Clinical:Case Study: Women and Alcohol and Substance Dependency

Original materials created in November 2002 by Rachel CB Molander

History

KR is a 42y/o woman with complaints of 3 months of right upper quadrant pain and fatigue. Two months ago KR presented with a similar complaint and labs revealed slightly elevated ALT and AST. Chem7, CBC and TFTs were normal. KR missed her follow up appointment to review these labs and presented today as a walk-in visit.

Past Med Hx: Seizure d/o of unknown etiology, with 3xgrand mal in last year, negative brain imaging and EEG. Hx of elevated LFT’s without subsequent work up due to poor follow up.

PsychHx: Depression and anxiety, no suicidality

Meds: Neurontin, Dilantin, Prozac

Social History

KR is a computer professional and has been married for 15 years. She has 2 children. She denies physical abuse, but reports a history of sexual abuse at age 13. KR denies smoking or street drugs. She reports 1-2 cocktails per day, occasionally up to 4 on weekends. CAGE questions: SR occasionally thinks about Cutting back on her drinking, feels slightly Guilty about a recent picnic where she may have gotten a little too drunk and embarrassed her kids, denies ever having an Eye–opener, and says that the only person who ever gets Annoyed about her drinking is her 13 yo daughter. Husband drinks approximately 4-6 beers/night.

Fam Hx: Father died at age 55 of complications from his alcoholism

Exam: Thin woman, appearing older than stated age. V/S normal HEENT: dry and red oropharynx and slight odor of alcohol on breath.

ABD: tenderness to palpation in the right upper quadrant, liver palpated 6cm below the costal margin Exam otherwise normal Studies: ALT 150, AST 210, T-bili 2.5, albumin 4.5; coag studies, CBC and Chem7 all normal

Discussion

Substance abuse and dependence is a growing problem among US women. The National Institute on Drug Abuse estimates that 10-15% of Americans suffer alcohol or drug dependence. Among US women: 21.5 million smoke, 4.5 million are alcoholics or abuse alcohol, 3.5 million abuse prescription drugs and 3.1 million regularly use illicit drugs. Women are more likely to have polysubstance abuse and dependence than men. Alcoholism in women has steadily increased over the last 20 years. In 12 to 17 year old alcoholics, the male to female ratio is 1:1, and in the same age group, females surpass males in use of cigarettes, cocaine, crack, inhalants and prescription drugs. Among incarcerated women, 40% report use of illicit drugs in the month prior to arrest. Substance abuse during pregnancy has decreased in the last 20 years, but recent data show that 5.5% of pregnant women report using illicit drugs while pregnant, 18.8% drink alcohol and 20.4% smoke cigarettes. (1,2,3) The epidemiological data are clear: substance abuse and dependence in women is on the rise and represents an increasingly important area of women’s health in need of research and awareness.

Alcoholism in women has both sex and gender components about which the provider should be aware. Historically, research in substance abuse has primarily focused on men with women consistently underrepresented in most major treatment and outcome studies. In the last 2 decades there has been increasing research and awareness of sex and gender differences in the epidemiology, pathology, and treatment of substance abuse, but much more is needed.

Evidence suggests that women and men have different biological predispositions to adverse consequences of alcohol use. Women begin drinking later in life (first intoxication: 20.3 for women, 17.3 for men), consume smaller quantities, and drink less frequently, however, they progress to problem drinking earlier and seek treatment services sooner. Women develop liver disease, cognitive dysfunction, fatty liver, hypertension, malnutrition and gastrointestinal hemorrhage sooner than men. Alcohol dependence raises the risk of death by 5x in females vs. 3x in males. Sex differences in alcohol metabolism may be related both to increased blood concentration of alcohol in women and increased organ susceptibility to the effects of alcohol in women. Women have increased blood alcohol levels with a given consumption of alcohol because they have decreased body water content (alcohol is distributed in body water), and they have decreased “first-pass metabolism” in the gut. All women have less alcohol dehydrogenase in the gastrointestinal mucosa, and in alcoholic women the expression of this enzyme falls to near zero. New evidence suggests that estrogen may play a role in increased liver susceptibility to the toxic effects of alcohol. (1,2)

Women have psychosocial experiences that affect addiction, access to treatment services, and success in treatment. Women are often mothers and more likely to be the head of single parent households, resulting child care issues and fears of losing children upon entry into treatment. Guilt and shame may result as mothers struggle with the impact that their substance dependence has on their children. A history of sexual and /or physical abuse is very common for women in addiction treatment. Estimates are that 50-70% of women in treatment have abuse histories compared to 10-15% of men in treatment. Women are more likely than men to have a partner that also is alcohol or drug dependent, which increases risk for relapse and domestic violence. Depression is 2x more prevalent in women, and decreases the likelihood of sustained recovery in women as well as men. (1,2,3)

Research on addiction treatment outcomes for women is lacking. The commonly employed 12-step program was developed with an all male model (the Alcoholics Anonymous “Big Book” uses almost entirely male pronouns and stories of male’s experiences). The few data regarding mixed gender versus female-only treatment programs are inconsistent, and difficult to interpret.

Addiction, in men or women, is a multidimensional disease that involves distortions in the biologic, psychologic, social and spiritual realms. While women and men have much of this experience in common, providers must acknowledge sex and gender differences to identify and treat this disease effectively.

Plan

I discussed my diagnosis of probable alcoholic hepatitis with KR. I also suggested that her seizures might be withdrawal related. KR was reticent to discuss her drinking with me, and at first denied that she had a problem. I emphasized that my concern came without judgment, that I understood that this was a difficult topic for her, and that I truly felt that she was putting her life in danger. KR eventually admitted that her drinking had escalated substantially over the last year, paralleling her increasing depression. She was currently drinking over a pint of vodka per day. Much of her drinking was taking place in isolation and she was trying to hide this from her family. She acknowledged that the seizures had all taken place after she had “tried to quit – go cold turkey,” and that she had lied to the doctors when they’d asked about her drinking. She reported tremendous shame and feelings of helplessness surrounding her use of alcohol. I validated her feelings of helplessness and talked to her about the disease concept of alcoholism. We agreed on a plan for management of her acute liver condition. More importantly she agreed to speak with her family about her alcohol use and consider entering a detox and treatment program. A follow up appointment was scheduled for KR and her family the next day.

References

• Drug Addiction Research and the Health of Women; National Institute on Drug Abuse. US Dept of Health and Human Services. 1998.
• Greenfield, SF. Women and Alcohol use Disorders; Harvard Review of Psychiatry. Vol 10 Number 2. March/April 2002.
• Jessup, M. Addiction and Women: Prevalence, profiles and Meaning. J. Of Obstetric, Gynecologic, and Neonatal Nursing. Volume 26 (4). July/August 1997.