Module 1: Substance Use Disorders
The first module in this course is titled Substance Use Disorders. This module provides important background information on Substance Use Disorders in the general population, in women, and during pregnancy. The role of trauma in Substance Use Disorders in women is also discussed.
Learning Outcomes
By the end of this module, you will be able to:
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, known as the DSM-5, a distinction is no longer made between substance abuse and substance dependence. Moreover, the term “substance abuse” is no longer used. The term now used is Substance Use Disorders, or SUDs.
SUDs can include problems with a variety of substances including alcohol, cannabis, opioids, stimulants, and hallucinogens. A disorder occurs when the recurrent use of substances leads to clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.
According to the DSM-5, 11 different criteria signal that a SUD may be present. Whether a SUD is classified as mild, moderate or severe is determined by how many of the following criteria are met:
Let’s talk a little about the role that brain chemistry plays in substance use disorders.
National Institute on Drug Abuse (NIDA) Director, Dr. Nora Volkow explains this well.
Per an interview with Dr. Volkow,
“All drugs of abuse, whether legal or illegal, cause large surges of dopamine in brain areas crucial for motivating our behavior—both the reward regions as well as prefrontal regions that control our higher functions like judgment, decision making, and self-control over our actions. These brain circuits adapt to these surges by becoming much less sensitive to dopamine, a process called receptor downregulation. The result is that ordinary healthy things in our lives, all the pleasurable social and physical behaviors necessary for our survival no longer are enough to motivate a person; the person needs the big surge of dopamine from the drug just to feel temporarily okay … and they must continually repeat this, in an endless vicious cycle.”
Dr. Volkow highlights the connection between chronic pain, opioid use, co-morbid conditions and suicide in her blog from September 2019, which can be found by clicking here.
As stated earlier, Substance Use Disorders can include a variety of substances. However, for the purposes of this training, we will focus primarily on mothers with Opioid Use Disorders.
Opioids may include illegal drugs, such as heroin and prescription-obtained pain relievers such as Morphine, Oxycodone and Hydrocodone. These drugs can all cause similar serious health effects in those who misuse them.
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Opioids: |
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reduce the pain messages to the brain, |
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reduce feelings of pain, |
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can cause drowsiness, confusion, and euphoria, and, |
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depending upon the amount of the drug taken, can depress respiration leading to overdose |
For information on the appropriate use of opioids for chronic pain visit the CDC Guideline for Prescribing Opioids for Chronic Pain webpage.
In Texas, overdose is a leading cause of maternal mortality. Texas Senate Bill 1462, relating to opioid antagonists and their use as treatment during the course of an opioid overdose went into effect September of 2015. One such opioid antagonist medication is Naloxone (trade name Narcan®). Opioid antagonists will be discussed further in the next module.
A guide to developing and managing overdose prevention and take-home Naloxone projects, produced by the Harm Reduction Coalition, can be found in the Resources section of this online training.
To wrap up this section on Opioid Use Disorder, withdrawal symptoms that may occur after stopping or reducing the use of opioids include:
Next, we will discuss national statistics. Substance Use Disorders are a growing public health concern in the United States. Rising rates of SUDs are likely related to the nationwide increase in the use of prescription opioid pain relievers or OPR’s.
National sales of opioid pain relievers quadrupled between 1999 and 2014, according to the Centers for Disease Control (CDC). In addition, there is a trend toward the prescribing of opioid pain relievers that are stronger than morphine. For example, in 1999, only 17% of opioid users were using OPRs stronger than morphine, but in 2012, this number had risen to 37%.
In 2011, the CDC, reported that drug overdose deaths had become the leading cause of injury death in the United States, surpassing motor vehicle accidents. Further, in 2015, 52,000 deaths resulted from the use of heroin – the highest number ever recorded in U.S. history. Unfortunately, the 2016 overdose rate exceeded this number by 22% with 64,000 Americans dying from overdose. Texas ranks 44th in the nation for the prevalence of drug overdose death rates and 33rd for the number of opioid pain relievers prescribed. Between the years 1999 and 2010, the overdose death rate in Texas increased by 78%! Since 2010, the number of heroin-related deaths in Texas steadily increased from 260 to 530 deaths, and deaths attributed to synthetic opioids (mainly Fentanyl) rose from 156 to 250.
Substance Use Disorders in women tend to be complex and highly correlated with other psychiatric conditions that occur at the same time, such as depression and anxiety. Low socioeconomic status, intimate partner violence, and trauma are also common in women with SUD’s. People who have Substance Use Disorders as well as mental health disorders are diagnosed as having co-occurring disorders, or dual disorders.
According to a 2014 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration, or SAMHSA, approximately 7.9 million adults had co-occurring disorders; more than half of this number were women.
It is estimated that roughly 50% of women with SUDs have co-morbid mental illness. Additionally, women with serious mental illness are 5 to 11 times more likely to have a Substance Use Disorder than those in the general population. Co-occurring disorders are more difficult to treat and must be considered together in an integrated treatment plan. According to SAMHSA: Integrated treatment is “a unified treatment approach to meet the substance use, mental health, and related needs of a client.”
The most common co-occurring mental health disorders in women with SUDs include Mood Disorders, especially Major Depressive Disorder, Anxiety Disorders, Posttraumatic Stress Disorder, or PTSD, and Personality and Eating Disorders. We will discuss some of the characteristics of these disorders and how they relate to substance use in the upcoming slides.
Major Depressive Disorder, or MDD, can be characterized by a depressed or sad mood, feelings of low self-worth and guilt, thoughts of suicide, poor concentration, low levels of energy and motivation, and sleep and appetite disturbance.
Women are nearly twice as likely to suffer from MDD than men. Both MDD and SUD need to be identified and addressed concurrently to minimize relapse and improve quality of life and quality of care. MDD can also increase the risk of suicide. It is important to note that depressive symptoms may increase or decrease during the phases of substance use (including intoxication, use, and withdrawal).
MDD with peripartum onset should be addressed concurrently with NICU and neonatal abstinence syndrome care. The incidence of MDD with peripartum onset in mothers of babies in the NICU is much higher than those for mothers of infants in standard care and estimated at 28% to 70%. There are a number of factors that affect the development of MDD with peripartum onset in mothers of NICU babies including grief, shame, loss, and lack of control.
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Anxiety Disorders |
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can be characterized by feelings of worry that are difficult to control, feelings of dread or panic, restlessness, muscle tension and sleep disturbance. |
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Posttraumatic Stress Disorder |
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is often characterized by hypervigilance, sleep disturbance, intrusive memories of the trauma, distress and nightmares. |
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Eating Disorders |
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can include not eating enough calories because of concerns over body image or binge eating with or without vomiting. |
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Personality Disorders |
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are often described as enduring patterns of subjective experiences and interactions with the world that are long-standing and lead to distress or impairment. |
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Psychotic Disorders |
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are characterized by delusions or fixed, false beliefs that cannot be changed in light of conflicting evidence, and hallucinations which are sensory experiences in the absence of corresponding external stimuli. |
Now let’s discuss the role of trauma in SUDs. Because so many women with Substance Use Disorders have experienced trauma, it is important to understand what trauma means. Trauma is an emotional response which results in feelings of fear, threat to life, horror, and helplessness. Traumatic events have lasting effects on those who experience them and impact a person’s mental, physical, social, emotional, and spiritual well-being.
According to SAMSHA, “Trauma results from an event, series of events or set of circumstances that are experienced by an individual as physically or emotionally harmful or life threatening.”
Since trauma is so common in women who use substances, a trauma informed approach to care is essential. According to the Substance Abuse & Mental Health Service’s Administration’s (SAMHSA) concept of a trauma-informed approach, “A program, organization, or system that is trauma-informed: Realizes the widespread impact of trauma and understands potential paths for recovery; Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; Responds by fully integrating knowledge about trauma into policies, procedures, and practices; and Seeks to actively resist re-traumatization.” A trauma-informed approach can be implemented in any type of service setting or organization and is distinct from trauma-specific interventions or treatments that are designed specifically to address the consequences of trauma and to facilitate healing.
Trauma-informed care will be discussed further in another course module.
Big "T" Traumas
Francine Shapiro, a well-known trauma psychologist, talks about little t and big T traumas, meaning that trauma comes in different sizes. Trauma can be caused by a single event or through the impact of ongoing abuse over time. Some individuals who experience extreme or repeated trauma develop severe symptoms of trauma and have great difficulty functioning. Big “T” events are things such as a natural disaster, physical assault, sexual assault, death or a horrible accident.
Little “t” Traumas
There are smaller traumas that also effect people. Little “t” events such as being bullied or excluded, can be devastating to a person who is experiencing them. Little “t” traumas include experiences such as:
It is important to understand that trauma is based on the individual’s experience and perception of the experience. Everyone experiences trauma differently, and so one person may respond differently than another who has gone through the same experience.
It is estimated that 50-90% of women with Substance Use Disorders report that they have experienced personal violence and trauma.
Of the women seeking treatment for Substance Use Disorders, approximately 80% report a lifetime of both physical and sexual assault. Furthermore, rates of co-occurring disorders, specifically PTSD, in this group of women range from 39 to 50 percent.
Individuals may attempt to relieve distress related to past traumatic events through the use of substances, or they may be more at risk for experiencing traumatic events as a result of their substance use.
Traumatic events occurring during childhood are strongly correlated with these disorders. Additionally, the severity of childhood trauma is a significant predictor of Substance Use Disorder relapse in women attempting to recover.
In addition, women diagnosed with both PTSD and Substance Use Disorder, compared to women diagnosed with only one of these disorders seem to have more severe clinical profiles. They also may experience additional problems such as interpersonal issues and other psychiatric illnesses.
Trauma Resources
Research has shown us that experiences of trauma can have serious negative impacts on psychological, social, and health outcomes throughout a person’s life.
For more information on treatment options for women with PTSD and substance use disorders, you can click here to access a resource offered by the National Institute on Drug Abuse.
Let us now switch gears to discussing gender differences in SUDs. Gender-specific studies focused on substance use show there are distinct differences between men and women with respect to these disorders. When compared to men, women are more likely to have chronic pain and be prescribed prescription painkillers at higher doses and for longer periods of time. Women are also more likely to engage in “doctor shopping” which means they obtain prescriptions from multiple prescribers. More specific information about "doctor shopping" can be found in this Innovations in Clinical Neuroscience journal article.
In addition, studies show that women more rapidly become dependent upon painkillers than men, but may be reluctant to seek help for a SUD due to the social stigma and fear of losing their children to an agency, such as Child Protective Services.
As you can see, Substance Use Disorders impact women differently than men.
Now we will discuss the issue of Substance Use Disorders specifically in pregnant women. The nationwide trends toward greater use of opioids, both prescribed and illicit, have inadvertently affected women of childbearing age. Substance use during pregnancy seems to reach peak numbers during the adolescent years, occurring in approximately 16% of pregnant teens. Between the years 2000 and 2012 national rates of maternal opioid use during pregnancy increased five-fold.
Substance use during pregnancy can lead to multiple health and social problems for both mother and child. Pregnancy may be an opportunity for women with Substance Use Disorders to seek treatment. However, pregnant women who are using substances face enormous personal guilt and are often stigmatized by health care providers. In this sense, pregnancy is both a motivator and barrier for seeking treatment. We will talk more about interventions in the later modules of this course.
Now that we have discussed Substance Use Disorders and pregnancy, let’s take a look at the stories of two different women to get an idea about how substance use impacts people in their lives. We will follow the stories of these two women throughout this course as a way to help service providers understand what might lead someone to substance use, how substance use can impact families, and how these individuals make their journey through recovery.
Angela is a 23 year-old young woman who left home at the age of 17. She was no longer able to cope with the sexual abuse of her mother’s boyfriend and told her mother. Angela’s mother did not believe Angela and did not take the situation seriously. Angela lived with friends at first and then on the streets for several years trying various drugs to help her cope with her feelings of failure, betrayal and severe anxiety. While high, she was gang raped. She first tried snorting heroin at age 19 and found that her bad feelings about herself and many fears “floated out of her” when she was high. This was the first time she felt any relief in her life, but soon discovered she needed more and more to get the feeling of peace. At age 19 Angela started using intravenous heroin on a daily basis.
Marta is the mother of three young children. Two years ago, while helping one of her kids out of the tub, Marta slipped and fell, injuring multiple discs in her back. After seeking medical help for the severe pain she was in, Marta was given a prescription for Hydrocodone. Initially, Marta was grateful that the pain subsided with the use of this medication. Unfortunately, as time went on, Marta became aware that she needed more and more Hydrocodone to ease her chronic pain. She started to go to multiple doctors to get enough of this medication to keep her pain at bay. When she was unable to obtain a prescription, she experienced severe nausea and vomiting which promoted her to buy heroin on the street. She has hidden her addiction from her husband, Miguel, who believes she is no longer taking pain medication.
Keep the stories of Angela and Marta in mind as you work through the modules of this course and follow the trajectory of their recovery as they engage in the Mommies program.
In summary, Substance Use Disorders often identified through a set of criteria in the DSM-5, are a growing public health concern in the United States. Rising rates are likely related to the nationwide increase in the use of prescription opioid pain relievers.
Women tend to be impacted differently than men by Substance Use Disorders. In addition, their disorders tend to be complex and highly correlated with comorbid conditions such as depression and anxiety. Low socioeconomic status, intimate partner violence, and trauma are also common in women with Substance Use Disorders.
Lastly, opioid use in pregnancy has been increasing at dramatic rates. and can lead to problems for both mother and child.
You are now ready to proceed to Module 2: Neonatal Abstinence Syndrome.