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Treatment of Women With

Substance Abuse Problems

David J. Mactas

INTRODUCTION:

STATEMENT OF THE PROBLEM

The estimated number of American women age 12 and older who

use or abuse legal or illegal drugs is startling. This information comes

as no surprise to those of us engaged in substance abuse research and

treatment endeavors. Recognition of the severity of the problem—its

health effects on women and its social and economic consequences for

women, their families, and society—inspired this conference and the

participation of those attending. Working partnerships between and

among those in the treatment field, researchers, and public policymakers

are critical. Treatment in general, and the treatment of women with

substance abuse problems in particular, clearly needs further actionoriented research.

CENTER FOR SUBSTANCE ABUSE TREATMENT

ACTIVITIES RELATED TO TREATMENT

OF WOMEN AND THEIR CHILDREN

In July 1992 Congress enacted Public Law 102-321, the ADAMHA

Reorganization Act, creating the Center for Substance Abuse Treatment

(CSAT), formerly the Office for Treatment Improvement. In response

to the lack of access and barriers to treatment for women, CSAT established a national program for women and children that included creation of the Women and Children’s Branch (WCB), which is the focal

point for CSAT’s wide-ranging activities related to treatment of women

and children. Significant activities of this branch and other components of CSAT include the following:

• Administration of 65 residential treatment programs for women

and their children, including pregnant and postpartum women

and infants.

• Administration of 12 outpatient substance abuse treatment

programs that serve pregnant and parenting women and their
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children. As with the residential programs, these programs

provide services that meet the particular needs of women and

their children, either by providing these services directly or

making referrals to appropriate providers.

• Development and dissemination of the treatment manual Practical

Approaches in the Treatment of Women Who Abuse Alcohol and

Other Drugs (Center for Substance Abuse Treatment 1994) for

treatment providers, researchers, and policymakers. This manual

presents issues and strategies related to specific populations of

women, including women of color, adolescent and older women,

women involved in the criminal justice system, and lesbians.

• Administration of several memorandums of agreement (MOAs)

with other Government agencies to carry out activities related

to the treatment of women and their children.

• Engagement in a wide range of collaborative activities designed

to expand and improve treatment services for women and their

children.

• Production of seven treatment improvement protocols (TIPs).

TIPs are consensus-based documents designed to improve the

ability of treatment program personnel to provide quality care

to their patients. All TIPs are distributed to programs serving

women and their children, including the programs receiving

CSAT grant funds. TIP documents include Pregnant, SubstanceUsing Women (Mitchell 1993); Assessment and Treatment of

Patients With Coexisting Mental Illness and Alcohol and Other Drug

Abuse (Ries 1994); Improving Treatment for Drug-Exposed Infants

(Kandall 1993); Guidelines for the Treatment of Alcohol- and Other

Drug-Abusing Adolescents (Schonberg 1993); and Screening for

Infectious Diseases Among Substance Abusers (Barthwell and

Gilbert 1993).

• Development and support of a number of training efforts designed

to improve services for women and children and to ensure that

States meet requirements for set-aside programs to ensure that

interim services are provided to women.

• Development of interim regulations covering State mandates

that provide women with (1) preferential access and (2) interim

services when treatment cannot be provided within a given time.
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Preferential access helps ensure that treatment capacity for

women is expanded and requires that States give priority to

pregnant women who inject drugs and to other pregnant

substance-using women. The interim services requirement

ensures that, when substance abuse treatment slots are not

available, the women have access to services for tuberculosis,

AIDS (acquired immunodeficiency syndrome), and prenatal care,

as necessary; referral for services must be made within 48 hours

of request for treatment.

Several of these activities relate to the partnership among the

research, treatment, and public policy areas regarding women and

substance abuse treatment.

Collaboration Activities

CSAT collaborates with other agencies—such as the National

Institute of Child Health and Human Development (NICHD), Office

of Population Affairs, and Center for Substance Abuse Prevention—to

further develop highly effective treatment services for women and their

children.

The collaboration with NICHD reflects the importance that CSAT

attaches to collaboration between the treatment and research communities. A CSAT/NICHD research/treatment study initiated several years

ago by Dr. Loretta Finnegan is expected to contribute substantially to

the design and implementation of improved treatment services for

pregnant and postpartum women and their children by making available

neurodevelopmental assessment plans and instruments for assessing life

circumstances of women and their children. Some of the instruments

used have been modified expressly for this study, and one instrument is

being field-tested in 12 of the WCB residential treatment programs.

This 5-year project to study the effects of maternal lifestyles on infant

outcome involves approximately 3,000 mother-child dyads at 4 sites—

University of Miami, University of Tennessee, Wayne State University,

and Brown University.

Another example of CSAT’s collaboration with other agencies is a

pending MOA with the Bureau of Justice and the National Institute of

Justice for a collaborative effort to access and treat women through the

domestic/family court systems at the local level.
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PROGRAM AREAS/RESEARCH ISSUES

FOR WOMEN IN TREATMENT

An understanding of the interrelationships among the client, treatment program, and community is critical to the success of the comprehensive treatment approach. As CSAT notes in its statement of mission,

goals, and programs, the consensus among those foremost in the field of

addiction is that, for most individuals, treatment and recovery services

work best in the context of a community-centered, coordinated system

of comprehensive services designed to ensure a continuum of support for

recovery (Center for Substance Abuse Treatment 1993, p. 4).

Research has demonstrated that no single modality of care is effective for all individuals and that clients may experience varying degrees

of success with different modalities (or combinations of modalities) at

different times. The combination of comprehensive services required

can vary according to the gender, race, ethnicity, socioeconomic status,

age, and physiological and neurophysiological condition of the client.

In addition to the obvious lack of funding for action-oriented

research related to women and treatment, the diversity of theoretical

views and biases hampers the development of research and evaluation

studies that could identify differences in treatment outcome. For example, the underlying concept of addiction serves as an explicit or

implicit foundation for the design of research and evaluation. Many in

the general public (and some in positions of leadership) still support the

view that, in general, alcohol and other drug abuse is a moral condition,

particularly when women are the abusers. Many others support the

medical model, which defines substance abuse as a disease. If the field is

to address successfully the complex problems of alcohol and other drug

abuse among women and evaluate the success of treatment programs,

successful, replicable treatment models must be developed. The Federal

Government plays a major role in the development and dissemination

of these models.

The paucity of adequate data and information on women and

substance abuse underscores the need for more and improved data and

information on the epidemiology of substance abuse among women,

health and socioeconomic cofactors of substance abuse, and availability

and use of treatment services by women as well as research on the

effectiveness of various treatment approaches for women.
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Ensuring effective collaboration among NIDA, CSAT, and other

Federal agencies with respect to programs of mutual interest, such as the

Perinatal-20 project funded by NIDA (Rahdert 1996) and the residential

treatment programs funded by CSAT, will significantly enhance the

ability to effectively use the scarce research funds available to address

the issues of women in treatment. Specific research needs include:

• Ensuring that federally sponsored epidemiologic and services

research includes gender-disaggregated data in the collection,

analysis, and reporting process

• Identifying the effectiveness and efficiency of substance abuse

treatment services for women in settings other than substance

abuse treatment programs (e.g., mental health clinics, well-baby

clinics, family planning clinics, and adolescent health clinics)

that are often the first and sometimes the only point-of-treatment

contact for women

• Identifying what modalities of care (residential and outpatient)

are most effective for women in treatment—with which cohort

of women and with which primary substance of abuse

• Identifying what mechanisms are most effective and efficient to

ensure the provision of adequate comprehensive services to

women in outpatient or residential treatment settings

• Identifying the relationships among case severity, characteristics

of specific cohorts of women, and use of treatment services and

treatment outcomes

• Adapting standardized physical, mental health, and substance

abuse assessment instruments to ensure that they are appropriate

according to gender and culture or designing, testing, and validating new instruments

• Identifying the most appropriate and feasible treatment outcome

measures for women in general and for specific cohorts of women

(e.g., those with and without children, with and without dual

diagnoses, and with or without histories of sexual or physical

abuse)

• Identifying at what point in the treatment of women it is

appropriate to address critical issues related to their children,

sexual abuse history, and violence
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• Identifying the relationships among level of care, complexity of

children’s special needs, and treatment outcomes

• Identifying the effects on treatment outcomes for substanceabusing women with children and for their children when women

and children are treated separately and when they are treated

together in the same setting

• Identifying the most critical factors contributing to retention

of women in treatment and the factors contributing to different

retention rates for women in outpatient treatment v. residential

treatment

For all these issues, it is important to have available data and information to describe the differences in race, ethnicity, and socioeconomic

and health status of the women.

REFERENCES

Barthwell, A.G., and Gilbert, C.L. Screening for Infectious Diseases Among

Substance Abusers. Treatment Improvement Protocol (TIP) Series 6. DHHS

Pub. No. (SMA)93-2048. Rockville, MD: U.S. Department of Health and

Human Services, Public Health Service, Substance Abuse and Mental

Health Services Administration, Center for Substance Abuse Treatment,

1993. 160 pp.

Center for Substance Abuse Treatment. Providing National Leadership in

Treatment Services: Mission, Goals, and Programs. Rockville, MD: U.S.

Department of Health and Human Services, Substance Abuse and Mental

Health Services Administration, 1993.

Center for Substance Abuse Treatment, Women and Children’s Branch.

Practical Approaches in the Treatment of Women Who Abuse Alcohol and Other

Drugs. U.S. Department of Health and Human Services, Public Health

Service, Substance Abuse and Mental Health Services Administration,

Center for Substance Abuse Treatment, Division of Clinical Programs, the

Branch. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1994.

275 pp.

Kandall, S.R. Improving Treatment for Drug-Exposed Infants. Treatment

Improvement Protocol (TIP) Series 5. DHHS Pub. No. (SMA)93-2011.

Rockville, MD: U.S. Department of Health and Human Services, Public

Health Service, Substance Abuse and Mental Health Services

Administration, Center for Substance Abuse Treatment, 1993. 94 pp.
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Mitchell, J.L. Pregnant, Substance-Using Women. Treatment Improvement

Protocol (TIP) Series 2. DHHS Pub. No. (SMA)93-1998. Rockville, MD:

U.S. Department of Health and Human Services, Public Health Service,

Substance Abuse and Mental Health Services Administration, Center for

Substance Abuse Treatment, 1993. 90 pp.

Rahdert, E.R., ed. Treatment for Drug-Exposed Women and Their Children:

Advances in Research Methodology. NIH Pub. No. 96-3632. National

Institute on Drug Abuse Research Monograph 165. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1996.

Ries, R. Assessment and Treatment of Patients With Coexisting Mental Illness and

Alcohol and Other Drug Abuse. Treatment Improvement Protocol (TIP)

Series 9. DHHS Pub. No. (SMA)94-2078. Rockville, MD: U.S.

Department of Health and Human Services, Public Health Service,

Substance Abuse and Mental Health Services Administration, Center for

Substance Abuse Treatment, 1994. 114 pp.

Schonberg, S.K. Guidelines for the Treatment of Alcohol- and Other Drug-Abusing

Adolescents. DHHS Pub. No. (SMA)93-2010. Rockville, MD: U.S.

Department of Health and Human Services, Public Health Service,

Substance Abuse and Mental Health Services Administration, Center for

Substance Abuse Treatment, 1993. 109 pp.

AUTHOR

David Mactas

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental

 Health Services Administration

Rockwall II, Suite 615

5600 Fishers Lane

Rockville, MD 20857

(301) 443-5700 (Tel)

(301) 443-8751 (Fax)

dmactas@samhsa.gov (E-mail)