hormonal Effects on Drug Seeking

David C.S. Roberts, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Smoking, Eating, Stress, and Drug Use: Sex Differences

Neil E. Grunberg, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Translating Basic Research Into the Clinical Setting

James R. Woods, Jr., M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Treatment

Psychosocial and Behavioral Treatments for Women

Karla Moras, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Pharmacology: Sex-Specific Considerations in the

Use of Psychoactive Medications

Sidney Schnoll, M.D., Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Researcher/Sex Issues

Jacqueline Wallen, Ph.D., M.S.W. . . . . . . . . . . . . . . . . . . . . . . . . 55

Service Provider/Treatment Access Issues

Shirley D. Coletti, D.H.L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Etiology

The Etiology and Genetic Epidemiology of Psychiatric

and Drug Disorders Among Women

Kathleen R. Merikangas, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . 66
vii

Etiology Panel

Childhood and Adolescent Precursors to Drug Use

Judith S. Brook, Ed.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Victimization and Posttraumatic Stress Disorder

Dean G. Kilpatrick, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Harm Reduction

Marsha Rosenbaum, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80

Stress and Coping Among Women

R. Lorraine Collins, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Consequences

Medical and Health Consequences of

HIV/AIDS and Drug Abuse

Peter A. Selwyn, M.D., M.P.H. . . . . . . . . . . . . . . . . . . . . . . . . . . 86

Social and Behavioral Consequences

Rafaela R. Robles, Ed.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Consequences Panel

The Consequences of Drug Dependence on Social Supports,

High-Risk Sexual Behaviors, and Homelessness

Adeline Nyamathi, R.N., Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Psychiatric Sequelae of Drug Abuse

Linda B. Cottler, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Partner Violence

Brenda A. Miller, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Prevention

Links Between Prevention and Treatment

Karol L. Kumpfer, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
viii

Intervention

Intervention, Outreach, and Special Needs

Kathy Sanders-Phillips, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Legal and Criminal Justice Issues

Punishing Women for Their Behavior During Pregnancy:

An Approach That Undermines the Health of Women

and Children

Lynn M. Paltrow, J.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Crosscutting Issues Panel

African-American Women and Trauma: Depression,

Drugs, and Families

Sheryl Brissett-Chapman, Ed.D., A.C.S.W., L.I.C.S.W. . . . . . . 117

Drug Abuse and HIV Among Lesbians

Marjorie J. Plumb, M.N.A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Hispanic Women

Margarita Alegría, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Research Needs of American Indian Women

Pamela Jumper-Thurman, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Closing Session

Concluding Remarks

David J. Mactas

Director, Center for Substance Abuse Treatment . . . . . . . . . . . . . 131

Toward the Development of a Drug Abuse Research Agenda

on the Health of Women

Richard A. Millstein

Deputy Director, National Institute on Drug Abuse . . . . . . . . . . . 132

Conference Speakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
1

Opening Session

WELCOME AND OPENING REMARKS

Loretta P. Finnegan, M.D.

Senior Adviser on Women’s Issues

Office of the Director

National Institute on Drug Abuse

Dr. Finnegan explained the purposes of the conference: (1) discuss

the status of research on drug addiction and women’s health and learn

about recent research findings and (2) determine what important research questions have not been answered and what questions should be

given priority for future research. She encouraged participants to give

NIDA written suggestions about what NIDA’s research priorities should

be and how its research agenda can be changed to improve the situation

of women who suffer from drug addiction.

WELCOME FROM THE OFFICE OF

RESEARCH ON WOMEN’S HEALTH

Vivian W. Pinn, M.D.

Associate Director for Research on Women’s Health

Office of Research on Women’s Health

Dr. Pinn greeted the conference participants on behalf of the Office

of the Director at the National Institutes of Health (NIH) and the Office

of Research on Women’s Health (ORWH). Established in 1990, ORWH

serves as the focal point for biomedical and behavioral research that

addresses issues of sex differences across NIH. ORWH promotes a

multidisciplinary approach to research that examines women’s health

across the lifespan.

ORWH’s Basic Mandates

Dr. Pinn described ORWH’s three basic mandates:

1. To determine what is known and not known about women’s

health. ORWH identifies priority issues and establishes the NIH

research agenda on women’s health, which includes stimulating
2

research on conditions that affect both women and men, but until

now have been studied primarily in men, as well as diseases and

conditions unique to women.

2. To fulfill the congressional mandate, codified in the NIH Revitalization Act of 1993, to ensure the inclusion of adequate numbers

of women of diverse racial, ethnic, and socioeconomic backgrounds in NIH-supported clinical studies. To monitor inclusion

across the entire NIH, a computer-based system has been established to track the inclusion of women and racial and ethnic

minorities in clinical trials. Because inclusion raises important

ethical and legal issues, ORWH commissioned a study by the

Institute of Medicine (IOM) to define the implications of including women in clinical trials, especially women of childbearing age

and potential. The resulting IOM report upheld the importance

of inclusion, stating that, “women and men should have the

opportunity to participate equally in the benefits and burdens of

research.”

3. To create and direct initiatives that will increase opportunities for

women to pursue biomedical careers and to assume positions of

leadership in biomedical research and participate in formulating

public policy in this area.

ORWH’s Research Agenda

• Published in 1992, ORWH’s comprehensive research agenda

Opportunities for Research on Women’s Health is based on an

expanded definition of women’s health, one that addresses health

across the lifespan and goes beyond reproductive issues. The

agenda includes a broad range of scientific disciplines; medical

specialties; and psychosocial, behavioral, and environmental

factors. ORWH encourages future research to merge the study of

biological and behavioral issues whenever possible.

• ORWH’s agenda identified several research topics related to drug

abuse, including (1) the link between drug abuse and neurobiological abnormalities; (2) the interaction among biological,

psychological, and social factors that lead to harmful behaviors

such as drug abuse; (3) the patterns and mechanisms of drug
3

abuse, including drug addiction, by adolescent females; and

(4) the influence of sex roles and relationships with male

partners.

• One top research priority that ORWH has supported with

supplemental funding is examination of behavioral and cultural

factors related to women and disease risk or intervention. These

factors include drug abuse, unsafe sexual behavior, domestic

violence, and other abuse of elderly persons.

• The ORWH agenda stresses the need to include all populations

of women in clinical research, including women from different

racial and ethnic minority groups, socioeconomic statuses, sexual

orientations, and geographic locations.

NIH is required by law to include women and members of racial and

ethnic minority groups and subgroups in all federally funded clinical

research using human subjects. In clinical trials with humans, it is

necessary to include these groups so that valid data analyses can reveal

any differences in interventions between the sexes and among racial and

ethnic subgroups. ORWH constructed guidelines to help implement

the law and has sought a balance between the requirement to include

women as research subjects and the policies to protect them from

potential risks.

WELCOME FROM THE NATIONAL

INSTITUTE ON DRUG ABUSE

Alan I. Leshner, Ph.D.

Director

National Institute on Drug Abuse

Dr. Leshner presented a brief summary of NIDA’s approach to

research on drug abuse and women’s health:

• NIDA views drug addiction as a chronic and relapsing disease

that affects both women and men. Although most research on

drug abuse has used men as research subjects, drug abuse may

present different challenges to women’s health, may progress

differently in women than in men, and may require different

treatment approaches.
4

• At the time of the conference, more than 4.4 million women had

used an illicit drug at least once in the past month, and almost

half of all women ages 15 to 44 years had used illicit drugs at least

once in their lives. In 1991 NIDA established a Women’s Health

Issues Group to help focus research on women, initially on

maternal-fetal interactions. Although the effects of drug abuse on

pregnancy are still a priority, NIDA has broadened its research to

examine the effects of drug abuse on all phases of women’s lives.

• More attention is needed on the relationship between AIDS and

drug abuse and how a patient’s sex may affect this relationship.

Drug abuse increases the risk of AIDS for women, especially

women who inject drugs, share drug paraphernalia, or have sexual

relationships with injection drug users. In the past few years,

there has been a significant rise in the number of AIDS cases

occurring in women who are injection drug users.

Dr. Leshner encouraged conference attendees to advise NIDA

about research questions they believe should be prioritized and the

most effective approaches for obtaining answers to those questions.

WELCOME FROM THE U.S.

PUBLIC HEALTH SERVICE

Susan J. Blumenthal, M.D., M.P.A.

Deputy Assistant Secretary for Health (Women’s Health)

Assistant Surgeon General

Office on Women’s Health

U.S. Public Health Service

Women’s Health and Drug Abuse

Drug abuse is a major contributor to premature morbidity and

mortality in the United States. The annual direct and indirect costs of

drug abuse total more than $58 billion. The Center on Addiction and

Substance Abuse at Columbia University found that drug abuse and

addiction are responsible for at least 20 percent of the $40 billion

medicaid budget. Despite the widespread concern about addictive

disorders in the United States, relatively little is known about the causes,

treatment, and prevention of drug abuse disorders among women.

Approximately 200,000 women are expected to die of illnesses related
5

to drug abuse in 1994, more than four times the number of women

who will die of breast cancer.

Society’s denial about women and drug abuse is finally ending.

Efforts to understand, treat, and prevent drug abuse are being strengthened at NIH since the 1992 ADAMHA Reorganization Act, which

brought NIDA, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute of Mental Health under the auspices

of NIH. The reorganization has placed mental illness and addictive

disorders, as critical elements of our national research agenda, side

by side with cancer and heart disease. This is a major step forward

in shattering the stigma that has surrounded addictive disorders.

Women’s Health Research Issues

• Because of general improvements in public health, women’s

average life expectancy has increased by almost 30 years since

1900, and women live an average of 7 years longer than men.

However, they now face—in greater numbers than men—the

health problems that accompany old age, such as osteoporosis,

depression, and Alzheimer’s disease, and suffer from more illnesses and more chronic, debilitating conditions than men.

Generations of physicians have not been trained about how

diseases manifest differently in women or how to be sensitive

to women’s health concerns.

• Biomedical research has historically neglected research on

women’s issues, and most previous studies have been conducted

with men only, with the results generalized to women. Research

on drug addiction often has not been conducted with female

subjects. Whereas women of childbearing age sometimes were

excluded from medical research because of fear of damaging the

fetus, the exclusion often reflected a social bias. In studies of

everything from the link between smoking and cataracts to the

benefits of aspirin for lowering the risks of a heart attack, the

subjects have been all men.

• Women and men have different physiological responses to

medications and drugs and may develop different manifestations

of disease as a product of drug abuse. Women have more side

effects and more fatal drug reactions to psychotropic medications
6

than men, but little research has been done in this area. Sex

differences in weight, body composition, cerebral blood flow,

gastric emptying time, and use of the exogenous hormones in

oral contraceptives and estrogen replacement therapy may

cause differences in drug reactions.

• Many individual genetic, biological, environmental, and psychosocial factors affect health and disease in men and women.

Research has just begun to focus on sex-based differences in the

morbidity of addictive disorders. Women suffer from illnesses and

disabilities related to drug abuse that in the past were associated

only with men, as well as disorders that appear to be unique to

women.

• Most studies of drug abuse among women have centered on the

effects of women’s addiction on children and families, particularly

on the fetus. These concerns reflect the traditional view that

women are valued primarily for their reproductive capacity, but

there has been a change in this philosophy and in the focus on

women’s health within the U.S. Department of Health and

Human Services (DHHS).

Effects of Omitting Women From Research

• Major heart disease and cancer studies found smoking to be a

major risk factor, but because they were conducted with only

male participants, all smoking prevention trials have targeted

men. However, in 1985 lung cancer surpassed breast cancer as

a cause of death among women in the United States. Smoking

also contributes significantly to other cancers in women—of the

larynx, oral cavity, esophagus, and cervix—and contributes to

impaired fertility, early menopause, pregnancy complications,

and birth defects. Tobacco also interacts with other drugs such

as oral contraceptives, markedly increasing the risk for cardiovascular disease among women.

• The complex psychosocial and biological reasons behind smoking

behavior and cessation among women have not been evaluated

and may complicate efforts to reduce the high rate of smoking

among women. Approximately 25 percent of women younger

than age 25 smoke cigarettes, and 23 percent of the adult female

population are heavy smokers.
7

• The lack of research on how diseases manifest or can be prevented

in women has led to increases in the rate of HIV infection. AIDS

is the number one cause of death of reproductive-age women in

many major cities. As many as 65.6 percent of the cases of HIV

infection among women can be attributed to injection drug use or

sex with an injection drug user.

• Young women use alcohol and other drugs at slightly higher

rates than ever before and are at risk for drug abuse-related

motor vehicle accidents and suicidal behavior.

• The incidence of polypharmacy (mixing medications for other

than the intended purpose) is high among older women. Although elderly women represent only 11 percent of the population, they receive more than 25 percent of all written prescriptions—2-1/2 times more than those received by elderly men.

Little research has been conducted on this high-risk population

of women.

• Social sanctions and stigma against drug abuse among women

have made them less willing to seek treatment for addictive

disorders. As a result, data on the incidence and prevalence of

drug abuse among women, generally based on contact with

treatment facilities or help hotlines, may underrepresent the

magnitude of the problem.

• Little awareness exists among health care professionals about

sociocultural and environmental risk factors for women, particularly those affecting racial and ethnic minority groups. Environmental factors include sexual and other physical abuse, anxiety

from having multiple roles as caregivers and wage earners, poor

self-esteem, dead-end employment or unemployment, low educational attainment, and life stresses such as divorce and loneliness.

How these factors may predispose women to drug abuse and what

protective factors may exist remain unknown.

• In 1990 women’s health began to receive unprecedented attention

in both scientific circles and the media. The public and scientists

have become aware of the exclusion of women from previous

clinical trials, the inequity of access to health care services for

women, the inadequate attention to health care and researchrelated sex differences, and the lack of women in senior medical

positions in research and clinical practice.
8

Goals and Priorities of the Office on Women’s Health

The U.S. Public Health Service’s Office on Women’s Health

(PHS OWH) coordinates research, service delivery, and education

programs across the agencies of DHHS, including NIH, the Food and

Drug Administration, the Substance Abuse and Mental Health Services

Administration, and others. PHS OWH is addressing crucial women’s

health issues and redressing inequities in the health care system that

have compromised women’s health. PHS OWH has the following goals:

• To support comprehensive, community-based health promotion

and disease prevention programs for women, to improve access

to health care services for women, and to promote healthier

behaviors and lifestyles. Research shows that behavioral changes

can reduce premature death by 70 percent and acute illnesses by

more than 30 percent.

• To foster and sustain a comprehensive program of research on

women’s health issues.

• To support the training of health care professionals in women’s

health issues. PHS OWH is collaborating with NIH and the

Health Resources and Services Administration to develop a

model women’s health curriculum for the training of health care

professionals.

• To foster the promotion and advancement of women in health

care and research careers.

THE HISTORY OF DRUG ABUSE AND

WOMEN IN THE UNITED STATES

Stephen R. Kandall, M.D.

Abstract

Dr. Kandall presented a brief summary of the history of drug abuse and

women in the United States. Although the news media may imply that drug

abuse is a recent development, marijuana was brought by Jamestown settlers

to the United States in the 17th century, and opiates were widely used during

the Revolutionary War to control pain and diarrhea. Women made up the

majority of drug users during the 19th century, and for the past 150 years,

women, compared with men, have been overmedicated by physicians.
9

Although women have represented a large portion of the drug-using population

in the United States, research on and treatment of drug abuse among women

has received relatively little attention. Antidrug legislation has been promoted

throughout U.S. history by linking drug abuse to prostitution and to public

fears of racial and ethnic minority groups. In the past 25 years, there has been

much progress in research and advocacy on women and drug abuse, but

negative attitudes toward drug abusers have slowed this process. Women now

represent approximately 30 percent of the drug-using population; this figure

would be significantly higher if prescription drugs were included.

Introduction

Drug abuse as a health and social problem was first identified in

1850, but the extent and severity of drug abuse in society have never

been determined. By 1900 the number of opiate addicts in the United

States was estimated at 200,000, most of them women. Women usually

took these drugs as laudanum (tincture of opium), paregoric (camphorated tincture of opium), and gum or powdered opium. Heroin was

introduced in 1898 primarily as a cough suppressant, but because it was

taken orally, which weakens its effect, heroin was not used widely in

the late 19th and early 20th centuries.

Medicinal Use of Opiates and Cocaine

in the 18th and 19th Centuries

The heavy use of opiates and the high rate of addiction in the

19th century were due largely to the way medications were used. Physicians and pharmacists had limited therapeutic options at their disposal,

especially for treating pain and diarrhea. For example, during the Civil

War, almost 3 million ounces of opium were distributed to the Union

forces alone, and many wounded Civil War veterans became addicted.

Almost all diseases were treated with opiates, including cholera, food

poisoning, gallstones, headaches, rheumatism, pneumonia, asthma,

consumption, cardiac conditions, syphilis, rabies, gangrene, earaches,

hemorrhoids, and impotence.

The overmedication of women compared with men has been a

major issue for the past 150 years, beginning with the image of the

Victorian woman as less able to bear pain than a man and therefore

more in need of medication. The typical drug addict during this period
10

was a white, upper class woman from the South. Almost all anecdotal

reports and epidemiologic studies written during the Victorian period

cited gynecologic problems as the major reason for opiate treatment and

addiction in women. Another major factor contributing to drug use in

women during the late 19th century was neurasthenia, a condition of

chronic physical and mental weakness that was said to be caused by

exhaustion of the nervous system. Women were considered to be more

susceptible to neurasthenia than men and were treated regularly with

opiates.

Cocaine was introduced in the United States in 1876 and became

a popular ingredient in many tonics and beverages, such as Coca-Cola,

which contained the drug until it was replaced with caffeine in 1906.

Cocaine also was used as a topical anesthetic for children and as a

treatment for neurasthenia and was recommended as a treatment for

opiate and alcohol addiction. Cannabis was prescribed widely between

1840 and 1900 for many conditions. In women it was prescribed for

gynecologic problems, labor pains, postpartum psychoses, gonorrhea,

and headaches.

The link between drugs and sexuality is another theme that has

persisted over the past 150 years. Many images in the press showed

women as helpless slaves to the opium habit and being lured into

prostitution with drugs.

Drug Use at the Turn of the Century

By 1890 drug use had peaked and began to decrease by 1900, in part

due to the changing sociodemographics of the United States. Physicians

were becoming aware of the fact that drugs could be dangerous, and

opiates were used less frequently to treat women’s diseases.

In the late 19th and early 20th centuries, women from all economic

classes formed the majority of opiate addicts in the United States and

were prominent users of the “four Cs”: chloroform, chloral hydrate,

cocaine, and cannabis. At the same time, sectors of the U.S. pharmaceutical industry concentrated on developing and supplying drugs to

women who were opiate addicts. Women were medicated disproportionately for physical, mental, and emotional complaints, but Victorian

society would not acknowledge the existence of their drug problems.
11

Advances in public health and newer and safer analgesics made the

use of opiates less acceptable, and physicians became aware of the risks

of drug use during pregnancy. The 1865 standard gynecology textbook

by William Byford recommended that amenorrhea be treated with

opium, but the 1898 edition stated, “He who is compelled to resort

frequently to opium must be considered devoid in diagnostic ability, and

consequently ought not to be entrusted with the management of such

cases.” Mothers were held increasingly accountable for the inappropriate administration of opiates to their children, although in previous

years opiates had been prescribed routinely for the treatment of many

childhood illnesses.

Another major development at the turn of the century was the

passage of antidrug legislation to control racial and ethnic minority

groups who were seeking economic and social expansion, specifically

Asian immigrants and blacks. Public fears of drug-induced attacks on

women by racial and ethnic minority groups were used to promote

antidrug legislation. In 1909 the international Shanghai Commission

made it easier to move ahead with national antidrug legislation, claiming that “cocaine is often the direct incentive to the crime of rape by the

Negroes of the South and other sections of the country,” even though

it had no evidence to support this claim. The perceived link between

sexuality and drugs was strengthened by the increasing pervasiveness

of the press and movies in everyday life.

The Harrison Act of 1914 was a watershed for antidrug legislation

in the United States. It introduced repressive drug laws and reinforced

negative attitudes toward drug abusers that persist today. The Harrison

Act was a tax act that was not meant to restrict the use of narcotics but

to tax their sale and track their flow. In 1919 the U.S. Supreme Court

issued decisions that upheld the Harrison Act and prevented physicians

from prescribing drugs solely for drug maintenance. The options available to drug addicts during this era were few. The first reported rise in

crime among drug-addicted women occurred after passage of the

Harrison Act. Between 1919 and 1923, the only organized treatments

available were 44 drug treatment clinics scattered throughout the

United States.
12

Drug Use and Drug Treatment Efforts in the 20th Century

Supporters of antimarijuana legislation promoted the image of

women as potential victims of Mexican immigrants, which contributed

to the passage of the Marijuana Tax Act of 1937. Just as opiates and

cocaine were promoted in the 19th century, advertisements in the 1950s

hailed the arrival of “happy pills,” “peace-of-mind drugs,” and “miracle

drugs.” In 1957 physicians wrote more than 48 million prescriptions

for tranquilizers; by 1967 more than two-thirds of prescriptions for

psychoactive drugs were written for women.

An attempt at organized drug abuse treatment by the Public Health

Service can be found in the Lexington and Fort Worth “farms,” which

existed from the late 1930s to the early 1960s. In the late 1950s and

early 1960s new drug treatment opportunities were offered in the form

of outpatient and inpatient treatment, nonmaintenance treatment, and

correctional treatment. Scientists pioneered methadone as another

treatment option in the 1960s, and therapeutic communities were

established.

The National Institute on Drug Abuse was founded in 1974. During

the 1970s NIDA estimated that 1 million to 2 million women were

addicted to prescription drugs, but physicians continued to write excessive numbers of prescriptions for women. In 1974, 22 million new

prescriptions were written to provide Valium to women. Odyssey House,

which opened in New York in 1966, was one of the first programs to

offer care for pregnant addicts and their children with the support of a

grant from NIDA.

Heroin use increased in the United States in 1970, and the proportion of female heroin addicts increased from about 18 to 30 percent.

However, women were still underrepresented in drug treatment programs. The rate of arrests of women related to narcotics, larceny, theft,

fraud, and forgery rose from 18 to more than 100 per 100,000 in only

10 years.

By 1971 President Nixon had declared drug abuse to be public

enemy number one. The number of federally funded methadone programs grew from 16 in 1969 to 926 in 1973, with women making up

almost 10,000 of the 42,000 methadone patients. However, these

treatment programs did not address the multiple service needs of

female addicts.
13

Public Law 94-371, passed in 1974, mandated special consideration

for women in drug abuse prevention and treatment programs. During

that same year, the Program for Women’s Concerns was established

within NIDA to address the lack of drug abuse treatment, prevention,

and research programs for women. In 1975 NIDA began funding a series

of 3-year comprehensive drug treatment demonstration projects for

women in Detroit, Houston, New York, Philadelphia, Washington, DC,

and San Raphael, CA, with an initial focus on treatment related to

pregnancy.

In the 1980s and 1990s an impressive number of programs for drugaddicted women were created and implemented through the Public

Health Service. For example, Congress designated a 5-percent set-aside

for women’s alcohol and other drug abuse treatment services for fiscal

year 1986 (raised to 10 percent in 1989). These funds were channeled

through an Alcohol, Drug Abuse, and Mental Health Services Administration (ADAMHA) block grant, which targeted services for pregnant

women and women with dependent children. In 1988 ADAMHA

funded the Pregnant and Postpartum Women and Infants demonstration

grant program, which awarded 131 grants by the end of 1991. A variety

of Government agencies began to operate programs for drug-addicted

women, including the Office of the Assistant Secretary for Health, the

Administration on Children and Families, the Administration for

Native Americans, the Administration for Developmental Disabilities,

and the Social Security Administration.

Even as women began receiving more treatment and prevention

services, they also were blamed for certain health problems, including:

• An increase in the number of “crack babies” born, a term widely

and indiscriminately used by the news media. Although there

were widely differing estimates of the number of cocaine-exposed

babies who were born during the 1980s and 1990s—from 100,000

to 375,000—the news media often reported the highest figures

projected.

• A rise in perinatal AIDS because of transmission of HIV through

the mother.

• Increased use of drugs by children.

• An increase in the incidence of congenital syphilis, a disease that

was almost eradicated in the 1970s and early 1980s.
14

Punitive measures were taken against women who abused drugs. By

April 1992 more than 160 women in 24 States had been prosecuted for

drug use or drug-related behaviors during pregnancy. Racial bias was

an important factor in determining who would be prosecuted. Dr. Ira

Chasnoff, in his study of one Florida county, showed that even though

drug use generally occurs equally across racial and ethnic groups, a

member of a racial or ethnic minority group was 10 times more likely

to be reported to child protective services than a white person.

Summary of Major Trends

• Throughout U.S. history, many drug abusers have been women.

Before 1900 opiates and cocaine were standard treatments for

many illnesses, including gynecologic problems. Women made

up the majority of drug users during the 19th century and now

make up about 30 percent of the total drug-using population.

Historically, drug manufacturers have promoted images that

portray women as weak and have marketed drugs to women to

make a profit.

• Drug use and sexuality have been linked throughout U.S. history.

Unfounded fears that drugs incite members of racial and ethnic

minority groups to rape women have been used to promote

antidrug legislation. The media have sensationalized stories

about women’s drug use, portraying women as victims of drug

abuse or as mothers who allegedly abuse their children.

• Drug treatment for women received little attention until the

1970s. In the past 25 years, there has been much progress in

research and advocacy on women and drug abuse. However, drug

treatment is still relatively inaccessible for women. Persistent

negative attitudes toward drug abusers have prevented progress

in drug treatment.

Questions From the Audience

The question-and-answer session below followed Dr. Kandall’s

presentation.

Unidentified Audience Member: Have you encountered information specific to the epidemiology of drug abuse among women from

racial and ethnic minority groups?
15

Dr. Kandall: Until the turn of the century, it was not discussed.

Because much of the written epidemiology is contained in doctors’ and

pharmacists’ records (I reviewed them as far back as the 1860s), minority

groups are rarely mentioned. People who lived in rural or poor areas

could not consult with physicians and tried to treat their own illnesses.

However, as people and drugs moved to the inner cities, the problem of

drug abuse among women in racial and ethnic minority groups became

more serious. The analysis of the epidemiology of drug abuse has been

poor, and even today, estimates vary about the number of drug addicts

in different populations.

Unidentified Audience Member: It is important to know how

many women and men are using drugs. For instance, we heard that

100,000 women were using opiates, but in addition to the absolute

number, it is also important to know the proportions. For example,

100,000 out of 10 million women means something different from

100,000 out of 100 million. It also is important to know the age

distribution. We need to understand the extent of the problem, the

changes over time, and the distribution among different sectors of

the population.

Dr. Kandall: Thank you very much.

Unidentified Audience Member: Would you like to speculate on

what might have happened in the United States if there had not been

groups of nonwhite people present who could be blamed for drug problems and be used to justify the passage of laws to limit drug use in this

country? I am thinking of the United Kingdom, where people have

been obtaining methadone on a regular basis since World War II. The

number of nonwhite groups living in the United Kingdom is smaller

than the number of racial and ethnic minority group members in the

United States.

Dr. Kandall: That is a very provocative question. The major

quantitative contribution to the drug problem was the medicinal use of

drugs as prescribed by physicians and pharmacists and people who selfmedicated because they had no access to physicians. There is no question that the numbers, which peaked in the 1890s, probably would have

decreased anyway. I believe that the legislative agenda would have

changed drastically if people from different racial and ethnic groups

had not immigrated to the United States.
16

Unidentified Audience Member: In terms of the information that

you have reported, it is interesting that the population groups that were

targeted by antidrug legislation are the same groups that have serious

drug problems and have no access to health care or drug treatment. As

researchers, physicians, and health care providers, we need to look at

creative ways of attacking and researching the problem; certainly, drug

abuse prevention should be part of our approach.

Dr. Kandall: Thank you for that comment.

Unidentified Audience Member: I was struck by how similar the

political motivations in the 1800s were to today’s anti-abortion movement. I wonder if you came across any connections or parallels in your

research.

Dr. Kandall: No, I have tried to write the book as a drug abuse

history and not as a feminist tract. If there is information concerning

that movement that you feel would be relevant, I would love to hear

about it.

Unidentified Audience Member: I believe that one of the political

bases for the anti-abortion movement was xenophobia because immigrants were reproducing more frequently than white women. Some

people believed that outlawing abortion would increase the number of

white infants who were born. There seems to have been a negative

reaction to women using drugs in the same way that the anti-abortion

movement reacted to the incipient women’s movement.

Dr. Kandall: I guess the more things change, the more they stay the

same.

Unidentified Audience Member: Would you give us some more

background on how violence was tied to drug use, particularly the rape

of women? I would like to know when that issue first emerged.

Dr. Kandall: It reached its apogee just prior to the Harrison Act

when the so-called “cocaine-crazed blacks” allegedly were raping white

women. Newspaper headlines on the subject were widely and boldly

displayed. A side issue was the opium dens run by Chinese immigrants.

It was not so much a matter of violence against women but the belief

that women were being lured into prostitution with opium. The violence issue focused predominantly on blacks and was repeated to a lesser

degree with the antimarijuana legislation brought on by the arrival of

Mexican immigrants and their alleged sexual violence. Much of this
17

was an attempt to control groups as they sought economic growth, and

the issue of violence against women had no factual basis. An entire

chapter in my book deals with the influence of movies and the major

role played by these images of violence against women.

Unidentified Audience Member : Are you saying that there was an

increase of violence against women or that this belief was a construction

of the media?

Dr. Kandall: It was a construction of the media.

Unidentified Audience Member: What were some of the forces and

events that triggered the news media’s use of this theme and that helped

to create an era of panic?

Dr. Kandall: The major issue, which you can read about in the

testimony given before the U.S. House of Representatives, was the fear

that women were becoming the victims of sexual predators from different

racial and ethnic groups. The issue was raised to move antidrug legislation along more quickly, but there were no facts to back up this fear.

One study of black cocaine users in Georgia who had been admitted

to a particular hospital found that blacks had a much lower rate of

sexual crimes than whites.

KEYNOTE ADDRESS: NEUROBIOLOGICAL

CORRELATES OF THE ADDICTIONS: FINDINGS

FROM BASIC AND TREATMENT RESEARCH

Mary Jeanne Kreek, M.D.

Abstract

Dr. Kreek presented information on the neurobiological basis of drug

addiction and sex differences. Researchers have hypothesized that the endogenous opioid system may be involved in drug addiction and that multiple genes

may contribute to the development of addictive and other diseases. Dr. Kreek

proposed that more research is needed on the human opioid system, how it

responds to different drugs, and sex differences. To improve efforts in drug

abuse prevention, early intervention, and treatment, researchers must have

a better understanding of the neurobiological basis of different drug addictions.

Dr. Kreek stated that it is critical to combine laboratory studies and basic

clinical research studies with applied treatment research to better understand

the diseases of opiate, cocaine, and alcohol addiction.
18

Areas of Research

Dr. Kreek acknowledged the remarks of previous speakers regarding

the critical importance of research on drug abuse and women, particularly because research has shown the correlation of drug abuse and HIV

infection. She stated that the rapid rise of HIV infection among women

makes it imperative to address the drug abuse problems of women at the

prevention, early intervention, and treatment levels. In 1969 Dr.

Kreek’s laboratory began collecting blood samples from various studies

of drug abusers in New York City. The researchers discovered that HIV

began to appear in the blood of drug abusers in 1978.

In recent years, the New York City Department of Health has

reported a high incidence of women infected with HIV, many through

injection drug use or heterosexual contact with male injection drug

users.

• One area of Dr. Kreek’s research examines issues that help

explain the neurobiological basis of drug addiction. Researchers

suspect that multiple genes may contribute to the development

of addictive diseases and other behavioral and physiological

diseases. Vulnerability to drug addiction may exist when normal

genes occur in specific combinations, but exposure to drugs is

necessary also, thus making drug abuse prevention and early

intervention particularly important.

• Data demonstrate that drugs of abuse alter normal human physiology, including stress response, reproductive biology, and immune function. Chronic diseases and responses to stressors may

contribute to changing physiology, which also may increase

vulnerability to drug addiction. These physiologic changes occur

in both women and men and may contribute to other health

problems. Many studies are in progress to determine whether the

physiologic changes caused by drugs are persistent or permanent.

Role of the Endogenous Opioid System

• Dr. Kreek and others have been studying the role of the endogenous opioid system in heroin addiction, cocaine dependence,

and alcoholism. The endogenous opioid system is involved in

aspects of normal physiology-related stress response, reproductive

biology, immune function, gastrointestinal function, cardiovascu-
19

lar status, and many behaviors, such as emotions and pain response. The three classes of endogenous opioid neuropeptides

(peptides) are endorphins, enkephalins, and dynorphins.

• The partial structure of the opioid receptor gene is known, but

not the complete five-prime sequences; many laboratories are

studying the five-prime region in the gene because it controls

how much of the gene message will be formed and therefore

how much peptide will be produced. Two areas in the five-prime

region are of special interest to scientists: (1) the area where

stress-responsive steroids, like cortisone, bind to their receptors

and act to change gene expression and (2) the area where

estrogen and progesterone may act to change gene expression.

• One fundamental question being studied is whether there are

differences between the sexes in gene expression because of the

presence of differing amounts of estrogen and progesterone.

Dr. Kreek’s laboratory is conducting research with rodents to

measure quantitatively how much gene message is expressed

and to map where each opioid gene is expressed. There is gene

expression in the hypothalamus, an area where there is neuroendocrine control both of stress response and reproductive biology.

• Scientists are trying to discover where and when gene expression

for different opioid receptor genes (mu, delta, and kappa) occurs

in the brain, how gene expression and receptor peptides are

affected by drugs of abuse, and whether there are any sex differences. Mu and kappa opioid receptors are abundant in the

regions of the brain where it is known that drugs of abuse act,

as well as in the hypothalamus. New technology to image the

human brain has made it possible to conduct studies in both

those suffering from addictive diseases and those who are not

addicted.

Pharmacotherapy for Opiate Addiction

• Early research on the treatment of heroin addiction led to a

rationale and specific pharmacotherapeutic objectives for treating

opiate addiction and other types of drug addiction: (1) prevent

withdrawal symptoms such as those that occur with opiate

dependence, (2) reduce drug craving, and (3) normalize any
20

physiologic functions disrupted by drug abuse. To achieve these

objectives, research should target the effect of treatment agents

on specific sites of drug action, opiate receptors, or physiologic

systems that have been affected or damaged by drug abuse.

• Methadone’s pharmacokinetic profile is different from those of

heroin and morphine and has a long-acting effect in humans.

Dr. Kreek and her colleagues conducted a series of studies to

analyze the action of methadone and determine whether there is

any physical risk to addicts who use heroin while on methadone.

They found that proper doses of methadone created tolerance to

short-acting opiates like heroin and had no adverse or narcoticlike effects on the addict. Administering proper doses of methadone creates greater tolerance for, and thus a blockage of, heroin’s

effects and allows normalization of disrupted physiology. Steadydose methadone treatment does not create any narcotic effects,

prevents withdrawal symptoms, and prevents the development

of hunger for illicit opiates.

• Many studies have shown that highly significant reductions in

the incidence of HIV infection occur among drug addicts who

participate in effective methadone treatment programs.

• Dr. Kreek recommended that more access is needed to effective

drug addiction treatment programs. In such programs, voluntary

retention rates are from 70 to 85 percent, and continued use

of heroin drops to less than 15 percent after stabilization (3 to

6 months in treatment). However, funding cuts in the past

20 years have reduced the ability of clinics to provide effective

drug treatment and have reduced the availability of all types of

treatment.

• Dr. Kreek asserted that an effective methadone program that

combines drug abuse services with counseling and health care

services would cost approximately $6,000 to $8,000 a year per

individual. Although this is more than the current $1,500 to

$3,500 a year often spent for pharmacotherapy, it is much less

than the cost of treating end-stage AIDS (which has risen

to $100,000 a year) or the cost of crime on the streets (up to

$100,000 a year).
21

Neurobiological Correlates of Addictions

• The acute use of opiates and chronic use of short-acting opiates

like heroin have been found to suppress the hormones of the

hypothalamus, pituitary, adrenal (HPA) axis, which are involved

in many physiological functions. Dr. Kreek found that during

steady-dose methadone treatment, the HPA axis returned to

normal and followed its normal rhythm of hormone release.

Studies have found that patients on methadone experience

a normalization of the reproductive biologic axis, the stressresponsive axis, and, in turn, the immune function that may

be linked to the normalization of neuroendocrine function.

• Both cortisol and the endogenous opioid peptides are involved

in the normal regulation of the HPA axis, and these opioids are

regulated abnormally in individuals who are addicted to opiates

and cocaine. New information reported by Dr. Kreek shows that

opioid antagonists also activate the HPA axis, which has implications for the neurobiology of several addiction disorders, such as

alcoholism. Activation of the HPA axis also may be important

in explaining the small number of heroin addicts who have

responded to treatment with naltrexone, an opiate antagonist.

• Basic clinical research has shown that the administration of acute

doses of morphine or heroin affects humans differently than it

does rodents. In humans, an injection of morphine causes the

inhibition of the release of the adrenocorticotropic hormone,

an important stress-responsive hormone, and beta endorphins.

Opiates also inhibit the release of the luteinizing hormone that

controls ovulation and testosterone levels.

• Acute doses of opiates also suppress or change the release of

the glucocorticoid cortisol from the adrenal cortex. Recent

research has examined where a glucocorticoid like cortisol,

for example, dexamethasone, affects corticotropin-releasing

factor (CRF). Dexamethasone affects CRF primarily in the

hypothalamus, although researchers also have found CRF gene

expression in other regions of the brain that may be involved in

controlling emotions, behavior, and immune function.

• Acute use of opiates increases the release of prolactin, which

modulates women’s lactation and the immune system. Women

in chronic methadone treatment have normal prolactin levels;
22

however, their prolactin levels increase modestly in response to

peak plasma levels of methadone. The same was true in studies of

women who were pregnant. During the second half of pregnancy,

when prolactin levels normally increase dramatically, normally

elevated prolactin levels were found in methadone-treated women.

Because of the liver’s enhanced ability to eliminate certain medications during pregnancy, plasma levels were significantly lower

among methadone-treated women, even when the pregnant

woman was maintained on a steady dose of methadone. After

delivery, the woman’s plasma level of methadone returned to what

was considered normal. Physicians must be careful when considering any reduction in methadone dose during the late stages of

pregnancy; methadone levels may be reduced even when the dose

remains the same. Doses of methadone should not be lowered

during the last two trimesters of a woman’s pregnancy and should

be maintained in a steady state to prevent the onset of drug

withdrawal symptoms.

• Studies with rodents have shown that chronic cocaine administration increases the density of mu and kappa opioid receptors. Dr.

Kreek’s group has been trying to determine the role of dynorphin

peptides in modulating the density of kappa opioid receptors, with

the ultimate goal of discovering whether the natural endogenous

opioid peptides can help decrease excess dopamine activity.

• Dynorphin peptides are potent modulators of prolactin release.

Among healthy subjects, serum prolactin levels increased in direct

response to dynorphin administration. In humans, prolactin is

influenced almost exclusively by dopamine levels; therefore,

Dr. Kreek and colleagues have suggested that dynorphin peptides

may increase the release of prolactin by decreasing dopamine

tone. This information may help researchers understand how

to manage cocaine dependence.

• Heroin addicts are hyporesponsive to chemically induced stress,

but former addicts maintained on methadone become normal in

their response to such stress. Studies continue to investigate the

relationship between stress and drug addiction. Drug-free, former

heroin and cocaine addicts have been found to be hyperresponsive

to chemically induced stress. Researchers now want to find out

whether such hyperresponsiveness in drug-free, former heroin and
23

cocaine addicts may drive them to readminister or begin using

opiates.

• Studies of humans and rodents have shown that both endogenous

and exogenous opiates (e.g., heroin) may alter specific indices of

immune function. Dr. Kreek’s group studied heroin addicts and

former addicts who were maintained on moderate-to-high-dose

methadone treatment for at least 11 consecutive years. Both

groups had used injection drugs for a similar number of years, so

it was assumed that both groups had been exposed equally to drugrelated diseases. The heroin addicts, who were HIV-1 negative,

were found to have abnormally high levels of CD4+ and CD8+

cells and lowered natural killer cell activity, which are all important for balancing the immune function and are disrupted by

AIDS. However, the absolute number of cells was normal in the

former addicts who had been in long-term treatment with methadone and had normal natural killer cell activity. Research on how

drugs of abuse affect CD4+ and CD8+ cells is particularly important because these cells are the first line of defense against many

diseases.

Issues for Future Research

• More research is needed on how different opioid receptors are

affected by drugs of abuse and what sex differences may exist.

• In humans, prolactin is influenced almost exclusively by dopamine levels; therefore, Dr. Kreek and colleagues have suggested

that dynorphin peptides may increase the release of prolactin by

decreasing dopamine tone. More research in this area may help

researchers understand how to manage cocaine dependence.

• Research should target the effects of specific treatments on

specific sites of action, receptors, or physiologic systems that have

been affected or damaged by the drug of abuse.

• Former heroin and cocaine addicts who are drug-free have been

found to be hyperresponsive to chemically induced stress. Research is needed to determine whether such hyperresponsiveness

may drive former addicts to readminister opiates.

• Research is needed on how drugs of abuse affect the activity

of CD4+ and CD8+ cells and natural killer cells, which is
24

particularly important because these cells are the first line of

defense against many diseases and may be related to the progression of AIDS.

Epidemiology

EPIDEMIOLOGY OF DRUG USE

AND ABUSE AMONG WOMEN

Denise B. Kandel, Ph.D.

Abstract

Dr. Kandel’s presentation dealt with the epidemiology of drug abuse

involving two different paths of research: (1) examining patterns of drug

abuse by individuals, including frequency of drug abuse, and (2) attempting

to measure the extent of drug abuse by investigating behaviors and symptoms

that meet the criteria for diagnosis of a drug abuse disorder. Dr. Kandel

asserted that epidemiologic studies based on samples of the general population

rather than on specific high-risk groups can better assess the distribution of drug

abuse and the need for drug treatment services because such samples are free

from selection and referral biases. She presented data on the epidemiology of

drug use and drug abuse disorders from two national studies and data on the

developmental patterns and consequences of women’s drug use from the

longitudinal cohort that she has followed from their adolescence to mid-thirties.

There is a well-developed sequence from licit drug use to illicit drug abuse.

Dr. Kandel’s study revealed the intergenerational transmission of smoking and

showed that cigarette smoking may play an important role in women’s progression to illicit drug abuse. Dr. Kandel suggested that research involving a

collaboration of disciplines, ranging from biology to psychology, may increase

understanding of drug abuse behaviors.

Results of the 1992 National Household Survey on Drug Abuse

The National Household Survey on Drug Abuse collects information on drug use by individuals age 12 and older. Dr. Kandel presented

data from the 1992 survey, the most recent one for which sex-specific

data were available [at the time of this presentation], to illustrate three

important points:
25

1. The prevalence of drug abuse differed markedly for different

drugs, with prevalence highest for licit drugs. Among illicit

drugs, marijuana was used most frequently, followed by cocaine.

Illicit drugs include psychotherapeutic drugs used for nonmedical

purposes.

2. Most abuse of both licit and illicit drugs occurred among young

people between ages 12 and 34 and peaked during ages 18 to 25.

As individuals grew older, their drug abuse declined, but more

gradually with licit drugs than illicit drugs.

3. About 22 percent more males than females used drugs. Differences between the sexes in drug abuse seemed to increase with

age. The level of drug involvement also differed between the

sexes. For example, among high school seniors who had used

cigarettes or other drugs daily, more than twice as many males

as females also used alcohol and marijuana daily.

Results of the National Comorbidity Survey

Dr. Kandel also presented data from the National Comorbidity

Survey, conducted by Professor Ronald Kessler of the University of

Michigan, which provided the most recent data on the distribution of

drug abuse disorders among the U.S. population. This survey was carried

out in a representative sample of individuals ages 15 to 54. Professor

Kessler’s unpublished data indicated the following:

• There was more drug dependence and abuse of illicit drugs and

alcohol by men than by women. Six percent of women ages 15

to 54 met the criteria for lifetime drug dependence. Of women

who had ever used illicit drugs, 13 percent met the criteria for

dependence, and of those who had used heroin, 25 percent met

the criteria for heroin dependence.

• Women were dependent on cigarettes more than any other class

of drugs. Tobacco (nicotine) may be the most addictive of any

of the drugs studied. Thirty-one percent of women who had ever

smoked met the criteria for dependence. There was a slight

difference between women and men in the number who were

dependent on tobacco smoking.

• More women than men were at risk of becoming dependent on

psychotherapeutic drugs used nonmedically.
26

• There was much comorbidity among psychiatric disorders,

and most comorbidity was alcohol-related. The most frequent

class of psychiatric disorder diagnosed among women was anxiety;

among men, the most frequent psychiatric disorder was related to

conduct or use of drugs. Professor Kessler and his group were able

to determine whether a drug abuse disorder was primary or

secondary (whether it appeared before any other psychiatric

disorders). In four out of five cases, a drug-related disorder was

secondary to another psychiatric disorder.

Dr. Kandel argued that if drug abuse disorders occur secondarily

to other psychiatric disorders, then prevention efforts should be emphasized when an individual first seeks treatment for the primary disorder.

Drug abuse prevention and treatment efforts must be tailored with an

understanding of the different disorders that are prevalent in women

and men.

Studies of Developmental

Stages of Drug Involvement

On the basis of studies by Dr. Kandel in the early 1970s on a cohort

of individuals she followed for nearly 20 years, a well-developed sequence or progression from licit to illicit drug abuse was determined.

Some of Dr. Kandel’s findings were as follows:

• The first drug used was either alcohol or nicotine. Cigarettes

seemed particularly important in females’ progression to illicit

drug abuse. For males, alcohol alone was sufficient to lead to use

of illicit drugs, and cigarettes were not significant.

• The use of licit drugs in the early stage of drug abuse seemed

necessary, but it was not the only factor for movement to the

next stage of drug abuse. Therefore, the use of licit drugs at an

early age, especially cigarettes, is important for predicting subsequent drug abuse and behaviors.

• If young people followed the sequence to using illicit drugs, the

first illicit drug most tried was marijuana. Few people used other

illicit drugs without experimenting first with marijuana.
27

Consequences of Drug Use by Women

These studies also revealed the health consequences of women’s

drug use:

• The age-specific rates of childbearing were compared with the

age-specific rates of illicit drug use or heavy smoking (one pack

a day). The age-specific rate of childbearing peaked at the point

where there also was a high rate of illicit drug use.

• Interviews of mothers, fathers, and preadolescent children revealed intergenerational transmission of smoking behavior.

Analysis of the tobacco-smoking behaviors of 192 mother-child

pairs revealed that smoking during pregnancy was related to

smoking by preadolescents, with a much stronger effect on girls

than on boys. Multivariate analyses of the data controlled for

current smoking, sociodemographic characteristics, and other

variables, and results indicated that if the mother smoked

during pregnancy, it was likely the daughter also would become

a smoker. Dr. Kandel replicated this finding in a national

sample of 804 mother-child pairs. Her data raise the possibility

that nicotine or other tobacco components released by maternal

smoking during a critical period of prenatal brain development

might alter the brain response to the effects of nicotine later in

life. Such changes may predispose a child, especially a female,

 to smoke and persist in smoking. Therefore, prenatal exposure

to drugs may affect drug abuse behaviors that are not manifested

for more than 10 years.

Issues for Future Research

• Collaboration among disciplines ranging from biology to psychology and sociology is needed for better understanding of drug abuse

behavior. Women’s dependence on nicotine may be the most

important area to study, particularly because smoking may be

transmitted from one generation to the next.

• As they grow older, more women than men meet the criteria for

a diagnosis of drug dependence. Cultural and metabolic factors

require further investigation.
28

Questions From the Audience

The question-and-answer session below followed Dr. Kandel’s

presentation.

Unidentified Audience Member: What is the possible relationship

between depression in the mother and smoking by daughters? Could

depression be a mediating variable?

Dr. Kandel: This is an important point that I plan to explore in

future studies. We know there is a strong relationship between depression and smoking. There could be various physiological explanations,

but it may be that women who persist in smoking are more depressed and

have a genetic liability either to depression or to smoking. This may

explain why transmission is stronger among females than among males.

Unidentified Audience Member: An alternative explanation could

be the role-modeling of the smoking mother for the adolescent daughter.

How did you rule that out as an alternate explanation?

Dr. Kandel: As I mentioned earlier, we included maternal current

smoking in the multivariate logistic regressions, as well as other

covariates, when we estimated the effect of prenatal smoking on offspring smoking. In descriptive tabular analyses, we examined the

children’s smoking among four groups of women who had different

combinations of current and prenatal smoking patterns. The results

showed that the mother’s current smoking had absolutely no effect on

the daughter’s smoking behavior, and that the prenatal effect was the

most significant factor.

Unidentified Audience Member: What is the effect of the mother’s

smoking during the child’s developmental stages rather than before

birth? Were the intermediate stages of child development checked?

Dr. Kandel: We did not have enough cases to examine that differentiation, but we had continuous retrospective histories of smoking, so

we created a measure that was a proportion of the child’s life during

which the mother was smoking. Although we could not do the refined

analysis you suggest, this crude categorization of current smoking versus

smoking during pregnancy captured the persistent smoking behavior and

the child’s length of exposure to the mother’s smoking.
29

Biological/Behavioral

Mechanisms

DRUG ABUSE AND REPRODUCTION IN WOMEN

Nancy K. Mello, Ph.D.

Abstract

Dr. Mello addressed the question of how alcohol, cocaine, opiates, and

other drugs of abuse disrupt the functioning and regularity of the endocrine

system and how such disruption may subsequently relate to menstrual cycle

disorders and compromise other aspects of women’s health. She and her

colleagues studied the menstrual cycles of female rhesus monkeys, whose

neuroendocrine control system is similar to that of human females; preliminary

data suggest that cocaine and alcohol may stimulate release of an essential

reproductive hormone, luteinizing hormone (LH), and also increase adrenocorticotropic hormone (ACTH), resulting in the disruption of the normal menstrual cycle and amenorrhea. These data complicate earlier assumptions about

how cocaine may disrupt the menstrual cycle. More research is needed on how

cocaine interacts with female reproductive hormones and prospects for recovery.

Menstrual and Reproductive Disorders

Alcohol, cocaine, opiates, and other commonly abused drugs have

been associated with disruption of the menstrual cycle and compromising

of female reproduction. Several major reproductive disorders may be

associated with the interaction of hormones and drugs such as cocaine:

• Amenorrhea: complete cessation of menstruation for months or

years

• Luteal phase dysfunction: a short luteal phase, consisting of 8

days or less from ovulation to menstruation; an inadequate luteal

phase during which progesterone levels are abnormally low

• Anovulation: failure to ovulate

• Disorders of prolactin regulation: abnormally high levels of

prolactin (hyperprolactinemia)

• Galactorrhea: a condition involving the abnormal secretion of

breast milk, sometimes associated with hyperprolactinemia
30

• Spontaneous abortion: abortion that occurs naturally

• Ovulation is preceded by a surge in LH, and there is evidence

that the LH pulsatile release gradually increases in amplitude and

culminates in ovulation. Infrequent or absent LH pulses have

been associated with fertility disorders and amenorrhea. The

rhythm of the menstrual cycle is controlled in part by the

rhythms of the pulsatile release of LH and follicle-stimulating

hormone (FSH). In an anovulatory cycle, menstruation may

occur, but there is no midcycle peak in LH and FSH.

• Preliminary data on monkeys suggest that cocaine and alcohol

may disrupt pulsatile release of LH, resulting in disruption of the

normal menstrual cycle and amenorrhea. It is not clear whether

amenorrhea associated with chronic cocaine exposure is a consequence of cocaine’s effects on LH; estradiol, which regulates LH

release; or the regulation of prolactin.

Effects of Cocaine on the Menstrual Cycle

• Studies of rhesus monkeys reveal that administration of synthetic

corticotropin-releasing factor (CRF) suppresses the release of LH

and FSH, which can result in anovulation and amenorrhea.

Emerging research data indicate that acute cocaine or alcohol

intoxication may stimulate ACTH and stimulate rather than

suppress the release of LH from the pituitary gland. These data

complicate earlier assumptions about how cocaine may disrupt

the menstrual cycle.

• Recent research has revealed that cocaine stimulates LH production in both female and male humans and rhesus monkeys; the

only exception was ovariectomized female monkeys, in which

cocaine had no effect. This information is unexpected because

studies of pharmacologic actions have shown that administration

of dopamine agonists suppresses rather than increases LH. Yet a

significant increase in LH after acute cocaine administration has

been a consistent, robust finding across species. The implications

of a cocaine-induced increase in LH are unknown, but if cocaine

increases LH levels near the middle of the menstrual cycle, this

could trigger ovulation and result in an increased risk of pregnancy.
31

Hyperprolactinemia

• High levels of prolactin have often been associated with chronic

cocaine abuse and withdrawal; however, the clinical implications

are not clear.

• An acute dose of cocaine results in prolactin suppression, presumably by increasing dopamine levels. It is possible that chronic

cocaine exposure impairs the regulatory relationship between the

production of hypothalamic dopamine and prolactin. Some data

suggest that a dopamine probe can reveal cocaine-related changes

in prolactin regulation before the development of overt hyperprolactinemia.

• Hyperprolactinemia may contribute to menstrual cycle abnormalities and amenorrhea, compromise the immune system, and

increase vulnerability to AIDS.

Sex Differences

• The presence of estradiol may be an important factor in whether

cocaine stimulates LH or ACTH production. Researchers found

that cocaine stimulated the production of LH and ACTH in both

female and male humans and rhesus monkeys, with the exception

of ovariectomized female monkeys who had only trace amounts of

estradiol. Presumably, differences between the sexes in the biologic effects of drugs would reflect hormonal differences between

women and men.

• There is a possibility that estrogens and progestins may protect

women from cocaine-associated cerebral vasospasms. Estrogens

may protect women from mild atherosclerosis, and after menopause, estrogen replacement therapy also has a protective effect

and reduces women’s risk for premature cardiac disease and

osteoporosis. Research has revealed that cerebral perfusion

abnormalities are common in cocaine abusers. One surprising

discovery was found in a group of nine women and nine men

who were cocaine abusers and were matched in terms of age.

The women had fewer cerebral perfusion defects than the men,

even though the women reported using cocaine for significantly

longer periods than the men, an average of 15.0 years and

8.2 years, respectively. The investigators concluded that
32

differences between the sexes in cerebral perfusion abnormalities

could not be explained by differences in age, race, body mass index,

level of alcohol or cocaine use, or route of drug administration.

Issues for Future Research

• It is not clear whether amenorrhea associated with chronic

cocaine exposure is a consequence of cocaine’s effects on LH;

estradiol, which regulates LH release; ACTH, which may suppress

LH release; or the regulation of prolactin. Studies are under way

to examine the role of estradiol in cocaine’s effects on LH, but

more research is needed on cocaine’s effects on reproductive hormones. What are the implications of cocaine-induced increases

in LH and the possible effects on ovulation and the increased

likelihood of pregnancy?

• Research is needed on the mechanisms that underlie cocaine’s

effects on prolactin regulation and the clinical significance of

hyperprolactinemia.

• Future research should clarify how cocaine interacts with

reproductive hormones to cause menstrual and other reproductive

disorders. What is the effect of reproductive hormones influenced

by cocaine on the functioning of the brain and the immune system?

Questions From the Audience

The question-and-answer session below followed Dr. Mello’s

presentation.

Dr. James Woods: Were you able to account for any weight changes

that might have influenced the hormonal and menstrual abnormalities?

Or did you not find any differences in weight during your research?

Dr. Mello: We did not find differences in weight. Your question

is important because a number of things can be associated with amenorrhea. Inherent in your question is the fact that cocaine is known to

have anorectic effects. The monkeys were allowed to self-administer

food, so we had an objective measure of how much they took. We also

supplemented that diet each day with fruit, vegetables, and monkey

chow, and we recorded the weight about every 2 weeks. The monkeys
33

developed tolerance to cocaine’s anorectic effects rapidly, within about

2 weeks. The weight of the monkeys remained remarkably stable.

Unidentified Audience Member: Has anyone observed a relationship between the pattern of cocaine abuse by women and the use of

hormonal contraceptives?

Dr. Mello: I do not know of any data or any study that directly

addresses that question.

Unidentified Audience Member: In your research, have you noted

any differences in the sexual arousal of females related to cocaine use? Is

there any evidence of sexual arousal correlated with an increase in LH in

women? Is cocaine-related sexual arousal most often reported by men or

women?

Dr. Mello: We do not have direct observations of the sexual

behavior or receptivity of female monkeys because they are housed

individually. There is speculation that cocaine’s stimulation of LH may

be related to the sexual arousal that cocaine abusers report. Both men

and women have reported sexual arousal related to cocaine use.

SEX DIFFERENCES, DRUGS, AND

DEFENSIVE BEHAVIOR

D. Caroline Blanchard, Ph.D.

Abstract

Dr. Blanchard’s presentation addressed sex differences in anxiety, depression, and defensive behaviors among humans and other animals and their

relationship to drug abuse. She defined “defensive behavior” as a large number

of actions taken by humans or other animals when they are threatened or

traumatized by a painful or harmful event—actions such as flight, avoidance,

freezing, defensive threat and attack, risk assessment, sonic vocalizations, and,

in some species, ultrasonic mobilizations. She asserted that anxiety, depression, and defensive behaviors involve neurotransmitter and neuromodulator

systems that operate differently in females and males. Almost no preclinical

research has been conducted with female subjects on the effects of serotoninergic compounds. Dr. Blanchard asserted that these sex differences are

too great to be ignored and should be studied because they are important

factors in drug abuse.
34

Sex Differences Related to Anxiety,

Depression, and Defensive Behaviors

• Anxiety and panic disorders are more prevalent among women

than among men; agoraphobia is about three times as common

among women. Some large community studies suggest that

women account for as many as 70 to 75 percent of those suffering

from posttraumatic stress disorder. Because women are diagnosed

with anxiety and depression disorders more often than men, they

are prescribed drugs more often to treat these disorders.

• Anxiety, depression, and other psychiatric conditions can promote abuse of mood-altering drugs, including alcohol and prescription and nonprescription medications. The use of alcohol in

particular is viewed as an attempt to self-medicate. In one study

of approximately 5,000 young adults, 22 percent abused alcohol

and nonprescription drugs. Those who abused drugs suffered

more from anxiety and depression than the average member of

the group. In approximately 75 percent of the drug abusers, the

onset of anxiety or depression preceded drug abuse, sometimes

by a substantial period.

• Studies of the defensive behaviors of rats and mice have revealed

some parallels with human behavior. Under conditions of great

social stress, those animals that behave most defensively are the

ones that demonstrate the greatest increase in alcohol consumption. Clinical studies in human subjects indicate that a family

history of violence predicts alcohol abuse and spouse abuse by

children when they grow older.

• Females of every mammalian species studied have exhibited more

defensive behaviors than the males of the same species. A recent

article revealed that the administration of testosterone to some

female mammals dramatically reduced their defensive behaviors,

suggesting that there is some biological basis for sex differences in

these behaviors. Sex differences have been found in virtually all

measures of defensive behaviors. The behaviors most responsive

to anxiolytic drugs were also the ones that most differentiated

male and female rats.

• Among both humans and laboratory animals, there are major sex

differences in the neurotransmitter and neuromodulator systems.
35

The neurotransmitters are known to be involved in reactions to

stress or threats of danger.

• Almost no preclinical research on the effects of serotoninergic

compounds has been conducted with female subjects, or even

with a mix of females and males. It is important to conduct

preclinical research in psychopharmacology using female animals,

given that the mechanisms of the serotonin system differ by sex.

Serotoninergic medications are used to treat anxiety, and selective serotonin reuptake inhibitors are used to treat panic and

depression. Because of the lack of knowledge about sex differences in the mechanisms and treatment of anxiety and depression, current treatment for those disorders is inadequate for both

women and men. Dr. Blanchard speculated that researchers may

have abandoned studies of treatments that did not show potential

for male subjects but may have had potential for females.

• If anxiety and depression can be treated more effectively in

women, then progress can be made in solving drug abuse problems that originate from the need to self-medicate or from

exposure to medications for those disorders.

Issues for Future Research

• Evidence suggests that anxiety, depression, and defensive behaviors involve neurotransmitter and neuromodulator systems that

operate differently in women and men. Because those systems are

important factors in drug abuse, sex differences must be studied

thoroughly.

• Dr. Blanchard speculated that more effective treatments for

anxiety and depression might reduce the prevalence of drug

abuse.

• Given that there are sex-related differences in the serotonin

system and serotonin is linked to defensive behaviors, it is

important to conduct preclinical research in psychopharmacology

using nonhuman female animals. Almost no preclinical research

has been conducted on the effects of serotoninergic compounds

with female subjects. A special initiative is therefore needed

to ensure that such research is conducted. Preclinical psychopharmacologic studies are the precursors to clinical trials, and
36

therefore the research is necessary to discover the most effective

treatments of anxiety and depression for women.

Questions From the Audience

The question-and-answer session below followed Dr. Blanchard’s

presentation.

Dr. Risa Goldstein: I am concerned that a lot of the research that

has been discussed relies on retrospective recall to date the presence of

mood disorders and defensive behaviors related to substance abuse.

Given the inherent difficulties with retrospective recall, do you feel that

caveats should be added to the information presented today?

Dr. Blanchard: Yes, there is good reason to insert a number of

caveats. I examined the data from human research, but in most cases I

am not qualified to analyze the data because my expertise is in animal

research. However, as Dr. Kandel pointed out in her presentation, many

people who abuse drugs also suffer from anxiety or some other psychiatric disorder; the degree of comorbidity is too high to be ignored. We

should be cautious about drawing conclusions, but I believe that we gain

insights from animal research. I encourage the integration of animal

and human research and the recognition that the results of animal

research are not irrelevant to human research. In many cases, the

animal data can help to develop a firmer scientific foundation for the

results of human research.

Dr. Zili Sloboda: I concur with what has been said about the

problems inherent in research based on retrospective recall. We are

learning that drug abuse is complex, and it is difficult to separate the

individual factors involved. The presentations of Dr. Blanchard and

others suggest the importance of developing studies that link human

epidemiologic research with animal research.

Dr. Karla Moras: I want to highlight the points made by the last

few speakers about the methodological difficulties in analyzing anxiety

and mood disorders among chronic drug abusers. At the University of

Pennsylvania, we are conducting a NIDA-funded multisite study of

cocaine addiction. We find it extraordinarily difficult to determine what

is a freestanding mood or anxiety disorder separate from the results of

drug abuse.
37

Dr. Blanchard: I do not think anyone will disagree with that. The

animal research provides hypotheses for the human work, as well as vice

versa. For example, the concept of risk assessment in animals—highly

motivated information-gathering—has led us to examine to what extent

this is a feature of anxious individuals. We discovered that it is a definite feature of at least the clinical descriptions of many anxious individuals. We will not understand the value of this research until a lot

more evidence is in.

Biological/Behavioral

Mechanisms Panel

SEX DIFFERENCES AND HORMONAL

EFFECTS ON DRUG SEEKING

David C.S. Roberts, Ph.D.

Abstract

Dr. Roberts presented background information on how the brain responds

to cocaine and estrogen. Animal self-administration experiments are used to

simulate the human condition and achieve better understanding of brain mechanisms. Such experiments can examine how the brain responds to drug

reinforcement mechanisms and how brain systems are altered. The results of

an experiment several years ago revealed that the estrous cycle of female rats

affects their motivation to self-administer cocaine. Dr. Roberts discussed the

implications for research on whether the human menstrual cycle can affect the

drug-dependent behavior of women addicted to cocaine.

Background

• In Dr. Roberts’ research, rats were given the opportunity to

perform an action—usually to press a lever—that resulted in

their receiving an intravenous injection of cocaine. The action

of pressing the lever was used to measure the animal’s drugdependent behavior. Brain manipulations were performed to

determine whether it was possible to affect the reinforcing

actions of cocaine. The data revealed that there are a number
38

of critical areas in the brain that could totally disrupt the rat’s

cocaine self-administration behavior.

• Researchers in Ann Arbor and Quebec have been studying

the effects of the estrous cycle, estrogen administration, and

ovariectomies on the behavioral responses of female rats. Their

research has determined that female rats are more responsive

than male rats to psychomotor and stimulant drugs. Treatment

with estrogen usually increases the female rat’s response to the

drugs, and ovariectomies dampen the response.

• The rat’s estrous cycle and treatment with estrogen affect the

release of the brain’s dopamine cells in response to amphetamines

and other stimulants.

Findings on Cocaine Use and the Estrous Cycle

• If the animal was allowed to obtain a drug injection for each

lever press, the animal consistently waited a specific period of

time before repeating the lever press and obtaining the next

injection; this behavior was dose-dependent.

• The motivation of the rats to obtain cocaine injections was

measured by use of a progressive ratio schedule in which the

number of times a rat had to press the lever before obtaining

another injection increased exponentially. Male rats receiving

low doses of cocaine would press the lever 300 times before

giving up. As the dose of cocaine increased, the rats increased

the number of times they were willing to press the lever before

giving up.

• Female rats exhibited a similar drug-response behavior, but

their motivation to respond was higher than that of males; they

completed much higher ratios than males to obtain the same

doses of cocaine. The drug-response behavior of female rats

also was less consistent than that of male rats.

• To determine whether female rats self-administer cocaine differently during their 4- or 5-day estrous cycle, their behavioral

inconsistency was analyzed. The analysis revealed that female

rats exhibited different drug use behavior on just 1 day—the day

of estrus—when they would go to enormous lengths to obtain

an injection of cocaine, pressing the lever more than 600 times.
39

Future Research

Research is needed to determine whether the menstrual cycle

has an important influence on women who are drug-dependent. Although it is known that the estrous cycle increases the motivation of

female rats to self-administer cocaine, it is not known whether women’s

menstrual cycle can have a similar effect. Human experiments are

needed to determine whether the menstrual cycle has a similar, motivating effect on women’s drug-dependent behavior.

SMOKING, EATING, STRESS, AND

DRUG USE: SEX DIFFERENCES

Neil E. Grunberg, Ph.D.

Abstract

Dr. Grunberg’s presentation emphasized that sex differences are key issues

in drug abuse research, particularly with regard to the interaction of drug use,

smoking, eating, and stress. The interaction of these variables must be

understood for researchers to address the biological mechanisms of drug abuse.

Two-way interactions have been well researched, including studies of stress

and eating, stress and drug use, sex differences and eating, and sex differences

and drug use. There is a critical need, however, for research on three-way

interactions that involve examining sex differences in drug use and simultaneously measuring the effects of two additional variables such as stress and

smoking, stress and eating, or smoking and eating.

Stress

Stress and the use of illicit drugs, and licit drugs such as alcohol and

tobacco, have been correlated in humans during drug initiation, maintenance, and relapse phases. The effects of psychological, perceptual, and

cognitive strategies on drug use are important to reducing stress and

treating drug abuse. Few studies have examined whether women and

men can be influenced differently by the expectancy of drug effects and

the cognitive variables that affect drug actions.
40

Smoking

The use of tobacco and nicotine has a significant effect on women’s

health, and it is critical that scientists understand how tobacco affects

women and men differently. Twenty-five percent of women in the

United States smoke. More young women smoke than young men,

and the number of young women who smoke is increasing.

• Females, both humans and laboratory animals, are more sensitive

to the actions of nicotine than are males, and females are more

likely to respond to the toxic effects of high levels of nicotine.

• According to Dr. Grunberg’s research, females are more sensitive

to nicotine’s effect on eating and body weight. Female rats have

been shown to eat more and gain more weight when they quit

using nicotine, and women are concerned about weight gain

when they quit smoking.

Eating

• Dr. Grunberg suggested that drug abuse research include eating

disorders. Many of the same mechanisms that regulate eating

behaviors and eating disorders are common to drug addiction.

He asserted that one’s sex and one’s eating behaviors interact

and have powerful effects on drug use. Eating behaviors and

responses can reveal the basic mechanisms of drug abuse and

related sex differences. With more research, it may be possible

to understand how different drugs cause drug dependence and

eating disorders among females and males.

• Stress and eating disorders are related, and both have a powerful

effect on drug use. Generally, men eat more than women, but

stress affects eating behaviors among men and women in opposite

ways. In mild, anxiety-provoking situations, women eat greater

amounts of foods that are sweet and high in carbohydrates.

In contrast, stress causes men to eat less food overall.

• Eating disorders, such as anorexia nervosa, bulimia, and overeating, are more common among women than among men.
41

Opiates and Alcohol

• Stress and opiate use also are correlated in humans, in terms of

drug initiation, maintenance, and relapse; increases in stress

increase the likelihood of opiate use. But the use of opiates in

the general population is less frequent than the use of nicotine

or alcohol. The discovery of sex differences in opiate effects

dates back at least 10 years, but little work has been done to

examine the effects of these relationships.

Dr. Grunberg’s group conducted a series of studies that compared the

drug administration response and stressors of female and male laboratory

animals. The research revealed the following:

• As with nicotine, the interaction of opiates and stress had

significantly different effects on females and males. Stress caused

both female and male animals to self-administer more opiates,

but females consumed more opiates than did males.

• There were sex differences in both alcohol use and its effect on

the stress response. Women and men may drink while under

stress but for different psychological or biological reasons.

Issues for Future Research

• Decisions and clarifications are needed on which drugs will be

included or excluded in the national drug abuse research and

public policy agenda. Will the research agenda focus exclusively

on illicit drugs? Or will it also include tobacco and alcohol?

• Examination of stress is a critical element in drug abuse research.

Stress can be used as an independent variable in studying different responses and revealing the underlying mechanisms of drug

action.

• It is important to study how a person’s sex interacts with different

drugs and behaviors because the interactions usually reveal the

most important and serendipitous information about the mechanisms at work.

• Hypotheses about the biological and behavioral interactions of

drug use, stress, and sex can be developed and analyzed through

use of nonhuman animal models and comparison of the results

with information based on research with humans.
42

• Stress and cocaine use correlate, particularly with regard to drug

relapse; more research is needed to examine sex differences in the

interaction of cocaine and stress.

• It is critical to do additional research on three-way interactions,

such as the interactions of sex differences and stress with use of

alcohol, cocaine, opiates, nicotine, and other drugs. Such studies

must examine sex differences at the same time they measure the

effects of drug use, stress, smoking, or eating.

• More research is needed to examine the suggestion that the

expectancy of drug effects and the cognitive variables that affect

drug action may interact with stress and have different influences

on women and men.

TRANSLATING BASIC RESEARCH

INTO THE CLINICAL SETTING

James R. Woods, Jr., M.D.

Abstract

Dr. Woods emphasized that all obstetricians should be concerned about

drug abuse because it is the most widespread problem in maternal-fetal

medicine and high-risk obstetrics. Research is needed on drug-related questions

that obstetricians have faced for years. His presentation focused on the

progress of basic research on drug abuse and pregnancy, particularly the need

for more research on cocaine use. There is preliminary evidence linking

cocaine use with the unexpected deaths of pregnant women, and there are

serious concerns about how cocaine affects a pregnant woman’s uterine blood

flow and the blood pressure and heart rate of the fetus. Many miscarriages

and cases of premature labor have been linked to cocaine use. Dr. Woods

noted that drug abuse is not unique to poor and medically underserved individuals; it involves individuals from all racial and ethnic groups. He acknowledged the difficulty of separating the problem of drug abuse from the poverty

and violence that often accompany it and offered suggestions for improving the

medical system’s approach to caring for women addicted to drugs.
43

Effects of Cocaine Abuse on Pregnant Women

Dr. Woods described some observations that he and other researchers have made in the past few years about cocaine and its effect on the

physiology of pregnant women.

• Cocaine stimulates a pregnant woman’s heart and raises her blood

pressure and heart rate, which subjects the fetus and delicate

blood vessels in the placenta to unusual increases in blood

pressure. The increases in maternal heart rate and blood pressure

also create the need for an increase in blood flow and oxygen to

the heart. However, cocaine has been shown, in nonhuman

animals that were not pregnant, to restrict the increase in coronary blood flow that normally occurs when the heart rate and

blood pressure rise. Although cocaine causes the heart rate and

blood pressure to increase, it causes the blood flow in the uterus

to decrease. There are serious concerns about what effects

cocaine may have on the coronary blood flow of pregnant

women. There is preliminary evidence linking cocaine use

with unexpected deaths of pregnant women.

• Many miscarriages and cases of premature labor have been related

to the use of cocaine during pregnancy. According to research in

Michigan, chronic cocaine exposure may make the uterus unable

to respond to beta-receptor agonists, the primary medication used

to stop premature labor.

• Cocaine use by a pregnant woman raises the fetal blood pressure

and heart rate. Several researchers have observed that cocaine

crosses the placenta quickly, and within 2 minutes the cocaine

levels in the fetus can equal those in the mother.

• Dr. Woods and his colleagues recently published reports on a

study in which cocaine was instilled directly into the amniotic

fluid of nonhuman animals that had not been exposed previously

to the drug. Cocaine can enter the fetal circulatory system at

about 3 to 5 percent of the cocaine concentrations in the amniotic fluid. The researchers believe that cocaine in the amniotic

fluid can enter the fetal circulatory system through the placenta

or the umbilical cord. They do not know whether amniotic fluid

might act as a reservoir that could expose the fetus to cocaine

long after a pregnant woman has stopped using the drug.
44

Approaches to Improving the Care of Women

Dr. Woods emphasized that efforts to reduce drug abuse and related

health risks among women also must respond to other problems caused

by poverty, violence, and socioeconomic issues. He asserted that drug

abuse and approaches to treating it should be redefined; an improvement

in medical care will fail to change the current situation unless there are

increased efforts to connect women to the social services and medical

care they need. He suggested several activities that clinics could implement to improve the care of women addicted to drugs:

• Increase outreach programs that complement the resources of the

medical community. Such programs facilitate prenatal care and

help build trust with women in the community. Some pregnant

women who are addicted to drugs need assistance with solving

basic problems such as obtaining social services or coping with

the lack of transportation or a telephone.

• Link obstetrics with community residential drug treatment

programs, mental health programs, intensive day treatment care,

and outpatient care to help women who use drugs gain access to

contraceptives and prenatal care.

• Address the distrust and fear felt by many pregnant women who

are addicted to drugs. Many women avoid contact with the

medical community because they are afraid their children will

be taken away from them.

• Provide patients with continuity of care, an important factor in

building trust; patients want to be able to see the same clinician

each time they visit the clinic.

• Be more responsive to the practical problems and needs of the

patients; make clinic procedures flexible enough to respond to

patients who may have difficulty adhering to clinic rules and

schedules. For example, rescheduling an appointment for a

patient who arrives late rather than “fitting her in” may be very

discouraging if the patient has little access to transportation.

Issues for Future Research

• Cocaine causes an increase in maternal heart rate and blood

pressure, but it restricts the increase in coronary blood flow that
45

should occur. More research is needed on how such restriction

in blood flow affects pregnant women.

• Some evidence suggests that pregnancy may predispose a

woman to enhanced cocaine cardiotoxicity. Additional research

is needed to understand how cardiotoxicity affects pregnant

women who use drugs.

• More research is needed on the relationship of cocaine use to

miscarriage and premature labor. Alternative medications to

prevent premature labor should be developed. Chronic cocaine

use may reduce the effectiveness of beta-receptor agonists, the

primary medications used to stop premature labor.

• Cocaine raises the fetal blood pressure and heart rate. Nonhuman animal research suggests that cocaine concentrations can

be transferred from the mother to the fetus through the placenta

or umbilical cord. More research is needed on the effects of

maternal cocaine use on the fetus.

• Research is needed on drug-related questions that obstetricians

have faced for years. For example, should women who are

addicted to heroin go through drug detoxification during pregnancy? If so, how should the fetus be monitored during the

process?

BIOLOGICAL/BEHAVIORAL

MECHANISMS PANEL DISCUSSION

The discussion presented below followed presentations by members

of the Biological/Behavioral Mechanisms Panel: Drs. Roberts,

Grunberg, and Woods.

Dr. Shirley Coletti: How can researchers use the information that

NIDA has collected to better educate those who make decisions about

the funding of drug treatment, including members of Congress, other

legislators, and other decisionmakers? There is a tremendous focus now

on the criminalization of drug abuse and funding the building of prisons

rather than drug treatment. How can NIDA’s information be used to

educate people?

Dr. Woods: The only way to convince members of Congress of the

need for funding of drug treatment is to remind them that drug abuse is

truly a medical disease. Treatment of drug abuse is complex; it cannot
46

be treated in the way that a simple pain can be treated with aspirin. In

the next few years, the biggest challenge will be to prove that drug abuse

treatment programs are effective and cost-efficient.

Dr. Loretta Finnegan: Research on mental health and drug abuse

(of both licit and illicit drugs) has been integrated into NIH. Under the

auspices of NIH, drug abuse clearly is defined as a health issue. However,

educating people about drug abuse is a continuing struggle, and it is

important to get information to the news media. Congress also needs

education on the effect of advertising on drug abuse, particularly with

regard to women.

Dr. Stephen Kandall: Part of the answer has to do with Dr.

Grunberg’s suggestion to reframe the dialog and redefine drug abuse.

When drug abuse is viewed as a problem affecting a small number of

people, money for treatment and research is not available. When AIDS

was redefined as a disease affecting the large, white, heterosexual population, more money was made available for research. If drug abuse can be

defined more broadly to include abuse of alcohol and nicotine, it is more

likely to gain funding because it is an issue that is relevant to larger

numbers of people.

Unidentified Audience Member: I want to comment on an area

that has tremendous growth potential. The hospital-based studies of the

American Society of Addiction Medicine have revealed that drug abuse

is a major factor contributing to other health problems that patients first

present at the hospital. We have tried to collaborate with colleagues

in pediatrics, obstetrics, and psychiatry, and I think we need to do more

of this. We also need more information about the cost of health care

services related to drug abuse and its effect on the delivery of health

care services in this country, particularly with regard to women.

Dr. Woods: It is an irony that cigarette smoking and alcohol use are

clearly the greatest health problems in obstetrics, but screening for these

substances usually is not done.

Dr. Kandall: But that has nothing to do with science; it reflects the

political agenda that directs our work. Alcohol is far worse than any

other drug I can think of in terms of the effects on the fetus and the

newborn infant, but alcohol abuse is viewed differently from other drug

abuse solely because of how society chooses to define drug abuse. If drug

abuse continues to be viewed as a problem affecting just a small number
47

of people rather than our whole society, then the definition of drug

abuse will not be broadened and there will not be an increase in support

for research and treatment.

Dr. Grunberg: One way to change the perspective of physicians

about drug abuse is to influence the medical education of physicians.

The best time to educate physicians is during their first year of medical

school. If we explain to medical students at the beginning of their

medical education that drug abuse, including abuse of nicotine and

alcohol, is the single most preventable cause of death and illness, then

they are more likely to maintain a broader view of drug abuse in their

medical practices. Perhaps NIDA and others could persuade the accrediting boards, the American Medical Association (AMA), and particularly the American Association of Medical Colleges (AAMC) to require

educating physicians about the effects of nicotine, alcohol, and other

drug abuse. Many medical schools do not include drug abuse in their

curriculums. I recently presented a paper at an international conference

in Germany where we discussed how to improve the education of

physicians around the world about the effects of tobacco.

Unidentified Audience Member: I want to comment on Dr.

Woods’ characterization of drug abuse as a chronic, relapsing disease.

We may have enough evidence to conclude that drug abuse is a relapsing

disorder, but I am concerned about using the word “disease” to define it.

The concept of disease is a double-edged sword. On the one hand, it

can relieve people of stigma, but on the other hand, it involves certain

assumptions about etiology and potential treatment. The data presented

here today do not lead to the conclusion that drug abuse is a disease, but

they do indicate that there are environmental influences, such as

psychosocial stressors, that affect people’s use of drugs.

Dr. Finnegan: But one could say that also about heart disease.

With the science that has been presented today, one can say clearly that

drug abuse causes a disruption in the normal functioning of the brain

and hormones. I think that we are getting closer and closer to defining

drug abuse as a chronic, relapsing disease.

Dr. Woods: The point is well taken. For the most part, I use the

term “disease” when referring to drug abuse because I want to convince

my physician colleagues that they need to change their attitudes and

approaches to drug abuse.
48

Dr. Risa Goldstein: Dr. Woods’ recommendations concerning a

kind of “one-stop shopping” and the availability of multiple services for

pregnant and postpartum women really struck a chord with me. I did a

study several years ago of contraceptive behavior among drug abusers

during a 3-month period before they entered a drug detoxification

program. The most striking finding was that 40 percent of both women

and men who were heterosexually active (including those not known to

be pregnant, postmenopausal, or surgically sterile) used no contraceptive

method at all during that 3-month period. One facet of the medical

management of chronic, relapsing conditions is the patient’s responsibility for self-care and for planning life events, including pregnancies. How

can we encourage female drug abusers to take more responsibility in this

area?

Dr. Woods: We brought together a focus group of women and asked

them that very question. It became instantly clear to us that these

women are capable of determining when they are ready for a certain stage

of drug treatment. Dr. Ira Chasnoff told me several years ago that you

cannot place women into residential treatment unless they feel ready to

work on their drug problem. Women do not enter residential treatment

when they feel good about their lives; they choose to enter residential

treatment when they are unhappy and have hit “rock bottom.”

The issue of contraception should be raised immediately after women

give birth. First, they have to be helped to adjust to the postpartum

period so that they have more confidence about taking control of their

health care and their sexuality. Then they can be helped to make

decisions about contraceptive planning. I think Norplant and DepoProvera are going to have an effect, particularly Depo-Provera. One side

effect of Norplant is weight gain, and this is causing many women to

discontinue use after about 6 months.

Dr. Finnegan: I want to address Dr. Grunberg’s challenge to NIDA

to research licit as well as illicit drugs. NIDA deals primarily with illicit

drugs, but its research is not necessarily restricted to those drugs. Several

years ago, NIDA developed a protocol that focused on maternal lifestyles

and infant outcomes, and this study encompassed many of the issues that

have been discussed today.

Mr. Richard Millstein: Different Government agencies are responsible for various aspects of research on drug abuse. Abuse of alcohol

always has been separated from other forms of drug abuse. In many
49

States, alcohol abuse and other drug abuse are the responsibility of a

single agency, but the Federal Government has a long history of keeping

them separate. In the past few years, NIDA has looked at expanding its

research on nicotine addiction, and we have started to bring together

other Institutes and Government agencies to address this addiction. We

want all conference participants to tell us what areas NIDA should be

researching. This is vital information for NIDA to receive.

I also want to respond to an earlier comment about the common

view of drug abuse as a problem affecting a small number of people

rather than the larger population. When we speak to members of

Congress about drug abuse, we find that they have this view of drug

abuse. The points that have been discussed today about drug abuse as a

disease and the changes that occur in the brain because of drug abuse

may be useful in changing these views. Congress is concerned about the

cost-effectiveness of drug treatment, and we have to convince them that

a long-term perspective is needed. We need to show Congress something tangible and demonstrate that progress can be made.

Treatment

PSYCHOSOCIAL AND BEHAVIORAL

TREATMENTS FOR WOMEN

Karla Moras, Ph.D.

Abstract

Few studies have examined the efficacy of different approaches to drug

abuse treatment for women. Dr. Moras presented research findings about the

efficacy of psychosocial and behavioral treatment strategies for drug abuse in

general and for women in particular. Evidence suggests that women respond

differently to the types of drug treatment used for men and that women may

be more responsive than men to psychosocial and behavioral treatment.

Interventions that emphasize increasing women’s self-esteem and encourage

choosing positive life options may be effective in treating drug abuse, particularly with adolescent females. Comprehensive treatment programs have been

recommended widely, but their efficacy is still under evaluation. Dr. Moras

cautioned that the term “female drug abusers” suggests that such women

constitute a homogeneous group; however, in terms of treatment strategies,
50

several subgroups must be studied: pregnant women (both adolescent and

adult), injection drug users, adolescent polydrug abusers, older women, single

professionals, and housewives.

Sex Differences in Drug Abuse Treatment Research

• There is little information about effective drug treatment strategies for women because women have been underrepresented in

studies to date. The most widely quoted study of psychosocial

treatments for opiate addiction, published in 1983, was conducted entirely with men at a Veterans’ Administration hospital.

• Women are less likely than men to seek treatment for drug abuse,

but women are more likely to seek treatment for psychiatric

disorders and other medical problems.

• Some subtypes of female drug abusers may be more responsive

than men to certain types of treatment. Psychosocial and behavioral treatments might be more effective with women than with

men because of important differences in self-esteem and environmental and socialization factors, all of which influence maintenance of drug abuse behaviors.

• There is evidence that female drug abusers tend to have higher

rates of comorbid mood and anxiety disorders than men who

abuse drugs, and several studies have found that they also have

lower self-esteem than men. Similar differences in levels of

depression, anxiety, and low self-esteem also are found between

women and men who are not drug users.

• Child-care responsibilities often interfere with women’s ability to

attend treatment programs.

• There are sex differences in employment options; women in drug

abuse programs often lack marketable skills.

• The growing awareness of sex differences in treatment needs has

led to a national focus on comprehensive treatment programs for

female drug abusers. Comprehensive treatment programs currently are being implemented in many NIDA-funded demonstration grants, but data on their effectiveness are incomplete. These

programs are aimed primarily at women who are chronic abusers

of drugs such as heroin and cocaine, adolescents, pregnant

women, and women who are poor or undereducated. Cognitive
51

behavioral treatments for depression and anxiety may be useful to

include in comprehensive treatment programs.

Conclusions From Literature Reviews

Dr. Moras presented conclusions based on literature reviews initiated

by the NIDA Treatment Research Branch to determine the status of

research on psychosocial and behavioral treatments for drug abuse.

• In most treatment studies, 50 percent or more of the eligible

participants drop out early. Better strategies are needed to motivate people who abuse drugs to change their behavior patterns.

• Many people in drug treatment who achieve abstinence or significantly reduce their level of drug use often return to drug-abusing

behaviors. This is true for treatment programs for all drugs,

including nicotine.

• Psychosocial and behavioral treatments using contingency management techniques (such as a rewards system) are promising,

but the behavioral change sometimes does not endure after the

rewards cease. Research is needed on how to maintain behavior

changes after the rewards stop.

• Many studies of psychosocial and behavioral treatments of drug

abuse are flawed. For example, therapists may not be trained

adequately to conduct the treatments being studied. However,

methodological advances in psychotherapy research are being

transmitted to the drug abuse field.

• Women, housewives, single female professionals, and older adults

often suffer from overprescription of drugs. Education of practitioners about the appropriate approach to prescribing psychoactive

medications for women is needed.

• Individuals who abuse hard drugs, such as heroin or cocaine,

generally abuse more than one drug. For example, heroin addicts

typically also abuse cocaine, and cocaine addicts also often abuse

alcohol.

Issues for Future Research

• More research is needed on sex differences in the efficacy of

psychosocial and behavioral drug treatment approaches and on
52

treatments for women, including pregnant women. What

psychosocial interventions are particularly effective in reducing

some women’s urge to take drugs?

• Self-esteem, life options, and environmental and socialization

factors should be considered in the design of psychosocial treatments for women.

• More research is needed on ways to reduce drug-using behaviors

and on methods to ensure that the behavior changes endure.

Although contingency techniques have been found to reduce use

of alternative drugs in methadone treatment programs (e.g.,

heroin-addicted people on methadone treatment who use cocaine

as an alternative), individuals sometimes revert to drug-using

behaviors when rewards are stopped.

• An important focus for future research is high-risk populations,

such as adolescent females. Because studies of women who are

chronic drug abusers show that identifiable behavior patterns

appear during adolescence, targeting research on adolescents

would be important to preventing drug abuse. Prevention

interventions with adolescents should focus on improving life

options and self-esteem.

• Research is needed on the overprescription of psychoactive drugs

to women. Practitioners need to be educated about appropriate

approaches to prescribing psychoactive medications for women.

• Comprehensive treatment programs are widely recommended;

however, thorough trials, data analysis, and followup are needed

to determine their effectiveness. The effectiveness of cognitive

behavioral treatments for depression and anxiety should be

examined more closely in such settings.

PHARMACOLOGY: SEX-SPECIFIC CONSIDERATIONS

IN THE USE OF PSYCHOACTIVE MEDICATIONS

Sidney Schnoll, M.D., Ph.D.

Abstract

Studies of psychoactive drugs in nonhuman animals have found pharmacologic and pharmacodynamic differences between females and males, but the
53

few studies conducted with humans have included only male subjects. High

rates of anxiety and depression have been found among women who seek

treatment for drug abuse problems, and studies show that women tend to seek

medical help for emotional problems, whereas men tend to “medicate” themselves with alcohol and other drugs. Women are prescribed psychoactive

medications nearly twice as often as men, but researchers have little information on the effects of these drugs on women, particularly when they are

pregnant or of childbearing age. More research is needed on the effects of these

drugs on women and the most appropriate treatment of psychiatric conditions.

Current Research on Psychoactive

Drugs and Sex Differences

• Despite popular concern about overprescribing, most women

are not being treated for the conditions diagnosed, although data

indicate that psychiatric diagnoses are between 1.5 and 3.6 times

more prevalent among women than among men. Furthermore,

when women are treated for psychiatric diagnoses, they frequently are not treated appropriately. About 69 percent of

patients diagnosed with major depression do not receive medication, even though antidepressant medication is effective.

Women with anxiety syndromes are seldom treated with medication or given any other treatment.

• Most studies of psychoactive drugs are performed with laboratory

animals, and there is evidence of pharmacologic and pharmacodynamic differences between male and female animals. Few

human studies of psychoactive drugs are done, and most of those

use young male medical students. Nonhuman animal studies do

not indicate behavioral teratogenesis.

• Most drug companies do not study the effects of psychoactive

drugs on women because of potential legal liabilities if there is

danger of teratogenesis in subjects who become pregnant. Companies also avoid studies with women because menstrual cycles

and hormonal changes may alter drug results. The menstrual

cycle has dramatic effects on a woman’s body, but research is

rarely done on how psychoactive drugs affect the menstrual cycle.

Studies of new drugs usually involve postmenopausal women.
54

• All psychoactive drugs are lipophilic (fat-soluble), and the

differences in muscle mass and fat tissue distribution between

men and women require that the drugs be administered differently. Also, the amount of time drugs are in the gastrointestinal

tract is critical in drug absorption, and the transit time changes

during the menstrual cycle.

• Many psychoactive drugs are not adequately studied among

women of childbearing age, although these women have high

rates of depression and anxiety and often are prescribed such

drugs for treatment. The side effects of antipsychotic drugs occur

more frequently in women than in men, so more care should be

taken in prescribing these drugs to women.

• The placenta continually changes during pregnancy, and any

drug that crosses the blood-brain barrier can pass through the

placenta. The fetus is most at risk of adverse drug effects at days

18 to 55 of development. Most drugs have prolonged half-lives

in the fetus, and therefore possible dysmorphic and behavioral

teratogenicity are concerns. Most psychoactive drugs used during

pregnancy, including antidepressants such as Prozac, produce a

kind of neonatal withdrawal syndrome after delivery. Infants

exposed to these drugs are often delivered prematurely and are

undersized.

• There also are risks in not treating a pregnant woman for psychiatric conditions, including suicide, violence, and a decreased

ability to function. If left untreated, the woman’s physical and

mental health may suffer, and she may refuse to accept prenatal

care or abuse the fetus.

• Women are less responsive than men to imipramine in the

treatment of depression, but the difference is not discussed in the

literature. Older women metabolize benzodiazepines faster than

men, and undesirable side effects from benzodiazepines occur

more frequently in women.

Issues for Future Research

• Few studies examine sex differences in the effects of psychoactive

drugs on humans. More research is needed on how drugs affect

women of childbearing age, particularly pregnant women, and
55

how women’s hormones and menstrual cycles may influence the

effects of psychoactive drugs.

• What is the appropriate method for treating depression and other

psychiatric conditions in women, particularly pregnant women?

Risks exist in both prescribing and not prescribing drugs to treat

depression in pregnant women.

• Hard-core, long-term opiate addicts need a combination of

psychotherapy, behavior modification, and pharmacotherapy.

What combinations of behavioral therapies and pharmacotherapies provide the most effective treatment of anxiety, depression, and other psychiatric conditions for women in general and

for drug-addicted women in particular? Practitioners typically

give inadequate therapy, which can be worse than providing no

treatment at all.

• Practitioners must be taught that cognitive behavioral treatments

and antidepressants are highly effective and that proper prescribing of tranquilizers and pain medications reduces adverse effects.

RESEARCHER/SEX ISSUES

Jacqueline Wallen, Ph.D., M.S.W.

Abstract

Dr. Wallen addressed the issues and problems that researchers must

consider when conducting studies of women who are in drug abuse treatment.

Most drug abuse research has focused on men, and much of the recent

research on women has been evaluation research focused on pregnancy-related

areas. Research, including analysis of existing databases, is needed to determine (1) the characteristics of women in treatment for drug use, (2) the

methods women use to finance treatment, (3) the pathways through which

women enter treatment, (4) the kinds of services offered to and used by

women, (5) the treatment outcomes for women in different kinds of programs,

and (6) the costs and benefits of different treatment programs, particularly

those that offer comprehensive services to women and their families.
56

Special Considerations for Research on

Drug Abuse Treatment Among Women

• Not enough data on women in drug abuse treatment have been

collected and analyzed. NIDA and the Center for Substance

Abuse Prevention have funded numerous demonstration programs for pregnant and postpartum women and their children.

Some research findings have resulted, but there has been less

research on women in drug treatment at other stages in the

female life cycle. Characteristics such as low self-esteem, lack

of child care, experiences of sexual abuse, and insufficient insurance may affect women’s ability to enter drug treatment.

• The first step in collecting information about women is to find

women with drug problems; their settings often are different from

those of men.

• The Perinatal-20 study found that women who chose to enter

treatment were less willing to accept random assignments in

experimental studies. Such reluctance may present barriers to

conducting research.

• Women are more likely than men to complete drug treatment,

but a comparison of men and women in treatment who were at

the same socioeconomic level found that women expressed more

emotional distress. The assumption often has been that women

experience more emotional distress than men, but Dr. Wallen

suggested that men in drug treatment trials may not be expressing

the emotional distress they actually feel.

Issues for Future Research

• There is commitment at the Federal, State, and local levels to

make women’s drug treatment programs comprehensive, but

there is little research to support any particular drug treatment

approach for women. More research is needed to determine the

types of services offered to or received by women when they enter

drug treatment. What are the costs and benefits, particularly of

comprehensive programs? For which women are comprehensive

programs most cost-effective? What are the treatment outcomes

in different types of programs?
57

• It is important to determine the characteristics of women who do

not enter treatment. What are the barriers for different groups?

What factors facilitate the entry of women into drug treatment?

Researchers should examine the large, national databases to

identify the characteristics of women in drug treatment. Data are

needed on income, health insurance coverage, age, marital status,

sexual orientation, number and ages of children, race and

ethnicity, housing situation, and primary language spoken. Type

and severity of drug problems, psychiatric problems, history of

sexual and other physical abuse, and HIV status are other factors

that should be analyzed.

• It is important to conduct longitudinal research on infants and

children regarding their resiliency and protective factors to help

demonstrate the effectiveness of drug treatment in overcoming

early risk factors.

• What are the characteristics of women who receive drug treatment from their personal physicians rather than from a treatment

program? Do the treatment programs offer child care, medical

care counseling, family planning services, HIV screening,

parenting education, housing assistance, and transportation?

• How do women typically pay for drug abuse treatment? Which

groups of women, and what proportion, pay for their own treatment, have private health insurance, or use communitysponsored drug treatment services? What are the costs of not

treating women who need treatment—physical and mental

health costs, protective services, income maintenance programs,

and effects on families?

• What are the pathways through which women enter drug treatment? It is assumed that women are less likely than men to enter

treatment via the correctional system, but there are conflicting

research findings.
58

SERVICE PROVIDER/TREATMENT ACCESS ISSUES

Shirley D. Coletti, D.H.L.

Abstract

Dr. Coletti described Operation PAR, the largest nonprofit drug abuse

program in Florida, whose programs feature innovative strategies to reduce

barriers to drug treatment for women. Those innovations are important

because few treatment programs focus on the special needs of women, the

barriers they must overcome to obtain treatment, or ways to help women

complete drug treatment. These barriers include (1) fear of separation from

their children and lack of day care; (2) lack of safe, drug-free housing;

(3) financial and legal difficulties; (4) health problems requiring services

beyond drug treatment; (5) lack of knowledge about women and drug abuse;

(6) lack of transportation; (7) long waiting lists for treatment; and (8) lack

of youth-specific services. Because comprehensive drug treatment programs

are expensive, collaboration among agencies is critical if such services are

to be provided to women.

Barriers to Drug Treatment

• Fear of separation from their children and lack of day care.

Many women leave treatment because they fear losing their

children or being separated for an extended time. Some treatment programs ban communication between a woman and her

family for 6 months. Operation PAR provides developmental day

care for the children of mothers in drug treatment. Mothers can

even participate in planning day care activities.

• Lack of safe, drug-free housing. Operation PAR overcame the

housing problem in part by purchasing houses slated for demolition and moving them to its property.

• Financial and legal difficulties. Many female drug abusers are

single parents with several children. Some women have a history

of child abuse and neglect.

• Serious health problems. Women who abuse drugs often have

other serious health problems. The trend toward HMOs or

capitation plans may lead to a reduction in the number of health
59

care services provided to these women because such programs

profit by providing fewer services.

• Lack of knowledge about women and drug abuse. Many health

care professionals lack awareness and knowledge of some of the

unique needs of drug-abusing women, particularly pregnant

women. When physicians take medical histories, they often do

not ask important questions that would enable them to diagnose

drug addiction.

• Lack of transportation. Many women who abuse drugs have

financial problems and rely on public transportation to see

physicians or obtain treatment. Operation PAR provides

transportation to clients with a fleet of about 30 vehicles funded

in part by the U.S. Department of Transportation.

• Long waiting lists. Long waiting lists often discourage women

who agree to enter treatment. Outpatient counseling encourages

women to endure the wait for residential treatment.

• Lack of youth-specific services. Adolescents also need the full

range of drug treatment services, but to be effective, services must

be designed to meet the specific concerns of adolescents. Operation PAR has a 50-bed residential treatment program for female

and male adolescents ages 13 to 17. It is a joint venture among

the State of Florida, the county, private funders, and a bank.

DISCUSSION OF TREATMENT ISSUES

The discussion presented below dealt with treatment issues and

followed the presentations of Drs. Moras, Schnoll, Wallen, and Coletti.

Dr. Christine Hartel: Are you aware of any governmental efforts

to address problems you raised in testing drugs in pregnant women?

Dr. Schnoll: There has been a lot of effort in this area. Various

government agencies now require the inclusion of women in testing

programs. However, drug companies are concerned about liability

issues and have not progressed very far.

Dr. Moras: What kind of incentives could be given to drug

companies to study the effects of their agents on women?
60

Dr. Schnoll: The major issue is potential liability. Drug companies

would be willing to do more tests on women if they did not have the

risk of legal liability.

Dr. Mary Jeanne Kreek: The lack of studies among pregnant women

is a critical issue. We did two studies on the pharmacokinetics of methadone given in steady doses to pregnant women who were not abusing other

drugs. These studies were possible because one vendor was involved and

provided pro bono services, and no pharmaceutical company was involved.

Both my institutional review board (IRB) and the FDA agreed the studies

were critical because they would lead to recommendations for the treatment of pregnant women. Only methadone and phenytoin have been

rigorously studied. Do you know whether any additional drugs have been

studied during human pregnancy with respect to pharmacokinetics?

Dr. Schnoll: Probably none have been studied. It is an appalling

situation. My IRB demands that a drug prove efficacy in a nonpregnant

population before it will consider a study in pregnant women.

Dr. Kreek: A prestigious university has insisted that pregnant

women be included in a medications development study, but the medication has not been evaluated for teratogenicity. Investigators and IRBs

need help in interpreting the guidelines for including women in studies

and facilitating the development of needed studies that follow a step-bystep progression.

Dr. Schnoll: I agree. How do we start to develop studies on the

interactions of behavioral therapies and pharmacotherapies? Such

combinations may allow the use of fewer drugs and smaller doses.

Dr. Moras: Studies on depression show no evidence to support

superior efficacy of combined drug and psychotherapy treatments.

However, combined treatment would likely affect a higher proportion

of people. Some will respond to the drug; some to psychotherapy. A

colleague and I have requested a grant to study combined treatment for

patients with drug-resistant depression. With comprehensive treatment

programs for women, there is an underlying hypothesis that women

more than men might benefit from combined psychosocial and drug

treatment strategies.

Dr. Lisa Onken: NIDA is interested in encouraging research on the

integration of behavioral and pharmacological treatments. A monograph

on that topic will be coming out soon.
61

Dr. Karen Allen: As noted earlier by Dr. Moras, most treatments

are not directed at housewives, single professionals, and older women.

Do you have any recommendations for drug treatment for these groups?

Dr. Moras: One recommendation is educating health practitioners

who serve those groups. A higher proportion of women than men

present for treatment for panic disorder, and benzodiazapines are often

prescribed, although there is evidence of a rebound effect when a patient

withdraws. There is clear evidence that cognitive behavioral treatments

are highly effective, as are some antidepressants. Perhaps educating

health practitioners to stop overusing tranquilizers and overprescribing

pain medications for women would be helpful.

Dr. Allen: What about treatment for alcohol, cocaine, and other

drugs that housewives, single professionals, and older women sometimes

use?

Dr. Schnoll: Part of the problem is that most practitioners are not

trained to recognize drug problems in this population, and they do not

take appropriate histories. With changes in health care delivery, primary

care practitioners are going to be the gatekeepers. They must be trained

to recognize the problems of addiction and how to treat it, mostly in

their own clinical setting. Data indicate that 8 to 16 percent of a

primary care physician’s practice is composed of patients suffering from

addiction, and most are not being treated for the addiction. Education

is critical.

Dr. Dean Kilpatrick: Primary practitioners spend 8 to 10 minutes

per patient. Training to screen and refer patients for drug treatment

makes sense. Primary care practitioners who spend little time with each

patient are not likely to be effective in treating such a complex problem

as addiction.

Dr. Schnoll: We find that insurance companies are reluctant to pay

for referrals to drug treatment programs; this is part of the move toward

managed care.

Dr. Ruth Gordon: Some time ago there was an experiment to link

mental health with primary care. Primary care physicians were trained,

but there was no permanence because they did not do that kind of work

continually. What can be done to support trained primary care physicians so that they continue to assess and treat people? What peer

support can be provided?
62

Dr. Schnoll: There have been financial disincentives in the past

associated with the kind of treatment and screening that primary care

physicians should provide. With managed care, the financial incentives

are there because the primary care physicians are responsible for the

total health care costs and will seek to reduce their costs. Those working in drug abuse treatment need to offer more continuing education to

primary care physicians.

Dr. Loretta Finnegan: I would like to see NIDA in a partnership

with groups such as the American Society of Addiction Medicine to

provide training to primary care practitioners, internists, and psychiatrists. Questions concerning addiction recognition and treatment

should be included on medical boards. We must make the American

Association of Medical Colleges aware that the prevalence of addiction

is so high that it affects every other specialty. Medical students used to

think they would not be dealing with addiction, but now they find that

pediatricians have to care for babies undergoing drug withdrawal.

Dr. Joyce Roland: We are starting to address that issue. The North

Carolina Governor’s Institute sponsors a summer institute for health

professionals at the University of North Carolina, and information about

drug treatment is included. Is it possible to do animal studies in the lab

that give an idea of how pregnant monkeys or rats might respond to

certain medications? When we talk about how to approach pregnant

women, what kind of work at the laboratory level is transferable?

Dr. Schnoll: If a drug company wants to use a drug with pregnant

women, it has to do studies on several different species of animals to

determine whether the drug is teratogenic. We have learned that a lot

of information is not transferable—a drug may be teratogenic in certain

animal species but not among humans and vice versa. It is difficult to do

animal studies on behavioral teratogenesis.

Dr. Finnegan: Dr. Kreek, how much should a methadone dose be

lowered when a woman wants to breastfeed?

Dr. Kreek: We conducted two studies on a small number of

methadone-maintained patients who were not polydrug users and who

had no serious medical or behavioral illnesses. Larger studies are needed.

Earlier studies showed that less than 3 percent of orally administered

methadone circulates in systemic blood, and less than 10 percent of

methadone is free in plasma that can pass into breast milk. To be

accurate, we need information on the volume of breast milk an average
63

infant consumes after the first 2 to 4 weeks of life. With the information

we had, we calculated that the amount of methadone that could pass

from mother to baby was smaller than the dose of methadone a neonatologist would give a child for pain relief. Therefore, the amount of

methadone delivered in breast milk is less than what an infant would

have been exposed to in utero.

Although we do not hesitate to recommend breastfeeding to women

on methadone maintenance2 who have no other drug abuse problems,

we do hesitate to recommend breastfeeding to women who have HIV.

Of children born to HIV-positive mothers, 50 percent are HIV positive

at birth. Of these, 20 to 35 percent are truly infected, but this cannot be

determined until the child is at least 6 months old. If the child is not

infected, an infected mother could expose the child to the virus through

her breast milk. On the other hand, breastfeeding is good for babies

from a psychological and immunological viewpoint. This is a difficult

problem involving medical and ethical issues. We, in New York, hesitate to recommend breastfeeding for women who are infected with HIV.

Dr. Stephen Kandall: Based on Dr. Kreek’s research, a local panel I

chaired recommended that breastfeeding was acceptable and should be

supported for methadone-maintained women who were not polydrug

users and were not infected with HIV. However, the New York State

Department of Health issued a document recommending that all drugusing women be discouraged from breastfeeding.3

 I do not know how that

happened given the science that supports the safety of breastfeeding.

Dr. Kreek: I think we have to ask why scientific research information about drug abuse often is communicated inaccurately. Education is

needed for physicians, nurses, social workers, and others to get rid of

preconceived notions and bigotry about our patients. We know that

hard-core, long-term opiate addicts need a combination of psychotherapy, behavior modification, and pharmacotherapy, but this knowledge still is not accepted.

Unidentified Audience Member: The FDA consent-to-treatment

form for methadone maintenance also advises that these women should

not breastfeed.

2 Data are not available on the long-term effects of methadone in infancy.

3 See footnote 2.
64

Dr. Marsha Rosenbaum: What effect does the combination of

marijuana and methadone have in breastfeeding?

Dr. Kreek: I wish this question would be researched. I know of no

study measuring levels of marijuana in breast milk. Another question is

how much effect marijuana has on a person’s behavior if it has been

weeks since the drug was taken.

Dr. Schnoll: To answer that question would mean giving measured

doses of marijuana to a woman who is breastfeeding and then getting

samples of blood and breast milk. Such a study is not likely to be

approved by an IRB.

Dr. Finnegan: Dr. Moras, you indicated that comprehensive care

components include prenatal and neonatal care, family involvement,

parenting skills, vocational training, employment counseling, medical

services, and HIV risk prevention, and you said there are no data

concerning these issues. Did you mean there are no data looking at all

these components together? Do we have data on them separately?

Dr. Moras: Right, we do not have efficacy data on comprehensive

multimodular programs.

Dr. Kandall: Given the effects of early influences on these women’s

lives, how likely is it that treatment will overcome those influences?

How do we assess the effectiveness of treatment programs in terms of

outcome variables?

Dr. Wallen: More longitudinal studies are needed on infants and

children regarding their resiliency and protective factors, even though

following a cohort of children for any period of time is expensive. This

is extremely important research that should be done.

Unidentified Audience Member: Another issue being studied

involves women who do not receive treatment services and those who

are referred for drug treatment but refuse it. In addition, it is important

to know the level of addiction a person has reached when she/he enters

treatment because different levels produce different consequences and

problems.

Dr. Rosenbaum: It is necessary to establish that there is common

ground between researchers and research participants. In our experience, women can establish rapport with other women through one-onone discussions. A major issue is how to help women access drug
65

treatment if they cannot afford to pay for it. Lack of money to pay for

treatment is a major barrier for some women.

Dr. Moras: One study reported that female drug abusers did not

care whether those treating them were of the same ethnic or racial

group; they were more concerned that those providing treatment

services knew what they were doing and were helpful.

Dr. Peggy Stotts : Have researchers investigated how the attitudes

of health care providers act as barriers to people in drug treatment? Bias

on the part of providers has been recognized as a barrier because it

discourages those seeking treatment.

Dr. Wallen: I agree. Some national databases collect data on

facilities, their services, and whether staff members have had special

training on women’s issues. However, the data are collected at an

aggregate level so there is no way to know how many women actually

received services from providers who received the special training. We

need more specific data about how services are delivered to those women

who need them most. If you were making a recommendation for collecting national data, how would you suggest this question be asked?

Dr. Stotts: Health care providers should examine their own biases

or attitudes toward women who use drugs during pregnancy and work

through these issues so that they can provide nonjudgmental care to

these clients. We need research to document the problem and address

it through continuing education and medical schools.

Dr. Finnegan: We know that providers’ attitudes toward men,

women, and pregnant women can be very different. Addressing the

problem requires more than a questionnaire. Nonverbal communication

and interaction with clients can be observed by using videotape.

Dr. Kathleen Jordan: I have good news on this issue. At Research

Triangle Institute, we are conducting two large, longitudinal, national

studies of treatment clients. Your concerns about information gaps in

research results are being addressed in some manner in these studies.

One is DATOS, the Drug Abuse Treatment Outcome Study, which is

funded by NIDA. The other is the National Treatment Improvement

Evaluation Study (NTIES). Unfortunately, much of the funding for

NTIES was used to support mainstream rather than enhanced services.

I hope the studies that follow ours will learn from our experience.
66

Unidentified Audience Member: Early identification of women

who are willing to enter treatment is important. Another important

issue is the early development of children. A NIDA-funded grant that

I am working on found that almost 50 percent of women in treatment

neglected their children during the first 18 months and relied on the

other family members for support. Are there studies of how to support

the family while the mother is in treatment and incapable of caring for

a child?

Dr. Wallen: I do not know of any such study. Very few of the largescale databases collect information on whether women are ever offered

financial or benefits counseling. It is important to know what support or

benefits a treatment program can offer women so that barriers can be

overcome.

Dr. Moras: I know of one model program that focuses on ways to

involve the extended family of the pregnant or postpartum woman to

provide help with parenting, as well as supporting her efforts to get off

drugs.

Unidentified Audience Member: To get women into treatment,

it is necessary to work with members of the extended family.

Etiology

THE ETIOLOGY AND GENETIC EPIDEMIOLOGY

OF PSYCHIATRIC AND DRUG DISORDERS

AMONG WOMEN

Kathleen R. Merikangas, Ph.D.

Abstract

Dr. Merikangas presented information about genetic epidemiology as a

method of studying the gene-environment interactions that may be involved in

the etiology of drug abuse. She described the appropriateness of applying the

methods of genetic epidemiology to disorders such as drug abuse. She presented research data suggesting that drug abuse and drug dependence are

transmitted in families and that sex is not a significant factor in the family

transmission of drug dependence. Researchers found no distinct genetic factors

underlying drug abuse in women and men.
67

Genetic Epidemiology Methods

Genetic epidemiology is the study of the etiology, distribution, and

control of disease in families rather than in the general population.

Unlike behavioral genetics, it focuses on diseases or disorders rather than

traits and behavior patterns. Inheritance factors in genetic epidemiology

refer to any factors that are transmitted in families, including cultural

and biologic factors. Genetic epidemiology methods can be used to

investigate whether sex differences in the prevalence of a particular drug

abuse disorder are attributable to genetic or other transmissible factors.

In general, epidemiology ignores the family history of a disease or

disorder even though it is one of the strongest risk factors for the etiology of chronic human disorders; instead, it provides information about

the environment and the patterns of diseases in populations. Genetics

focuses almost exclusively on host factors and fails to take into account

the role of environmental influences. Therefore, researchers need to

address gene-environment interactions when studying the genetic

contributors to the etiology of drug abuse.

• One way to examine gene-environment interactions is to use

study designs that control for the genetic background while

letting the environment vary or vice versa. For example, the

study of monozygotic twins (same genes) who are discordant for

a particular disease is a powerful way to identify environmental

factors that either potentiate or protect against the expression

of the underlying genetic vulnerability.

• Twin offspring studies offer another approach. By controlling for

family and genetic background (because the offspring of monozygotic twins are half-siblings rather than cousins), researchers can

examine the role of factors such as exposure to peer networks,

parents who abuse drugs, and parents with serious medical or

psychiatric illnesses. Differences noted in these environmental

factors help researchers identify factors that may lead to differential expressions in genetically similar individuals.

• The study of half-siblings who grow up in families in which the

parents have divorced and remarried may help identify the role

of drug exposure, environment, and family disruption.

• Studies of migrant populations may be the ideal way to identify

the role of cultural influences on the development of a particular
68

disease. Researchers can analyze changes in the disease rates of

genetically similar groups who are from different areas of the

world.

Research on Families and Risk Factors for Drug Abuse

• The National Comorbidity Survey showed that the rates of drug

abuse and dependence are higher among males in the general

population compared with females, a finding consistent with

other epidemiologic studies across the United States. Therefore,

the threshold for females to develop drug abuse is assumed to be

higher than that for males. If females have a higher threshold

for developing drug abuse, it is assumed that they would need to

accumulate more risk factors, which then should cause greater

rates of illness in both the male and female relatives of female

probands. If genetic factors are responsible for the major sex

differences in drug abuse and if women have more risk factors

then men, then women’s families should have greater familial

transmission than men’s.

• Data suggest that a family history of drug abuse is one of the most

powerful risk factors for the development of drug abuse in individuals. Dr. Merikangas and colleagues recently completed a

large, longitudinal family study (cosponsored by NIDA and

NIAAA) of comorbidity of drug abuse, alcoholism, and anxiety

disorders. Researchers from many disciplines, including psychologists, neurologists, sociologists, and anthropologists, interviewed children and other family members to determine what

risk factors may be involved in the etiology of drug abuse.

• The study involved selecting a female proband and collecting

family history information from parents, children, teachers, and

other informants. Subjects were selected from both treatment

settings and the community at large and were classified according

to whether they had a major anxiety disorder, including panic

disorder, social phobia, or agoraphobia. All probands met strict

criteria for dependence rather than abuse of marijuana and

anxiolytic drugs. A control group (“normals”) selected from

the community had none of the anxiety disorders and no history

of drug abuse. Approximately 1,200 first-degree relatives and
69

250 spouses were interviewed. The researchers sought to

understand the relationship among anxiety disorders, affective

disorders, antisocial personalities, and drug abuse.

• The rate of drug dependence was 2 percent among relatives of the

control group but was 12 percent among relatives of proband drug

abusers. This suggested that there was a familial transmission or

aggregation of drug dependence, and this transmission seemed to

be specific to particular drugs rather than drugs in general.

• The nearly twofold increase in rates of drug dependence among

male relatives confirmed the finding of population studies that

men have higher rates of drug dependence than women. However, the sex of the proband made no significant difference in the

drug dependence rates of relatives. When this hypothesis was

tested in models that controlled for age, comorbidity, and other

covariates, no sex difference was found in the transmission of

drug dependence.

• After controlling for sex differences in base rates of psychopathology, no differences were found in the comorbidity patterns of

male and female relatives, suggesting that comorbidity with

affective and anxiety disorders in alcoholism does not lead to

greater risk of drug dependence among relatives. After controlling for comorbid alcoholism in the probands, anxiety and

affective disorders were not associated with an increased risk to

the relative, suggesting some specificity in the transmission of

drug abuse and the underlying etiologic factors.

• The data suggested that familial patterns of drug dependence

were similar in families with relatives in drug treatment as well

as in families from the community at large.

• Reports about drug dependence did not appear to be significantly

influenced by whether the report was made by relatives or the

individual proband. However, the information source was an

important factor in reports about most psychiatric disorders.

Study Conclusions

• The data suggested that drug abuse and drug dependence were

transmitted in families, but drug dependence appeared to have
70

greater familial aggregation than abuse, particularly with respect

to alcohol.

• There was specificity of transmission of drug abuse; that is,

relatives of alcoholics who had no other drug abuse issues did not

have elevated rates of drug abuse themselves, suggesting a difference in the etiologic factors for alcohol dependence and dependence on marijuana and anxiolytic drugs.

• After population base rates were controlled for, patterns of

comorbidity did not differ between male and female drug abusers.

• Sex was not a significant factor in the transmission of drug

dependence through the family. There were no distinct genetic

factors underlying drug abuse in either men or women.

Issues for Future Research

• The key question over the next decade concerns the family

characteristics that increase the risk of drug dependence and have

a greater effect on dependence than sex differences. Research

should be done on families with half-siblings to help identify the

role of family disruption and environment in the etiology of drug

abuse. Attempting to identify genes that increase the risk of drug

dependence is too complex.

• The data suggested that drug abuse and drug dependence were

transmitted within the family, but drug dependence appeared to

have greater familial aggregation than abuse, particularly with

respect to alcohol. To replicate and confirm these findings, a

similar study of familial transmission of drug dependence is

needed using individuals dependent on cocaine and opioids.

• What factors cause men to be at higher risk of drug abuse than

women? Cultural and metabolic factors need further investigation.

• Research involving migrant populations is needed to identify the

role of cultural influences on the development of drug disorders.

Questions From the Audience

The question-and-answer session below followed Dr. Merikangas’

presentation.
71

Dr. Mary Jeanne Kreek : Did you use actual exclusion criteria for

abuse or dependence of opiates and stimulants, including cocaine?

Dr. Merikangas: Many people were dependent on multiple substances so we looked at the relationship between alcohol and anxiety to

see whether that extended to anxiolytic-type drug abuse. A person who

had predominant cocaine dependence, opioid dependence, or any kind of

injection drug dependence was not included in this study.

Dr. Kreek: Even the best instruments, such as the widely used

Addiction Severity Index, do not measure magnitude of use and require

only yes or no responses. Was the use of any of these drugs an exclusion

criterion, or was it a question of what drugs were used predominantly?

Dr. Merikangas: Armed with the individuals’ treatment records and

detailed diagnostic interviews, we asked about drug preference, craving,

and what the person would do if he or she had all the money in the world.

We also looked at drug preference, duration of dependence on each

substance, and age period when the individual used the substance. Based

on this information, we tried to determine the major drug of abuse. For

instance, if individuals had used cannabis, as most cocaine and opioid

abusers do, from ages 13 to 14 and then never used it again, they would

not be classified as cannabis users.

Dr. Kreek: This is important as we move toward more sophisticated

molecular genetic studies, more sophisticated environmental risk factor

impact studies, and their intersection. These data seem to show the

dominance of other drugs over alcohol or, as you stated, a selectivity.

Does that selectivity go even further within a drug group? It is difficult to

judge how to label the phenotype in these kinds of studies. It will become

critically important to include details about the instruments used and the

cutoff criteria for those who used cannabis, anxiolytic drugs, or other

substances. As far as outcome studies for the relatives, was the drug

primarily one of the three that you named?

Dr. Merikangas: No. It could have been dependence on any drug.

One of the major goals was examining specificity. We wanted to study

not only the drug preference but also the specificity of actual drugs used

among people who have been exposed to virtually every drug in their

lifetimes. Many cannabis abusers have been exposed to a large number of

different drugs, use cannabis daily, and have been doing so for 20 years.
72

Dr. Kreek: This is our finding, too, in the opiate-dependent group

and more recently in the cocaine-dependent group. It is important in

all the instruments to tease this information out and explain how it was

done. Most studies still lump all drug abuse together, yet there are

profound differences.

Dr. Brenda Miller: Please give more background on the characteristics of the proband group, particularly with regard to ethnicity, age,

and social class.

Dr. Merikangas: With regard to socioeconomic class, all classes

were represented. We also want to examine ethnic patterns to see

whether there are differences in risk and drug use. Data presented

today are for Caucasians only because the original study followed up

on Dr. Myrna Weisman’s family study of depression, which had an

all-Caucasian sample. We extended the sample to include blacks and

Hispanics. At present, we are analyzing some early data on blacks and

Hispanics separately. The substance abusers tend to be in a somewhat

lower social class than the control subjects. This is always a problem,

but one that is controlled for in our analyses.

Dr. Miller: Many people assume the word “inherited” means

genetic factors. I would encourage you to come up with a word other

than inherited because the assumption is to equate that with genetics.

Dr. Merikangas: I agree with and appreciate your comment. Our

work is designed to identify the noninherited factors and that is why I

tend to use the term “transmissible.”

Unidentified Audience Member: Were quality assurance procedures used by your interviewers? Was there a model that could be used

by other programs?

Dr. Merikangas: Our priority was to have as interviewers clinicians

who had clinical experience in asking questions about drug use and

anxiety disorders. We used a diagnostic interview that is semistructured,

so quality assurance was difficult. We have traded some reliability to

gain clinical validity. Interviewers were trained carefully, using videotapes and group evaluations. Another clinician reviewed each interview

that was done to ensure that the correct format was used. Periodically,

someone observed each interviewer as she or he conducted interviews

and performed a review of the interviewer’s work.
73

Dr. Karen Allen: Is transmission of drug abuse through families

more true for women than men?

Dr. Merikangas: No, the sex proband effect was not significant.

Neither women nor men have a genetic vulnerability to drug dependence. Having relatives who abuse drugs increases a person’s risk of

having drug abuse by a factor of about 2.5. Knowing this helps to

predict who may abuse drugs, but it tells us nothing about etiology. We

need to understand what it is about the family that leads to drug dependence. We want to examine family background and explain why there is

an increased risk of drug dependence and why some children in a family

become dependent but their siblings do not. But this is just one study

and requires replication.

Unidentified Audience Member: Why did you use semistructured

interviews and focus on clinicians skilled in the disorders rather than use

clinicians skilled in using the structured diagnostic interviews?

Dr. Merikangas: We were interested in psychopathology and its

association with drug use. The structured interviews work well in

obtaining information on drug and alcohol dependence. However, this

is not true with regard to anxiety and affective disorders. The validity

of some of the structured interviews was inadequate for examining the

subtypes of anxiety and affective disorders. The so-called unstructured

interviews actually were structured and coded, but the clinician made a

“best-estimate diagnosis” based on more than the actual responses to the

interview. Psychopathology—bipolar disorder, for instance—is usually

missed by people who do not have some clinical experience or training

in how to probe for relevant information.

Dr. Karla Moras: You can use clinically skilled diagnostic interviewers with structured interviews to reach the same goal. It is difficult

for people who have no clinical experience to use a structured interview

and obtain accurate diagnoses, but unstructured interviews are not a

necessity. You have to hire skilled people.

Dr. Merikangas: Yes, particularly with children. The semistructured interview seems to be far superior in working with children.
74

Etiology Panel

CHILDHOOD AND ADOLESCENT

PRECURSORS TO DRUG USE

Judith S. Brook, Ed.D.

Abstract

Dr. Brook presented data from a 20-year longitudinal study of precursors

to drug use in children who were first assessed at 1 to 10 years of age and

followed to young adulthood. Two main types of childhood personality

attributes appeared to be important predictors of drug use during adulthood:

(1) reckless and predelinquent behaviors, including aggression, and (2) poor

emotional control. Specific predictors for drug use during childhood were

associated with the development of personality attributes during early and

late adolescence that, in turn, were related to higher stages of drug use in

adulthood.

Longitudinal Study of Childhood and

Adolescent Precursors to Drug Use

• A sample of 1,000 children, ages 1 to 10, was assessed in 1975.

Investigators met with the mothers and the children, and both

groups were reassessed during early and late adolescence. The

last followup assessment occurred during young adulthood, when

the subjects were 18 to 27 years old.

• During early adolescence, characteristics related to unconventionality were reported by young women who later had high

stages of drug use: lower achievement, lower church attendance,

greater rebelliousness, less responsibility, and greater tolerance of

deviance. Those at higher stages of drug use reported difficulty in

terms of emotional control (i.e., frequent expression of anger and

impulsiveness). In the interpsychic area, only low ego integration was related to higher stages of drug use. Depression and

anxiety were not related to higher stages of drug use.

• The behavior patterns of early adolescence persisted during late

adolescence, although correlations were higher then, a result to

be expected for predictions made closer in time to the present.
75

• The study findings supported using a mediational model to

examine the relationship of childhood personality attributes to

higher stages of drug use. That is, childhood personality risk

traits were associated with the development of personality risk

traits during early adolescence that related, in turn, to the

development of personality risk traits in late adolescence. In

turn, the risk traits of late adolescence were associated with

higher stages of drug use in adulthood.

• Two main types of childhood personality attributes appeared to

be important predictors of drug use during adulthood: reckless

and predelinquent behaviors, including aggression, and poor

emotional control, attributes similar to adolescent characteristics

implicated in drug use. Early prevention efforts that focus on

crucial personality attributes may not only inhibit initial drug use

but also prevent drug use later in adulthood.

• Researchers identified several protective traits in childhood that

can offset the effects of adolescent drug use on adult drug involvement over time, including achievement orientation during

adolescence and a close mutual attachment between parent and

child.

Followup Study Results

A followup study analyzed information on three generations over

the 20-year study period: grandmothers, parents, and 2-year-old children. The analyses revealed the following:

• Drug use during adolescence and young adulthood appeared to

interfere with the bonding relationship between these young

women and their children. Personality attributes such as unconventional behavior, intrapsychic distress, or difficulty in relating

to people also appeared to interfere with parent-child bonding.

After controlling for personality traits, illicit drug use by parents

directly affected the parent-child bonding relationship and

reduced the expression of parental affection.

• There was evidence that illicit drug use by parents was related to

poor social adjustment in the child. A history of unconventional

behavior and intrapsychic distress in the parent strongly affected

the 2-year-old’s behavior; parents who were rebellious during
76

adolescence and young adulthood had children who were not

well adjusted socially and who expressed greater negativity and

aggression.

• The risk factors for drug use in females at all developmental

stages studied were found to be similar to those of males, but

females exhibited lower levels of all the major risk factors. For

example, females demonstrated lower levels of aggression, anger,

predelinquent behavior, and hyperactivity and were better able to

control their emotions and had friends who were not deviant and

who were achievement oriented.

• One area in which females rated higher than males was intrapsychic distress, such as depression, anxiety, and obsessiveness.

Intrapsychic factors are important in predicting drug dependence

or abuse but not experimental or moderate drug use. Early and

appropriate interventions can reduce risk factors for drug use

among women and enhance protective factors.

Conclusion

Dr. Brook suggested that drug abuse prevention programs (1) focus

on strengthening certain crucial personality traits that not only inhibit

initial drug use but also may help prevent drug use during adulthood and

(2) be initiated during childhood, because certain traits are precursors to

adolescent drug use risk traits that later affect adult drug use.

Issues for Future Research

• A study similar to the research of Dr. Brook and colleagues is

needed to examine childhood and adolescent precursors to

drug abuse. A larger sample (more than 1,000 children) is

needed to confirm whether illicit drug use by parents is related

to increased negativity, aggression, and poor social adjustment

in their children.

• Future research on sex differences should be based on a developmental perspective and include models that emphasize the

interactive and reciprocal influences of the child, family, culture,

and community. This broader approach will facilitate examining

how different adaptive and maladaptive developmental pathways

in females and males lead to drug use.
77

VICTIMIZATION AND POSTTRAUMATIC

STRESS DISORDER

Dean G. Kilpatrick, Ph.D.

Abstract

Dr. Kilpatrick reported information from a retrospective and longitudinal

survey of adult women in the United States that showed a clear relationship

among assault, family history of drug use, posttraumatic stress disorder

(PTSD), and sensation-seeking behaviors. Women subjected to violence had

a higher risk of alcohol dependence and other drug abuse problems. Women

who had alcohol or other drug problems, particularly with hard drugs, were at

high risk of repeated assaults. PTSD is an important factor in alcohol and

other drug abuse, and women often developed PTSD after experiencing a

violent assault.

National Women’s Study

Drug abuse disorders are more prevalent among women who have

been crime victims. Several studies of drug abusers seeking treatment

reveal that they have higher than average rates of past victimization.

However, these studies seldom addressed the question of whether drug

abuse occurred prior to violent assault or crime or whether the violent

assault increased the risk of drug abuse. Is the relationship between

violent assault and drug abuse a vicious cycle in which both events foster

the development of the other?

Dr. Kilpatrick presented data from the NIDA-funded National

Women’s Study, a retrospective, longitudinal, national probability

household survey of adult women in the United States. A random

sample of women was interviewed by telephone. After the initial

assessment, followup interviews were conducted at years 1 and 2.

Complete followup information was obtained for 72 percent of the

sample, and partial followup was accomplished for 83 percent of the

sample. Aggravated assault was defined as an attack with or without

a weapon but with the intent to kill or seriously injure the victim.

New victimizations were defined as those that occurred during the

followup interval. Current PTSD was measured by the National

Women’s Study PTSD module.
78

Initial Assessment—Wave 1

• It was found that 12.7 percent of the women surveyed had been

victims of one or more completed rapes during their lifetimes,

and about 10 percent had been victims of aggravated assault.

Only about one in five cases of rape and aggravated assault had

been perpetrated by strangers. Among women who had been

assault or rape victims, more than half had experienced more

than one type of criminal incident. Only 16 percent of rape

cases and 46 percent of aggravated assault cases had been reported to police.

• The lifetime prevalence of PTSD was 12.3 percent; prevalence

for the past 6 months was 4.6 percent.

• There appeared to be a linear relationship between the number of

prior assaults experienced and the likelihood of lifetime alcohol

dependence. Some women had experienced as many as three

rapes or aggravated assaults prior to the initial assessment.

• The assessment also revealed other risk factors for the development of alcohol dependence: family history of drug abuse problems, high level of sensation-seeking, and lifetime history of

PTSD.

• There was a clear relationship among assault, family history of

drug abuse, PTSD, and sensation-seeking, even when the analysis

controlled for other variables. Those who were alcohol dependent in the past were 25 times more likely than other subjects

to be dependent on alcohol.

Followup Assessments at Years 1 and 2

Followup data at years 1 and 2 indicated a clear relationship between

category of drug use at baseline assessment and an increase in the likelihood of suffering a new assault.

• About 28 percent of the sample used drugs, and a mutually

exclusive grouping was used for analysis. A subgroup of polydrug

or heavy drug abusers included those using heroin, cocaine, and

any hard drugs or other substances. Another subgroup included

those who used marijuana and alcohol but not “hard” drugs.

Another subgroup included those who had met the DSM-III-R
79

criteria for alcohol dependence and did not use other types of

drugs.

• Of those women who did not use drugs at baseline assessment

or may have used alcohol alone, 3.9 percent reported having

experienced aggravated assaults during this period. Of those who

met the diagnostic criteria for alcohol dependence, 6.1 percent

reported having experienced new assaults. Even after controlling

for past-year alcohol dependence, subjects who suffered a new

assault were three times as likely to be alcohol dependent as other

subjects. Of women who did not report any experiences of

assault or rape at the initial assessment but experienced a rape

or assault subsequent to that assessment, 16 percent developed an

alcohol problem. After controlling for other variables, subjects

with PTSD were found to be 5.5 times more likely to be alcohol

dependent. Essentially, 100 percent of those women who experienced a prior assault or a prior alcohol problem and who developed PTSD also had an alcohol problem at followup.

• Of those who had used marijuana but not other drugs at baseline

assessment, 9.6 percent had experienced new assaults. Of those

who reported use of hard drugs at baseline assessment, 28 percent

had experienced a rape or aggravated assault during the followup

intervals.

• Among women who had ever received treatment for drug abuse

problems (alcohol or other drugs), only 16 percent had no history

of rape or aggravated assault and no PTSD. Eighty-four percent

had experienced either an aggravated assault or rape or had

developed PTSD. Forty percent had been assaulted but did not

develop PTSD, and more than 30 percent of the group had

experienced both assaults and PTSD. These figures are similar to

data collected in other studies of women seeking drug treatment.

Of particular concern is the young age at which most women who

received treatment had been raped; 62 percent of the women

reported being raped before age 18, and 30 percent before age 11.

Other types of sexual assault were not included in these data.
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Conclusions

• Women who have been subjected to violence have a higher risk of

alcohol and other drug abuse problems.

• Women who have alcohol or other drug abuse problems, particularly with hard drugs, are at high risk of repeated assaults.

• Women who develop PTSD after experiencing an aggravated

assault or rape are at greater risk of developing drug abuse problems. PTSD is an important factor in alcohol and drug abuse, and

it is important to identify and address this disorder as soon

as possible. Therefore, women in drug treatment programs should

be screened to determine (1) whether they have been subjected to

violent assaults in the past and (2) whether they have developed

PTSD.

Issues for Future Research

• Future research should examine the presence of similar risk

factors (e.g., alcohol dependence, PTSD, having been the victim

of assault) in adolescents and young children; researchers found

that most assaults were committed against adolescent girls before

age 18.

• Clinical interventions designed specifically to prevent future

assaults may increase clients’ safety.

HARM REDUCTION

Marsha Rosenbaum, Ph.D.

Abstract

Dr. Rosenbaum stated that pragmatic treatment strategies are needed to

help drug-abusing women who want treatment, particularly pregnant women.

There is insufficient support for treatment programs, and most are not sensitive

to the needs of women. Harm reduction is a viable strategy for minimizing the

harm of drug abuse even if abstinence from drugs is not possible. She presented

information from an ethnographic study that indicated that drug-abusing women

who were pregnant used some form of harm reduction to achieve the best

possible pregnancy outcomes given their drug abuse. More research is needed

on these harm-reduction strategies and how to assist women with their efforts to
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minimize the harmful effects of drug abuse. Researchers and treatment

specialists may have to accept strategies that minimize drug abuse and reduce

its consequences rather than insisting on abstinence.

Findings on Harm-Reduction Strategies

Harm reduction is a pragmatic strategy that has been used in relation to methadone treatment for about 30 years and with AIDS patients

who are drug abusers. Harm reduction emphasizes minimizing the harm

brought about by drug abuse, even if drug abuse cannot be stopped

completely.

Dr. Rosenbaum found that many women who abused drugs practiced

personal harm-reduction strategies. The following findings are from a

NIDA-funded ethnographic study of 120 women who were either

pregnant or postpartum. The women used crack, heroin, or methamphetamine, and most were not in drug treatment.

• All women interviewed believed that their drug abuse would

damage their fetuses and cause deformities, behavioral problems,

or mental retardation. Reducing drug-related harm during

pregnancy was imperative. The women varied greatly in terms of

the harm they perceived and the strategies they used to reduce

harm to their fetuses. Strategies included reducing or quitting

drugs, attempting to counteract drug effects, improving diet,

taking vitamins, getting more sleep, moving, changing lifestyles,

and seeking prenatal care. Abortion was another method, but it

was not a popular choice.

• Attempts to reduce drug-related harm seemed linked to the

intensity of women’s perceptions of possible harm. Crack users

seemed to perceive their drug abuse as very harmful, which may

be related to the large amount of media attention given to crack

use. On the other hand, heroin users expressed less concern

about drugs harming the fetus, which also may be related to the

fact that stories about heroin and methamphetamine use appear

in the news media less often than those about crack.

• Although all forms of drug treatment were considered by the

women to be good methods for reducing drug abuse, drug treatment overall was not considered a sure solution. Many women

combined drug treatment programs with their own methods of
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avoiding drugs. They were often not successful at permanently

abstaining from drugs; temporary periods of drug abstinence were

the norm. However, the women attempted to balance what they

referred to as drug “cleanup times” with “mess-up times” and tried

to maximize the cleanup periods.

• Another harm-reduction strategy was to combine or substitute

the drug of choice with drugs that were perceived to be less

harmful, such as replacing crack with marijuana.

• Health care services, particularly prenatal care, were perceived

as the best way to improve health during pregnancy, but most

women did not get as much health care as they wanted. They

were more likely to disclose their drug abuse to health care

providers during pregnancy so that they would obtain the best

medical care possible, but they were likely to stop seeking health

care during or immediately after pregnancy if they felt caregivers

were judging them or ridiculing them for being pregnant and

abusing drugs.

• In conclusion, data indicated that pregnant drug abusers often

practiced harm reduction in some way.

Issues for Future Research

• More research is needed on how to assist women with harm

reduction and the use of new strategies for harm reduction.

How can treatment services be modified to complement the

efforts of women to reduce the harm of drug abuse? Women

who abuse drugs need more information about how drugs affect

their health so that their efforts at harm reduction can be more

successful. Dr. Rosenbaum asserted that women should have

access to treatment even if they are not successful in being

totally abstinent.

• Female drug abusers, particularly those who are pregnant, want

and need health care services, but they will end contact with

health care providers who appear to judge, blame, or humiliate

them for their drug abuse. Drug treatment services should be

designed to ease the problem of women avoiding or dropping

out of drug treatment programs.
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STRESS AND COPING AMONG WOMEN

R. Lorraine Collins, Ph.D.

Abstract

Dr. Collins presented the results of a survey on stress, coping, and drug

use in a sample of nearly 2,000 female nurses in New York State. Prevalence

of drug use among the nurses was compared with its prevalence among a

subsample of women who participated in the 1991 National Household

Survey on Drug Abuse (NHSDA). The key study question was whether

stress and coping contributed to drug use or whether neuroticism influenced

drug use. The definition of neuroticism included (1) anxiety and depression,

(2) hostility, (3) self-consciousness, (4) impulsiveness, and (5) vulnerability.

The nurses reported higher rates of prescription drug use than the women in

the NHSDA. Cross-sectional analysis suggested that neuroticism was related

directly to drinking alcohol as a way to cope with work stress and becoming

acutely intoxicated but that it was not related to typical drinking. Future

research should focus on longitudinal studies, studies of other populations,

and examinations of sex differences.

Current Information From the Literature

Dr. Collins prefaced her findings with brief comments on what is

known from the research literature on work stress and drug use, adaptive

versus maladaptive coping, and the role of neuroticism.

• The existing literature is inconsistent as to whether stress and

coping techniques are connected to drug use. There is little

literature support for drug use as a direct response to work stress,

but there is some support for the idea that job stress combined

with ineffective coping strategies increases the potential for drug

abuse.

• Drug abuse often is viewed as a short-term maladaptive coping

strategy that provides temporary release from stress. Some

literature suggests that women more often than men use maladaptive, or emotion-focused, coping strategies; therefore, it may be

that women turn to drugs to alleviate anxiety, depression, and

stress temporarily.
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• Neuroticism has been linked independently to stress as well as to

coping; therefore, it was hypothesized that it also may be linked

to drug use. Highly neurotic people report more exposure to

stress and appear to react more strongly to stress and to use

maladaptive and ineffective coping strategies.

Findings of the Study on Stress and

Drug Use Among Female Nurses

Dr. Collins presented information from a survey on drug use that

was completed by 1,951 female nurses in the State of New York. Nurses

were selected because their profession is highly stressful and allows easy

access to medications, factors that are believed to place them at risk of

drug abuse as a way of coping. The study examined the nurses’ past and

present use of alcohol, tobacco, caffeine, prescription drugs, and illicit

drugs. The prevalence data from this survey were compared with data

from the 1991 NHSDA on women in the northeastern United States.

• A high percentage of nurses reported using licit drugs at some

time in their lives. Alcohol had been used by almost everyone,

and there was a relatively high rate of caffeine and tobacco use.

When these data were compared with NHSDA data, it was found

that the nurses had higher rates of past-month and lifetime

alcohol use. The rates of past-month tobacco use were approximately equal. (Caffeine use was not included in the NHSDA,

and therefore data were not available for comparison.)

• The rate of prescription drug use, both past-month and lifetime,

was higher among nurses than among women in the NHSDA,

particularly for tranquilizers and barbiturates. This higher rate is

a concern because health care professionals have easy access to

drugs and are knowledgeable about their effects.

• The data on illicit drug use showed that the nurses used marijuana and opiates at higher rates but used cocaine at lower rates

than the women in the NHSDA sample. The rate of hallucinogen use was about equal.

Subsample of Current Alcohol Drinkers

Data on a subsample of 637 nurses who were current alcohol

drinkers were analyzed by causal modeling, and three alcohol-related
85

outcomes were examined: (1) drinking to cope with stress at work,

(2) typical drinking, and (3) drinking for the acute effects of intoxication.

• Data suggested that neuroticism led directly to alcohol-related

outcomes; that is, drinking was used to cope with work stress.

Data also suggested that neuroticism was related to the perception

of stress, which, in turn, was related to alcohol-related outcomes.

The data did not indicate any link between coping strategies and

alcohol-related outcomes.

• Neuroticism was not related to typical drinking even though it was

related to drinking to cope with work stress. This finding suggested

that typical drinking was a response to social and cultural issues

rather than a response to stress.

Future Research

Longitudinal studies are needed to determine whether there are

causal relationships between neuroticism and drug use. Studies similar

to those described by Dr. Collins are needed on drugs other than alcohol,

and future study populations should be more heterogeneous and examine

sex differences.

ETIOLOGY PANEL DISCUSSION

The discussion presented below followed presentations by members

of the Etiology Panel: Drs. Brook, Kilpatrick, Rosenbaum, and Collins.

Unidentified Audience Member : We published an article in the

American Journal of Psychiatry several years ago that analyzed data on the

causal association and onset of drug abuse and PTSD. We did not collect

data on incestuous rape, which usually occurs at young ages, so these

events were not included in the analysis. However, our data from a sample

of 3,000 people indicated that drug abuse preceded PTSD. We hypothesized that involvement in the drug culture put these people at risk for

violent attacks and similar crimes. This is another area for future research.

Unidentified Audience Member : It is critical that we know more

about childhood victimization before we assume which originates first:

PTSD or other drug and alcohol problems. Data from a NIDA study of

drug-abusing women indicate that childhood victimization occurs first,

followed by signs of PTSD, and then by drug and alcohol problems.
86

Dr. Coryl Jones: Dr. Kilpatrick’s study indicated that victimization

often occurred before the age of 11, in children who were 6, 7, and

8 years of age.

Dr. Nan Vandenberg: First, what would be an ideal prevention

program based on the strengths of these women that mediate the effect

of drug abuse? Second, you noted that the young girls less likely to

develop drug abuse disorders tended to conform to sexual stereotypes.

Some research suggests that adherence to sexual stereotypes in adults

can predict a greater potential for drug abuse. Can you explain this

seemingly inverse finding?

Dr. Brook: For prevention programs, I would first focus on individual personality traits and include solid achievement-oriented activities. Second, some of our research showed that the atmosphere in the

school is an important protective factor. Youngsters in a school where

there was harmony among the administration, teachers, and students

were more insulated from drug use. Youngsters in nondeviant peer

groups benefited from that powerful protective factor, and finally, some

aspects of the neighborhood and culture might be important. Researchers are just beginning to identify the protective and risk factors.

Consequences

MEDICAL AND HEALTH CONSEQUENCES

OF HIV/AIDS AND DRUG ABUSE

Peter A. Selwyn, M.D., M.P.H.

Abstract

Dr. Selwyn gave an overview of the key issues of the HIV epidemic among

women, with special reference to disease manifestations and clinical care. He

pointed out areas of research relevant to the dynamics of this epidemic and

presented epidemiologic information that suggested there were few sex differences in the progression of AIDS. Injection drug use is currently the most

important risk factor for HIV infection among women. Recent studies

indicate that HIV-infected women who use drugs are at higher risk of developing cervical abnormalities, gynecologic infections, and sexually transmitted

diseases than HIV-infected women who do not use drugs. More research is
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needed on HIV infection among women and the medical and health consequences of drug abuse.

Overview of the Epidemiologic

Features of the AIDS Epidemic

• The rate of heterosexual transmission of AIDS has increased in

the United States. In 1994 AIDS became the leading cause of

death among young adult males and the fourth leading cause of

death among young adult females. Among African-American

women, it is the second leading cause of death, and in parts of

the Northeast where AIDS is most concentrated among people

of color, it has been the leading cause of death among both young

men and women for several years.

• Injection drug use is the most important risk factor for HIV

infection among women and accounts for half of all AIDS cases

among women. One-third of AIDS cases among women have

been attributed to heterosexual contact, and most involved

contact with injection drug users.

Recent Research on HIV and Implications

for Improving Women’s Health

• Drug abuse, particularly of cocaine, is one of several factors that

seems to increase the risk for HIV infection. A 1991 study in

New York found that crack use, prostitution, and sex in exchange

for drugs predicted HIV infection among women, but a history of

syphilis was not a significant predictor. Among men, syphilis was

found to be a predictor, along with crack use and contact with

prostitutes.

• A 4-year study in Louisiana found that HIV-positive women who

injected drugs were at greater risk of developing sexually transmitted diseases than HIV-positive women who did not inject

drugs.

• Studies have shown a strong relationship between cervical

dysplasia and HIV infection. An Italian study of female drug

abusers found that those infected with HIV were more likely than

those who were not infected with HIV to experience cervical

abnormalities, ulceration, and infection with common organisms.
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• Dr. Selwyn suggested that, in addition to gynecologic disease,

many differences in the manifestations of HIV/AIDS between

men and women were primarily due to differences in screening,

access to care, utilization of care, and stage of disease at presentation. An anonymous seroprevalence study found that, in an

emergency room, male patients were more likely than female

patients to be screened for HIV.

• Dr. Selwyn reported the results of several studies conducted at the

Montefiore Medical Center with female and male drug abusers:

1. There was high compliance among subjects when clinical

care, including specific medical services for women, and

methadone treatment were linked with AIDS research.

2. No differences were found in the rate of progression to AIDS

between the sexes or among racial and ethnic groups. There

were no differences in AIDS progression because all subjects

had equal access to care at the center.

• The overall manifestations of AIDS among women and men were

similar after controlling for certain sociodemographic variables

and gynecologic manifestations.

• No differences were observed between drug abusers and those

who did not use drugs in terms of HIV progression. Dr. Selwyn

believes the key to differences in disease progression was the lack

of AZT therapy; drug use may be a barrier to AZT therapy.

• A study of a multicity, representative sample of HIV-infected

people needing drug treatment services showed that up to half

needed many other things such as mental health services, housing, home care, transportation, or entitlements. Dr. Selwyn

noted that because many of these needs and circumstances

affected outcomes, innovative approaches were needed to meet

needs and improve outcomes.

• In a recent study of HIV transmission to infants in utero (ACTG

076), only 8.3 percent of the infants born to mothers who were

treated with AZT during pregnancy were born infected with HIV,

compared with 25.5 percent of those born to women who received a placebo. ACTG 076 is the first study to show a measurable effect of intervention in preventing HIV transmission from

mothers to infants, and it raises significant issues that need
89

scrutiny, such as how to identify women who may need AZT

treatment and how best to counsel women and implement

treatment.

• Several studies have found that among HIV-infected patients,

women, drug abusers, and people of color are less likely than

white men to be offered AZT treatment. Women who were

injection drug users or had been incarcerated were much less

likely to seek HIV care than women who had not used drugs or

been in jail.

• Women who were drug dependent were found to be at high risk

of violence and other abuse, but those who also were infected

with HIV were at even greater risk.

Issues for Future Research

• Women with HIV infection are at risk of developing sexually

transmitted diseases and other gynecologic problems. Research

is needed on what diseases are specific to women with HIV and

how they are manifested. Clinical manifestations specific to

women need to be investigated thoroughly, including the efficacy

of new HIV therapies.

• Much more research is needed on the etiology of HIV infection

and finding methods to help women prevent infection at both

the individual and community levels.

• More research is needed on eliminating barriers to health care for

HIV-infected women and developing new models of care that

integrate approaches from the biologic and social sciences. What

are the most effective strategies for HIV screening and long-term

followup? Are these strategies effective for women of color and

poor women?

• Further research and more conclusive studies are needed on how

to help women, particularly drug-abusing women, avoid common

pathways to HIV infection. How can the rights of women be

safeguarded in community programs designed to prevent HIV

transmission?

• Research is needed on how best to identify women who are at

high risk of HIV infection, particularly female drug abusers; how
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to make services available to them; how to consult with them

before and during pregnancy about AZT intervention; and how

to implement treatment that is effective and likely to have the

desired outcomes.

Questions From the Audience

The questions and answers presented below followed Dr. Selwyn’s

presentation.

Unidentified Audience Member: Were patients in the clinical

research setting offered any antiviral agents besides AZT?

Dr. Selwyn: At the time of the data collection, ddI (dideoxyinosine)

was just becoming available through expanded access and compassionateuse programs. Since then, all the other antiviral agents have been offered

through research, but women have shown little interest in most clinical

trials. There is more acceptance of antiviral agents when they are prescribed by open label.

Unidentified Audience Member: What were the differences between

women and men and active drug users and nondrug users regarding their

willingness to comply with ongoing care that could detect the progression

to AIDS?

Dr. Selwyn: In general, active drug use predicted nonadherence or

worse outcomes in terms of followup for both men and women. However,

other studies suggest that even active drug users outside a drug treatment

program can be followed clinically in some areas and achieve relatively

good treatment outcomes. It is unrealistic to conclude that a person using

drugs cannot be treated effectively.

SOCIAL AND BEHAVIORAL CONSEQUENCES

Rafaela R. Robles, Ed.D.

Abstract

Dr. Robles gave an overview of research on drug abuse in Puerto Rico and

compared data from a NIDA-funded study of AIDS among Puerto Rican and

white women, conducted in both Puerto Rico and the United States. She noted

a substantial increase in drug abuse among Puerto Rican women in recent years.

Despite this trend, drug treatment programs in Puerto Rico and the United States
91

have continued to plan and deliver services without considering the special

needs of Puerto Rican women. Dr. Robles asserted that there is an urgent

need to integrate social support services with nonpunitive drug treatment

services for women. Drug treatment programs must be based on an understanding of the ideology, sociocultural perspective, and needs of Puerto Rican

women and their families. Puerto Rico is one of the epicenters of the AIDS

epidemic, and drug addiction is the primary risk factor for both men and

women.

Trends in Drug Abuse in Puerto Rico

• Dr. Robles and her colleagues assessed the drug abuse education

needs of health care personnel in Puerto Rico and found that

nursing and medical education curriculums had little instruction

on drug abuse except for pharmacology-related information. The

clinicians surveyed wanted more information on drug addiction

and legal and policy issues, especially those related to women.

• There has been a substantial increase in drug abuse among Puerto

Rican women. More women than men seem to be abusing

barbiturates, sedatives, tranquilizers, and amphetamines. A

survey of high school adolescents found that more girls than boys

were smoking. More women than men are becoming HIVinfected through drug abuse or having sex with drug abusers.

Female sex workers who abuse drugs are more likely to be HIVpositive than their peers who do not abuse drugs.

• Despite these trends, many health and drug treatment centers in

the United States and Puerto Rico continue to deliver services

without considering the special needs of women, and in Puerto

Rico, most do not recognize and address drug abuse among

women unless it is related to motherhood.

• In Puerto Rico, women are seldom offered HIV testing in settings

other than family planning clinics. Late recognition of HIV

infection and poor access to services may contribute to the

different patterns of disease progression and survival in women

and men.

• Sociocultural biases are reflected in legal actions against drugabusing mothers. Such actions include the removal of newborns

from their mothers and court-ordered detentions of pregnant
92

women who abuse drugs. Women of color and low-income

women are disproportionately affected by punitive legal measures,

and fear of such actions discourages women from obtaining drug

treatment and social services.

Early Findings of an AIDS Demonstration Research Study

• Dr. Robles presented the early findings of the NIDA AIDS

Demonstration Research Project among Puerto Ricans. The data

were drawn from 996 female subjects who abused drugs:

351 islanders (those residing in Puerto Rico) and 287 Puerto

Ricans and 358 non-Hispanic whites living in the United States.

• Both groups of Puerto Rican women were more likely than whites

to live on welfare. Puerto Rican women living in the United

States were most likely to use illicit methods to obtain money.

Most Puerto Ricans in the United States (77.4 percent) were

unemployed, followed by whites (65.9 percent), and islanders

(49.9 percent).

• Drug-abusing women in Puerto Rico had a high HIV seroprevalence rate (41.6 percent), similar to that of drug-abusing men.

Logistic regression analysis showed that a history of incarceration,

injection drug use for more than 6 years, lack of condom use,

and syphilis were significantly associated with HIV infection.

Women ages 25 to 34 were at highest risk.

• People who were HIV-positive tended to use more safe sex

measures than those who were not HIV-positive. The reasons

behind this finding are unknown.

Research on Sex Differences Among

Drug Abusers in Puerto Rico

• A comparison of drug-abusing men and women in Puerto Rico

found that more women than men had completed high school,

lived with their children, and received support from the government. Women were more likely to engage in oral and anal sex,

have multiple sex partners, and trade sex for money. They were

more likely to use health services.

• Puerto Rican drug abusers who had social support reported fewer

psychiatric symptoms and physical illnesses and were more likely
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to live longer than those who had little or no social support.

Women were more likely than men to live with their children

in their own homes and to have conflict with family members.

Men were more likely than women to rely on family members

for support, especially with regard to completing drug treatment.

However, drug-abusing women, those both in and not in treatment, were more likely than men to report feeling depressed and

attempting suicide, a finding that is consistent with previous

studies in the United States.

• There were large differences between women and men in experiences of physical abuse. Nearly one-third of the women reported

having been physically abused during childhood, and 21 percent

said that they had been abused in the previous year.

Issues for Future Research

• Research is needed on which drug treatment programs and

services are most effective in meeting the needs of Puerto Rican

women who abuse drugs. What are the differences between

women who receive treatment and those who do not?

• More research is needed on the effect of social policies and laws

on people who abuse drugs, particularly women. Are low-income

women or women of color disproportionately affected by legal

actions, such as the removal of newborns or court-ordered

detention of those who are pregnant? How do such policies affect

their willingness to enter drug treatment?

Consequences Panel

THE CONSEQUENCES OF DRUG DEPENDENCE

ON SOCIAL SUPPORTS, HIGH-RISK SEXUAL

BEHAVIORS, AND HOMELESSNESS

Adeline Nyamathi, R.N., Ph.D.

Abstract

There has been insufficient research on the psychosocial predictors of risk

behaviors and coping behaviors of women, in terms of both AIDS and drug
94

addiction. Knowledge of these risk factors and their influence may suggest

effective new strategies for intervention programs. Dr. Nyamathi presented

information from a 5-year study of factors that predicted risk behavior in

African-American and Latino women who resided in homeless shelters and in

residences provided by drug recovery programs. A Comprehensive HealthSeeking and Coping Model was used to examine situational, personal, and

sociodemographic factors; community resources; cognitive appraisal; threat

appraisal or perception; coping skills for managing threats; and outcome

variables. Self-esteem was found to be an important predictor that affected all

other variables, including social support, emotional distress, threat appraisal or

perception, barriers to condom use, active coping and avoidant coping skills,

drug abuse, and AIDS and sexual risk behaviors. It is important to implement

culturally sensitive intervention strategies that will enhance women’s coping

skills, self-esteem, and social support. More research is needed on the psychosocial predictors of both risk behaviors and coping behaviors related to drug

abuse among women.

Five-Year Intervention Study of Risk Factors

Among Women in Poverty or Drug Treatment

Previous research has shown that women with high self-esteem or

social support are less likely to perceive threats in their environment,

more likely to cope adaptively with problems, and less likely to experience emotional distress. Dr. Nyamathi’s study hypothesized that women

with greater self-esteem and social support were likely to experience

little emotional distress, perceive fewer threats in their environment,

and experience fewer barriers to condom use. Therefore, they also

would be likely to use more active coping techniques, engage in fewer

AIDS risk behaviors, and use drugs less often.

The researchers further speculated that individuals with greater

emotional distress were likely to perceive more threats, experience more

barriers to condom use, use more avoidant coping techniques, engage in

more AIDS risk behaviors, and abuse drugs more often. They hypothesized that coping was associated with risk behaviors and that ethnicity

and acculturation were related to all of the other psychosocial variables.

The subjects included 714 African-American women and

691 Latino women who were recruited from drug recovery programs

and homeless shelters. Nurses and outreach workers of AfricanAmerican and Latino backgrounds administered the survey
95

questionnaires, and the content and semantics were examined to ensure

that they were valid and culturally appropriate.

Self-esteem, social resources, and emotional distress were defined

as predictor variables; threat perception, barriers to condom use, and

coping were considered mediating variables. AIDS, sexual risk behaviors, and drug abuse behaviors were defined as outcome variables. Drug

abuse behavior was measured in terms of noninjection drug use, injection drug use, and sharing needles.

The women in the study were separated into three groups for data

analysis: African-Americans, highly acculturated (HA) Latinas, and less

acculturated (LA) Latinas. Many of the hypothesized relationships were

supported by the models.

• Fifty-nine percent of African-American women used noninjection drugs, compared with 25 percent of HA Latinas and

4 percent of LA Latinas. Injection drug use was highest among

HA Latinas (23 percent), compared with African-American

women (10 percent) and LA Latinas (1 percent).

• Self-esteem was an important variable and affected all the others.

Among African-American women, self-esteem was positively

related to a high level of social resources and negatively related to

emotional distress. The higher the social supports, the higher the

self-esteem and the lower the emotional distress. The relationships among the variables were similar among African-American

and Latino women, except that for Latino women, self-esteem

was not related directly to barriers to condom use.

• Emotional distress was the main predictor of threat perception.

Individuals with more distress tended to use avoidant coping and

were more likely to use drugs. Dr. Nyamathi speculated that

interventions that reduce emotional distress may influence

women’s perceptions of threats. A high level of threat perception

predicted barriers to condom use for both African-American and

Latino women. In addition, a high level of threat perception

combined with avoidant coping predicted drug abuse. Active

coping indicated less AIDS risk and drug abuse behaviors;

therefore, enhanced coping skills are critical to drug abuse

intervention strategies.
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• Among Latinos, social support predicted barriers to condom use,

and AIDS and sexual risk behaviors among Latino women were

predicted by barriers to condom use, threat perception, and

avoidant coping techniques. The higher the acculturation level,

the greater the barriers to condom use and the greater the level

of AIDS, sexual risk behaviors, and drug abuse behaviors. Interventions with Latino women need to incorporate elements of

the traditional Latino family and community to strengthen

support for condom use.

Conclusion

The cross-sectional design of the study limited the conclusions that

could be made about causal relationships, but it is clearly important to

implement culturally sensitive intervention strategies for women that

will enhance coping skills, self-esteem, and social support. This research

begins to pinpoint the ways in which personal resources influence

healthy behaviors.

Issues for Future Research

• More research is needed to assess the psychosocial predictors of

drug abuse and AIDS risk or sexual risk behaviors among women

who live in poverty. Research also is needed to test models for

assessing the psychosocial predictors of health-seeking and coping

behaviors among poor women.

• The differences in psychosocial predictors among racial and

ethnic minority groups need to be identified so that culturally

appropriate interventions can be designed, developed, and

evaluated.

PSYCHIATRIC SEQUELAE OF DRUG ABUSE

Linda B. Cottler, Ph.D.

Abstract

Dr. Cottler’s presentation focused on the psychiatric sequelae of drug

abuse in women, such as antisocial behavior and depression. She stressed the

importance of researching psychiatric issues related to drug abuse because these
97

topics often receive little attention. There are differences between women and

men in the psychiatric sequelae of drug abuse, but such differences also can be

found among subgroups of drug-abusing women in terms of age, socioeconomic status, and other factors. Data were examined on early drug abusers

(those who started drug use by 15.7 years of age) and later drug abusers

(those who started drug use by 18.8 years of age). Early drug use was

associated with greater drug abuse and phobic, depressive, and antisocial

disorders. These findings point to the need for more studies to develop effective

strategies for treating psychiatric disorders in women who abuse drugs.

Results From Two Studies

Dr. Cottler merged data on drug abusers from two studies conducted

in St. Louis. The two samples included people who had received drug

treatment and those who had not been treated but had consented to be

in the study. The data on women were stratified to identify patterns,

such as age of initial use and the use of cannabinoids, amphetamines,

sedatives, cocaine, heroin, opioids, PCP, hallucinogens, and inhalants.

The results were as follows:

• Early drug abusers (those who started drug use by 15.7 years of

age) were more likely to be alcoholics than later drug abusers

(those who started drug use by 18.8 years of age).

• When data from the St. Louis studies on antisocial personality

(ASP) disorder and subtypes were examined, some women met

the criteria for ASP disorder but had not been formally diagnosed. Later drug problems seemed to be associated with later

antisocial adult behavior. Early drug abuse by women was

characterized by more irritable and aggressive behaviors, such as

repeated physical fighting and physical attacks on partners. Early

drug abusers also showed less remorse for hurting people or

stealing than did later drug abusers.

• Almost all early drug abusers had used cannabis, and 60 percent

had used amphetamines, compared with 27 percent of later

abusers. Early abusers tended to use multiple drugs, including

cannabis, amphetamines, sedatives, and cocaine, and 68 percent

used injection drugs. Later drug abusers used primarily cannabis

and cocaine. However, the two groups did not differ significantly

in terms of being diagnosed with drug abuse or dependence,
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except that early abusers were more likely to be alcoholics.

The earliest symptom of drug abuse or dependence was hazardous

drug use or use with increased risk of injury, and this symptom

appeared when the women were about 20.2 years of age.

• Other research has found that externalizing disorders, such as

ASP disorder and other personality disorders, are more common

among men than among women, whereas internalizing disorders

are more common among women. Data show that women may

be subtyped in terms of psychiatric sequelae and that psychiatric

diagnoses are much more prevalent among drug-abusing women

than they are among women in general.

• Drug abuse begins at about the same time as antisocial behaviors,

but depression starts after the onset of drug abuse and may be a

consequence of drug abuse. About 30 percent of the St. Louis

research participants had attempted suicide, and 54 percent had

thought about dying or committing suicide.

Issues for Future Research

• Research is needed on the psychiatric conditions found in

different subgroups of women who abuse drugs, such as those

of different ages and those who use different types of drugs. It is

important that comorbid psychiatric conditions be assessed and

that levels of drug addiction be analyzed.

• Research is also needed on antisocial and depressive behaviors

among drug-abusing women, both singly and in combination,

because women are more likely to seek treatment for depression

than for antisocial behaviors. Studies are needed to develop

effective treatment strategies for women.

Questions From the Audience

The question-and-answer session presented below followed Dr.

Cottler’s presentation, which was part of the Consequences Panel.

Unidentified Audience Member: There is controversy about

whether certain people who are diagnosed with ASP disorder really

should receive that diagnosis on the basis of drug abuse-related

behaviors. With regard to ASP rates among the women in the study,

particularly those who had only adult symptoms, have you looked at
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the issue of how many of the behaviors labeled as antisocial are a direct

result of the drug abuse as opposed to being a distinct antisocial type?

Dr. Cottler: The old criteria for an ASP diagnosis eliminated anything caused by other drugs and alcohol, and this restricted the prevalence rate of drug abuse somewhat. But we found that some researchers

mark the responses they get in the drug section. For example, if someone is an injection drug user, that is automatically counted toward both

drug use and the antisocial behavior criteria. We did not do that in our

study.

Unidentified Audience Member: What about other behaviors that

are directly the result of drug abuse but are not actual drug abuse? For

example, the only time someone steals is to get money for drugs. Have

you tried to look at that factor when you separate the actual effects of

the drug abuse from other types of antisocial behaviors?

Dr. Cottler: That is a good point, but it is extremely difficult to ask

respondents to tell you why they stole money—whether it was because

of drugs or something else. But this is an important issue for people who

do this kind of research to figure out when they are asking questions and

doing the algorithms for antisocial behavior.

PARTNER VIOLENCE

Brenda A. Miller, Ph.D.

Abstract

Dr. Miller discussed recent research on partner violence and its relationship to drug abuse. Research shows that women who abuse drugs regularly

and are in drug treatment programs are significantly more likely to report

partner violence than women in the same treatment settings who do not abuse

drugs regularly. Preliminary data from a NIDA study showed that 90 percent

of women in drug treatment had experienced severe violence from a partner

during their lifetimes. Women from the general population in the same

geographic area who were not in drug treatment had a significantly lower rate

of violent experiences. The data indicate that drug treatment interventions are

important in addressing partner violence and its effect on women’s treatment

outcomes. More research is needed to determine whether there is a causal

relationship between drug abuse and partner violence.
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Earlier Studies on Family and Partner Violence

Data have indicated a connection between partner violence and

drinking among both women and men. However, most violent situations occurred when neither partner had been drinking; therefore,

drinking is not a necessary correlate of partner violence.

The analysis of national data has revealed that the combination of

blue-collar occupational status, drinking, and the approval of violence

is closely associated with high levels of violence.

NIAAA Study of Women in New York State

Dr. Miller reported the results of a study sponsored by the National

Institute on Alcohol Abuse and Alcoholism (NIAAA) of 472 women

in western New York. The women were from outpatient alcoholism

clinics, classes for alcohol-impaired driving, battered women shelters,

outpatient mental health clinics, and the general population.

There was a significant difference in the amount of severe partnerto-woman violence among women in alcoholism treatment compared

with women in the general population. Women who regularly abused

drugs and were in treatment (treatment for alcoholism, mental health

outpatient services, or battered women’s shelter) were significantly more

likely to report partner violence than women in the same treatment

settings who did not regularly abuse drugs. Although women in the

sample may have had several partners during the course of the study,

these findings endured regardless of which partners were involved.

Preliminary Data From NIDA Study

of Women in Drug Treatment

Dr. Miller presented preliminary data from a NIDA study examining

drug issues and drug problems among two groups of women in the same

geographic area; one group was in drug treatment, and the other was not.

A third group of women was recruited from battered women shelters and

matched with a group of women who were not in shelters but who lived

in the same geographic area.

• Preliminary data for the women in drug treatment and the

matching general population sample showed that 90 percent of

women in drug treatment had experienced severe violence from
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a partner during their lifetimes. The rate of severe partner

violence in the general population sample was high, but it was

significantly lower than that experienced by women in drug

treatment, even after the women had been in drug treatment for

6 months.

• There were no significant differences in rates of violence between

the women in the two groups selected from the general population, but there were significant differences in the rates of partner

violence when the women in drug treatment and in shelters were

compared with the women in the general population groups.

• It is not known whether partner violence is a consequence of

drug abuse or vice versa. Dr. Miller noted that the NIAAA study

found a slightly stronger connection for victimization experiences

predicting alcohol problems than the reverse; therefore, the

possibility of a connection exists. She speculated that acute

intoxication or chronic abuse of alcohol or other drugs may make

a person vulnerable to victimization; however, she cautioned

against blaming drug abusers for being the victims of violence.

Implications for Drug Treatment and Prevention

• It is important that drug treatment strategies for women address

partner violence and its implications for treatment outcomes.

Support systems for women need to be designed to respond to

the problems of partner violence and alcohol and other drug

problems. Most shelters and drug treatment settings address

only one of the two problems.

• Dr. Miller asserted that there is an acceptance of violence in

our society that is an environmental and social barrier to drug

treatment and needs to be addressed. Treatment or intervention

strategies that focus solely on individual change are ineffective if

the drug abuser must return to the same environment and stresses

encountered before entering drug treatment.

Issues for Future Research

• Is partner violence a consequence of drug use or vice versa?

Does victimization make women more vulnerable to alcohol and

other drug problems? What is the relationship between partner
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violence and drug abuse? How does partner violence affect a

woman’s treatment outcome? Treatment programs for drug abuse

must take into account the significance of violence and the

woman’s history of victimization.

• Researchers who seek to develop more effective drug abuse

interventions for women must recognize and examine the

intergenerational patterns of family violence and alcohol and

other drug problems. Individual and cultural differences need

to be recognized.

• Researchers need more time to analyze data and write and

disseminate their research findings so that myths about drug

abuse are not perpetuated. Better methods are needed to disseminate research findings and ensure their application in the health

care system.

Questions From the Audience

The discussion points presented below followed Dr. Miller’s presentation, which was part of the Consequences Panel.

Dr. Judith Brook: There is a possibility that drugs and victimization may eventually demonstrate a reciprocal model. Assuming that

drug use has a later impact on victimization, two important mechanisms

to explore are the family and types of friendships or social networks. It

also might be useful to control for some personality traits because it is

known that they are related to alcohol and other drug use and may be

related to victimization as well.

Dr. Miller: I think you have two good points.

Prevention

LINKS BETWEEN PREVENTION AND TREATMENT

Karol L. Kumpfer, Ph.D.

Abstract

Dr. Kumpfer presented information from the research literature on the

links between drug abuse prevention and treatment among drug-abusing
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women and their families. She noted the need to design drug abuse prevention

programs that focus on specific research-based risk factors, such as poor

maternal-child relationships, child abuse and neglect, sexual abuse, partner

violence, posttraumatic stress disorder, poverty, and the excessive stress and

social isolation often experienced by single parents. Drug treatment programs

that strengthen the family and include parent training, family therapy, and

children’s skills training successfully reduce children’s interest in drugs. Little

research has been done on drug abuse prevention for women and adolescents

who do not have children, and programs for high-risk female adolescents are

rare.

Current Information on Drug Abuse

Prevention and Children

There is little research on drug abuse prevention for women and

adolescents, although there is mounting research on drug abuse risk

factors. Most current information is based on research conducted with

the children of alcohol-abusing parents, but recently research has been

conducted with the children of parents who abuse drugs other than

alcohol to identify similarities.

• Research has shown that children of drug abusers are at high risk

of future drug abuse. They use drugs at higher rates than children

in the general population, but drug treatment programs for

women rarely address preventing their children’s drug abuse.

Early research findings suggest that the children of drug-abusing

parents can develop resilience that makes them less vulnerable

to stress.

• Five years of research on drug treatment and prevention have

indicated that the behavioral and emotional problems of children

are reduced in a relatively short time when mothers are trained in

parenting and family skills, including therapeutic child play.

These changes also reduce the mother’s level of drug use and

stress.

• Researchers have found that a variety of environmental and

biological factors may increase a child’s risk of becoming a drug

abuser. Environmental factors that contribute to drug abuse

include poor family relationships and communication; increased

conflict; poor discipline style characterized by inconsistency,
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repressiveness, or violence; lack of adult supervision and unrealistically high expectations of children; sexual or other physical

abuse of children; parental and sibling modeling of drug use;

mental or physical illness; criminal involvement; and poor

school environment.

• Child neglect and abuse are significant factors predicting drug

abuse; studies have shown that about 19 percent of opiateabusing families and 27 percent of alcohol-abusing families had

children who were neglected to some degree.

Results of the Strengthening Families Program

Dr. Kumpfer described the results of the Strengthening Families

Program (SFP), a family skills training and drug treatment demonstration program funded by NIDA that includes 14 weeks of parent training,

family therapy, and children’s skills training.

• Drug-abusing parents and their children benefited from participation in an intensive program in which a counselor role-modeled

desired parent-child interactions with parent and child, observed

the parent-child interaction, and then reinforced improved

behaviors. Skills training and family therapy were an important

part of the drug treatment process for mothers. Randomized

clinical trials funded by NIDA suggest that SFP helped the

mothers become better parents, increased their self-esteem, and

reduced their depression.

• Children in the program had less interest in starting to use drugs,

and those who already used drugs began to reduce their level of

use. There were significant decreases in the children’s level of

aggression, depression, conduct disorders, and social withdrawal.

These results have been replicated in other studies, and the results

have been robust in programs that were modified for different racial

and ethnic groups and in those conducted in both urban and rural

communities.

Recommendations for Drug Abuse Prevention

Among Women and Children

• Women at high risk need to be recruited into prevention

programs, and drug-abusing women need to be recruited into
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treatment programs. Recruitment is difficult, but the most

successful programs are those that develop a trusting environment and provide child care, transportation, and social services.

• Prevention programs need to educate mothers about birth control

and about the consequences of their drug abuse on their children.

Programs should be based on specific, research-based risk factors

in mothers: poor maternal-child relationships, child abuse and

neglect, sexual abuse, partner violence, posttraumatic stress

disorder, poverty, and the excessive stress and social isolation

experienced by single parents.

• Drug abuse prevention efforts with adolescent girls should focus

on preventing school dropout and increasing academic success;

preventing pregnancy, sexual abuse, and eating disorders; enhancing mother-daughter relationships; teaching social skills, particularly in choosing friends and boyfriends; and conducting parentpeer support groups in the school.

• Treating the total family unit is critical to any lasting improvement in the family system. Unfortunately, most women’s drug

treatment programs do not do this, despite research on the

psychology of women that suggests women’s relationships to

children and significant others are critical to mental health. It is

necessary to intervene in the multigenerational process of dysfunctional families and drug addiction. Children should be

taught life skills to help them develop resilience and cope with

drug-addicted parents.

Issues for Future Research

• Research is needed on sex-specific drug abuse prevention efforts.

Drug abuse treatment professionals and researchers need to work

together to ensure that etiological research results are translated

into effective drug abuse prevention programs for women and

their children. Research is needed on prevention and treatment

efforts with women and adolescent girls who do not have children; most previous research has focused on those who have

children.

• More research is needed on the parent-child relationship and

why the children of drug-abusing parents are more vulnerable to
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drug abuse. Is it due to in utero exposure, parental drug abuse, or

poor parenting? What are the differences between children of

alcohol-abusing parents and those whose parents abuse other

drugs? Are there differences in terms of genetics, environment, in

utero exposure, or direct versus passive exposure? Prevention

programs that focus on children from birth to age 6 need to be

developed.

• Early research suggests that children who live with drug-abusing

parents may have increased competencies and resilience to stress

because of the challenges and stresses they are inadvertently

exposed to. More study is needed on what can be done to

strengthen the resilience of these children.

• Programs for adolescent girls should focus on school dropout

prevention, academic encouragement, sexual abuse prevention,

mother-daughter relationship enhancement, eating disorder

prevention, and assistance with social skills such as choosing

friends and boyfriends. What are the factors that cause some

adolescent girls to lose interest in academic success as they

mature physically? Parent-peer support groups also are needed.

Questions From the Audience

The question-and-answer session presented below followed

Dr. Kumpfer’s presentation.

Dr. Risa Goldstein: Have you or anyone else applied the “Strengthening the Families” interventions in residential treatment settings?

Dr. Kumpfer: These interventions have been used in methadone

maintenance programs and mental health outpatient clinics. Although

they are appropriate for residential programs, they require additional staff

training. A residential program that already involves children presents

an ideal opportunity for a demonstration program.

Dr. Judith Brook: Your program seemed to be developmentally

appropriate, taking into consideration the age, stage of development, and

sex of the child.

Dr. Kumpfer: Our program is for 6- to 12-year-olds. We desperately

need a program for children from birth to age 6 because these are the ages

of most children who are in residential programs.
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Dr. Brenda Miller: We tend to overlook teenagers when we

develop drug abuse prevention programs, but the teenage years are when

drug use patterns are established. Could you comment about where we

might go in prevention programs for teenagers?

Dr. Kumpfer: We have not seen the prevention field move toward

programs for adolescent females. We need to work with these adolescents on the importance of academic success and how to choose good

friends. Peer influence is a most important factor in their risk for

becoming drug abusers. It is important to help parents understand and

communicate with their teenage children.

Dr. Miller: The teenagers who most often have problems with

drugs and early pregnancy are those who are estranged from their

parents. Some families do not believe they need to protect their teenage

children. When you hear about a teenage girl’s sexual activity, it is

always assumed that the activity was her choice. Our models for prevention do not address the complexities of that age group.

Dr. Kumpfer: You have raised an issue that could be addressed, for

example, through harm-reduction programs to help girls avoid date rape

or sexual abuse. Such programs would be useful for younger girls as well

as for girls in junior high and high school. It is also a good idea to reach

parents, perhaps through public service announcements, and remind

them that they need to protect their children.

Intervention

INTERVENTION, OUTREACH,

AND SPECIAL NEEDS

Kathy Sanders-Phillips, Ph.D.

Abstract

Dr. Sanders-Phillips addressed the correlates of health behavior among

low-income women from racial and ethnic minority groups and the implications for drug abuse prevention and intervention. Drug abuse is a health or

risk behavior that represents the endpoint of a series of health decisions. Dr.

Sanders-Phillips’ research indicated that there were highly significant ethnic

differences, not only in the health behaviors of black and Latino women but
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also in other related factors. In almost every category, Latino women were

more likely than black women to engage in healthy lifestyles and behaviors.

Dr. Sanders-Phillips suggested examining the roles of internalized racism and

exposure to violence to determine what effect they have on drug abuse among

women from racial and ethnic minority groups. The study findings reaffirmed

the conclusion that the social and cultural environment has a substantial effect

on the health behaviors of these populations.

Information From the Research Literature

• Research at the University of Pittsburgh indicates that life

events, physical health problems, and internalized racism have

an important effect on alcohol abuse by black women. Religious

orientation has an inverse relationship with alcohol consumption

and is correlated positively with internalized racism in black

women.

• Physical health problems and internalized racism are significant

predictors of depression among black women. Dr. SandersPhillips asserted that the data raise the possibility that factors

such as internalized racism may mediate the relationship between

depression and drug abuse.

• There is evidence that exposure to daily violence creates feelings

of powerlessness, hopelessness, and alienation that influence

women’s health behaviors, decisions about family planning and

prenatal care, and relationships with their children.

Study of Health Promotion Behaviors and Barriers

Dr. Sanders-Phillips asserted that by examining drug abuse in the

larger context of women’s health decisions and behaviors, it is possible

to identify the correlates of drug abuse and health behaviors and identify

factors that increase the risk of drug abuse. She recruited 243 black and

Latino women from Head Start programs in south-central Los Angeles

for a study that examined how frequently women engaged in four health

behaviors: eating breakfast, sleeping 7 or 8 hours per night, exercising at

least three times per week, and using alcohol or tobacco. This research

confirmed the importance of social and cultural factors in women’s

health behaviors and decisionmaking.
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• Race and ethnicity were significant factors that predicted health

promotion behaviors. In almost every category, Latino women

were much more likely than black women to engage in healthy

lifestyles and behaviors. Only 21 percent of black women ranked

health as a first priority in their lives, compared with almost

51 percent of Latino women. More black women than Latino

women ranked religion as their first life priority. The data suggest

that social and ecological factors are significant correlates of

health behaviors.

• Health behaviors, with the exception of exercise, were correlated

highly with low consumption of alcohol and other drugs.

Women who reported eating breakfast and sleeping 7 to 8 hours

per night tended to report lower levels of alcohol and tobacco

abuse.

• A woman’s perception of the health care worker and whether the

person truly cared about her health was another important factor

in whether she engaged in health promotion behaviors.

• Black women were more likely than Latino women to report

good or excellent health status, and they were much more likely

than Latino women to be employed and to have health insurance. Latino women were more likely than black women to

perceive their health status as fair or poor.

• Black women were more likely than Latino women to report

experiences of violence. Exposure to violence was negatively

related to engaging in healthy behaviors. The findings suggest

that exposure to violence, perhaps in addition to direct victimization, may influence health behaviors, including alcohol and

other drug abuse.

Issues for Future Research

• More studies are needed to examine the racial and ethnic differences in the factors associated with the health behaviors and

correlates of drug abuse among women. Is there a relationship

between internalized racism and health behaviors? Research on

internalized racism may provide information about sources of

stress for women from different racial and ethnic minority groups

and will help develop more effective intervention programs.
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• It should be determined whether exposure to violence increases

the abuse of illicit drugs or serves as a precursor to individual

victimization. Are there racial and ethnic differences in the

relationship of exposure to violence and victimization to health

behaviors and drug abuse?

Questions From the Audience

The questions and answers presented below followed the presentation by Dr. Sanders-Phillips.

Dr. Rafaela Robles: Are there studies that have used acculturation

as a mediator variable? Migrants who are not integrated into mainstream society often do not know how to use the health care system.

Dr. Sanders-Phillips: We looked at acculturation, but we were

dealing with a sample that was not highly acculturated. Some literature

suggests that as Latino women become more acculturated, their health

behaviors become poorer. These findings have tremendous implications

for our understanding of drug abuse in that population.

Dr. Robles: With regard to the finding that Latino women’s health

behaviors worsen as they become acculturated, it has been said that

Americans do not like to acknowledge being sick because they do not

want to miss work. Another important variable is migration status.

Recent migrants often are not integrated into the health care system

because they have not become acculturated.

Dr. Sanders-Phillips: The main message is that for researchers to

understand the health behavior patterns of different groups, they have

to examine the social experiences of those groups.

Dr. Robles: When I compare data on drug abuse among women in

Puerto Rico and Puerto Ricans living in the United States, I find large

differences because of the differences in the social experiences between

those groups. For example, in Puerto Rico, we are not a minority as we

are in the continental United States.

Dr. Sanders-Phillips: I believe that minority status and social

experiences are tied to Taylor’s finding of relationships between internalized racism and health behavior.

Dr. Nan Vandenberg: Taylor’s study has suggested that within

the gay and lesbian population, the use of drugs is 20 to 30 percent.
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However, most researchers ask subjects about marital status rather than

sexual orientation, and therefore, homosexuality often is not identified.

If 20 to 30 percent of the gay and lesbian population are drug addicted,

it may be explained by internalized homophobia in confluence with

sexism and racism. I think we need more studies that examine sociocultural contexts.

If Latino women were more likely to engage in healthy behaviors,

why did they feel less healthy?

Dr. Sanders-Phillips: That question has intrigued me, and we are

still investigating it. Rates of depression tend to be high among Latino

women, and the literature suggests that they may somaticize this depression. My data also suggest that many of Latino women’s health habits

are culturally determined so they may not be making conscious decisions

about their health behaviors.

Unidentified Audience Member: Black women in the study said

they were slightly more likely to exercise than Latino women. Why was

this not reflected in their overall health behaviors and lifestyles?

Dr. Sanders-Phillips: That is another intriguing question. Exercise

was correlated less highly with other health behaviors, and evidence in

the literature suggests that other health behaviors are influenced more

by psychological factors such as stress and depression. But exercise

patterns are also affected by stress and depression, so psychological

factors are one potential answer. The ethnic difference is related in part

to the perceptions of danger in the community, which were higher

among black women.

Dr. Joyce Roland: Do you have a method or an instrument that

measures internalized racism?

Dr. Sanders-Phillips: Jerome Taylor at the University of Pittsburgh

has a scale to measure internalized racism.

Dr. Roland: A factor contributing to the finding that black women

feel more healthy than indicated by their health behaviors might be

their belief that God will take care of them.

Dr. Sanders-Phillips: I believe the discrepancy between perceptions of health status and health behavior is explained in part by possible

ethnic differences in how women define health status and related

factors. I believe there is a historical precedent, particularly for black

women in this country, to define oneself as healthy because health is
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related to the ability to take care of one’s family, but this ability may be

unrelated to how a person feels.

Unidentified Audience Member: Did you control for the fact that

Mexican-Americans, in the Southwest in particular, are so eager to

please that they often give positive answers, which can bias the questionnaire results? Also, did immigration status affect whether they had

insurance coverage? A third question is whether you identified their

religious affiliation, because the Catholic church has a significant

influence on the Latino population. Were the concepts of alternative

medicine and the use of shamans and healers that are popular among

Mexican-Americans considered in the findings?

Dr. Sanders-Phillips: We did not look at alternative therapies, but

we are aware of their use. We avoided direct questions about immigration status because they tend to create fear that mitigates against the

trust we need. We recruited, to the extent possible, through the Head

Start program and had the support of teachers in the classroom. This

increased the probability that we would get more truthful answers from

the Latino women. Also, the questionnaires were in Spanish and were

administered by Spanish-speaking interviewers. It was easier to recruit

Latino women possibly because they are eager to integrate into the

mainstream system. Black women, for the most part, have given up on

that hope.

Unidentified Audience Member: Latinos tend to be predominantly

Catholic. How does internalized racism relate to the religious message?

Dr. Sanders-Phillips: We did not look at that, but I would say that

there are implications in the broader system. However, an investigator

who has examined power differentials between physicians and patients

from racial and ethnic minority groups found that the greater the power

differential, or the perception of it, the less likely women were to engage

in healthy behaviors.

Dr. Judith Brook: Our research shows that there are a number

of risk factors that are similar in different racial and ethnic groups. A

study in East Harlem found some major differences between AfricanAmericans and Puerto Ricans in terms of protective factors. For

example, among African-Americans, modeling was important in terms

of family, mentors, and the general environment. Among Puerto

Ricans, behavioral modeling had more to do with the dynamics of the

family interaction.
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Dr. Sanders-Phillips: We need to examine the racial and ethnic

similarities as well as the differences. But we should not confuse the fact

that there may be similarities in risk factors with the possibility that

there may be differences in the situations and environments that cause

those risk factors. Similar risk factors may be associated with different

experiences in different groups of women.

Legal and Criminal Justice Issues

PUNISHING WOMEN FOR THEIR BEHAVIOR

DURING PREGNANCY: AN APPROACH

THAT UNDERMINES THE HEALTH OF

WOMEN AND CHILDREN

Lynn M. Paltrow, J.D.

Abstract

Ms. Paltrow provided an overview of the issue of civil and criminal

punishment as applied to drug-abusing pregnant women, with special emphasis

on its negative effects. She also presented some suggestions, as formulated by

the Coalition on Alcohol and Drug Dependent Women and their Children,

for avoiding the adverse affects caused by such legal actions.

Background

For more than a decade, Government officials have sought to punish

women for drug-using behavior during pregnancy. Some advocates of

“fetal rights” argue that children should be able to sue their mothers for

“prenatal injuries.”

Women’s and children’s advocates agree that women should

engage in behaviors that promote the birth of healthy children, but

they recognize that a woman’s drug abuse involves complex factors

that must be addressed in a constructive manner. Punitive approaches

fail to resolve addiction problems and can undermine the health and

well-being of women and their children. For this reason, public health

groups and medical organizations uniformly oppose measures that treat

pregnant women who abuse drugs as criminals.
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Many types of prenatal conduct can harm a fetus or cause physical

or mental abnormalities in a newborn, including smoking, drinking

alcohol, failure to obtain prenatal care or proper nutrition, environmental hazards, and the contraction of or treatment for certain diseases, such

as diabetes and cancer. Charging mothers with the crime of child abuse

according to the health or condition of the newborn child would subject

many mothers to criminal liability for engaging in all sorts of legal or

illegal activities during pregnancy.

Criminal Prosecution

Although no State has enacted a law that specifically criminalizes

prenatal conduct, prosecutors have used child abuse and neglect statutes

to charge women for actions that potentially harm the fetus. At least

200 women in more than 30 States have been arrested and criminally

charged for their alleged drug use or other actions during pregnancy.

All appellate courts reviewing criminal charges and guilty verdicts

based on a woman’s prenatal conduct have ruled that criminal statutes

must be strictly construed in favor of defendants, and words such as

“child” may not include the fetus. Courts have unanimously held that

drug delivery laws apply solely to circumstances in which drugs are

transferred between two persons already born. Courts also have refused

to apply murder or feticide statutes in such cases, concluding that those

laws were never intended to punish a woman for prenatal conduct

affecting her fetus or to hold her criminally liable for the outcome

of her pregnancy.4

Negative Effects of Punitive Laws

Punitive measures can be counterproductive by causing pregnant

women who are drug abusers to avoid prenatal or medical care for fear of

being detected and severing them from the health care system, thereby

4

In July 1996 the Supreme Court of South Carolina became the first appellate court in

the United States to uphold a prosecution of a woman for child abuse based on her use

of a drug during pregnancy. In a divided 3-to-2 opinion, the court ruled that a viable

fetus is a person for the purposes of South Carolina’s child neglect law and that a woman

could be prosecuted for any behavior that poses a risk of harm to the viable fetus and be

subjected to up to 10 years in prison. A petition for rehearing is pending in this case.
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increasing the potential harm to both mother and fetus. Although only

a minority of States have laws that mandate reporting to civil child

welfare authorities in cases where a newborn is dependent on or tests

positive for an illicit drug, hundreds, if not thousands, of women across

the country have had their children taken away because of a single

positive drug test.

In numerous States, legislators have introduced measures that would

provide prosecutors and courts with explicit authorization to penalize

pregnant and parenting women with drug abuse problems. To date, no

State has expanded its criminal code to punish women who are pregnant

and use drugs, although approximately 10 States have revised their civil

child protection laws to require the reporting of a newborn’s positive

drug test.

Legislative Efforts

The failure to pass any criminal statutes and the limited adoption of

the mother’s prenatal drug use as evidence of civil child neglect reflects,

in part, the overwhelming opposition by the medical community and its

recognition of the extreme shortage of drug treatment programs for

pregnant women.

Recommendations

The Coalition on Alcohol and Drug Dependent Women and

Their Children recommends the following legislative action to improve

maternal and child health:

• Provide that pregnant women may not be subjected to arrest,

commitment, confinement, incarceration, or other detention

solely for the protection, benefit, or welfare of her fetus or

because of her prenatal behavior. Any person aggrieved by a

violation of such a provision should be allowed to maintain an

action for damages.

• Provide that positive toxicology tests performed at birth may

be used only for medical intervention and not for the child’s

removal without additional information being obtained on

parental unfitness, which assesses the entire home environment.
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• Provide that child abuse reporting laws may not be triggered

solely on the basis of alcohol or other drug use or addiction

without reason to believe that the child is at risk of harm

because of parental unfitness.

• Provide that alcohol and other drug treatment programs may

not exclude pregnant women and increase appropriations for

comprehensive alcohol and other drug treatment programs.

• Utilize existing funds for the prevention and treatment of

alcoholism and other drug dependence among women and

their families.

• Review agency services and propose the coordination of related

programs among alcohol and other drug treatment programs,

social services, education, and the maternal health and child

care field to improve maternal and child health.

Questions From the Audience

The discussion presented below followed Ms. Paltrow’s presentation.

Dr. Kathleen Jordan: The majority of women in North Carolina

prisons have high rates of drug abuse and other psychiatric disorders.

Most have been victimized from early childhood, abused by family

members, thrown out of their homes, and involved with male partners

who abused drugs and were abusive. Prisons present an opportunity to

provide drug abuse treatment to many women who have demonstrated

motivation to change their lives.

Ms. Paltrow: The female prison population has tripled since the

war on drugs began. Women in prison are denied many things; neither

pregnant women who give birth while in prison nor other mothers can

see their children. On the one hand, we need treatment in prison. On

the other hand, if better services are available in prison than in the

community, it could send the message that a woman has to be convicted

of a crime to get help.

Dr. Loretta Finnegan: Thank you for suggesting communication

among Government agencies. NIDA’s divisions communicate with

other agencies; for example, NIDA has an interagency agreement with

the Center for Substance Abuse Treatment and the Administration for

Children, Youth, and Families.
117

Ms. Paltrow: When you are a public figure, it is hard to have any

cause of action for libel. Sometimes it is possible to get a correction

from the media, which can be more effective than the original report.

Perhaps the solution is more speech and more correction rather than

silencing or punishing the media.

Dr. Coryl Jones: NIDA is active with the Federal Interagency

Panel on Child Abuse and Neglect, which brings together the Departments of Defense, Justice, Health and Human Services, and Agriculture—all the programs that work with children and families in the

United States and in the military abroad.

Unidentified Audience Member: Please address how the probation

system affects women, particularly women who abuse drugs.

Ms. Paltrow: In many legal cases, woman are poorly advised and

plead guilty to nonexistent crimes. Some feel that probation is a way to

avoid having to deal with the courts. However, if they relapse to drug

use, and without treatment they are likely to relapse, they will end up

in jail.

Crosscutting Issues Panel

AFRICAN-AMERICAN WOMEN AND TRAUMA:

DEPRESSION, DRUGS, AND FAMILIES

Sheryl Brissett-Chapman, Ed.D., A.C.S.W., L.I.C.S.W.

Abstract

Dr. Brissett-Chapman asserted that the analytical approach to understanding African-American women and drug abuse poses serious cultural

constraints. For African-American women, trauma is represented more by

the chronic and unmitigated life circumstances they face than by a series of

assaults or events. Research efforts and methodology that take a more comprehensive and synthesizing approach are needed. Applying scientific observations

to the qualitative experiences of African-American women who abuse drugs

will help produce more effective treatment programs. African-American

women who abuse drugs need structured settings in which building self-esteem,

self-responsibility, and parenting education is combined with drug treatment.

In addition, the development of extended family support systems is critical to

helping these women after they leave drug treatment.
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Depression

• Depression among African-American women is an adaptive,

coping response to their traumatic life circumstances and the

perception that they have few options in life. For AfricanAmerican women, trauma is caused more by chronic and unmitigated life problems than by assault. The stigma associated with

being homeless, abusing drugs, or failing to care adequately for

one’s children has a powerful effect on African-American women

and contributes to their depression.

• African-American women who abuse drugs, are homeless, or are

in prison have to develop survival skills to cope with the trauma

in their lives. Reliance on these skills has become normalized

for many women in shelters and prisons. Dr. Brissett-Chapman

asserted that this normalization of survival skills has serious

implications because it leads to social alienation, family violence

and victimization, abandonment, unmet personal needs, and,

most important, unresolved grief and loss issues.

Drug Abuse and Families

• Eighty percent of the residents of the Baptist Home for Children

and Families are African-American women. Although they do

not come to the shelter for drug treatment, 40 to 50 percent have

drug abuse problems. Other factors that compel women to enter

the shelter include unresolved childhood sexual abuse, evictions,

overcrowding, job loss, and lack of job skills.

• Women often must leave their homes to escape violence by their

partners, which also may involve sexual abuse of children; 30 to

40 percent of the women at the shelter have problems with

domestic violence. In 95 percent of domestic violence cases,

the male perpetrator abuses drugs.

• Drug abuse by family and friends is a problem for many of the

women because they may not be able to limit these relationships

and their effects and because they do not have alternatives for

housing and support.
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Recommendations

• Structured, supportive programs are needed to help AfricanAmerican women confront drug abuse, depression, and family

problems. Successful treatment programs include components

such as self-esteem support groups and interagency planning.

At the Baptist Home for Children and Families, women work

with the staff to develop a plan for their families’ futures. An

extended family system is important to help them deal with

depression and avoid drug abuse. Such support should include

help for depression, treatment incentives, recognition of needs,

and a redefined sense of community and family. Parenting

education is critical because it increases mothers’ self-esteem

and their hopes for their children. They need to experience

incremental successes in various aspects of their lives to support

their efforts to stop drug abuse.

• Women in drug treatment need to be supported until they are

ready to go to permanent housing or other arrangements. Most

treatment programs are too short and unforgiving of drug relapse,

and traditional 12-step programs usually are not sufficient for

these women. At the Baptist Home for Children and Families,

the average stay is 5 months. During this time the women must

take care of their children, follow curfews, assume responsibilities,

comply with drug treatment (although relapses are seen as part

of the path to recovery), and try to meet self-determined case

management goals.

Issues for Future Research

• The analytical model cannot be applied to African-American

women because it poses serious cultural constraints. Research

is needed to identify the qualitative experiences of AfricanAmerican women and to combine this information with

analytical research so that more effective drug abuse treatment

programs can be developed.

• More research is needed on the identity and psychological

development of young African-American females and their

vulnerability to developing depression and abusing drugs to cope
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with traumatic life circumstances. How can the needs of

African-American women be recognized, and what incentives

will help them confront depression and avoid drugs?

• Research is needed on how to address the need of many drugabusing African-American women for external support and

extended family systems. How can a new sense of family and

community involvement be encouraged?

DRUG ABUSE AND HIV AMONG LESBIANS

Marjorie J. Plumb, M.N.A.

Abstract

Ms. Plumb identified shortcomings in research conducted on drug abuse

and HIV among lesbians, including a lack of data on sexual orientation among

general population surveys. The stigma that society associates with lesbians

has hindered progress on research in this community. Some studies have found

that some subpopulations of women who have sex with women, such as IV

drug users, are at higher risk of HIV infection than comparable subpopulations

of heterosexual females. Ms. Plumb suggested that lesbian researchers be

consulted on how to design and conduct research studies on drug abuse in this

population.

Current Knowledge

Ms. Plumb asserted that there are three major problems with the

drug abuse research that has been conducted in the lesbian and gay

communities:

1. Research on HIV, AIDS, and drug abuse often does not include

gathering information on lesbians because researchers assume

that all their female subjects are heterosexual. It is difficult to

adequately conduct research on drug abuse behaviors among

lesbians because many women believe that identifying themselves

as lesbians may put them at risk of losing their children, jobs, or

housing.

2. Many lesbians accept only specific terms to identify their sexual

orientation, and different terms can confound researchers. For

example, some women who have sex with women do not identify
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themselves as lesbian or bisexual. In addition, an individual’s

sexual identity and behavior can change over time.

3. The lesbian community is reluctant to deal openly with drug

abuse and HIV issues because society already stigmatizes these

women for their sexual orientation. Some treatment providers

reportedly advise lesbians not to discuss their sexual orientation

while in treatment to avoid homophobic situations and treatment personnel who inappropriately pathologize lesbianism.

Ms. Plumb presented the following observations from research that

has been conducted with lesbians:

• One study suggested that more lesbians than heterosexual women

smoke cigarettes and that lesbians consume more alcohol for

longer periods. Other studies found that lesbians use alcohol

in combination with other drugs more often than women who

responded to the 1990 National Household Survey on Drug

Abuse. The National AIDS Demonstration Research Projects

found that women who had sex with women were more likely

than heterosexual women to use drugs and be homeless. Research in 1994 indicated that 23.5 percent of lesbians ages 26 to

34 had used marijuana in the preceding month, in contrast to

9.1 percent of women of the same ages in the 1990 National

Household Survey on Drug Abuse.

• Lesbians are at higher risk for HIV infection than heterosexual

women, who are otherwise demographically similar. A Seattle

study of women entering a drug treatment program found

lesbians to be five times more likely to be HIV-positive than

other women. In a 1993 seroprevalence study in San Francisco,

1.2 percent of lesbians were infected with HIV, a rate three

times higher than the estimated rate of HIV infection among

all women and adolescent girls. From this random sample

of lesbians and bisexual women, 10.4 percent reported using

injection drugs since 1978, with 3.8 percent reporting injection

drug use during the preceding 3 years. Seventy-one percent

reported sharing needles, and 31 percent reported sharing

needles with gay and bisexual men.

• The Centers for Disease Control and Prevention (CDC) reports

that about 1 percent of women with AIDS are lesbians (CDC

defines lesbians as women who have had sex only with women
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since 1978). But Ms. Plumb observed that this definition may

exclude a large number of women, and the data are incomplete,

possibly because of the heterosexist bias of providers who complete the CDC reports. A California study found that 21 percent

of women entering a drug treatment program reported having

had sex with both men and women or with women exclusively.

In this study, of women who had one or more female sexual

partners since 1980, 76 percent were injection drug users (IDUs).

A Kinsey Institute study of 400 lesbians found that 46 percent

reported having sex with men, 88 percent reported having had

vaginal sex with men, and 30 percent reported having had anal

sex. Only 5 to 8 percent of individuals in these two groups

reported regular use of condoms.

Recommendation

To avoid heterosexual bias in research, it is necessary to stress the

confidentiality of participants and request information on sexual orientation. Language implying a heterosexual bias needs to be removed.

Lesbian and gay researchers can help design studies, develop research

questions, and make recommendations.

Issues for Future Research

• Research is needed to determine the rates of smoking, alcohol

consumption, and other drug abuse behaviors among lesbians.

The rates of HIV infection among lesbian IDUs compared with

heterosexual women who are IDUs need to be investigated.

• Information is needed to determine if there are differences in

treatment outcomes among lesbian, bisexual, and heterosexual

women as well as treatment differences in terms of race and

ethnicity. The characteristics of successful drug abuse programs

in the lesbian community need to be identified.

• According to some research, lesbians are at higher risk of HIV

infection than are heterosexual women. More research is needed

on this risk factor and the epidemiology of HIV/AIDS among

lesbians.

• Beliefs held by the lesbian community may indicate important

areas of research. For example, one belief is that societal ho-
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mophobia leads to increased drug abuse among lesbians; another

is that alcohol use is high because, until recently, bars were the

only social venue available to lesbians. A third belief is that the

lack of treatment services sensitive to lesbians and gays has led to

an increase in drug abuse.

HISPANIC WOMEN

Margarita Alegría, Ph.D.

Abstract

Dr. Alegría pointed out that there is a lack of research on Hispanic women

who abuse drugs, but the information that does exist indicates that patterns

of drug use and correlates of drug abuse vary among ethnic subgroups. She

asserted that the current conceptual models were not adequate for understanding drug-related behaviors among Hispanic women. Multicausal models need

to be investigated and should examine institutional, individual, and interpersonal factors, with an emphasis on institutional factors. Longitudinal studies

are needed to understand the development of drug abuse in Hispanic women,

its consequences, barriers for Hispanic women in obtaining drug treatment,

treatment outcomes, and the effectiveness of treatment methods. More

information is needed on the influence of acculturation level, social class,

rural versus urban settings, and stressful life experiences on Hispanic women’s

abuse of drugs.

Current Knowledge

Many researchers agree that there is little understanding of the

factors associated with drug abuse by Hispanic women. Most studies

have included only a small proportion of Hispanics and omitted collecting data on sex differences. Recent national data on drug abuse have

begun to reveal some sex differences and have provided descriptive

information on drug abuse by Hispanic women.

• Hispanic women are as likely as white women to have used

cocaine and as likely as blacks to have used crack or alcohol, but

they are less likely than either group to have used cigarettes or

marijuana.
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• The use of drugs appears to vary among the three major Hispanic

groups—Mexican-Americans, Puerto Ricans, and CubanAmericans—and the correlates of drug abuse appear to vary

significantly. It is not known whether the variations are because

of cultural differences or other variables such as level of acculturation, social class, rural or urban setting, or stressful life

experiences.

• There are methodological problems in studies that have been

conducted on drug abuse by Hispanic women. For example,

sex workers and incarcerated women have been excluded from

studies. The underreporting of drug abuse is a potential problem

because women fear losing their children. Self-administered

questionnaires have presented problems for women of low

literacy, and instruments have been used that were not designed

or validated for use by Hispanic women. Cross-sectional study

designs have been used that do not provide information about

the development of drug abuse in Hispanic women.

• Current conceptual models are not adequate for understanding

the drug abuse behaviors of Hispanic women because these

models typically neglect unique variables such as family orientation, migration, loss of status within the community, and strong

interpersonal networks. Models that focus on interpersonal,

institutional, and community variables are needed so that social

norms and constraints are examined and better understood;

the institutional component is particularly important.

• Some correlates of drug abuse by Hispanic women have been

identified, including hopelessness, depression, attitudes toward

deviance, conduct problems, early sexual activity, low educational achievement, degree of religiosity, and boredom. Interpersonal factors identified as correlates include nontraditional

family values, friends and relatives who use drugs, family discord,

and social isolation. At the social and community levels, the

correlates of drug abuse are acculturation, urban-rural differences,

social class, and drug availability.

• Little attention has been given to the nature of and access to

drug treatment for Hispanic women. Some studies report

underuse of treatment services by Hispanics, whereas others find
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Hispanics are overrepresented. Most treatment interventions

and strategies used with Hispanic women have been based on

models developed for Hispanic men. There is a dearth of knowledge about the effectiveness of drug treatment services delivered

to Hispanic women.

• Researchers have found important differences among racial and

ethnic minority groups regarding their denial of the need for drug

treatment or their perception of benefits from treatment. Hispanic drug abusers who had been arrested were significantly less

likely than whites to have received drug abuse treatment or to

recognize that they needed such treatment.

Recent Findings

Dr. Alegría observed that little is known about what drug treatment

programs are most appropriate for Hispanic women. She described the

findings of research with inner-city Puerto Rican women who abused

drugs, which was conducted to determine to what extent social service

variables affected their willingness to seek treatment.

• The women reported that their most urgent needs were for jobs,

housing, social services, help for their children, and drug rehabilitation. Health services usually responded only to women’s

physical health needs, without attention to coexisting problems

such as depression, physical and sexual abuse, or domestic

violence.

• There was a lack of coordination among Government service

agencies that allowed women to fall through the cracks and miss

intervention opportunities. In addition, eligibility requirements

for entering drug treatment or rehabilitation programs excluded

many women. Requirements such as a stable home environment,

a medicaid card, or absence of a criminal record marginalize

women and keep them out of institutional programs.

• Barriers to drug treatment were related more to the agencies that

were to provide treatment than to women’s personal factors.

These barriers included rejection by providers, lack of available

services or poor quality services, programs too short in duration

to be effective, and lack of transitional programs.
126

Issues for Future Research

• A multicausal model of drug abuse in Hispanic women needs

to be investigated and should include individual, interpersonal,

institutional, and community factors. More research is needed

on the influence of acculturation level, social class, rural and

urban settings, and stressful life experience on drug abuse in

ethnic subgroups of Hispanic women.

• The correlates to drug abuse among Hispanic women need to be

examined; they include hopelessness, depression, attitudes toward

deviance, conduct problems, early sexual activity, low educational achievement, degree of religiosity, and boredom. Other

factors requiring attention include nontraditional family values,

friends and family who use drugs, family discord, social isolation,

and drug availability.

• Longitudinal studies of Hispanic women are needed to help

explain the developmental course and consequences of drug

abuse in this population.

• Research is needed on the problems, needs, and access barriers

experienced by Hispanic women who seek drug treatment. What

is their rate of participation, and what factors motivate Hispanic

women to seek treatment? How effective is drug treatment for

them? Another hypothesis to test is whether sustained drug

problems and the lack of effective interventions cause an inordinate number of Hispanic women to be imprisoned.

• There seems to be a dearth of knowledge about the effectiveness

of drug treatment services delivered to Hispanic women, and

more emphasis is needed on understanding what services enhance clinical and functional outcomes. Studies should seek to

identify successful treatments in community-based settings with

parameters for what would be considered successful outcomes.

• The quality of programs needs to be assessed to identify the

service elements that can improve clinical and functional outcomes for Hispanic women. Conceptual models cannot remain

focused on the individual and personal variables associated with

a woman’s prolonged use of drugs.
127

RESEARCH NEEDS OF AMERICAN INDIAN WOMEN

Pamela Jumper-Thurman, Ph.D.

Abstract

Dr. Thurman presented research information about the health of American Indian women and alcohol and other drug abuse. The needs of American

Indian women vary according to tribe and reservation, yet many women are

affected greatly by alcoholism, other drug abuse, and poverty. The ageadjusted mortality rates for tuberculosis, alcoholism, and accidents among

American Indians are more than twice that for all other races in the United

States. There is little information on rates of crime and violence among

American Indians, but some evidence suggests that alcohol abuse is highly

associated with criminal and deviant behavior. Research is needed to identify

drug abuse prevention, intervention, and treatment strategies that meet the

needs of American Indian women, but researchers must work in partnership

with American Indian tribes to ensure community participation and support.

Information From the Research Literature

American Indians are a diverse group, and women from various

tribes and regions respond to problems differently. Drug abuse behavior

varies according to tribal region, and each tribe has its own way of

evaluating community needs. To be effective, drug abuse interventions

must be consistent with the community’s understanding of its needs.

• Many American Indian women are single parents, and they

sometimes support the children of friends and relatives. Many

American Indian women are affected greatly by alcoholism, other

drug abuse, poverty, limited opportunities, and violence, and it

has been reported that some American Indian children have

learning disabilities and are undernourished, neglected, and

unsupervised.

• Nineteen percent of American Indian families receive public

assistance, compared with 5 percent of the total U.S. population.

Thirty-one percent of American Indians earn salaries below the

poverty level, compared with 13 percent of all other races in the

United States. As many as 75 percent of reservation households

are headed by women.
128

• The Indian Health Service reports that the age-adjusted mortality rates for some diseases and conditions are higher among

American Indians than among all other races in the United

States. For example, mortality from tuberculosis is 520 percent

greater among American Indians, and the mortality rate from

alcoholism is 433 percent greater. The mortality rate for American Indian women from accidents, including those involving

motor vehicles, is twice the rate for women of all other races in

the United States. Homicide and suicide rates also are higher

among American Indians, and a significant number die at an

early age.

• Anecdotal reports from physicians serving American Indian

tribes have expressed concern about high rates of sexually

transmitted diseases and increasing HIV infection rates.

• Although there is little information on rates of crime and violence in the American Indian population, existing data show

that alcohol use is highly associated with criminal and deviant

behavior.

• The use of cigarettes and inhalants among American Indian

females is high, and cigarette use is higher among females than

among males.

• Alcohol use appears to be a problem for many American Indian

tribes and reservations. National comparative studies across

racial and ethnic groups indicate that American Indian adolescents have the highest rates of alcohol use when compared

with other adolescents. Alcohol use is slightly higher among

adolescent males than females, and high rates of fetal alcohol

syndrome are reported in some areas.

Issues for Future Research

• Research projects with American Indian populations must be

developed in equal partnership. The research goals must be

consistent with the community’s understanding of its needs

and must offer something of value to the community that will

improve living conditions and empower tribes. American Indian

women are reluctant to participate in programs that operate for

3 to 4 years and then disappear.
129

• Research is needed on the barriers to drug treatment faced by

American Indian women and on strategies for prevention,

intervention, and treatment that will meet their needs. Better

health education and outreach strategies also are needed.

• Given the anecdotal information on violence, victimization,

and alcoholism among American Indian women, a continuing

database is needed to track mental health information, including

data on posttraumatic stress disorder, and to track trends in drug

abuse and crime in the American Indian population.

CROSSCUTTING ISSUES PANEL DISCUSSION

The discussion presented below followed presentations by members

of the Crosscutting Issues Panel: Dr. Brissett-Chapman, Ms. Plumb,

Dr. Alegría, and Dr. Jumper-Thurman.

Dr. Nan Vandenberg: It is assumed that 25 to 30 percent of

lesbians are mothers, but we have not heard anything about drug abuse

programs for these women. I challenge those in research to recognize

the population of drug-abusing lesbian mothers in designing prevention

and intervention programs. In the past 10 or 15 years there has been

an increase in the number of lesbian or bisexual women who are having

children through artificial insemination. I want to underscore the

continuum of sexual behavior in the sense that someone who may have

been heterosexual at one point in time may later have sex with other

women, and then return to having sex with men. Second, we need to

realize that the workplace might be an important place to direct drug

abuse prevention programs at gays and lesbians because many “come

out” only in their 20s or 30s. Government-sponsored research on drug

abuse needs to collect and analyze data on sexual orientation.

Unidentified Audience Member: I am in the Office of AIDS

Research, and my Internet communications around the world indicate

that few lesbians are concerned about HIV; they point to the lack of

research [that would substantiate the danger]. I have been in a number

of studies as a control because I am a healthy female. No one ever asks

about my sexual orientation, but when they wonder why I am not on

birth control, I explain that I am a lesbian.
130

Ms. Plumb: I want to underscore the point that the white lesbian

and gay community has little contact with lesbians and gays from

communities of color, so those communities have had difficulty dealing

with white lesbians and gays. Few studies include lesbian and bisexual

women of color; therefore, the intersection of race and sexual orientation probably has not been evaluated.

Dr. Brissett-Chapman: I want to comment from the AfricanAmerican perspective. I believe the African-American community has

been researched intrusively for information that does not always lead

to particular program or policy responses. The more questions we ask

of women, for example, at the shelter, the more responsible we must

be in understanding what effect this information may have on women

in the community. How will we address the issues of stigma often

associated with lesbian women of color, and how will we support these

women in the community?

Dr. Coryl Jones: Marj Plumb has offered to help researchers gain

access to this population of women in terms of drug abuse research.

There are cultural, ethnic, and language problems in our studies that

affect communication between investigators and research subjects.

We must translate our research instruments to ensure they mean the

same thing in the languages of everyone involved and to make sure

that desired information is communicated between investigators and

research subjects. We must add communications skills to our research

agenda.
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Closing Session

CONCLUDING REMARKS

David J. Mactas

Director

Center for Substance Abuse Treatment

Mr. Mactas reported that he is committed to having the Center

for Substance Abuse Treatment (CSAT) collaborate with NIDA, the

National Institute on Alcohol Abuse and Alcoholism, and other

research organizations. He described the following future initiatives

of CSAT:

• CSAT will work with the National Institute of Child Health and

Human Development, which has developed a manual on treatment approaches for women who abuse alcohol and other drugs.

CSAT also will collaborate on preparing a comprehensive model

of care for treatment of women and their children.

• As mandated by Congress, CSAT will support drug abuse treatment research and services for women and children. CSAT funds

65 residential and 12 outpatient drug abuse treatment programs

that serve mothers with children younger than 10.

• CSAT will respond to its constituency and help people who face

barriers to treatment and who rely on Government support to

obtain treatment. Efforts may include scholarships, advocacy,

and the acquisition of new resources.

Mr. Mactas invited the audience to speak with him and his staff

about CSAT’s programs in more detail after the session.
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TOWARD THE DEVELOPMENT OF A

DRUG ABUSE RESEARCH AGENDA ON

THE HEALTH OF WOMEN

Richard A. Millstein

Deputy Director

National Institute on Drug Abuse

Mr. Millstein thanked conference participants for sharing their

knowledge about women and drug abuse and in this way helping shape

NIDA’s research agenda. He observed that conference speakers had

identified the wide information gap on women and drug abuse and

identified new research ideas to bridge that gap. The results of research

on men cannot be confidently and safely generalized to women.

Mr. Millstein reviewed NIDA’s efforts to study drug abuse among

women and sex differences. Although many previous studies have

focused on pregnant women and their offspring, the focus is expanding

to include women of all ages. He described the following NIDA initiatives on women:

• In June 1993 NIDA undertook a technical review on drug abuse

and HIV infection and their effect on women and children.

• NIDA issued two program announcements in 1993 seeking

applications for research on the etiology, consequences, and

behavioral pharmacology of female drug abuse and treatment for

women of childbearing age and children. Some NIDA program

announcements on HIV focused indirectly on women’s issues,

such as partner notification of HIV-infected drug abusers and

strategies to reduce high-risk sexual practices among drug abusers.

• In June 1994 NIDA held a technical review on methodological

issues related to the etiology and consequences of drug abuse

among women.

• NIDA has produced brochures, videotapes, and NIDA Capsules

with information on women and drug abuse.

NIDA has provided many grants to fund research programs that

focus on women’s issues and sex differences, but Mr. Millstein noted that

more research is needed. Research on women and drug abuse is one of

NIDA’s key priority areas. The Institute wants to determine the biological and behavioral sex differences that need to be addressed and the
133

effectiveness of various drug abuse prevention and treatment programs.

Mr. Millstein urged conference participants to apply for NIDA grants,

and he asked clinicians and practitioners to make recommendations

regarding NIDA’s research agenda.

Mr. Millstein summarized the questions and issues identified during

the conference that are important to developing NIDA’s research agenda

on drug abuse and women’s health. The following are illustrative of

those he addressed:

Prevention and Treatment

• Because the rates of anxiety and affective disorders, which are

possible precursors to drug abuse and dependence, are higher

among women than among men, research is needed on better

treatment of these disorders in women. Research also is needed

on the consequences of providing or withholding such treatment,

particularly for pregnant women.

• Prevention and treatment programs should be designed to address

specific research-based risk factors among women, including

childhood physical and sexual abuse, victimization, posttraumatic

stress disorder, and partner violence.

• The sex differences found in drug abuse treatment research

include legal barriers and women’s fears about losing their children; lack of comprehensive health care services; lack of access to

child care services, perinatal programs, and prenatal care; inadequate vocational education; dangerous physical environments

and housing; low self-esteem; and feelings of hopelessness and

depression that require mental health counseling and treatment.

• Research is needed on how to improve the recruitment and

retention of women in research studies. Women have been found

to be less likely than men to accept random study assignments.

Women may respond to treatment strategies that are different

from those that men respond to and may respond less to treatments that are successful with men. Strategies that may be more

successful with women than men include comprehensive services

and treatments that address violence, victimization, stress, and

health and social services case management.
134

• Diverse care models and integrated approaches are needed to

link health care, drug treatment, and HIV services. Research

on health care services should be broad and incorporate not just

drug abuse treatment but also AIDS treatment, primary care

and access to care, and use of services.

• Information is needed on the effectiveness of drug abuse-related

program approaches for different racial and ethnic subgroups and

other subgroups of women. Specific factors such as sex-related

issues, violence, racism, sexual orientation, and program philosophies also need to be examined for their effect on drug abuse

prevention and treatment approaches. Examination is needed

of the combined effects of social, cultural, economic, environmental, and genetic factors.

• The definition of substance abuse with regard to licit and illicit

drugs should be reexamined, discussed, and clarified. Discussion

also is needed to reach agreement on the definition of successful

drug treatment outcomes.

• Discussion is needed on the appropriate use of the term “relapse”

in relation to drug abuse treatment. Would it be more appropriate to use the term “recurrence,” an expected or normal return

of symptoms, than “relapse,” the return of a disease? Recurrence

is the term used by clinicians when referring to other chronic

disorders such as hypertension or diabetes.

• The drug abuse research and treatment communities need to

work with Congress, the executive branch, the medical community (including obstetricians, gynecologists, and pediatricians),

the academic community, and the media to educate the public

about the importance of drug abuse prevention, intervention,

and treatment.

• The complex issues related to women’s enrollment in clinical

trials to determine drug efficacy, including the enrollment of

pregnant women, should be discussed and resolved.

Epidemiology

• The role of sex differences in vulnerability to drug abuse

requires study, as does the progression from drug use to abuse
135

and dependence. What are the implications of these sex differences for prevention and treatment strategies? This work holds

enormous promise and will further understanding about dopamine system regulation and drug use.

• Replication is needed of the initial findings of research on the

intergenerational transmission of smoking from women who

smoke during pregnancy to their female offspring. At the same

time, researchers must avoid judging or blaming women for

their behaviors and fetal outcomes.

• Information is needed on the different risk factors for HIV

infection among women and men. Drug abuse is a vector for

AIDS in women more often than it is in men. What is the

reason for this difference?

• More research is needed on the epidemiology of drug abuse and

AIDS among various populations of women. For example, there

is little epidemiologic information on drug abuse among lesbians,

and therefore there is little information about the epidemiology

of AIDS and drug abuse prevention and treatment for this

population.

Etiology

• Research is needed on the etiology of drug abuse and the child

and adolescent precursors and personality pathways that lead to

drug use and progression to abuse and dependence. Research is

needed on protective factors, resiliency, invulnerability, and

prevention of drug abuse.

• Important research and prevention issues should be addressed

relating to intergenerational models of violence and of alcohol

and other drug problems. Family dynamics and their effect on

drug abuse also need attention.

• More information is needed on the efficacy of strategies to reduce

the harmful consequences of drug use. Attempts must be made to

reach a consensus on the role of reductions in drug use and other

negative outcomes and consequences (short of drug abstinence)

as successful treatment outcomes.
136

Biological and Behavioral Mechanisms

• Research is needed on the biological and behavioral mechanisms

of drug abuse, including cocaine’s effect on reproductive functioning, the effect of the menstrual cycle on cocaine selfadministration, sex differences in male and female responses to

serotoninergic transmission, and sex-specific considerations in

the use of psychoactive medications.

• The implications of recent findings on biological and behavioral

approaches to drug abuse intervention must be examined.

Consequences

• There are sex differences in the median survival time from AIDS

diagnosis to death. Do women present with the disease later than

men, and if so, why? Why are women underscreened for HIV

infection and drug abuse compared with men?

• Research suggests that AZT is more likely to be offered to men

than women. What are the implications for women, and what

are the barriers to treatment?

• Among women taking AZT, 8.3 percent gave birth to neonates

with HIV infection versus 25.5 percent among women not taking

AZT. Has this information been incorporated into drug treatment and demonstration programs? What changes in medical

practice have occurred?

• It is important to examine further the association of alcohol and

other drug use with mental health problems, poor pregnancy

outcomes, and high-risk sexual behaviors. What are the social

and behavioral consequences to women who have low selfesteem? How can social supports and protective factors be

strengthened?

Crosscutting Research Issues

• Women are a heterogeneous group, and different subgroups will

require different strategies for drug abuse prevention, treatment,

and research. Information on women of different racial and

ethnic minority groups, ages, and sexual orientations must be
137

collected and analyzed to determine what differences in strategy

will be needed for drug abuse prevention and treatment in

different subgroups.

• There has been a proliferation of agencies with drug abuse

programs, including NIDA; Substance Abuse and Mental Health

Services Administration (SAMHSA); Center for Substance

Abuse Treatment; Center for Substance Abuse Prevention;

National Cancer Institute; National Heart, Lung, and Blood

Institute; Centers for Disease Control and Prevention; National

Institute of Child Health and Human Development; National

Institute of Mental Health; National Institute on Alcohol Abuse

and Alcoholism; and Indian Health Service, among others.

Multiple partnerships among Government programs and agencies

are needed so that the responsibility for conducting research and

addressing issues is shared. Coordination is needed to ensure that

agencies will be held accountable for implementing comprehensive initiatives that address the needs of the whole person.

• Several conference speakers recommended more training for both

researchers and providers. NIDA has a role in research training,

and SAMHSA and the Health Resources and Services Administration are the agencies most likely to be involved in clinician

training.

• The dissemination and application of research findings is key;

therefore, models are needed of the most effective methods of

disseminating information and encouraging the application of

research information in clinical practice.

• More women researchers are needed to ensure that questions

related to sex differences are not overlooked. Researchers from

diverse population groups must be supported, including women

of color and women of different sexual orientations.

Mr. Millstein concluded his remarks by thanking the conference

organizers, presenters, and participants, and he again encouraged participants to contact NIDA with their input into the direction and priorities

of this research agenda.
138

Conference Speakers

Margarita Alegría, Ph.D.

Associate Professor

Center for Sociomedical Research

and Evaluation

Graduate School of Public Health

Medical Sciences Campus

University of Puerto Rico

P.O. Box 365067

San Juan, PR 00936-5067

D. Caroline Blanchard, Ph.D.

Professor

Department of Anatomy

Bekesy Laboratory of

Neurobiology

John A. Burns School of Medicine

University of Hawaii, Manoa

1993 East-West Road

Honolulu, HI 96822-2359

Susan J. Blumenthal, M.D.,

M.P.A.

Deputy Assistant Secretary for

Health (Women’s Health)

U.S. Department of Health and

Human Services

Office on Women’s Health

Humphrey Building, Room 730-B

200 Independence Avenue, S.W.

Washington, DC 20201

Sheryl Brissett-Chapman, Ed.D.,

A.C.S.W., L.I.C.S.W.

Executive Director

Baptist Home for Children and

Families

6301 Greentree Road

Bethesda, MD 20817

Judith S. Brook, Ed.D.

Professor of Community Medicine

Mount Sinai School of Medicine

Box 1044A

One Gustave L. Levy Place

New York, NY 10029

Shirley D. Coletti, D.H.L.

President

Operation PAR, Inc.

Pinellas Business Center,

Administrative Offices

Suite 1000

10901-C Roosevelt Boulevard

St. Petersburg, FL 33716

R. Lorraine Collins, Ph.D.

Senior Research Scientist

Research Institute on Addictions

1021 Main Street

Buffalo, NY 14203
139

Linda B. Cottler, Ph.D.

Associate Professor of

Epidemiology in Psychiatry

Department of Psychiatry

Washington University School

of Medicine

40 North Kingshighway

Boulevard, Suite 4

St. Louis, MO 63108

Loretta P. Finnegan, M.D.

Director

Women’s Health Initiative

Office of the Director

National Institutes of Health

Room 6C12

7550 Wisconsin Avenue

Bethesda, MD 20892-9112

Neil E. Grunberg, Ph.D.

Professor

Department of Medical and

Clinical Psychology

Uniformed Services University

of the Health Sciences

4301 Jones Bridge Road

Bethesda, MD 20814-4799

Pamela Jumper-Thurman, Ph.D.

Research Associate

Tri-Ethnic Center for Prevention

Research

Department of Psychology

Colorado State University

Clark C138A

Fort Collins, CO 80523

Stephen R. Kandall, M.D.

Professor of Pediatrics

Albert Einstein College of

Medicine

Chief

Division of Neonatology

Beth Israel Medical Center

7 Baird Hall

First Avenue and 16th Street

New York, NY 10003

Denise B. Kandel, Ph.D.

Professor of Public Health in

Psychiatry

College of Physicians and

Surgeons

Columbia University

Chief

Division of Epidemiology of

Substance Abuse

New York State Psychiatric

Institute

722 West 168th Street, Box 20

New York, NY 10032

Dean G. Kilpatrick, Ph.D.

Professor

National Crime Victims Research

and Treatment Center

Department of Psychiatry and

Behavioral Sciences

Medical University of South

Carolina

171 Ashley Avenue

Charleston, SC 29425-0742
140

Mary Jeanne Kreek, M.D.

Professor

Head

Laboratory on the Biology of

Addictive Diseases

Rockefeller University

1230 York Avenue

New York, NY 10021

Karol L. Kumpfer, Ph.D.

Associate Professor

Department of Health Education

Health Sciences Center

HPER N-215

University of Utah

Salt Lake City, UT 84112

Alan I. Leshner, Ph.D.

Director

National Institute on Drug Abuse

Parklawn Building, Room 10-05

5600 Fishers Lane

Rockville, MD 20857

David J. Mactas

Director

Center for Substance Abuse

Treatment

Substance Abuse and Mental

Health Services Administration

Rockwall II, Suite 615

5600 Fishers Lane

Rockville, MD 20857

Nancy K. Mello, Ph.D.

Professor of Psychology

(Neuroscience)

Co-Director

Harvard Medical School

Alcohol and Drug Abuse

Research Center

McLean Hospital

115 Mill Street

Belmont, MA 02178

Kathleen R. Merikangas, Ph.D.

Professor of Epidemiology and

Psychiatry

Departments of Psychiatry and

Epidemiology

Genetic Epidemiology Research

Unit

Yale University School of

Medicine

40 Temple Street, Suite 7B

New Haven, CT 06510-3223

Brenda A. Miller, Ph.D.

Acting Director

Research Institute on Addictions

1021 Main Street

Buffalo, NY 14203-1016

Richard A. Millstein

Deputy Director

National Institute on Drug Abuse

5600 Fishers Lane, Room 10-05

Rockville, MD 20857
141

Karla Moras, Ph.D.

Assistant Professor of Psychology

and Psychiatry

Center for Psychotherapy

Research

University of Pennsylvania

Seventh Floor

3600 Market Street

Philadelphia, PA 19104-2640

Adeline Nyamathi, R.N., Ph.D.,

F.A.A.N.

Associate Professor

School of Nursing

University of California,

Los Angeles

10833 LeConte Avenue

Los Angeles, CA 90024-6918

Lynn M. Paltrow, J.D.

Reproductive Policy Attorney

45 West 10th Street

New York, NY 10011

Vivian W. Pinn, M.D.

Associate Director for Research

on Women’s Health

Director

Office of Research on Women’s

Health

National Institutes of Health

Building 1, Room 201

9000 Rockville Pike

Bethesda, MD 20892

Marjorie J. Plumb, M.N.A.

Director of Public Policy

Gay and Lesbian Medical

Association

459 Fulton Street, Suite 107

San Francisco, CA 94102

David C.S. Roberts, Ph.D.

Professor

Department of Psychology

Life Sciences Research Centre

Carleton University

1125 Colonel By Drive

Ottawa, Ontario K1S 5B6

CANADA

Rafaela R. Robles, Ed.D.

Senior Scientist

Research Institute

Mental Health and AntiAddiction Services

Administration

Center for Sociomedical Research

Medical Sciences Campus

University of Puerto Rico

Center for Addiction Studies

School of Medicine

Universidad Central de Caribe

P.O. Box 21414

San Juan, PR 00928-1414

Marsha Rosenbaum, Ph.D.

Director

The Lindesmith Center-West

2233 Lombard Street

San Francisco, CA 94123
142

Kathy Sanders-Phillips, Ph.D.

Associate Professor

Department of Pediatrics

School of Medicine

University of California,

Los Angeles

5120 Goldleaf Circle, Suite 380

Los Angeles, CA 90056

Sidney Schnoll, M.D., Ph.D.

Professor

Departments of Internal Medicine

and Psychiatry

Chairman

Division of Substance Abuse

Medicine

Medical College of Virginia

Hospitals

Box 980109

Richmond, VA 23298-0109

Peter A. Selwyn, M.D., M.P.H.

Associate Director

AIDS Program

Associate Professor of Medicine,

Epidemiology, and Public Health

Yale University School of Medicine

135 College Street, Suite 323

New Haven, CT 06510

Jacqueline Wallen, Ph.D., M.S.W.

Associate Professor

Department of Family Studies

University of Maryland

1204 Marie Mount Hall

College Park, MD 20742

James R. Woods, Jr., M.D.

Professor

Obstetrics and Gynecology

Director

Maternal-Fetal Medicine

Strong Memorial Hospital

601 Elmwood Avenue, Box 668

Rochester, NY 14642-8668