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Substance Use, HIV, and Women PowerPoint Presentation

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Substance Use, HIV, and Women: What Clinicians Need to Know

TRAINER NAME
TRAINING DATE
TRAINING LOCATION
TITLE SLIDE
The purpose of this introductory training is to provide HIV clinicians (including, but not limited to physicians, dentists, nurses, and other allied medical staff, therapists and social workers, and counselors, specialists, and case managers) with a detailed overview of substance abuse and HIV among women. The curriculum reviews important epidemiological data focused on substance use trends in women and HIV prevalence; reviews standardized screening and assessment techniques to support the move to improve treatment effectiveness; and concludes with evidence-based and promising clinical strategies. The introductory training includes a 112-slide PowerPoint presentation, Trainer Guide, and a companion 2-page fact sheet. The duration of the training is approximately 90-120 minutes, depending on whether the trainer chooses to present all of the slides, or a selection of slides. For example, slides 83-102 represent information about interventions, and can be eliminated if you choose to end the training with the discussion about gender-responsive care on slide 82.

"Test Your Knowledge" questions have been inserted at the beginning and end of the presentation to assess a change in the audience's level knowledge after the key content has been presented. An answer key is provided in the Trainer's notes for slides 6-10 and slides 107-111.

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Training Collaborators and Acknowledgements
LA Region Pacific AIDS Education and Training Center
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs

We would like to thank Dr. Christine Grella for her contribution to this curriculum
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This PowerPoint presentation, Trainer Guide, and companion fact sheet were developed by Gloria Miele, PhD, in collaboration with Beth Rutkowski, MPH (Associate Director of Training of UCLA ISAP) and Thomas E. Freese, PhD (Director of Training of UCLA ISAP and Principal Investigator/Director of the Pacific Southwest ATTC) through supplemental funding provided by the Pacific AIDS Education and Training Center, based at Charles R. Drew University of Medicine and Science. We wish to acknowledge Phil Meyer, LCSW, Kevin-Paul Johnson, Maya Gil Cantu, MPH, and Thomas Donohoe, MBA, from the LA Region PAETC. We would also like to acknowledge the contributions of Dr. Christine Grella, UCLA Integrated Substance Abuse Programs.

Introductions
Briefly tell us:
What is your name?
Where do you work and what you do there?
What is a surprising fact about you?
What is one reason you decided to attend this training session?
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Bob
Mary
Jose
Derrick
Richell
Bethany
Tom
Sherry
INSTRUCTIONS
In an effort to break the ice and encourage group interaction, take a few minutes to ask training participants to briefly share the answers to these four questions. You can ask for several volunteers to share their responses, if the size of your audience prevents all participants from sharing.

If the group is too large for formal introductions, the trainer can quickly ask participants the following two questions to gauge their work setting and professional training:
1. How many [case managers, MFTs or LCSWs, counselors, administrators, physicians, PAs, nurse practitioners, nurses, medical assistants, dentists, etc.] are in the room? Did I miss anyone? {elicit responses}
2. How many people work in a [substance abuse, mental health, primary care, infectious disease] setting? Did I miss any settings? {elicit responses}

Educational Objectives At the end of this training session, participants will be able to:
Understand the epidemiology of HIV/AIDS and substance use in women
Identify the risks, challenges and consequences related to HIV/AIDS and substance specific to women
Define the 5 elements of gender responsive care
Identify behavioral interventions to address treatment challenge areas in women with HIV and substance use
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INSTRUCTIONS
Briefly review each of the educational objectives with the audience.

Test Your Knowledge
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INSTRUCTIONS
The purpose of the following five questions is to test the pre-training level of substance use and HIV knowledge amongst training participants. The questions are formatted as either multiple choice or true/false questions. Read each question and the possible responses aloud, and give training participants time to jot down their response before moving on to the next question.

Do not reveal the answers to the questions until the end of the training session (when you re-administer the questions that appear on slides 107-111).

Pre-Test Question
Approximately 1 in 4 HIV positive people in the US are women.

A. True
B. False
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INSTRUCTIONS
Read the question and choices, and review audience responses out loud.

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Pre-Test Question
Approximately what percent of women with HIV have experienced trauma in their lifetime?
A. 10
B. 20
C. 30
D. 40
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INSTRUCTIONS
Read the question and choices, and review audience responses out loud.

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Pre-Test Question
Which is NOT a component of "gender responsive" care for women?
A. Address women's unique experiences
B. Be trauma-informed
C. Take place only at a gender-specific program
D. Provide a healing environment

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INSTRUCTIONS
Read the question and choices, and review audience responses out loud.

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Pre-Test Question
Approximately what percentage of women drink alcohol while pregnant?
A. .5%
B. 2%
C. 9%
D. 17%

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INSTRUCTIONS
Read the question and choices, and review audience responses out loud.

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Pre-Test Question
Effective behavioral interventions for HIV risk reduction are not available for substance using women.

A. True
B. False

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INSTRUCTIONS
Read the question and choices, and review audience responses out loud.

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Why Gender Matters
Though women and men have much in common, sex and gender differences influence their lives and experiences.
Common differences between men and women affect the treatment and recovery needs of women with substance use disorders (SUDs) and HIV.

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Both sex and gender differences have an impact on the development of SUDs and on the treatment and recovery service needs of women and girls with SUDs.
Differences between men and women include biological, as well as social and environmental factors.

REFERENCES
Addressing the Needs of Women and Girls: Developing Core Competencies for Mental Health and Substance Abuse Service Professionals (pp. 2-9).

Guidance to States: Treatment Standards for Women with Substance Use Disorders, "Introduction and Background" (pp. 6-8).

TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women, "Executive Summary" (pp. xvii-xxiii).

Full citation for TIP 51: Substance Abuse and Mental Health Services Administration. (2013). Treatment Improvement Protocol (TIP) 51: Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville, MD: U.S. Department of Health and Human Services. Accessed November 8, 2015 from http://store.samhsa.gov/shin/content/SMA13-4426/SMA13-4426.pdf.

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Sex and Gender Differences
"Sex" and "gender" do not mean the same thing.
Sex differences are related to biology.
Gender is part of a person's self-representation. It relates to culturally defined characteristics of masculinity and femininity.
There are both sex and gender differences that relate to SUDs, HIV/AIDS and treatments that are more effective for men and women.
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The terms sex and gender are often used interchangeably in today's world, but their root meanings are not the same.

Sex differences relate to biology. Differences between males and females include reproductive organs, hormones, body size, metabolism, and bone mass.

Gender differences refer to the characteristics, roles, and expectations constructed by culture and social norms about what it means to be masculine or feminine, or to be a man or a woman.

Sex differences related to substance use, for women include developing SUDs and health-related problems more quickly than men, which is called the telescoping effect. As another example, women and girls have less of the gastric enzyme that metabolizes alcohol, so they have higher blood alcohol levels for a longer period of time when they consume the same amounts of alcohol as their male counterparts.

REFERENCES
For more information about sex differences, see: Tip 51: Chapter 3, "Physiological Effects of Alcohol, Drugs, and Tobacco on Women" (pp. 37-56) and "Biological and Psychological" (pp. 7-9).

National Institutes of Health's Office of Research on Women's Health website "A to Z Guide: Sex and Gender Influences on Health" at http://orwh.od.nih.gov/resources/sexgenderhealth/index.asp.

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Sex and Gender Differences
Culture, age, socioeconomic status, religion, disability, and racial and sexual identity all influence gender roles and expectations.
Common gender characteristics are not absolutes.

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The sense of masculinity or femininity is part of one's identity. People measure their femaleness and maleness against certain accepted norms and what it means to be a "man" or a "woman" in one's culture, religion, race, and so on. Certain characteristics are common among women and should be taken into consideration, but don't assume a woman fits common gender characteristics simply because she is female.

Gender characteristics are not absolutes, and no two women are the same. Even women with the similar backgrounds can have very different ideas about what it means to be a woman. Many women have traits that are associated with being masculine, and many men have feminine traits, regardless of their background, gender identity, or sexual orientation.

No matter what sex a person was assigned at birth, that person may identify as a woman, man, transgender man or woman, gender non-conforming, or another gender identity. The term women is used in this presentation to mean anyone who identifies as female. If a client woman identifies as a woman, she should be considered as such by treatment staff.
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Women Need Gender-Responsive Care
"Creating an environment through site selection, staff selection, program development, content, and material that reflects an understanding of the realities of women's lives, and is responsive to the issues of the clients."

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SOURCE: Covington, 2007.
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Review the definition of "gender responsive" by reading the quote or allowing time for trainees to read aloud or silently. How can gender-responsiveness help women in treatment?

REFERENCES
Covington, S. S. (2007). Women and addiction: A gender-responsive approach (The clinical innovators series). Center City, MN: Hazelden.

Covington, S. S., & Surrey, J. L. (1997). The relational model of women's psychological development: Implications for substance abuse. In R. W. Wilsnack & S. C Wilsnack (Eds.), Gender and alcohol: Individual and social perspectives (335351). New Brunswick, NJ: Rutgers Center of Alcohol Studies.

Why Be Gender-Responsive?
Gender-responsive services create an environment that reflects the understanding of the reality of women's lives and addresses the issues of women
Gender-responsive services help improve the effectiveness of services for women and girls.

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INSTRUCTIONS
Mention that more on gender-responsive care will be addressed later in the training when we talk about treatment.

Learning about, and implementing, gender-responsive principles can help improve prevention, treatment, and recovery programs for women and lead to more positive outcomes. Gender-responsive differs from gender-specific in that gender-specific are services those designed solely for women. Gender-responsive is a broader way of looking at services, environment, and experiences and how they address the lives of women.

Image Credit: SAMHSA, "Addressing the gender-specific treatment needs of women." Training of Trainers, March, 2016.

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On a scale of 1-5, how well does your program address the specific needs of women?
1. Not at all
2. Slightly
3. Somewhat gender-responsive
4. Very gender-responsive
5. Completely gender-responsive
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INSTRUCTIONS
Ask the question using the automated response system, if available. Consider staffing, programming, environment. Alternately, have trainees break into small groups to discuss examples of what their organizations do to address the specific needs of women.
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Epidemiology of HIV in Women
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TRANSITION SLIDE
This slide serves as the transition from setting the context of women's treatment needs to beginning a discussion specifically about women and HIV.
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HIV Diagnoses by Subpopulation
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Approximately 1 in 4 individuals diagnosed with HIV are women. New HIV diagnoses among women are primarily among women of color and a result of heterosexual contact. Black women are most affected, followed by Latinas and then whites (CDC, HIV among Women). An estimated 88% of women who are living with HIV are diagnosed, but only 32% have the virus under control.

These findings are based on CDC surveillance data. Surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event. HIV surveillance collects, analyzes, and disseminates information about new and existing cases of HIV infection (including AIDS) throughout the US.

REFERENCE
Centers for Disease Control and Prevention. (2015). HIV Surveillance Report, 2014, Volume 26. Accessed June 20, 2016 from http://www.cdc.gov/hiv/library/reports/surveillance/.
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Diagnoses of HIV infection, by year of diagnosis and selected characteristics, 2010-2014- United States and 6 dependent areas (Female adult or adolescent)
SOURCE: CDC, 2015.
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According to the CDC, the number of adult or adolescent females that were diagnosed with HIV in the US has been decreasing from 2010 to 2014.

Modes of contraction include:
Injection drug use, heterosexual contact or other, which includes hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or identified.
Women contract HIV from heterosexual contact at more than five times the rate than through IV drug use.
Contraction of HIV through heterosexual contact and Injection drug use decreased slightly every year from 2010 to 2014 with a slight rise in IV drug use from 2013 to 2014.
Contraction of HIV through other means is quite low.

REFERENCE
Centers for Disease Control and Prevention. (2015). HIV Surveillance Report, 2014, Volume 26. Accessed May 26, 2016 from http://www.cdc.gov/hiv/library/reports/surveillance/.

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Stage 3 (AIDS), by year of diagnosis and selected characteristics, 2010-2014 and cumulative- United States and 6 dependent areas (Female and adolescent)
SOURCE: CDC, 2015.
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A similar pattern emerges for AIDS diagnosis from the 2010 to 2014, with decreasing rates of diagnosis for women and adolescents for all methods of contraction. Women are nearly 4 times as likely to contract AIDS through heterosexual contact than IV drug use.

REFERENCE
Centers for Disease Control and Prevention. (2015). HIV Surveillance Report, 2014, Volume 26. Accessed May 26, 2016 from http://www.cdc.gov/hiv/library/reports/surveillance/.

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New Diagnosed HIV Infection, 2013Gender Distribution, California
SOURCE: CDPH, 2014.
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In California in 2013, 11.3% of newly diagnosed HIV infections were women. All but approximately 4% of the males were MSM.

REFERENCE
California Department of Public Health, Office of AIDS. (2014). The continuum of HIV Care California, 2014. Accessed June 22, 2016 from http://www.cdph.ca.gov/programs/aids/Documents/HIVCareContinuum-2014.pdf.

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People Living with HIV/AIDS, 2013Gender Distribution, California
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SOURCE: CDPH, 2014.
In California in 2013, 11.6% of PLWHA were women. All but approximately 4% of the males were MSM.

REFERENCE
California Department of Public Health, Office of AIDS. (2014). The continuum of HIV Care California, 2014. Accessed June 22, 2016 from http://www.cdph.ca.gov/programs/aids/Documents/HIVCareContinuum-2014.pdf.

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Prevention Challenges for Women
Racial disparities
Awareness of partner status
Trauma, abuse and increased risk
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A few challenges get in the way of prevention, especially for women of color. For example, the majority of people living with HIV (prevalence) are in African American and Hispanic/Latino communities. People tend to have sex with partners of the same race/ethnicity, so women from these communities face a greater risk of HIV infection with each new sexual encounter.

Some women may be unaware of their male partner's risk factors for HIV (e.g., IV drug use or having sex with men) and may not use condoms. They may assume that being in a monogamous relationship eliminates their risk. Women who have been sexually abused may be more likely than women with no abuse history to engage in sexual behaviors like exchanging sex for drugs, having multiple partners, or having sex without a condom.

REFERENCE
Cramer, R.J., et al. (2015). Substance-related coping, HIV-related factors, and mental health among an HIV-positive sexual minority community sample. BMJ Open, 3(2), e001928.

Tross, S.T., Campbell, A.N.C., Cohoen, L.R., Calsyn, D., Pavlicova, M., et al. (2008). Effectiveness of HIV/STD sexual risk reduction groups for women in substance abuse treatment programs: Results of a NIDA Clinical Trials Network Trial. Journal of Acquired Immune Deficiency Syndromes, 48(5), 581-589.
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Prevention Challenges for Women
The risk of getting HIV during unprotected vaginal sex is higher for women than it is for men.
Anal sex is riskier for getting HIV than vaginal sex, especially for the receptive partner.
STDs, such as gonorrhea and syphilis, greatly increase the likelihood of getting or spreading HIV
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Women are at greater risk of getting HIV during unprotected vaginal sex than men. Anal sex is riskier for getting HIV than vaginal sex, especially for the receptive partner. In a behavioral survey of heterosexual women at increased risk of HIV infection, 25% of HIV-negative women reported having anal sex without a condom in the previous year. STDs and other infections also increase the likelihood of contracting or spreading the HIV virus.

REFERENCE
Cramer, R.J., et al. (2015). Substance-related coping, HIV-related factors, and mental health among an HIV-positive sexual minority community sample. BMJ Open, 3(2), e001928.
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HIV and Pregnancy: Recommendations
HIV medicines reduce the risk of mother to child transmission and protect a woman's health.
Women who are already taking HIV medicines when they become pregnant should continue taking the medicines during pregnancy.
Women with HIV who are not taking HIV medicines when they become pregnant should consider starting HIV medicines as soon as possible.
Because pregnancy affects how the body processes medicine, the dose of an HIV medicine may change during pregnancy. But women should always talk to their health care providers before making any changes.

SOURCES: Townsend et al., 2008; Tubiana et al., 2010.
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NIH recommends that pregnant women with HIV take HIV medications to reduce the risk of mother to child transmission and protect their own health. Women who are HIV positive and are or may become pregnant should be assured that medication can almost entirely eliminate the risk of the baby becoming infected with HIV.

Women who are already taking HIV medicines when they become pregnant should continue taking the medicines during pregnancy.Women with HIV who are not taking HIV medicines when they become pregnant should consider starting HIV medicines as soon as possible.

Pregnant women with HIV can safely use many HIV medicines during pregnancy. Pregnant women and their health care providers carefully consider the benefits and the risks of specific HIV medicines when choosing an HIV regimento use during pregnancy.

Because pregnancy affects how the body processes medicine, the dose of an HIV medicine may change during pregnancy. But women should always talk to their health care providers before making any changes.

In the setting of maternal viral load suppressed to <50 copies/mL near delivery, use of combination ART during pregnancy has reduced the rate of perinatal transmission of HIV from approximately 20% to 30% to 0.1% to 0.5%. ART is thus recommended for all HIV-infected pregnant women, for both maternal health and for prevention of HIV transmission to the newborn. In ART-naive pregnant women ART should be initiated as soon as possible, with the goal of suppressing plasma viremia throughout pregnancy.
REFERENCES
Townsend, C.L., Cortina-Borja, M., Peckham, C.S., de Ruiter, A., Lyall, H., & Tookey, P.A. (2008). Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000-2006.AIDS, 22(8), 973-981. Available at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dop....

Tubiana, R., Le Chenadec, J., Rouzioux, C., et al. (2010). Factors associated with mother-to-child transmission of HIV-1 despite a maternal viral load <500 copies/ml at delivery: A case-control study nested in the French perinatal cohort (EPF-ANRS CO1).Clin Infect Dis, 50(4), 585-596. Available at http://www.ncbi.nlm.nih.gov/pubmed/20070234.
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HIV and SUDs
Both substance use and mental health issues increase chances of risky behavior that can increase a woman's exposure to HIV/AIDS.
Integrating HIV/AIDS prevention and treatment with substance abuse and mental health services for women with comorbidities can be most effective
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Active substance use can put a woman at greater risk of HIV. Women who are HIV negative and using substances may lack power or skills that still put them at risk.

Role play possible ways to behave differently and talk about strategies for managing risky situations, such as a partner who refuses to wear condoms or wants to share needles for drug injection.

HIV counseling and testing; have standard procedures to ensure women who receive testing receive counseling about what the results mean and what to do; and refer women who test positive for HIV treatment.

Build a close relationship with HIV/AIDS medical care providers within the community. Medical providers and substance use counselors can work together closely to support medical and substance abuse treatment and adherence to
treatment goals. This includes establishing agency agreements and creating formal referral mechanisms.

REFERENCES
For more information see: TIP 37: Substance Abuse Treatment for Persons With HIV/AIDS, Chapter 5, "Integrating Treatment Services," 2008.

TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders (pp. 9-10).

CDC, HIV among Women, http://www.cdc.gov/hiv/group/gender/women/.
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Epidemiology of Substance Use in Women
TRANSITION SLIDE
The purpose of the following section is to introduce issues of substance use in women and begin to develop an understanding of the importance of focusing on the relationship between women's substance use and HIV.
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Substance Use: Women vs. Men
Rates of substance use, abuse, and dependency are lower for women than for men.
Percentage
SOURCE: SAMHSA, 2015.
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Before jumping into some of women's experiences, it is important to look at some of the data in regard to women and SUDs. Overall, women are less likely to develop alcohol or illicit drug dependence than men.

Statistics show 4.4 percent of women ages 12 or older experienced past year alcohol dependence or abuse compared with 8.5% of men. Among adults 21 and older, men are also more likely to engage in heavy alcohol use in the past month (with 10.2 percent of men and 3.3 percent of women). In 2014, among individuals ages 12 and older. 1.9% of females compared with 3.4 percent of males have past year illicit drug dependence or abuse. (SAMHSA, 2015)

REFERENCE
Substance Abuse and Mental Health Services Administration. (2015). Behavioral Health Barometer: United States, 2015. HHS Publication No. SMA-16-Baro-2015. Rockville, MD: U.S. Department of Health and Human Services.

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Prevalence of Lifetime Drug Use Disorders in U.S. Population by Sex
SOURCES: NESARC Survey, 2001-02 results; Conway et al., 2006.
2:1 ratio
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Similar to the last graph, here you see an approximately 2:1 ratio in substance use disorders for men compared to women, with men using approximately double the amount that women use across each drug class

REFERENCES
Alcohol Use and Alcohol Use Disorders in the United States: Main Findings from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Alcohol Epidemiologic Data Reference Manual, Volume 8, Number 1, January 2006, NIH Publications No. 05-5737.

Conway, KP, Compton, W., Stinson, FS, Grant, BF. (2006). Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 67, 247-257.

Women and Addiction Forum
9/24/2020
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Substance Abuse Treatment Admissions by Primary Substance of Abuse
SOURCE: SAMHSA, DASIS, 2013.
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While the 2:1 ratio holds for drug use disorders, the rates of treatment admission based on primary substance of abuse changes when you compare men to women.

Demographic data collected from the Drug and Alcohol Services Information System (DASIS), the primary source of national information on the services available for substance abuse treatment and the characteristics of individuals admitted to treatment, indicate that men are 2-3 times more likely to be admitted to treatment for heroin, cocaine, marijuana and alcohol. However, the margin narrows when the primary substance is sedatives, other opiates (e.g., painkillers) and amphetamines.

REFERENCE
Substance Abuse and Mental Health Services Administration, Drug and Alcohol Services Information System. (2013). Substance Abuse Treatment Admissions by Primary Substance of Abuse. Accessed July 7, 2016 from http://wwwdasis.samhsa.gov/webt/quicklink/US13.htm.
Women and Addiction Forum
9/24/2020
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Sex and Gender Differences Related to SUDS
Women often differ from men in their:
Risk factors for substance use
Consequences of use
Barriers to treatment

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Sex and gender differences means that women and girls have different experiences than men. In regards to substance use, women and girls typically have different pathways to substance use, risk factors for use, consequences for use, barriers to treatment, and recovery support needs. Each of these will be discussed.

REFERENCES
Addressing the Needs of Women and Girls (pp. 2, 10-15, 24).

Introduction to Women and SUDs online course, Module One, TIP 51 (p. 6).

SAMHSA, "Addressing the gender-specific treatment needs of women." Training of Trainers, March 2016.
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Common Risks Factors for Initiation of Substance Use
Influence of relationships

Co-occurring disorders

Trauma history

Prescription medications

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Many pathways and risk factors exist for women to substance use and SUDs, but the following four are among the most common.

Relationships: Women are strongly influenced by familial substance use, friends and partners who use substances. Initiation of substance use often begins after introduction of substance through a significant relationship, such as a family member or intimate partner. Women are more likely than men to define selves in terms of their relationships and obligations.

Co-Occurring Disorders (COD): CODs are more likely for women than men, particularly mood disorders, anxiety disorders, and eating disorders. Women are more likely to use substances to decrease negative mood and increase positive -to relax, reduce stress, focus attention, increase confidence.
May use substances in relation to eating disorders/body image concerns: positive effects such as weight loss, increased energy.

Trauma: Past trauma more likely for women, including rape, sexual assault, intimate partner violence. Women may use substances to cope with emotional effects of trauma. Women who experience child abuse, sexual assault, or intimate partner violence are significantly more likely to develop SUDs than women who do not have traumatic experiences.

Prescription Drugs: Women are much more likely than men to be prescribed potentially addictive drugs by their doctors and to become dependent on them.

REFERENCES
TIP 51, pp. 18-26 under "Risk Factors Associated with Initiation of Substance Use and the Development of Substance Use Disorders Among Women." See page 26 for prescription drug use prevalence.

SAMHSA, "Addressing the gender-specific treatment needs of women." Training of Trainers, March 2016.
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Substance Use, Trauma, and Mental Health Cycle
SOURCE: Institute for Health and Recovery.
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INSTRUCTIONS
Talk through graphic and the cycle of trauma, mental health and substance use.

The is a high prevalence of trauma among women with SUDs, which impacts their treatment needs. Often women may initiate substance use as a way of coping with traumatic experiences. Substance use, though, can then also lead to risky behaviors, which make them more vulnerable to further victimization. If they re victimized while impaired, it is highly likely that they will be blamed, thus increasing shame, guilt, and stigma. Conversely, risky substance use can exacerbate mental health concerns and continued trauma/violence, which then re-traumatizes the woman and leads to continued substance use as an escape.

For women with trauma histories, the issues of trauma, substance use, and mental health concerns are interrelated.

REFERENCES
Action Steps for Improving Women's Mental Health (pp. 9-10) and TIP 51 (pp. 8-9) and Chapter 2, and TIP 57, (p. 89).

SAMHSA, "Addressing the gender-specific treatment needs of women." Training of Trainers, March 2016.

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Other Risk Factors for Substance Use and SUDs
Easy access
Positive effects
Mood disorders
Lack of positive activities
Home atmosphere

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Some additional risk factors that can lead to substance use and eventual SUDS in women include:
Easy access: Availability of substances in the home or community, affordable price, the ease with which substances can be purchased, and social norms that encourage rather than discourage substance use are all factors that increase the likelihood of girls and women initiating substance use.

Positive effects: If a woman experiences positive effects from her initial substance use such as weight loss, approval of an intimate partner, or stress reduction, her substance use is more likely to continue.

Lack of positive activities: Although involvement in positive activities is a protective factor, girls who are not involved in activities they enjoy and in which they are successful (such as sports, arts, and religious activities) are more vulnerable to substance abuse.

Home atmosphere. Taking on adult responsibilities as a child, including parenting of younger siblings and emotional support of parents, raises a girls' risk of initiating drug and alcohol use. A chaotic, argumentative, blame-oriented, and violent household is also major risk factor for substance initiation and dependence for girls/women.

REFERENCE
TIP 51, pp 18-26, under "Risk Factors Associated with Initiation of Substance Use and the Development of Substance Use Disorders Among Women."
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What is Telescoping?
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INSTRUCTIONS
Ask trainees by a show of hands if they know what telescoping is and why it's important for women. Take definitions and explanations.

Clarify, as needed, that women are also more likely than men to experience a phenomenon called telescoping, a term that reflects the more rapid progression from initiation of use to dependence to treatment. With both drinking and using drugs, women have a shorter gap between starting to use drugs or alcohol to developing problems related to substance use. This puts women at more immediate risk of developing a substance use disorder, even with using less of a substance for a shorter amount of time. Telescoping has been found in treatment seeking samples, but is less clear in the general population.

REFERENCESRandall, C.L., Roberts, J.S., Del Boca, F.K., Carroll, K.M., Connors, G.J., & Mattson, M.E. (1999). Telescoping of landmark events associated with drinking: A gender comparison. J of Studies on Alcohol, 60(2), 252-260.

Keyes, K.M., Martins, S.S., Blanco, C., & Hasin, D.S. (2010). Telescoping and gender differences in alcohol dependence: New evidence from two national surveys. Am J Psychiatry. 167(8), 969-976.
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Consequences of Substance Use and SUDs
Women with SUDs are more likely than men with SUDs to:

Risk losing children
Risk losing relationship with partner due to seeking treatment
Have reproductive consequences
Have SUD-related health conditions
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Although men and women both have risks and consequences to substance use and abuse, some are greater for women, including:
Children: Because women are more likely to be primary caregivers, they are typically at higher risk of losing custody of their children due to SUDs.

Relationship Loss: Women have patterns of drug abuse that are more socially embedded than men and revolve around their relationships. Drug use is often initiated by sexual partners. For women seeking SUD treatment, there is often difficulty involving male partners in the treatment, and some may prevent their female partners from entering or staying in treatment. Thus, women who fear losing their partner may not seek or stay in treatment.

Reproductive/pregnancy: Pregnant women who continue to use alcohol, illicit, or prescriptions drugs place their unborn babies at risk for a wide range of health issues, including premature birth, death, fetal alcohol syndrome, neonatal abstinence syndrome, etc. This will be further discussed in the section about pregnancy and parenting. Abuse of substances such as stimulants, opioids, and some prescription drugs can also cause adverse effects on women's menstrual cycles and fertility, along with their gastrointestinal, neuromuscular, cardiac systems, etc.

Health Conditions: Women with SUDS often have more health-related conditions than men, including organ damage, cardiac-related conditions, reproductive consequences, breast and other cancers, osteoporosis, and nutritional deficiencies.

REFERENCE
TIP 51, "Physiological Effects of Alcohol, Drugs, and Tobacco on Women," (pp. 37-55); (pp. xix, 7-14, 20).

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Consequencesof Substance Use and SUDs, continued
Women with SUDs are more likely than men with SUDs to:

Acquire infections (e.g., HIV)
Be exposed to violence (e.g., rape, sexual assault, IPV) which raises risk of homelessness.
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Infections: Women with SUDS are at increased risk of contracting HIV/AIDS and hepatitis from sharing needles or having sexual relations with men who inject drugs of have sex with other men. As noted in Tip 51, "Some women may have unrealistic notions about intimacy, assume their partners are monogamous, or fear alienating their partners by demanding safe sex practices. Women with a history of abuse may have particular problems negotiating the use of these practices." (TIP 51, p. 20).

Trauma: Trauma can be a pathway to initiation of substance use, and substances can be used as a coping mechanism. But SUDs also increase a woman's vulnerability to additional trauma, decrease her ability to defend herself, alter her judgment, and draw her into unsafe environments." (TiIP51, p. 23). Women may also continue to use drugs to cope with abusive relationships. Thus, trauma/violence are both a risk factor and a consequence of substance abuse.

REFERENCES
Messina, N.P., Burdon, W.M., & Prendergast, M.L. (2003). Assessing the needs of women in institutional therapeutic communities. Journal of Offender Rehabilitation. 37(2), 89-106.

Substance Abuse and Mental Health Services Administration. (2013). Treatment Improvement Protocol (TIP) 51: Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville, MD: U.S. Department of Health and Human Services. Accessed November 8, 2015 from http://store.samhsa.gov/shin/content/SMA13-4426/SMA13-4426.pdf.

SAMHSA, "Addressing the gender-specific treatment needs of women." Training of Trainers, March 2016.

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Pregnancy and Children
Pregnancy, parenting, and childcare increase a woman's likelihood of entering and completing substance abuse treatment.
SOURCES: Mitchell et al., 2009; Ondersma et al., 2008.
38
Many women with SUDs significantly decrease their use after becoming aware of their pregnancy. A woman often has the motivation to protect her unborn baby's health and this can motivate her to make life changes and enter SUD treatment.

It is often very difficult for women who used substances during their pregnancies to face the possible damage done to their children. It is also very difficult for mothers to admit to themselves and others some of the experiences that their children may have had while they were using, and the effects these experiences had on them. Understanding the dynamics of shame and guilt as these play out is critical to the ability to help women in treatment.

In one study looking at the relationship between pregnancy and motivation for treatment, researchers analyzed data collected from 149 drug-using women between 2000 and 2007; 49 of the drug-using women were pregnant and 100 were non-pregnant. The study found that pregnant women were more than four times as likely as non-pregnant women to express greater motivation for treatment. (Mitchell et al, 2010).

All pregnant drug-using women should be targeted for interventions aimed at increasing motivation for treatment. A pregnant woman who uses drugs endangers not only her own life but also that of an unborn child.

Non-confrontational interventions such as motivational enhancement therapy (MET) could rapidly increase a pregnant woman's motivation to seek treatment and improve the life of her child in countless immeasurable ways. MET aims to establish an internal motivation for treatment by examining and overcoming ambivalence about change. A study by Ondersma et. al. suggests that setting a clear goal to quit at the start of treatment may improve the efficacy of interventions such as MET (2008). More research is needed to examine how different approaches to drug treatment might affect the motivation among different groups of drug-using pregnant women.

REFERENCES
TIP 51 (p. 10).

Mitchell, M.M., Severtson, S.G., & Latimer, W.W. (2008). Pregnancy and race/ethnicity as predictors of motivation for drug treatment. American Journal of Drug and Alcohol Abuse, 34(4), 397-404.Ondersma, S.J., Winhusen, T., Erickson, S.J., Stine, S.M., & Wang, Y. (2008). Motivation enhancement therapy with pregnant substance-abusing women: Does baseline motivation moderate efficacy? Drug and Alcohol Dependence, 101(1-2): 74-79.

SAMHSA. (n.d.). Addressing the Needs of Girls and Women, pp. 20-21. RWC/PPW Program and Cross-Site Fact Sheets. Retrieved from http://www.samhsa.gov/sites/default/files/women-children-families-rwc-pp....
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Past Month Alcohol and Drug Use:Pregnant Females, Ages 15-44, 2013-14
Number
Percent
Illicit drugs
123,000
5.3%
Marijuana
96,000
4.1%
Heroin
5,000
0.3
Cocaine
7,000
0.2
Psychotherapeutics
30,000
1.3
Inhalants
8,000
0.3
Hallucinogens
4,000
0.2
Alcohol Use
214,000
9.3%

SOURCE: SAMHSA, 2015.
39
Among pregnant women aged 15 to 44, 5.3 percent were current illicit drug users based on data averaged across 2013 and 2014. This was lower than the rate among women in this age group who were not pregnant (11.4 percent). An annual average of 9.3 percent reported current alcohol use. The average rate of current illicit drug use in 2012 to 2013 (5.4 percent) was not significantly different from the rate averaged across 2010 to 2011 (5.0 percent). Current illicit drug use in 2012 to 2013 was lower among pregnant women aged 15 to 44 during the third trimester than during the first and second trimesters (2.4 percent vs. 9.0 and 4.8 percent). (SAMHSA, p. 26).

The rate of current illicit drug use in the combined 2012 to 2013 data was 14.6 percent among pregnant women aged 15 to 17, 8.6 percent among women aged 18 to 25, and 3.2 percent among women aged 26 to 44. These rates were not significantly different from those in the combined 2010 to 2011 data (20.9 percent among pregnant women aged 15 to 17, 8.2 percent among pregnant women aged 18 to 25, and 2.2 percent among pregnant women aged 26 to 44). (SAMHSA, p. 26).

REFERENCES
Center for Behavioral Health Statistics and Quality. (2015). 2014 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: U.S. Department of Health and Human Services.
39

Risks of Substance Use to Pregnant Women and Her Baby
Substance use during pregnancy can result in health concerns and risks for the woman and unborn fetus.
Risks include miscarriage, low-birth weight, fetal alcohol withdrawal syndrome, neonatal opioid withdrawal
Some complications are drug or alcohol specific, e.g., infants exposed to have more infections, including HIV.
Others risks are linked substance using lifestyle, social environmental risk factors or poverty.

40
A number of health concerns are related to substance use during pregnancy, including:
Miscarriage
Premature delivery
Low birth weight
Infant mortality
Spontaneous abortion
Stillbirth
Smaller head circumference
Fetal alcohol spectrum disorder (FASD)
Neonatal abstinence syndrome (NAS) or Neonatal Opioid Withdrawal

Examples of drug/alcohol specific complications include:
Use and withdrawal from opiates causes significant stress to the developing fetus, which can lead to serious consequences such as stillbirth or loss of the pregnancy.
Infants exposed to cocaine during pregnancy have more infections, including hepatitis and HIV/AIDS exposure.
Amphetamine use can cause withdrawal symptoms after birth, and impaired neurological development in infancy and childhood.
Alcohol exposure can lead to early-onset of alcohol disorders among children and adolescents.
Social environmental risk factors include higher levels of stress. Challenges to adequate self-care such as rest and nutrition which can be result of poverty, social environment or lifestyle.

Symptoms vary by the infant, but some of the following may result from fetal drug exposure (Medline Plus, 2015):
Blotchy skin coloring (mottling)
Diarrhea
Excessive crying or high-pitched crying
Excessive sucking
Fever
Hyperactive reflexes
Increased muscle tone
Irritability
Poor feeding
Rapid breathing
Seizures
Sleep problems
Slow weight gain
Stuffy nose, sneezing
Sweating
Trembling (tremors)
Vomiting

Interventions can reduce these risks. Considerations related to treatment interventions are addressed later on. Other risks after the baby is born include:
Decreased lactation with breast feeding
Disrupted infant sleep patterns
Infant somnolence, which is excess sleepiness
Irritability
Sudden infant death syndrome
Attention problems as the child ages

REFERENCES
Family-Centered Treatment for Women with Substance Use Disorders, pp. 15 -17.

SAMHSA. Addressing the Gender-Specific Treatment Needs of Women. Training of Trainers, November 2015.

TIP 51, pp. 48-51.
40

Priority for Services
Pregnant women with SUDs have priority admission status for SUD services.
Pregnant women need timely access to prenatal care, eitherby the program or by referral to appropriate healthcare providers.

41
Federal law requires that pregnant women receive priority admission into substance abuse treatment programs. This allows them to bypass waiting lists and gain immediate admission when a bed in a residential program is available. Also, the primary treatment provider must secure prenatal care if the woman is not already receiving it. They have priority because of the short length of time during which it's possible to intervene (often much shorter than the 9 months a typical pregnancy lasts), and because of possible damage to a fetus that is inflicted by continued substance use. If a provider is not able to admit a pregnant woman for treatment within 48 hours, interim services should be provided (e.g., crisis intervention, counseling on the potential effects of alcohol, tobacco and drug use on the fetus; referral to prenatal care; and HIV/TB screening and counseling). Inform individuals, collateral agencies, and the broader community that pregnant women have priority admissions to treatment for SUDs.

REFERENCE
TIP 51, p. 101.
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Importance of Outreach
Pregnant women with SUD benefit from early identification of pregnancy and an informed team response.
Pregnant women with SUDs have better outcomes when they:
Are able to obtain SUD services
Receive prenatal care
Prioritize outreach to pregnant women to prevent prenatal substance exposure.
42
An informed team response considers symptoms, pharmacological risks and options, and the possible need for other supports. Many pregnant women with SUDs don't discover their pregnancies right away, and often are ambivalent about seeking care. They may experience fear and shame due to their alcohol or drug use and fear that they will lose the child. Pregnancy also increases stress and for women with SUDs their primary way of coping with stress is alcohol/drug use and they often need assistance to feel ready to reduce or eliminate alcohol/drug use. But many of these women are motivated by pregnancy to make changes in their lives for the sake of their baby, and can be very open to treatment/recovery if they can overcome their fears.

REFERENCES
Addressing the Needs of Girls and Women: pp. 20-21

RWC/PPW Program and Cross-Site Fact Sheets. Retrieved from http://www.samhsa.gov/sites/default/files/women-children-families-rwc-pp....

Guidance to the States , pp. 13, 15, 26, and 39.
42

Alcohol Use in Women
43
TRANSITION SLIDE
This slide serves to move from discussions of epidemiology and impact of substance use to specific recommendations and impacts of around alcohol use and other substances in women.
43

Men: No more than 4 drinks on any day and 14 drinks per week
Women: No more than 3 drinks on any day and 7 drinks per week
NIAAA, 2011
Drinking Guidelines

Beer Wine Fortified Wine Liquor
12 oz 5 oz 3.5 oz 1.5 oz
Men and Women >65: No more than 3 drinks on any day and 7 drinks per week
NIAAA considers 1 drink per day to be the maximum for "moderate" use
Older Adult Drinking Guidelines
44
44
44
Drinking Guidelines

[Slide 5] Special concerns arise when developing alcohol consumption guidelines for the older adult population. Compared with younger people, older adults have an increased sensitivity to alcohol, as well as to over-the-counter and prescription medications. There is an age-related decrease in lean body mass versus total volume of fat. The resultant decrease in total body volume increases the circulating distribution of alcohol and other mood-altering chemicals in the body. Liver enzymes that metabolize alcohol and certain other drugs become less efficient with age. Central nervous system sensitivity increases with age.

As stated before, the potential interaction of medications and alcohol is a particular concern in this age group. For some individuals, ANY alcohol use with specific over-the-counter or prescription medications can be problematic. Because of the age-related changes in how alcohol is metabolized, and the potential interactions between medications and alcohol, alcohol use recommendations for older adults are lower than those for adults under 65. For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 1995b) and the CSAT Treatment Improvement Protocol (TIP) on older adults (Blow, CSAT, 1998b) recommend that persons age 65 and older consume no more than one standard drink per day or seven standard drinks per week (Dufour & Fuller, 1995; Dietary Guidelines Advisory Committee, 2000, page 39). In addition, older adults should not consume more than 2 standard drinks on any drinking day. It is recommended that the limit for older women should be slightly less than one standard drink per day.
**ANIMATIONS**
This slide animates in four parts. The first half of the slide presents information related to general drinking guidelines for men and women. The subsequent animations will reveal the drinking guidelines for men and women. The information is based on the recommended drinking guidelines of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Click to reveal the first bullet point
For men, the NIAAA recommends no more than 4 drinks on any day and no more than 14 drinks per week.

Click to reveal the second bullet point
For women, the NIAAA recommends no more than 3 drinks on any day and no more than 7 drinks per week. Women and men metabolize alcohol differently, so the drinking guidelines are gender-specific.

Click to reveal the third bullet point
For older adults (>65), the NIAAA recommends no more than 3 drinks on any day and no more than 7 drinks per week.

Click to reveal the fourth and final bullet point
The NIAAA considers 1 drink per day to be the maximum for moderate use.

Additional information for the Trainer(s)
As noted by the NIH, these guidelines are identified for adults who are healthy and do not take any medications. Taking medications or having a health condition may mean reducing drinking or not drinking at all. People have different personal definitions of what exactly constitutes an alcoholic "drink." The National Institute on Alcohol Abuse and Alcoholism has developed a definition of a standard drink. A standard drink can be a 12-ounce beer, 8-9 ounces of malt liquor, 5 ounces of wine, 3-4 ounces of fortified wine, 2-3 ounces of cordial, 1.5 ounces of brandy, or 1.5 ounces of spirits such as vodka, gin, or scotch. So, a drink for one person may be a "40-ouncer" of beer, which, if you use NIAAA's definition of a standard drink, would equal 3 1/3 standard drinks. It is very important for alcohol dependent clients to understand what is meant by "a drink" when you are assessing the extent of their alcohol problem.

Why are women's guidelines different?
45
On average, women weigh less than men, so effects of alcohol are greater.

45

Why are women's guidelines different?
46
H2O
46
Why are women's guidelines different? It's in the water.

Alcohol passes through the digestive tract and is dispersed in the water in the body. The more water available, the more diluted the alcohol. As a rule, men weigh more than women, and, pound for pound, women have less water in their bodies than men. Therefore, a woman's brain and other organs are exposed to more alcohol and to more of the toxic byproducts that result when the body breaks down and eliminates alcohol.

Other biological and hormonal differences also exist that result in different effects for women and men.
46

NIAAA Recommendations for Abstinence from Alcohol
Anyone under age 21
People of any age who are unable to restrict their drinking to moderate levels
Women who may become pregnant or who are pregnant
People who plan to drive, operate machinery, or take part in other activities that require attention, skill, or coordination
People taking prescription or over-the-counter medications that can interact with alcohol.
47
The NIAAA has recommendations for abstinence no drinking under the following circumstances. Under age 21 (illegal); unable to restrict drinking to moderate levels (lack of control); women who may become pregnant or who are pregnant (there has been no safe level of drinking established during pregnancy); engaging situations that could be hazardous; taking medications that may interact with alcohol.

For women with HIV, the highlighted items are most relevant and should be considered. For pregnant women, there has been no safe level of drinking established. Also, alcohol can interact with antiretrovirals and other medications.
47

Women and Drug Use
48
TRANSITION SLIDE
This slide serves to move from discussion of alcohol to other drug use in women.
48

Stimulants
49
INSTRUCTIONS
We will discuss the issues specific to women with two types of stimulants most commonly used: cocaine and methamphetamine.
49

Cocaine
Research in humans and animals suggests that women may be more vulnerable to the reinforcing (rewarding) effects of stimulants, with estrogen possibly being one factor for this increased sensitivity
In animal studies, females are quicker to start taking cocaineand take it in larger amountsthan males.
Women may be more sensitive than men to cocaine's effects on the heart and blood vessels.
50
SOURCES: Evans & Foltin, 2006; Justice and de Wit, 1999, 2000; Anker & Carroll, 2011.
Research in humans and animals suggests that women may be more vulnerable to the rewarding effects of simulants, with estrogen being one factor in this increased sensitivity. In animal studies, females are quicker to start taking cocaine, and take it in larger amounts, than males. Women may also be more sensitive than men to cocaine's effects on the heart and blood vessels.

REFERENCES

Evans ,S.M., & Foltin, R.W. (2006). Exogenous progesterone attenuates the subjective effects of smoked cocaine in women, but not in men. Neuropsychopharmacology,31, 659-674.

Justice, A.J., & de Wit, H. (1999). Acute effects of d-amphetamine during the follicular and luteal phases of the menstrual cycle in women. Psychopharmacology (Berl), 145(1), 67-75.

Justice, AJ, de Wit, H. (2000). Acute effects of d-amphetamine during the early and late follicular phases of the menstrual cycle in women. Psychopharmacology, Biochemistry and Behavior. 66(3), 509-551.

Anker, JJ, Carroll, M. (2011). Females are more vulnerable to drug abuse than males: evidence from preclinical studies and the role of ovarian hormones. Current Topics in Behavioral Neurosciences. 8(8), 73-96.

50

Methamphetamine
Women tend to begin using methamphetamine at an earlier age than men and have more problems related to their meth use
Women are less likely to switch to another drug when they lack access to methamphetamine
51
SOURCES: Brecht et al., 2004; Hser et al., 2005; Rawson et al., 2005; Kim & Fendrich, 2002.
Women tend to begin using the stimulant, methamphetamine, at an earlier age than men. Women also have more problems related to their meth use. Women who use methamphetamine do not tend to use other substances when meth is not available. As noted above, women tend to receive treatment more often for methamphetamine than for other substances.

REFERENCES
Rawson, R.A., Gonzales, R., Obert, J.L., McCann, M.J., & Brethen, P. (2005). Methamphetamine use among treatment-seeking adolescents in Southern California: Participant characteristics and treatment response. Journal of Substance Abuse Treatment, 29(2),67-74.

Brecht, M.L., O'Brien, A., von Mayrhauser, C., & Anglin, M.D. (2004). Methamphetamine use behaviors and gender differences. Addictive Behavior, 29(1), 89-106.

Hser, Y.-I., Evans, R., & Huang, Y.C. (2005). Treatment outcomes among women and men methamphetamine abusers in California. Journal of Substance Abuse Treatment. 28(1), 77-85

Kim JY, Fendrich, M (2002). Gender differences in juvenile arrestees' drug use, self-reported dependence, and perceived need for treatment. Psychiatric Services, 53(1), 70-75.

51

Opioids
52
INSTRUCTIONS
Next we will discuss opioid use in women. As a class of drug, opioids include heroin as well as prescription opioids, such as oxycodone, hydromorphone or other painkillers.
52

Heroin
Compared with men, women who use heroin are:
Younger
likely to use smaller amounts and for a shorter time
less likely to inject the drug
more influenced by drug-using sexual partners
One study indicated that women are more at risk than men for overdose death during the first few years of injecting heroin
SOURCES: Bryant et al., 2010; Gjersing et al., 2014; McElrath & Harris, 2013)
53
While women may inject less frequently, they also are more influenced by their drug-using sexual partners who may be injection drug users. This puts women at greater risk for HIV infection, not from sharing needles but from having unprotected sex with a drug-using partner. Women also tend to overdose during the first few years of injecting heroin. If they survive past the first few years, they are more likely than men to survive over the long run.

REFERENCES
Bryant, J., Brener, L., Hull, P., Treloar, C. (2010). Needle sharing in regular sexual relationships: An examination of serodiscordance, drug using practices, and the gendered character of injecting. Drug and Alcohol Dependence, 107, 182-187.

Gjersing, L., & Bretteville-Jensen, A.L. (2014). Gender differences in mortality and risk factors in a 13-year cohort study of street-recruited injecting drug users.BMC Public Health, 14, 440.

McElrath, K., & Harris, J. (2013). Peer injecting: implications for injecting order and blood-borne viruses among men and women who inject heroin. Journal of Substance Use, 18(1), 31-45.
53

Women and Prescribed Opiates
SOURCE: Ailes, et al., 2015.
54
While women are less likely to misuse pain medicines than men, there are still 4 million women who do. Also note that the usual 2:1 ratio of use for men and women increases to 5:4 for opiates.

Women have lower pain tolerance than men, therefore may be more likely to receive prescriptions for pain medications. This leaves them at greater risk for misuse and other negative consequences.

REFERENCES
Ailes, E.C., Dawson, A.L., Lind, J.N., et al. (2015). Opioid prescription claims among women of reproductive ageUnited States, 2008-2012.MMWR, 64(2), 37-41.

Center for Behavioral Health Statistics and Quality (CBHSQ). (2015). Results from the 2014 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD, U.S. Department of Health and Human Services.

Image Credit: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
54

Prescription Painkiller Overdose
Deaths from prescription painkiller overdoses among women increased more than 400% from 1999-2013, compared to 265% among men
Women between the ages of 45 and 54 are more likely than women of other age groups to die from a prescription pain reliever overdose
55
SOURCE: CDC, 2013.
Although men are still more likely to die of prescription painkiller overdoses (more than 10,000 deaths in 2010), the gap between men and women is closing. Deaths from prescription painkiller overdose among women have risen more sharply than among men; since 1999 the percentage increase in deaths was more than 400% among women compared to 265% in men. This rise relates closely to increased prescribing of these drugs during the past decade.

REFERENCE
Centers for Disease Control and Prevention. (2013). CDC Vital Signs: Prescription Painkiller Overdoses. Accessed June 20, 2016 from http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/.

55

Women and Other Prescribed Drugs
56
SOURCE: CBHSQ, SAMHSA, 2012-13 results.
Women are more likely than men to seek treatment for misuse of barbiturates, typically sleep aids prescribed by a physician. The majority of people admitted to treatment for barbiturate misuse are women (55%).

REFERENCES
Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. (2012). Treatment Episode Data Set (TEDS). Substance Abuse Treatment Admissions by Primary Substance of Abuse, According to Sex, Age Group, Race, and Ethnicity, 2012, United States. Accessed January 6, 2016, from http://www.dasis.samhsa.gov/webt/quicklink/US12.htm.

Also see http://wwwdasis.samhsa.gov/webt/quicklink/US13.htm. Accessed July 7, 2016.

Image Credit: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
56

Adolescent Girls and Prescription Drugs
57
Overall, more males than females abuse prescription drugs in all age groups except the youngest (aged 12 to 17 years); that is, females in this age group exceed males in the nonmedical use ofallpsychotherapeutics, including pain relievers, tranquilizers, and stimulants.

Amongnonmedical usersof prescription drugs, females 12 to 17 years old are also more likely to meet abuse or dependence criteria for psychotherapeutics.
57

Marijuana
58
INSTRUCTIONS
This slide serves to move discussion to marijuana use in women, as well as some general information about medical marijuana that is relevant to people living with HIV and AIDS.
58

SOURCES: Hernandez et al., 2004; Khan et al., 2013; Thomas, 1996 .
59
INSTRUCTIONS
Review the differences in marijuana use disorder for men and women.

With regards to the finding on the similarity between men and women both have at least one other comorbid mental health issue when there is a cannabis use disorder and both also have a low rate of seeking treatment for cannabis use.

REFERENCES
Hernandez-Avila, C.A., Rounsaville, B.J., & Kranzler, H.R. (2004). Opioid-, cannabis- and alcohol-dependent women show more rapid progression to substance abuse treatment. Drug Alcohol Depend, 74(3), 265-272.

Khan, S.S., Secades-Villa, R., Okuda, M., et al. (2013). Gender differences in cannabis use disorders: Results from the National Epidemiologic Survey of Alcohol and Related Conditions.Drug Alcohol Depend, 130(1-3),101-108.

Thomas, H. (1996). A community survey of adverse effects of cannabis use. Drug Alcohol Depend, 42(3), 201-207.

Image Credit: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
59

Medical Marijuana and HIV/AIDS: Reasons for Caution
People with HIV are living longer now because of early identification and effective therapies
A chronic disease that can be managed, not necessarily a terminal illness
People with HIV should be concerned about their long-term health just like everyone else
Dependence on marijuana poses a risk to physical and mental health for everyone, whether or not they are HIV+
60
People with HIV are living longer now than ever before because of early identification and effective medication therapies, treating HIV more like a chronic disease that can be managed rather than a terminal illness. People with HIV should be concerned about their long-term health and risk behaviors that may impact their overall health and well-being just like everyone else. The corollary to this is that dependence on marijuana poses a physical and mental health risk to everyone, regardless of whether or not the individual is HIV positive.

60

Medical Marijuana and HIV/AIDS: Reasons for Caution
Long-term marijuana use impairs learning and memory

47% of HIV+ marijuana users report memory problems

Marijuana's cognitive effects particularly strong for people experiencing HAND

Concern that cognitive impairment may compromise ART adherence
Forgetting to take medication is the leading cause of ART non-adherence
Use of most recreational drugs and alcohol is associated with lower ART adherence, less virological suppression, slower CD4 cell response rate

SOURCES: Chesney, 2003; Cristiani et al., 2004; Wooldridge et al., 2005.
61
Given the effects HIV can have on cognition, people living with HIV should be careful with marijuana, which also affects learning and memory. Almost half of HIV-positive marijuana users report having memory problems, and the drug's cognitive effects may be particularly strong for people experiencing HAND. Cognitive impairment may also compromise adherence to ART, since forgetting medication is the leading cause for ART non-adherence. Research shows that the use of most recreational drugs and alcohol is associated with lower antiretroviral medication adherence, less virologic suppression, and slower CD4 cell response rate.

REFERENCES
Chesney, M. (2003). Adherence to HAART Regimens. Aids Patient Care and STDs, 17(4), 169-177.

Cristiani, S.A., Pukay-Martin, N.D., & Bornstein, R.A. (2004). Marijuana Use and Cognitive Function in HIV-Infected People. The Journal of Neuropsychiatry & Clinical Neurosciences, 16(3), 330-335.

Woolridge, L., et al. (2005). Interaction between the CD8 Coreceptor and Major Histocompatibility Complex Class I Stabilizes T Cell Receptor-Antigen Complexes at the Cell Surface. The Journal of Biological Chemistry, 280, 27491-27501.
61

Medical Marijuana and HIV/AIDSFood for Thought
Studies have thus far not identified long-term negative effects of regular cannabis use on the progression of HIV
Two interesting recent studies:
Recently diagnosed individuals reporting daily cannabis use had significantly lower HIV plasma viral load levels one year after diagnosis than individuals reporting little or no cannabis use, even after controlling for age, gender, ethnicity, homelessness, alcohol use, injection drug use, and non-injection drug use
SOURCE: Milloy, 2015.
62
Consider these studies that indicate that the interaction between marijuana and HIV may not be as detrimental as indicated by previous studies (however, take this information with some caution until additional research is able to replicate or broaden findings). Studies have not been able to identify long-term negative effects of regular cannabis use on the progression of HIV for men or women. A recent study found that recently-diagnosed individuals who also used cannabis daily reported lower HIV plasma viral load levels one year following diagnosis than individuals who did not use. This study found these results even after controlling for age, gender, ethnicity, homelessness, and other alcohol/illicit drug use.

REFERENCE
Milloy, M.J. (2015). High-intensity cannabis use associated with lower plasma HIV-1 RNA viral load among recently infected people who use injection drugs. Drug and Alcohol Review, 34, 135-140.
62

Medical Marijuana and HIV/AIDSFood for Thought
Longitudinal study of 523 HIV+ illicit drug users (median age = 45),
No difference in antiretroviral adherence rates between individuals reporting daily cannabis use vs those reporting occasional or no cannabis use, again after controlling for possible confounding variables
Daily alcohol, heroin, cocaine, & crack use were all associated with lower ART adherence

SOURCE: Slawson, 2015.
63
The second study looking at medical marijuana and HIV/AIDS was a longitudinal study of 523 HIV positive illicit drug users with a median age of 45. During this study, researchers found that there was no difference in ART adherence rates between daily cannabis users and individuals infrequently or never using cannabis. However, daily alcohol, heroin, cocaine and crack use were all associated with lower ART adherence. The finding was the same for men and women.

REFERENCE
Slawson, G., et al. (2015). High-intensity cannabis use and adherence to antiretroviral therapy among people who use illicit drugs in a Canadian setting. AIDS & Behavior, 19, 120-127.
63

Co-Occurring Conditions
64
INSTRUCTIONS
This slide serves to transition to co-occurring mental and physical health issues that women living with HIV or AIDS may be experiencing.
64

Trauma Exposure in HIV+ women
30% or over 5 times of national average
55.3% have experienced intimate partner violence (IPV) or over twice the national average
HIV+ women with recent trauma had
4 times the odds of antiretroviral failure
3 times odds of sex with HIV negative or unknown partner with less than 100% condom use
65
SOURCE: Machtinger et al., 2012.
In a meta-analysis to estimate rates of psychological trauma and posttraumatic stress disorder (PTSD) in HIV-positive women from the United States, the investigators found disproportionate rates of trauma exposure and recent PTSD in HIV-positive women compared to the general population of women. For example, the estimated rate of recent PTSD among HIV-positive women is 30.0% (95% CI 18.8-42.7%), which is over five-times the rate of recent PTSD reported in a national sample of women. The estimated rate of intimate partner violence is 55.3% (95% CI 36.1-73.8%), which is more than twice the national rate. Studies of trauma-prevention and trauma-recovery interventions in this population are greatly needed.

Investigators from the UCSF program also conducted a study analyzing data from a prevention-with-positives program among 113 HIV-positive biological and transgender women to understand if socio-economic, behavioral, and health-related factors are associated with antiretroviral failure and HIV transmission-risk behaviors. Compared to participants without recent trauma, participants reporting recent trauma had over four-times the odds of antiretroviral failure (AOR 4.3; 95% CI 1.116.6;p=0.04), and over three-times the odds of reporting sex with an HIV-negative or unknown serostatus partner (AOR 3.9; 95% CI 1.311.9;p=0.02) and <100% condom use with these partners (AOR 4.5; 95% CI 1.513.3;p=0.007). Screening for recent trauma in HIV-positive biological and transgender women was found to identify patients at high risk for poor health outcomes and HIV transmission-risk behavior.

REFERENCES
Machtinger, E.L., Haberer, J.E., Wilson, T.C., & Weiss, D.C. (2012). Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders. AIDS and Behavior, 16(8), 2160-2170.

Machtinger,, E.L., Wilson, T.C., Haberer, J.E., & Weiss, D.C. (2012). Psychological trauma and PTSD in HIV-positive women: A meta-analysis. AIDS and Behavior, 16(8), 2091-2100.
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SUDs and Women's Health
SUDs can cause negative effects on women's physical health
Health issues may be neglected or exacerbated
Health issues are more severe and arise earlier than in men

SOURCE: SAMHSA, 2013.
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Women with SUDS often have co-occurring acute or chronic health problems that have been neglected or exacerbated during substance use. They have greater susceptibility to, and earlier onset of, serious substance use-related
medical problems and disorders than do men.

REFERENCE
Substance Abuse and Mental Health Services Administration. (2013). Treatment Improvement Protocol (TIP) 51: Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville, MD: U.S. Department of Health and Human Services. Accessed November 8, 2015 from http://store.samhsa.gov/shin/content/SMA13-4426/SMA13-4426.pdf.
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SUDs and Women's Health Risks

Liver and other GI disorders
Heart disease
Breast and other cancers
Gynecological and reproductive issues

Osteoporosis
Nutritional deficiencies
Cognitive and other neurological effects
Infections
Oral health problems

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SOURCE: SAMHSA, 2013.
These health problems can be caused or made worse by substance use: For example, women who drink are more likely to develop alcoholic hepatitis (liver inflammation) than men who drink the same amount of alcohol. Alcohol
hepatitis can lead to cirrhosis. Chronic heavy drinking is a leading cause of heart disease. Among heavy drinkers, women are more susceptible to alcohol-related heart disease than men, even though women drink less alcohol over a
lifetime than men do.

An association exists between drinking alcohol and developing breast cancer. Women who consume about one drink per day have a 10% higher chance of developing breast cancer than women who do not drink at all. That risk
rises another 10 percent for every extra drink they have per day.

Drinking during pregnancy is risky. A pregnant woman who drinks heavily puts her fetus at risk for Fetal Alcohol Syndrome, that causes learning and behavioral problems and abnormal facial features. Drinking during pregnancy
may also increase the risk for preterm labor.

Women who use substances also have higher rates of osteoporosis, nutritional deficiencies, cognitive deficits, oral health problems and other infections. Health care, health education, and preventive services are important recovery
supports for women with SUDs.

Physical health is a priority when figuring out a woman's needs and services during treatment planning. SUD treatment staff should refer women to primary health providers who understand SUDs. They can also help women
address any barriers to getting medical services, and follow up to ensure they attend medical appointments. The children of women with SUDs often also need primary health care and services.

REFERENCE
Substance Abuse and Mental Health Services Administration. (2013). Treatment Improvement Protocol (TIP) 51: Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville, MD: U.S. Department of Health and Human Services. Accessed November 8, 2015 from http://store.samhsa.gov/shin/content/SMA13-4426/SMA13-4426.pdf.
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Reproductive/Gynecology Issues and SUDs
Women with SUDs tend to have more gynecological and reproductive problems.
Women with SUDs are less likely to receive routine gynecological exams and mammograms
Less likely to receive treatment for STIs, receive an HIV test, etc.
Many medical issues result from substance use during pregnancy, as well as from detoxification and medications used to treat SUDs.
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Women with SUDs tend to have more gynecological and reproductive problems, including infertility, painful and/or irregular menstruation, cancers, hormonal changes, and sexually transmitted infections. (TIP51, p. 41). Substance
use and CODs increase women and girls' chances of contracting infectious diseases. (Addressing the Needs of Women and Girls, p. 21). Some substances make women more vulnerable to sexually transmitted infections due to
physiological changes, (TIP 41, p. 52). Substance use during pregnancy can result in fetal alcohol spectrum disorders, low birth weight, miscarriage, etc. (Module 5 of this presentation contains more information about pregnancy
and SUDs.)

REFERENCE
TIP 51 (pp. 40-55).
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Chronic Pain and SUDs
Chronic non-cancer pain (CNCP) is common in people with SUDs.
CNCP is pain that is not associated with an imminently terminal condition and is unlikely to lessen as a result of tissue healing.
CNCP requires long-term management.
Effective CNCP management in patients with or in recovery from SUDs must address both conditions at the same time.
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Women with SUDs who have chronic pain may be discouraged by providers from using medicines they need for pain management, yet pain relief medication is needed for quality of life. Since women tend to be more sensitive to
pain than men, they are more likely to receive prescription pain medications. Chronic pain issues complicate treatment for opiate or benzodiazepine addiction. Coordination with qualified pain management specialists can reduce
risks of SUDs returning after treatment.

Treatment for one condition can support or conflict with treatment for the other; a medication that may be appropriately prescribed for a particular chronic pain condition may be inappropriate given the patient's SUD. Both CNCP
and SUDs are associated with high rates of psychiatric comorbidities such as anxiety, PTSD, and depression. The presence of comorbid psychiatric conditions should be assessed regularly in every patient with CNCP.

Holistic approaches to pain management should be discussed and offered, such as nutrition, exercise, physical therapy, acupuncture, etc. A woman with CNCP and SUD should be referred for formal addiction treatment. Once the
patient's SUD recovery is stable, the likelihood of managing her pain increases. The need for formal addiction treatment often necessitates a change in the plan for opioids, by discontinuing them or by changing the treatment
setting through which they are provided (TIP 42, p. 45-46). Integrated treatment is vital with these CODs.

REFERENCES
Substance Abuse and Mental Health Services Administration. (2012). Treatment Improvement Protocol (TIP) 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Rockville, MD: U.S. Department of Health and Human Services.

Substance Abuse and Mental Health Services Administration. (2012). Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders Quick Guide for Clinicians Based on TIP 54. Rockville, MD: U.S. Department of Health and Human Services.
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HIV and Co-Occurring ConditionsTriple Diagnosis
"Triple diagnosis" (HIV, MH disorder, & substance use) presents a very complex scenario for clinicians
Prioritizing treatment needs for triply diagnosed patients is challenging
Requires careful assessment of which condition most impedes progress in overall treatment at any given time
Requires ability to see a patient holistically, to conceptualize the ways in which each of these conditions interacts with the others, rather than seeing them as separate, distinct conditions

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A "triple diagnosis" refers to a patient who is HIV-positive, has a diagnosed mental health disorder and a substance use disorder. These individuals present a very complex situation for clinicians due to the need to prioritize treatment. Patients who are triple diagnosed require very careful assessment as to which condition most impedes the individual's overall progress in treatment at any given time. As the conditions interact with one another and are not truly mutually exclusive in the individual's functioning, the provider must view the patient holistically in order to conceptualize the conditions' effects on one another rather than as three wholly distinct conditions.
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HIV and Co-Occurring ConditionsTriple Diagnosis
Cultural differences between medical, mental health, and substance abuse treatment systems engender differences in treatment priorities and communication styles
An integrated approach (involving the co-location of all three types of treatment provider and/or clinicians with expertise in more than one area) is the ultimate goal for treating the triply diagnosed
This will require a sustained multi-year effort
In the meantime, work toward increasing communication and coordination between treatment providers; build relationships with counterparts in the other disciplines
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Additional considerations to make when assessing a patient's functioning with multiple conditions present is to consider the cultural differences between medical, mental health and substance abuse treatment systems that may indicate competing priorities in treatment and communication styles that may prohibit efficient integration of care.

The ultimate goal for providers is to adopt an integrated approach among different treatment providers through co-locations or clinicians with multiple expertise areas. This change process and shift in assessment and treatment requires sustained, multi-year effort. While this is occurring in line with conceptualizations of integrated care, individual providers can begin to work toward increasing communication and coordination between treatment providers, as well as building consultation networks and relationships with providers in other disciplines.
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Case Study: Emma
Emma is a homeless 35 year-old African American mother of 4 children between the age of 4-10, diagnosed with HIV three months ago. Her HIV last test was five years ago, and she did not return for the results. Emma has a 15 year history of intravenous drug abuse. She stated that her last use of drugs was 12 hours ago.

The highest grade Emma achieved was the 10th and she has a history of Schizophrenia. Emma has had several close friends die of AIDS.

She receives care at an urban community clinic where all her providers are of European descent. She is very cautious about starting any drug therapy for HIV because of the stories she has heard of other African Americans being used in an experimental way without their consent. She has not expressed her concerns to her provider.
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INSTRUCTIONS
**Allow 10 minutes for this activity; individuals can pair up or work in larger groups, depending on audience size**

Read the case example out loud and ask the participants to identify presenting issues that would be clinical focus knowing what they know about the interaction of different substances, HIV, and women up to this point.

Continue with the questions on the next slide.

Adapted from Addressing HIV Care and Substance Abuse (n.d.). Accessed May 31, 2016 from http://www.aetcnmc.org/studies/substance_use_abuse.html.
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Case Study Questions
1. What do you do next?
2. What barriers to care are present in this case?
3. How can these barriers be overcome?
4. What are the comorbidity issues that need to be addressed?
5. What other issues may impact retention into care and treatment?

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INSTRUCTIONS
Allow 5-7 minutes for a general discussion regarding their impressions and how they would approach the case once groups have had a chance to talk amongst themselves. Ask groups to report out on their discussion.

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Making Treatment Gender Responsive
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TRANSITION SLIDE
The next segment of the presentation will explore strategies for making treatment gender responsive.
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Gender-Responsive Principles
The knowledge, models, and strategies of gender-responsive principles are grounded in five core components:
Addresses women's unique experiences
Is trauma-informed
Uses relational approaches
Is comprehensive, to address women's multiple needs
Provides a healing environment
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INSTRUCTIONS
Introduce the core components here. Each will be described in greater detail in the following slides.

It is important to provide ongoing training and supervision to staff to increase understanding and competency around gender-responsive services, and recognize/address their own biases related to gender. Counter-transference is very common when working with women, and clinical supervision is imperative to prevent counselors from doing harm.

REFERENCES
TIP 51 (pp. 4, 15, 273).

Harris & Fallot (eds.). (2001). Using Trauma Theory to Design Service Systems, San Francisco: Jossey-Bass.

Slides on Gender Responsive Principles adapted from SAMHSA, "Addressing the gender-specific treatment needs of women." Training of Trainers, March 2016.

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Component 1: Addresses Women's Unique Experiences
Person-centered and relevant to each women's experiences
Gender and culturally responsive; respectful
Acknowledges treatment needs of women are different and more complex than men
Addresses those treatment needs

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Acknowledge, address, and respect the vast diversity among women: socioeconomic issues, disability psychological, physical, race, ethnic, sexual orientation, gender identify, cultural, and religious. This can be as simple as considering the types of examples that are provided in an educational program to be sure there are examples that will resonate with female participants. More complex efforts include thinking about the types of services, access and approaches to determine if they fit with the priorities, and the needs and desires of women seeking help.

Promote staff cultural competence specific to women and their experiences within their cultures (ethnic, racial, religious, etc.). Offer staff training and clinical supervision around cultural competence, as all women differ, despite some common experiences, and becoming culturally competent takes time, practice, and knowledge.

Compared to men, women often have more caregiving roles, family responsibilities, higher rates of poverty, and a wider range of mental and physical health needs, leading to more complex overall treatment needs.

Entering treatment settings can feel foreign to women. It is important to normalize this experience for women--it is not easy just to "go to treatment" with all of the other relational and economic barriers that women experience.

Programs should consider offering gender-specific groups; offering gender-specific curricula and addressing women's issues in treatment planning.

REFERENCES
Addressing the Needs of Women and Girls (pp. 11-13).

TIP 51 (pp. 4-9).

Using Matrix with Women Clients (p. 3).
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Component 2:Trauma-Informed
More than half of women seeking substance abuse treatment report one or more lifetime traumas.
Over 30% of HIV+ women have PTSD
Conduct treatment with the assumption that most women have some type of trauma history
Focus on coping, understanding the relationships between trauma and substance use and avoiding retraumatizing or triggering situations

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We've already discussed the high rates of trauma in substance using women and women LWHA. The rates of trauma histories among women with SUDs is high enough that many substance abuse treatment settings assume that every woman they see may have had some form of trauma in their background, whether anyone knows about it or not.

Treatment staff can use a trauma-informed approach to help women feel safe, develop effective coping strategies, and recover from the effects of trauma and violence.

REFERENCES
Addressing the Needs of Women and Girls (pp. 4-5 and 17).

TIP 51 (pp. 2, 5-6, 22, 154-157).

TIP 57 (p. 10).

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Trauma and posttraumatic stress disorder disproportionally affect HIV-positive women. Studies increasingly demonstrate that both conditions may predict poor HIV-related health outcomes and transmission-risk behaviors.

UCSF's Women's HIV Program provides trauma-informed HIV treatment for women. Part of a national movement to provide trauma-informed primary care, the program addresses the high rates of trauma associated with HIV positive status.

REFERENCES
Machtinger, E.L., Haberer, J.E., Wilson, T.C., & Weiss, D.C. (2012). Recent Trauma is Associated with Antiretroviral Failure and HIV Transmission Risk Behavior Among HIV-Positive Women and Female-Identified Transgenders. AIDS and Behavior. 16(8), 2160-2170.

Machtinger, E.L., Wilson, T.C., Haberer, J.E., & Weiss, D.C. (2012). Psychological trauma and PTSD in HIV-positive women: a meta-analysis. AIDS and Behavior. 16(8), 2091-2100.

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Component 3: Relational
Women recover in connection, not isolation
Relationships are central in women's lives and in recovery
Women prioritize relationships as a means of growth and development.
Understand a woman's definition of family
Include children in treatment, if applicable
Focus on the therapeutic relationship

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Relational model: Traditional developmental models of growth emphasize independence and autonomy. The relational model focuses on women's connections with others.

A relational approach focuses on therapeutic alliance and building connections, rather than instructions and tasks. This person-centered, individualized approach encourages development of self-esteem and self-efficacy to encourage mutual, supportive relationships. Consider relationship and family history, both positive and negative. Take a family-focused perspective, using a broad definition of family that encouraged a woman to define who is in her family or support system. Part of the work might be to assess relationships, e.g., identifying healthy and unhealthy relationships, and improving relationships. This could include the impact relationships have on substance use.

REFERENCES
Addressing the Needs of Women and Girls (pp. 10, 15, and 18-19).

Miller, J. B. (1987). Toward a New Psychology of Women. Boston, MA: Beacon Press.

TIP 51 (pp. 143-45).
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Component 4: Comprehensive
Treat the whole woman and her comprehensive needs, including:
Physical and mental health care
Overall wellness
Survival needs
Child and family services
Housing
Recovery supports
Use an integrated and multidisciplinary approach to women's treatment that includes collaboration with other agencies and community supports.

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Treatment, clinical support, and community support services for women should be both gender and culturally competent. Be aware that women's physical health issues may be unaddressed and that substance use may have served to mask or anesthetize symptoms of underlying physical health problems. Women with SUDs often do no seek out or receive medical care. Comprehensive, integrated treatment programs are important to address the whole woman's needs.

Women with SUDs are at increased risk for mental-health related consequences, including depression, anxiety and trauma. Screen and assess level of family needs and of involvement individual family members might have in a woman's services and recovery. Assess the need for child care and transportation resources to support access to SUD treatment and various other services. Be culturally competent. Work to understand the sociocultural, gender, and generational dynamics of the woman's family when planning, delivering, and evaluating services. Screen family members/significant others for their own support and/or service needs and provide, procure, or refer for further assessment or services as appropriate.
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Component 5: Healing Environment
Provide services in a safe and comfortable environment
Offer women-only programming
Be open to feedback from participants
Offer staff training and development

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Providing a healing environment for women includes:
Physical safety: As examples, women can access the treatment services safety and feel safe. There is a well-lit parking lot, a safe building location, public transportation that lets off near the location, the women don't have to walk past a lot of men congregated outside the building, there are escorts to cars or public transportation at night, a calm internal environment in waiting room, and the environment is free of physical and sexual harassment.

Psychological safety: Examples include the treatment center has a gender-responsive, trauma-informed environment across all settings (nurturing, supportive, and empowering). There are non-threatening rules and signage. Women are made to feel physically and emotionally safe in their relationships with their counselors. Women can access women-only groups and peer support. Reception staff are friendly, welcoming, and trauma informed. Staff need to minimize power struggles and affect-laden interactions, as these can be triggering not only for women who are involved, but also for women who witness these interactions.

Comfort: Treatment environment should be inviting and welcoming, reception staff friendly, and the atmosphere inviting and calm. One technique is to have the check-in/reception area in a separate part of the waiting area from where people wait for services, to minimize overhearing discussions about attendance, fees, and other possible high-conflict topics. There can also be space for privacy and space where women can be quiet and meditative, space for child care and children's activities, and a recreational area.

Feedback: If you want to know how safe and comfortable your treatment facility and services are, ask your female clients and be open to their suggestions for improvement. Allowing participants to have a voice in creating group rules and guidelines will increase their sense of safety and feeling respected.

REFERENCES
TIP 51 (p. 188).

Using Matrix with Women Clients (p. 3).
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How gender responsive is your program?
Rate your program on a scale of 1-5 for each component of gender-responsive treatment. Determine where you do the best and where you need to improve.

Addresses women's unique experiences
Is trauma-informed
Uses relational approaches
Is comprehensive, to address women's multiple needs
Provides a healing environment

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INSTRUCTIONSTake 5 minutes for participants to rate their programs on gender-responsiveness. Depending on time and format, have participants break into groups of 5-8 to share their results. Where are they doing the best? Where do they need to improve?

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Treatment Seeking in Women with Substance Use Disorders
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INSTRUCTIONS
This slide serves as a transition to begin discussing treatment options for women with SUD and HIV.
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Women with Substance Dependence Have Lower Levels of Help-Seeking Compared With Men
84
SOURCE: Grella & Stein, 2013.
One of the challenges in treating women with SUDs and HIV is that women have lower levels of help-seeking than men. Getting women into treatment is a priority. This is one of the reasons gender-responsive treatment is so important and can facilitate admission and retention.

Using the NESARC Wave I sample, Grella and Stein found that women had lower levels of any helpseeking for past-year alcohol or other drug dependence. N = 1,262; p < .001.

REFERENCES
Grella, C.E. & Stein, J.A. (2013). Remission from a substance dependence: Differences between individuals in a general population longitudinal survey who do and do not seek help. Drug and Alcohol Dependence, 133(1), 146-153.

For more on NESARC data, see, Grant, B.F. & Dawson, D.A. Introduction to the National Epidemiologic Survey on Alcohol and Related Conditions. NIAAA Publication. http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm (Retrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
Women and Addiction Forum
9/24/2020
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Reasons for Not Seeking Help for Alcohol Problems by Gender
SOURCE: Grella & Otiniano Verissimo, 2015.
85
A recent study found that women are less likely to seek help for alcohol problems because of financial issues, stigma and fear.

REFERENCES
Grella, C.E. & Otiniano Verissimo, A.O. (2015). How do gender and race/ethnicity influence perceived barriers to help-seeking for substance use problems? Drug and Alcohol Dependence, 156(1), e84.

For more on NESARC data, see, Grant, B.F. & Dawson, D.A. Introduction to the National Epidemiologic Survey on Alcohol and Related Conditions. NIAAA Publication. http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm (Retrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
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Reasons for Not Seeking Help for Drug Problems by Gender
86
SOURCE: Grella & Otiniano Verissimo, 2015.
Women are less likely than men to seek treatment for drug problems due to stigma, fear and financial concerns, However, they are less likely to minimize their problems related to help seeking.

REFERENCES
Grella, C.E. & Otiniano Verissimo, A.O. (2015). How do gender and race/ethnicity influence perceived barriers to help-seeking for substance use problems? Drug and Alcohol Dependence, 156(1), e84.

For more on NESARC data, see, Grant, B.F. & Dawson, D.A. Introduction to the National Epidemiologic Survey on Alcohol and Related Conditions. NIAAA Publication. http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm (Retrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
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Places Where Help was Received for Alcohol Problems by Gender
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SOURCE: Grella & Otiniano Verissimo, 2015.
Differences among men and women also exist with regards to where they seek help for alcohol problems. Women are more likely than men to go to private practice clinicians or psychiatric settings to receive treatment. Men are more likely to go to rehab or a 12-step program.

REFERENCES
Grella, C.E. & Otiniano Verissimo, A.O. (2015). How do gender and race/ethnicity influence perceived barriers to help-seeking for substance use problems? Drug and Alcohol Dependence, 156(1), e84.

For more on NESARC data, see, Grant, B.F. & Dawson, D.A. Introduction to the National Epidemiologic Survey on Alcohol and Related Conditions. NIAAA Publication. http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm (Retrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
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Places Where Help was Received for Drug Problems by Gender
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SOURCE: Grella & Otiniano Verissimo, 2015.
Like with alcohol problems, women seeking help for drug problems are more likely than men to receive help in a private practice setting. Women are less likely to seek help at a psychiatric hospital or mental health program. Like the findings for alcohol, men are more likely to go to rehab and/or attend 12-step programs.

REFERENCES
Grella, C.E. & Otiniano Verissimo, A.O. (2015). How do gender and race/ethnicity influence perceived barriers to help-seeking for substance use problems? Drug and Alcohol Dependence, 156(1), e84.

For more on NESARC data, see, Grant, B.F. & Dawson, D.A. Introduction to the National Epidemiologic Survey on Alcohol and Related Conditions. NIAAA Publication. http://pubs.niaaa.nih.gov/publications/arh29-2/74-78.htm (Retrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
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Different Factors Influence Treatment Participation for Men and Women
Men
Spouse opposition to drug use
Family support/ assistance
Referral by family, employer, or criminal justice system
Women
Single mother
Self-initiation to treatment
Referral by social worker
Antisocial personality disorder
Exchanged sex for drugs or money

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SOURCE: Drug Abuse Treatment Outcome Studies (DATOS); (N = 7,652). Grella & Joshi, 1999.
A largescale, multisite study (DATOS) found that there were different factors the influenced treatment participation for men and women. Men sought treatment due to social and societal pressures, like a spouse's opposition to use, family support or referral from a family member, employer or CJ. Women are influenced to participate in treatment when they are a single mother, referred by a social worker, have antisocial personality disorder and exchange sex for drugs and money.

REFERENCES
Fletcher, B.W., Tims, F.M., & Brown, B.S. (1997). The Drug Abuse Treatment Outcome Study (DATOS): Treatment evaluation research in the United States. Psychology of Addictive Behaviors, 11(4), 216-229.

Grella, C.E., & Joshi, V. (1999). Gender differences in drug treatment careers among clients in the national Drug Abuse Treatment Outcome Study. American Journal of Drug and Alcohol Abuse, 25(3), 385-406.

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
Women and Addiction Forum
9/24/2020
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Substance Abuse Treatment Facilities that Provide Special Services or Programs for Women
N = 7,990 facilities providing substance abuse treatment services
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SOURCE: SAMHSA, National Survey of Substance Abuse Treatment Services (N-SSATS), 2014.
About one third of substance abuse treatment facilities provide special services or programs for women. In this 2012 survey of nearly 8,000 treatment facilities throughout the country, 35% reported providing services or programs specifically for women.

REFERENCES
Substance Abuse and Mental Health Services Administration (2014). The N-SSATS Report: Recovery Services Provided by Substance Abuse Treatment Facilities in the United States. http://www.samhsa.gov/data/sites/default/files/NSSATS-SR175-RecoverySvcs... (RSSetrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.
Women and Addiction Forum
9/24/2020
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Services Provided to Women in Substance Abuse Treatment Facilities
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SOURCE: SAMHSA, N-SSATS, 2012.
The types of specialized services for women are focused on their individual needs, mainly related to victimization and their childrens' needs. About 30% focused on domestic violence, nearly 19% on trauma-related services, 14% on pregnancy and post-partum services, 8% child care and nearly 5% child live in at residential treatment programs.

REFERENCES
Substance Abuse and Mental Health Services Administration (2014). The N-SSATS Report: Recovery Services Provided by Substance Abuse Treatment Facilities in the United States. http://www.samhsa.gov/data/sites/default/files/NSSATS-SR175-RecoverySvcs... (retrieved June 2016).

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.

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Treatment Components Associated with Better Retention & Outcomes for Women
Review of 38 studies with randomized and non-randomized comparison group designs:
child care
prenatal care
women-only program composition
Specialized services on women's focused topics
mental health services
longer duration & comprehensive programming
SOURCE: Ashley, Marsden, & Brady , 2003.
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A review of 38 studies found that a number of factors improved retention in treatment and treatment outcomes for women. included child care, prenatal care, women-only programs, specialized services on women's topics, mental health services, longer program duration and more comprehensive programming. This again points to the need for more comprehensive, gender-responsive services for women with SUDs to be successful.

REFERENCES
Ashley, O.S., Marsden, M.E., & Brady, T.M. (2003). Effectiveness of substance abuse treatment programming for women: a review. The American Journal of Drug and Alcohol Abuse, 29(1), 19-53.

Slide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.

Women and Addiction Forum
9/24/2020
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Structural Barriers to Drug Treatment
Level of impairment must be high to reach treatment through institutional channels
Lack of treatment availability, particularly in residential programs with capacity for children and outpatient programs that provide child-care or family-related services
Lack of co-ordination among substance abuse, health care, mental health, criminal justice, and child welfare systems
Lack of uniform policies on treatment standards regarding "gender-specific" treatment

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Women and Addiction Forum
9/24/2020
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INSTRUCTIONS
Review each of the structural barriers to drug treatment that exist for women.

REFERENCESlide adapted from Dr. Christine E. Grella, February 2016, Overview: Women and Addiction. Presented at the CLARE Foundation's State of Addiction Forum, Santa Monica, CA.

Evidence-Based Treatment Options for Substance Use
Motivational-enhancement therapy
Contingency management
Directly-observed therapy
Medication-assisted treatment
Integrated health services delivery
CBT and Relapse Prevention
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SOURCE: http://www.drugabuse.gov; http://www.samhsa.gov.
Motivational Enhancement Therapy (MET) employs a variation of Motivational Interviewing (MI) to analyze and dissect feedback gained from client sessions. MI focuses on re-patterning client behavior that is the result of ambiguous and undefined thoughts. This form of therapy is presented in a direct and client targeted manner that strives to transform undesired behaviors.Motivational Enhancement Therapy was developed byWilliam Miller and Stephen Rollnick. The goal of MET is to aid the client in clarifying his or her own perceptions and beliefs in order to direct him or her in a more decisive way. Most people who respond to this type of treatment have struggled for years in a mire of ambivalence and welcome the opportunity to have vision and focus in their lives.

MET is commonly used for the treatment of addictions, including abuse of alcohol and other substances. MET is administered in a receptive atmosphere that allows a client to receive feedback from the therapist for the purpose of fortifying the client's resolve for transformation and to empower the client with a feeling of self-control. Rather than engaging the client's defense mechanisms through confrontational discourse, the therapist works with the client to create positive affirmations and a sense of inner willingness to facilitate change. Once that is achieved, the client becomes receptive to the healing process and progresses toward wellness.

Contingency management utilizes behavioral reinforcement theories to enhance the possibility of favorable outcomes occurring with the patient. Contingency management is a systematic application of positive reinforces/rewards (and sometimes punishments) in order to highlight specific behavior and reinforce the occurrence of the behavior in the future. This can include receiving a voucher that can be redeemed for specific items following a negative urine screen or certain number of months without having used. It may be a point-based system attached to certain privileges or it could be a slight reduction in fee for services with demonstrated success in working toward treatment goals.

Directly-observed therapy is a specific supervisory technique to ensure that the provider is receiving real-time support in addressing issues and interpersonal dynamics between the provider and the patient. It may involve a recorded session that is debriefed later or the use of technology to provide real-time suggestions to the provider during session.

Medication-assisted treatment employs various medications to assist with reducing substance use; specifically demonstrated effects with opioid abuse and alcohol abuse. MAT provides on-going or acute support in assisting an individual to reduce use or detox from use of illicit drugs or alcohol.

Integrated health services delivery enhances the communication between providers and with the patient. Integrating different health providers provide the most comprehensive conceptualization and treatment planning for multiple conditions and diagnoses. Communication is critical in establishing goals and maintaining progress in treatment.

CBT and Relapse Prevention involve the identification of the interaction between thoughts, feelings, and behaviors in engaging in maladaptive coping behaviors such as substance use. Increasing insight and awareness assists in identification of appropriate coping skills. Relapse prevention includes specific identification of scenarios in which the patient may be triggered to use and develops specific refusal techniques and coping skills to enhance the individual's feelings of confidence in preventing relapse.
Behavioral interventions for HIV prevention should address the link between substance use and HIV/STD by focusing on high-risk sexual behaviors that are consequences of substance drug use, most commonly alcohol consumption. The focus for HIV prevention has been on effective interventions such as condom use, testing and counseling, pre- and post-exposure prophylaxis (preventive medicine), male circumcision, needle exchange services to reduce needle sharing that may lead to HIV transmission for injecting drug users. However, there is need to pay more attention now to preventing and treating non-injectable drug use including alcohol, which can interfere with these efforts, impairing people's judgment and making them less likely to use protection during sex. Preventing and treating substance use can reduce the incidence of substance induced high-risk sexual behaviors and subsequently reduce HIV transmission.

REFERENCES
For more information, visit drugabuse.gov or samhsa.gov/nrepp for the latest on evidence-based practices to treat substance use disorders.

NIDA. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition,). https://www.drugabuse.gov/publications/principles-drug-addiction-treatme.... (Retrieved Sept. 2016).

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Empirically Based Interventions that Address HIV/AIDS in Women
Education
Negotiation and refusal skills
Safety planning for women at risk of interpersonal violence
Role Play
Practice
All in the context of gender-responsive care
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A number of empirically-based interventions exist for women with HIV/AIDS and problems with substance use. The most effective tend to have the following in common:

Education: Knowledge is power. Interventions teach about health, STD transmission and ways to protect themselves. Understanding the effects of substance use on overall health is essential. Knowing about the relationship between trauma, SUD and HIV can help identify triggers that can lead to unsafe behaviors. You can pass along much of what you've learned today to educate your female clients about HIV and SUD.

Negotiation and Refusal Skills: Women benefit from learning how to negotiate. Negotiation is the process of achieving a desired goal through persuasion, bargaining, and compromise. Walk through possible scenarios that put them at risk to help them become more prepared for situations they may encounter. How do you negotiate safe sex with your partner when he comes home late at night and he's intoxicated? How do you negotiate condom use with a partner you've already had unprotected sex with?

Sometimes negotiation falls short and a woman just has to say no. This can be extremely difficult in the heat of the moment, especially if there's fear of interpersonal violence. Safety planning is also an important part of learning.

Role Play: Many of these skills can be practiced through role plays. You can find dozens of scenarios online by searching "Safe sex negotiation skills."

Other Practice: In addition to role play as a form of practice, have supplies available so women can practice using a condom. Allow her to tear open the package and unroll the condom on a penis model (yes, a banana or cucumber could work), going through all the steps to ensure understanding and greater comfort. If female condoms are available, practice with those as well. Make the process light-hearted and educational. Talk about ways to eroticize safe sex so that it may be more appealing.
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Provider/Patient Communication Strategies
Use a motivational approach
Listen to understand, rather than to diagnose/fix
Accept patients where they are rather than judging
Be genuinely compassionate
Egalitarian relationship rather than authoritarian
Use open-ended questions and reflective statements to understand, engage and show empathy
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Motivational enhancement techniques employ a style that increases the individual's insight and awareness while respecting their choice. The intent is to listen to understand rather than to diagnose and fix. The acceptance of the individual where they are rather than judging their behaviors enhances engagement with the treatment provider. The provider focuses on being genuinely compassionate rather than authoritarian.

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Evidence-Based Risk HIV Reduction for Women with SUDs
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The CDC offers a compendium of evidence-based interventions and best practices for HIV prevention. There are 96 total addressing different subgroups. The following are selected interventions shown to have positive results on HIV risk reduction for women with substance use and HIV.

The Compendium can be accessed at: http://www.cdc.gov/hiv/research/interventionresearch/compendium/rr/index....

Instructor's Note: Slides 99-102 are optional. Present specific treatments depending upon needs of audience.

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Women's Co-Op
Four sessions over six weeks using counseling, goal setting, informational pamphlets, and supplies
Uses empowerment theory and African American feminism as models
Participants were African American women who used crack and were not in drug treatment
Women were less likely to report any unprotected sex and showed significant decreases In sex trading, homelessness, and crack-use
Adaptation for pregnant women showed good acceptability as well
Mobile version under development; used worldwide

SOURCES: Wechsberg et al., 2003, 2004, and 2011.
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Women's Co-Op is a 4-session behavioral intervention developed to reduce HIV risk for African American women who were using crack. Results were positive, with reductions in unprotected sex, sex trading, homelessness and crack use. A pilot study of an adaptation for pregnant women showed promise, with good acceptability (6.5 out of 7) in a sample of 61 women.

REFERENCES
Wechsberg, W.M., Browne, F.A., Poulton, W., Ellerson, R.M., Simons-Rudolph, A., & Haller, D. (2011). Adapting an evidence-based HIV prevention intervention for pregnant African-American women in substance abuse treatment.Substance Abuse and Rehabilitation,2, 35-42. Available at: http://doi.org/10.2147/SAR.S16370.

Wechsberg, W.M., Lam, W.K., Zule, W. et al. (2003). Violence, homelessness, and HIV risk among crack-using African-American women. Substance Use and Misuse, 38, 669-700.

Wechsberg, W.M., Lam, W.K., Zule, W.A. et al. (2004). Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. American Journal of Public Health, 94, 1165-1172.
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Women On The Road to Health (WORTH)

Combines HIV education, risk reduction problem solving, partner abuse risk assessment, self efficacy, and social support to encourage and educate women on how to better protect and prepare for an unwanted unprotected sexual situation.
Uses social cognitive theory, scaffolding learning theory and empowerment theory
Available in multimedia and manualized format
4 weekly group sessions
Among drug involved high risk female offenders, WORTH increased condom use and reduced unprotected vaginal and anal sex
SOURCE: El-Bassel et al., 2014.
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WORTH is a psychoeducational group intervention that combines HIV education, risk reduction problem solving, partner abuse risk assessment, self-efficacy, and social support to encourage and educate women on how to better protect and prepare for an unwanted unprotected sexual situation. Based on social cognitive theory, scaffolding learning theory and empowerment theory, four group sessions are administered either in standard manualized format or with multimedia (videos demonstrations and video games) enhancements. Among drug involved high risk female offenders, WORTH increased condom use and reduced unprotected vaginal and anal sex.

REFERENCE
El-Bassel, N., Gilbert, L., Goddard-Eckrich, D., Chang, M., Wu, E., Hunt, T., Epperson, M., Shaw, S.A., Row, J., Almonte, M., Witte, S. (2014). Efficacy of a group-based multimedia HIV prevention intervention for drug-involved women under community supervision: Project WORTH. PLoS ONE, 9, e1111528.1-e111528.9.
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Safer Sex Skills Building (SSSB)
Five session group intervention using education, discussion, demonstration, modeling, practice and role play
Goals to increase condom use, decrease risky sexual behaviors, increase safer sex negotiation skills, and increase HIV/STD awareness
Program participants were heterosexually active women in drug treatment
Results- found reductions in unprotected vaginal and anal sex at the 6-month follow up. Also, women that attended at least 3 SSSB intervention sessions reported fewer occasions of unprotected vaginal or anal sex compared to women who attended one session at the 6-month follow up
SOURCE: Tross et al., 2008.
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Safer Sex Skill Building (SSSB) is a five session group intervention that was tested in a multi-site study at 12 outpatient drug treatment sites through NIDA's Clinical Trials Network. Heterosexual, drug using women participated. The intervention uses education, discussion, demonstration, practice and role play to develop safer sex negotiation skills and increased HIV/STD awareness. Results found reductions in unprotected vaginal and anal sex at the 6-month follow-up. There was a dose effect, with women who attended at least 3 sessions reporting fewer unprotected sex occasions compared to women who attended only one session.

REFERENCE
Tross, S., Campbell, A.N., Cohen, L.R., Calsyn, D., Pavlicova, M., Miele, G.M., Hu, M.C., Haynes, L., Nugent, N., Gan, W., Hatch-Maillette, M., Mandler, R., McLaughlin, P., El- Bassel, N., Crits-Christoph, P., Nunes, E.V. (2008). Effectiveness of HIV/STD sexual risk reduction groups for women in substance abuse treatment programs: Results of NIDA clinical Trials Network Trial. JAIDS Journal of Acquired Immune Deficiency Syndrome, 48, 581- 589.
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Motivational Interviewing-Based HIV Risk Reduction
HIV risk reduction intervention based on principles of motivational interviewing
Included counseling, discussion, risk reduction planning, and risk reduction supplies such as condoms
Program was delivered over 3 consecutive months, up to 12 sessions that lasted 30-45 minutes each
Participants included recently incarcerated, HIV negative women at risk for HIV
Participants in HIV risk group reported fewer episodes of unprotected sex at 3-month and 6-month follow up

SOURCE: Weir et al., 2009.
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Based on motivational interviewing techniques, MI based risk reduction was tested in recently incarcerated, HIV negative women. The intervention included individual counseling, discussion, risk reduction planning, and risk reduction supplies such as condoms. Participants in the risk reduction group were significantly less likely to report any unprotected vaginal or anal sex at 3 and 6 month follow up.

REFERENCE
Weir, B.W., O'Brien, K., Bard, R.S., Casciato, C.J., Maher, J.E., Dent, C. W., Dougherty, J.A., Stark, M.J. (2009). Reducing HIV and partner violence risk among women with criminal justice system involvement: A randomized controlled trial of 2 motivational interviewing-based interventions. AIDS and Behavior, 13, 509-522.
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Centering Pregnancy Plus (CPP)
Incorporates an ecological model and social cognitive theory
10 weekly 120-minute group sessions for HIV negative women in 16 to 40 week gestation
Incorporated goal setting and evaluation, discussion, role play, and video to increase condom use, reduce unprotected sex, and reduce STI incidence
Results- increased reports of fewer occasions of unprotected sex in the past 30 days, greater percentage of reported condom usage.
SOURCES: Kershaw et al., 2009; Ickovics et al., 2007.
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In an intervention delivered during prenatal care, CPP incorporates an ecological model and social cognitive theory to create change in HIV risk behaviors in pregnant women. Delivered in weekly group sessions, HIV negative women in 16-40 weeks of gestation learned goal-setting, evaluation, discussion, role play and video demonstrations to increase condom use and reduce unprotected sex. Participants reported fewer occasions of unprotected sex in the past 30 days and a great percentage of condom usage than baseline.

REFERENCES
Kershwa, T.S., Magriples, U., Westdahl, C., Schindler Rising, S., Ickovics, J. (2009). Pregnancy as a window of opportunity for HIV prevention: Effects of an HIV intervention delivered within prenatal care. American Journal of Public Health, 99, 2079-2086.

Ickovics, J.R., Kershaw, T.S., Westdahl, C., Magriples, U., Massey, Z., Reynolds, H., Rising, S. S. (2007). Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstetrics & Gynecology, 110, 330-339.
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Summary
Women and men follow different pathways into substance use treatment and present with differing clinical profiles
Treatment programs that are "gender responsive" and address women's specific needs, including providing trauma-informed care, are associated with higher retention and better outcomes
Women are at greatest risk of HIV transmission through heterosexual contact and IV drug use
Integrated treatments that address HIV risk reduction among women with substance use disorders are available
Women's treatment is most effective when it addresses the broad range of issues that accompany substance use and HIV among women

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Women and men have different pathways to problems with substance use and present with different clinical profiles. Treatment programs that are gender responsive and address the specific needs of women are associated with higher retention and better outcomes than those that are not. Paying special attention to trauma-informed care is particularly important for women with HIV/AIDS, since they are likely to have experienced some type of trauma in their lifetime. Integrated treatments that address a broad range of issues relevant for women are most effective in treating women with HIV/AIDS and substance use.
Women and Addiction Forum
9/24/2020
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Local Resources
AIDS Healthcare Foundation
http://hivcare.org/

Ryan White HIV/AIDS Program (888) ASK-HRSA or (888) 275-4772
http://hab.hrsa.gov/abouthab/aboutprogram.html

Tarzana Treatment Center 888) 777-8565
https://www.tarzanatc.org/

Los Angeles Centers for Alcohol/Drug Abuse (562) 906-2627
http://lacada.com/

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This slide features resources for local referrals.
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Resources for Providers
NIH Alcohol-Drug-HIV Infographic
http://www.drugabuse.gov/related-topics/trends-statistics/infographics/d...
SAMHSA TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women
http://store.samhsa.gov/shin/content//SMA15-4426/SMA15-4426.pdf
CDC Compendium of Evidence-Based Interventions
http://www.cdc.gov/hiv/research/interventionresearch/compendium/rr/index...
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This slide features online resources for providers to learn additional information about drug use, HIV, and women.
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What did you learn?
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INSTRUCTIONS
The purpose of the following five questions is to test the post-training knowledge as it relates to the topic of Substance Use, HIV, and Women. The five questions are formatted as either multiple choice or true/false questions. Read each question and the possible responses aloud, and give training participants time to jot down their response before moving on to the next question. Reveal the correct answer to each question.

Post-Test Question
Approximately 1 in 4 HIV positive people in the US are women.

A. True
B. False
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ANSWER KEY
Correct response: A (True)
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Post-Test Question
Approximately what percent of women with HIV have experienced trauma in their lifetime?
A. 10
B. 20
C. 30
D. 40
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ANSWER KEY
Correct response: C (30%)
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Post-Test Question
Which is NOT a component of "gender responsive" care for women?
A. Address women's unique experiences
B. Be trauma-informed
C. Take place only at a gender-specific program
D. Provide a healing environment

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ANSWER KEY
Correct response: C (Take place only at a gender-specific program)
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Post-Test Question
Approximately what percentage of women drink alcohol while pregnant?
A. .5%
B. 2%
C. 9%
D. 17%

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ANSWER KEY
Correct response: C (9%)

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Post-Test Question
Effective behavioral interventions for HIV risk reduction are not available for substance using women.

A. True
B. False

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ANSWER KEY
Correct response: B (False)
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Thank You For Your Time!
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For more information:
Beth Rutkowski: [email protected]
Thomas E. Freese: [email protected]
Kevin-Paul Johnson: [email protected]
Pacific Southwest ATTC: www.psattc.org
PAETC Training calendar: www.HIVtrainingCDU.org

This concludes the presentation. Thank the participants for their time and address any last-minute questions about the content. Encourage participants to reach out to the Pacific Southwest ATTC or the LA Region PAETC, should they have questions or concerns following the training session.

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