PSYCHOSOCIAL ISSUES
| WOMEN AND SUBSTANCE ABUSE —Robert Mallin, MD, Associate Professor, Department of Family Medicine
and Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
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| Addiction: physiologic problem occurring in different part of brain from physical dependence; working definition—
person continues to use addictive substance even after experiencing significant consequences; formal definition—
primary chronic disease with genetic, psychosocial, and environmental factors influencing its development and
manifestations; disease often progressive and fatal; characterized by impaired control over drinking (or drug use);
preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably
denial; symptoms may be continuous or periodic; brain disease (has nothing to do with lack of morals or willpower)
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| Neurobiology of addiction: abnormality centered in limbic system; more known about neurobiology of addiction than
other brain disorders, eg, depression, schizophrenia, bipolar disorder or anxiety disorder; dopamine-reward
pathway—common pathway for all drugs of abuse; drug of addiction stimulates substance-specific transmitters in
brain, eg γ-aminobutyric acid (GABA); dopamine released in prefrontal cortex (considered reward); genetic component
to addiction; ultimately, wanting to drink becomes need to drink
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| Epidemiology: men more likely to use alcohol or other addictive substances; ≈2 times as many men as women abuse
substances; women become addicted to alcohol more quickly than men (estrogen plays role, but role unclear);
women get sicker faster from alcohol and have more health consequences from excessive alcohol consumption
than men; unmarried women or women who do not have children at higher risk of abusing alcohol or other drugs
than married women or women with children (same for men); women more likely to be addicted to benzodiazepines
then alcohol, cocaine, and opioids (benzodiazepines in same drug class as alcohol; should not be prescribed
for patient who has problem with alcohol); women develop diseases related to substance abuse sooner than men;
woman abused as child (especially sexually abused) at higher risk for alcoholism (also true for men); women can
become intoxicated more rapidly than men, usually right before menses; women have less body fluid and more
body fat than men; since alcohol not fat soluble, concentration of alcohol in woman’s blood higher than man’s; alcohol
recommendation for woman—one drink per day; drink equals 1.5 oz of liquor, 12 oz of beer, or 6 oz of wine
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| Consequences from use of alcohol: most important finding in making diagnosis of addiction; 75% of people arrested
for driving under influence (DUI) have alcoholism, 99% if 2 arrests (ask how many times patient has been arrested
for DUI); asking when patient had last drink highly specific for identifying alcoholism, especially in patient seeking
treatment for alcohol-related problem, eg, pancreatitis; other consequences—alcohol single most damaging
drug to health, even more than tobacco (more people die from tobacco-related diseases than alcohol, but alcohol affects
more organs); family (eg, marital separation, divorce, loss of parental rights, extended family stress); social
(eg, isolation, unavailability, difficult relationships); psychologic (eg, substance-induced anxiety, mood disorders,
panic attacks, posttraumatic stress disorder [PTSD], psychosis, dementia); occupational problems (eg, job trouble,
job loss, working in positions lower than training); legal (eg, DUIs, arrests for domestic violence, drug possession
and sales, prostitution); financial problems (eg, bankruptcy, foreclosure, no bank account)
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| Approaching patient: moderate drinking defined—2 drinks daily for men, no more than 4 in any sitting; 1 for
women, no more than 3 in any given sitting; reflects what can be consumed without incurring adverse health effects;
more than moderate drinking associated with health problems; patient suspected of drinking too much—
appropriate for health care professional to express that patient may be drinking too much (“you may be drinking
too much, why not try cutting back and let me know how that goes”); alcohol abuse—difficult to determine at
what point patient abusing alcohol becomes dependent; appropriate to tell patient at risk for alcohol dependence to
cut back to no more than recommended amount and come back in 1 mo; alcohol dependence—counsel patient
about abstinence (alcohol-dependent patient never regains control with any regularity); moderation management
does not work for alcoholism (continuously challenges abnormality in brain); telling patient, “if you take another
drink it is certain to kill you” not recommended
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| Treatment: effective if patient follows program; direct relationship between time and intensity of treatment and success
in long-term recovery from addiction; treatment effectiveness estimated to be 30%; addiction chronic disease,
difficult to treat; abstinence from addictive substances essential but insufficient component of recovery; patient
should participate in recovery program that includes formal alcohol and drug treatment followed by aftercare for 1
to 2 yr; consistent involvement in 12-step recovery program most successful; treatment issues unique to women—
parenting issues; who will take care of children while parent in treatment can be legitimate concern as well as excuse
for not seeking treatment; treatment programs exist that allow children to accompany patient; high prevalence
of alcohol abuse and domestic violence; women frequently in lower paying jobs than men with addiction; problems
with prostitution; relationship problems significant in treatment; recommended women be referred to women-only
treatment programs; possible development of relationship with man also in treatment can undermine treatment;
women more likely than men to be without insurance, and typically have less financial support than men; currently,
insufficient funding to help people treat addiction problems; women appear to have more psychologic comorbidities
than men, eg, anxiety disorders, depression, PTSD; psychologic disorder will not resolve unless addiction addressed
first
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| DOMESTIC VIOLENCE —Carl A. Dunn, MD, Assistant Professor, Department of Obstetrics and Gynecology,
Texas A&M University Health Science Center College of Medicine, Temple, TX
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| Screening questions: is your partner frequently angry, and you don’t know why? does your partner blame you for
problems in your relationship? are you increasingly unhappy in your relationship, and feel there is no way out?
does your partner make you have sex when you do not want to, or in ways that you do not enjoy? are you isolated
from friends or family? has your partner hit, kicked, slapped, shoved, or threatened you? has your partner made excuses
for his actions, such as drinking or drugs, or stress at work?
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| Defining domestic violence: involves primary life partner; abuse can be physical, emotional, psychologic, and/or sexual;
child abuse and or elder abuse; historical perspective—Married Women’s Property Act of 1895 first English
Common Law addressing domestic abuse; woman could divorce if husband convicted of beating her; husband allowed
to beat wife as long as stick used smaller than width of his thumb (origin of expression “rule of thumb”)
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| Scope of problem: leading cause of injury to women in United States; 2 to 4 million women beaten in their homes annually;
episode of abuse occurs every 12 sec; abuse occurs in 30% of American families; 50% of women murdered
annually killed by husband, ex-husband, or boyfriend; <14% of battered women diagnosed correctly as victims of
domestic violence; abused women rank health care professionals below women’s shelters, police, clergy, social
workers, and lawyers in effectiveness of addressing abuse
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| Effects on children: in 50% of homes where women abused, children also victims of abuse; children from violent
homes at higher risk for alcohol and drug abuse, delinquency, and subsequent arrest; older children often injured
trying to protect their mothers; 63% of males between 11 and 20 yr of age convicted of murder are jailed for killing
mother’s abuser; males who witness abuse of mother 7 times more likely to abuse their partners later in life
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| What health care providers can do: make questions about domestic violence part of standard medical history (included
in American College of Obstetricians and Gynecologists [ACOG] prenatal form); look for warning signs
that patient may be victim of domestic violence; domestic violence crosses all boundaries of age, race, level of education,
and socioeconomic status; universal screening—only 8% of abused women self-report domestic violence
on questionnaire, but 29% report when asked directly by health care provider; abused woman less intimidated by
universal screening; suggested framing question—“because this is a common problem, I am making a point to ask
all of my patients about domestic violence”; barriers to universal screening—fear of “opening Pandora’s box”;
fear of offending patient; time constraints (if patient answers in affirmative, not enough time to deal with issue);
unsure what to do if domestic violence confirmed; know what to do, but believe it will not help
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| Screening and intervention: physical cues—bruises, burns, or other injuries that do not fit explanation or are in various
stages of healing; history of alcohol or drug abuse, suicide attempt, eating disorder, or depression; frequent visits
for multiple somatic complaints, eg, headache, insomnia, anxiety, chest pain, pelvic pain, gastrointestinal
symptoms; behavioral cues—changes in appointment pattern (can reflect patient’s desire to hide physical indicators
of abuse); overprotective partners; partner monitors examination or answers questions for patient (create reason
for partner to leave room, so patient has opportunity to disclose abuse); interventions—discuss domestic abuse
with every patient; document suspected or confirmed abuse in medical record, using drawings or photographs
where appropriate; post information about community abuse resources with abuse hotline numbers; provide handouts
and pocket cards where they can be picked up discreetly (eg, place in women’s bathroom)
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| Planning exit strategy: suggest patient develop code with family or friend to signal need for help; leave change of
clothes, duplicates of car and house keys, identification papers, eg, birth certificates, immunization records, passports,
financial records, medications, cash, copy of drivers license; memorize number for local abuse center; patient
at high level of risk if unable to plan exit strategy for fear of retribution if discovered
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| Abuse in pregnancy: 16% of pregnant adult women and 22% of pregnant adolescents hit at least once during pregnancy;
29% of battered women report increase in abuse during pregnancy; injuries include placental abruption, fetal
fractures, miscarriage, stillbirth, and injuries to maternal uterus, liver, and spleen; abused women 3 times more
likely to delay care until third trimester and more likely to miss appointments, including postpartum check-up (red
flag); less likely to breast-feed infants; higher risk for substance abuse, poor weight gain, noncompliance with medications,
and poor nutrition
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| Cycle of violence: phase 1 (tension-building phase)—gradual escalation of tension, marked by expressions of dissatisfaction,
intimidating remarks, and milder forms of abuse, eg, pushing or shoving; woman attempts to placate
abuser, avoids aggravating him, or withdraws from him; phase 2 (violent phase)—marked by uncontrolled release
of tensions and acute battering incident; may accompany bout of heavy drinking or drug abuse; violence may become
more severe with each cycle; phase 3 (remorse/apology phase)—abuser professes regret for action (may try
to blame victim); may show kindness, make promises, and shower with presents; victim may feel some responsibility
for incident and hope problem resolved; victim may lose resolve to leave abuser or press charges; phases become
shorter with each cycle
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| Reporting requirements: vary state to state; reporting of partner abuse not required in Texas; health care provider required
to provide patient with educational information; most states (including Texas) require reporting of child or
elder abuse; Texas Senate Bill 224—requires any medical professional who suspects patient’s injuries due to family
violence to provide patient with information about nearest abuse shelter; document information provided and
reasons for belief that injuries caused by domestic violence; provide patient with information about her rights to
protection under law; victim’s rights—may ask local prosecutor to file criminal complaint, and may apply for protective
order; protective order prohibits abuser from committing further acts of violence, threatening, harassing, or
contacting victim at home; directs abuser to leave household; establishes temporary custody of children and property;
Texas Senate Bill 224 provides immunity from civil liability for anyone who reports family violence in good
faith; does not cover bad-faith report or reporting by person who has committed violence
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| More on health care provider’s role: ask patient what she wants to do about situation; explain options and let patient
know that when she is ready, you will help her; verify report with notes and photographs; educate victim about her
rights under law; help patient access community resources; talk about escape plan; refer for legal and psychologic
help; other considerations—locate resources in area; call or visit and develop contacts with local district attorney’s
office, police, sheriff, child protective services, and abuse shelter; encourage local medical society and or medical alliance
to “adopt” area abuse shelter (help with fund-raising)
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| Coding for domestic violence: reimbursable; counseling codes exist; counseling codes and codes specific to type of
injury; can code for total time of visit if >50% of time spent in counseling
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Suggested Reading
Bischof G et al: Development and evaluation of a screening instrument for alcohol-use disorders and at-risk
drinking: the brief alcohol screening instrument for medical care (BASIC). J Stud Alcohol Drugs 68:607, 2007;
D’Amico EJ et al: Identification of and guidance for problem drinking by general medical providers: results
from a national survey. Med Care 43:229, 2005; Diehl A et al: Alcoholism in women: is it different in onset and
outcome compared to men? Eur Arch Psychiatry Clin Neurosci 257:344, 2007; Dienemann J et al: The Domestic
Violence Survivor Assessment (DVSA): a tool for individual counseling with women experiencing intimate
partner violence. Issues Ment Health Nurs 28:913, 2007; Edulund MJ et al: Clinician screening and treatment of
alcohol, drug, and mental problems in primary care: results from healthcare for communities. Med Care
42:1158, 2004; Epstein EE, et al: Women, aging, and alcohol use disorders. J Women Aging 19:31, 2007; McNutt
LA et al: Partner violence intervention in the busy primary care environment. Am J Prev Med 22:84, 2002; Trabold
N. Screening for intimate partner violence within a health care setting: a systematic review of the literature.
Soc Work Health Care 45:1, 2007.
Educational Objectives
| The goal of this program is to increase awareness about addiction in women and also about domestic violence. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Distinguish between alcohol abuse and alcohol dependence.
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| 2. Discuss sex-related differences in alcohol consumption and drinking behavior.
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| 3. Identify and counsel patients suspected of problem drinking.
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| 4. Identify and counsel patients who are victims of domestic violence.
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| 5. Discuss the epidemiology associated with domestic violence.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Mallin was recorded at the Fall Symposium on Issues in Women’s Health: How to Treat a Lady, sponsored by the
Medical University of South Carolina, held on October 20-22, 2006, in Charleston, SC. Dr. Dunn was recorded at The Female
Patient: Current Issues in the Care of Women, sponsored by Scott & White and the Texas A&M Health Science
Center College of Medicine, held on June 18-22, 2007, in South Padre Island, TX. The Audio-Digest Fondation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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