Gender Differences with Substance Use Disorder

Dr. Richard G. Soper Addiction Psychiatrist Nashville, TN

Dr. Richard Soper is an Addiction Psychiatrist practicing in Nashville, TN. Dr. Soper evaluates, diagnoses, and treats people who suffer from impulse control conditions related to addiction. As an Addiction Psychiatrist, Dr. Soper is a substance abuse expert, and is trained to fully understand the biological science... more

Addiction: Gender-specific Differences

Richard G. Soper, MD, JD, MS, FASAM

There are significant ways in which substance use disorder differs between genders. 

Depression is more frequent in women than in men; addiction is more frequent in men than women, but if women have a problem of addiction or alcoholism, they may also have other psychiatric disorders like depression. The likelihood that the women were exposed to trauma is higher. Women also experience different influences and relapse triggers, according to the Hanley Center, a residential treatment center for women ages 18-46.

The Numbers 

The National Institute for Alcohol and Alcohol Abuse estimates that about 5.5 million women drink alcohol at levels that place their health at risk. Double that number for men. Alcohol abuse can result in liver damage, hepatitis, brain disease, breast cancer and heart disease.

A report from the Substance Abuse and Mental Health Services Administration and U.S. Department of Health and Human Services found that in 2012 there were more than 1.7 substance abuse treatment admissions domestically. Alcohol was the most frequently reported primary substance at treatment admission among all racial and ethnic groups. The average age at admission among alcohol-only admissions was 41. Men and women metabolize alcohol differently.

Males, aged 12 and older, represented 67 percent of admissions to these treatment centers in 2012, down from 70 percent in 2002, suggesting that more women were beginning to seek help. For example, 41 percent of the patients at South Miami Hospital's Addiction Treatment & Recovery Center are women, compared to the 10 percent in the 1980s and ‘90s.

About two-thirds, 66 percent, of alcohol-only admissions nationwide were non-Hispanic whites, followed by blacks and Hispanics at 13 percent each.

Depression, which can stand alone or be a by-product of alcohol abuse, given alcohol's depressive effect on the central nervous system, impacted women at twice the rate of men, according to a national drug use and health study by SAMHSA. Among adults aged 18 or older, an estimated 14.8 percent (31.6 million adults) had experienced at least one major depressive episode in their lifetime. Females (10.3 percent) were almost twice as likely as males (5.6 percent) to report a recent past year episode.

Heroin and prescription drug addiction are on the rise among affluent women, according to a 2014 survey from Caron Treatment Centers, parent company of the Hanley Center. Women cited anxiety (65 percent), depression (67 percent) and a critical internal voice (69 percent) as significant factors for their addiction. The top three stressors were relationships with parents and siblings (63 percent), romantic relationships (60 percent) and work (49 percent).

Addiction: Brain Chemistry 

Addiction, for both genders, impacts the brain's medial forebrain bundle, also known as the reward target of the body that gets activated whenever an individual engages in an activity perceived as pleasurable, which can include eating and sex. Physical changes to the brain, brought about by the release of dopamine when pleasure centers are tapped, can render people vulnerable to overuse.

You eat, you enjoy, you eat again and derive nourishment to sustain life. Similarly, sex feels good, we procreate, the species survives. But drugs (alcohol is a drug) causes the brain to release dopamine in a disproportional quantity compared to regular pleasurable activity like eating, having sex or exercising. The brain is not built for such over-stimulation and as a result the pleasure centers of the brain require a larger hit to derive the same sensation, and addiction can take root.

Genetics is a risk factor but there is not a sex link gene to determine whether a person becomes addictive or not. The risk for addiction, in general, is higher if there is a first-order relative that is identified. A female grandparent doesn't mean the girls are more at risk. It's equal between the male and the female.

Gender Differences

A woman's physiological makeup makes her stand apart from her male counterparts, even when their size doesn't differ by much.

An ounce-and-a-half of alcohol is going to be metabolized differently in women than men regardless of their body size (mass).

Take two 135-pound individuals, a man and a woman. Give each a glass of alcohol.

Women physiologically have less alcohol dehydrogenase, which allows the liver to metabolize alcohol. So when a woman consumes an ounce-and-a-half of ethyl alcohol, it'll be metabolized much slower. If a woman then consumes another ounce-and-a-half an hour later, rather than having the initial alcohol metabolized like the men, there's going to be an accumulative effect with the initial amount not completely metabolized.

Weight equality aside, still other factors come into play. The same 135-pound person, the male is more likely to have more percentage of body muscle than fat. What's important is that alcohol gets distributed in fat and water substances more so than muscle. Alcohol dehydrogenase is much more prevalent in muscle tissue than in fat or water. Therefore, the male who consumes an ounce-and-a-half will start to digest it both in their intestinal tract and in their muscles, whereas in a woman it will be distributed in a larger volume and slower metabolism so the risk of a toxic effect of the drug goes up more in women than men.

And more often, men are larger in mass than women. 

Because of this, there is less distribution of alcohol in the body and because of more fat content women might be exposed to a higher percent of alcohol in the brain compared to men. That's the physiological and biological reason, it's not that men are tougher by some macho formula: 'I can hold my liquor  and you can't.' It isn't that at all. 

Alcohol is a central nervous system depressant. Part of its pharmacology is to slow nerve conduction. This can lead to a toxic effect when overused.

For women who drink socially, or for relief of tension, anxiety, the depressant properties of the beverage can become toxic even if the goal is innocent. That's part of the seductive nature of the alcohol. That’s where brain disorders, cardiomyopathy, fatty liver, bone marrow suppression, the risk of malnutrition, all come from the toxic effect of alcohol.

Triggers

When women seek treatment for alcohol abuse/dependence, the majority of them reported depression, anxiety and a critical internal voice, that subconscious inner monologue of: "I'm not a good mother. I'm not going to be able to get well. How am I going to meet friends for drinks after work?"

One interesting thing about gender is that women are able to identify that they have that critical inner voice. That voice is not gender specific. I found our study interesting that the women identified it as something that is a trigger for them.                                                                                        

The concept of having to "hit bottom" before seeking treatment can also be a dangerous exercise for women given the physiological differences in metabolism of drugs and alcohol. Externally motivated people actually do better in treatment. People who have something to get sober for. They don't want to lose family. Lose jobs. They are on probation. Those people have better results in group therapy, for which women generally gravitate more toward than men, is more effective.

Group therapy has the highest rate of efficacy for substance abuse treatment. Makes sense. We live, thrive and exist in systems. Group therapy offers us a chance to be part of a system.

When people abuse alcohol, they become depressed, alcohol also disrupts our normal sleep cycle. Inpatient treatment data show of those classified as alcohol abusers/dependent, 80 percent  are depressed. For a general population the report rate of depressions is closer to 30 percent might have clinical depression. Clinical depression, independent from alcohol, does improve with abstinence of alcohol. The depression still needs to be treated.

Other triggers to recognize and circumvent include surrounding stigmas, like "Now I'm an addict in recovery. How will I be seen at my place of employment and seen by my peers? How can I go out with my friends? What can I say?"

In summary, there are real and significant differences between women and men with substance use disorder. Thus, the treatment must be tailored for the individual patient and for gender.