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November 01, 1998
Steven Stocker

Recent NIDA-funded studies have found that women in drug abuse treatment relapse less frequently than men do, at least partly because women are more likely to engage in group counseling. Other NIDA-supported researchers have found that cocaine-addicted women and men differ in the factors that cause them to relapse, indicating that males and females might benefit from different relapse prevention strategies.

Likelihood of Relapse

In a study conducted at the University of California, Los Angeles, Dr. Robert Fiorentine and his colleagues have found that women drug abusers are less likely than men drug abusers to relapse after entering treatment because women participate more frequently in group counseling and that this more intensive level of treatment engagement helps them to remain drug-free.

The researchers followed 182 women and 148 men in 26 public outpatient drug abuse treatment programs in Los Angeles County. The programs provided group, individual, and family counseling; educational activities; and referrals to other health and social services. The treatment lasted 6 months.

About half the patients regularly used just one drug - primarily crack cocaine, marijuana, or powder cocaine, and about half used more than one drug. Regular use was defined as three or more times per week. The patients were interviewed while in treatment and approximately 6 months after the first interview.

The scientists found that the women in their sample were less likely than the men to relapse: only 22 percent of the women compared to 32 percent of the men relapsed to drug use in the 6 months between interviews. The researchers considered several theories to account for this finding.

One possibility was that the women used drugs less than the men, so abstaining from drug use was easier for them. However, the study findings showed otherwise. In the year preceding treatment, more women had used crack cocaine than men, and about the same percentages of women and men had used powder cocaine, marijuana, and other drugs. In addition, women used all drugs as frequently as men, except for crack and heroin, which women used more frequently. Finally, about the same percentage of women and men used two or more drugs.

Another possibility the researchers considered was that the women received more social support than the men from a variety of sources, such as families, friends, and coworkers. The investigators found that, although the women were more likely than the men to maintain a social network, they were no more likely than men to receive emotional support for their problems and encouragement to stop using drugs.

What did appear to explain the difference in relapse was the fact that the women were more likely to engage in treatment, particularly group counseling, says Dr. Fiorentine. In his study, the women engaged in an average of 10.9 sessions of group counseling per month compared to 7.9 sessions a month for the men. Research has shown that more intense participation in treatment is associated with lower rates of relapse.

The women did not seem to be attending group counseling sessions more often than men because the sessions were somehow oriented more toward women. The sessions dealt with the problems of both genders more or less equally and were usually attended by both men and women, Dr. Fiorentine says.

The reason that women attended group counseling sessions more than men may stem from women's greater willingness to seek professional help for their health problems, speculates Dr. Fiorentine. "Women appear to be more willing to seek help for their problems, including their substance abuse problems," he says. "Men, on the other hand, are more likely to say, ?I'm OK. I don't need help. I can take care of this. It's just a little problem.'" He recommends that treatment providers discuss with male drug abusers the possibility that their reluctance to seek help may be hampering their recovery.

Even though the women attended more group counseling sessions than men, they did not attend more individual counseling or family counseling sessions than men did. If women are more likely to use services in general, why did they not engage more often in these other types of therapies? The explanation seems to be that these other therapies are not offered as frequently as group counseling in Los Angeles County, primarily because of the county's budget constraints, Dr. Fiorentine suggests. "Individual counseling, for example, is expensive and there are only so many counselors to go around, so treatment programs ration individual counseling," he says.

"Both women and men already may be attending the maximum number of individual counseling sessions they can attend. If patients could attend as many of these sessions as they desired, you might see more women than men in these sessions, just as you see more women than men in group counseling sessions."

In a related study, Dr. Roger Weiss and his colleagues at McLean Hospital in Belmont, Massachusetts, also found less likelihood of relapse for women than for men among patients who were hospitalized for cocaine addiction. When 74 patients were interviewed 6 months after the hospitalization, 51 percent of the women had remained abstinent compared to 25 percent of the men.

Like Dr. Fiorentine, Dr. Weiss theorizes that the women in his sample were more motivated for therapy than the men were. "Studies have identified barriers to entering drug abuse treatment programs that exist for women but not for men," says Dr. Weiss. "These include childcare difficulties and the predominance of male patients and staff. There is also more social stigma for women in being labeled an addict. Women who come to these treatment facilities must be willing to overcome these barriers, which could lead to a higher percentage of women who are motivated to change."

Reasons for Relapse

In addition to identifying gender differences in the likelihood that drug abusers relapse, scientists also have identified gender differences in drug abusers' experiences before and during relapse. Dr. James McKay and his colleagues at the University of Pennsylvania in Philadelphia found that women in treatment for cocaine addiction were more likely than men to report negative emotions and interpersonal problems before they relapsed. The men, on the other hand, were more likely to report positive experiences prior to relapsing and were more likely to engage in self-justification and rationalizing afterward. They reported, for example, that they felt entitled to use cocaine or that they believed they could control their cocaine use. The women also were much more likely to be impulsive in their return to cocaine use. Fifty-six percent of the women, compared with only 17 percent of the men, reported that they relapsed immediately after the thought of using cocaine occurred to them.

These gender differences in relapse factors suggest that different relapse prevention strategies might be emphasized for women and men, says Dr. McKay. For example, women might benefit more from techniques that enable them to deal more effectively with unpleasant emotions and interpersonal problems. "One strategy is to take action quickly as your mood starts to deteriorate rather than waiting until you are in a really bad mood and then trying to do something about it," he says. "If it's a small problem, planning an enjoyable activity might be all that is needed. If, however, it's a serious depression, medication or psychotherapy might be necessary."

In contrast, men might benefit more from strategies that counter their tendency to let down their guard when feeling good, Dr. McKay says. "These strategies are derived from concepts taught in 12-step programs, such as not getting too cocky or confident when your mood improves," he says. "Patients are told to be on the lookout for warning signs that might be present when they're feeling good, such as thinking to themselves, 'I'm feeling great today. I don't need to go to that meeting. I can go hang out with this friend of mine. I know he uses, but I'm feeling good today, and I'm not vulnerable to using.'"

More Research

Gender differences in drug abuse are of intense interest to NIDA, says Carol Cowell of NIDA's Division of Clinical and Services Research. "Researchers are finding gender differences across the broad spectrum of drug abuse research - from basic research to studies such as these on treatment and services - and we would like to encourage more study of these differences," she says. She occasionally suggests that NIDA-funded researchers analyze their data in terms of gender differences. "This sometimes results in a study that increases our knowledge of the role of gender in treatment outcomes," she says.

"Performing gender analyses is simply a matter of doing good science," says Dr. Cora Lee Wetherington, NIDA's women's health coordinator. When gender differences exist but investigators fail to test for them, flawed conclusions may be drawn, either for males or females or both, she says.

Sources

  • Fiorentine, R.; Anglin, M.D.; Gil-Rivas, V.; and Taylor, E. Drug treatment: Explaining the gender paradox. Substance Use and Misuse 32(6):653-678, 1997.
  • Fiorentine, R.; Nakashima, J.; and Anglin, M.D. Client engagement in drug treatment. Journal of Substance Abuse Treatment, in press.
  • McKay, J.R.; Rutherford, M.J.; Cacciola, J.S.; Kabasakalian-McKay, R.; and Alterman, A.I. Gender differences in the relapse experiences of cocaine patients. The Journal of Nervous and Mental Disease 184(10):616-622, 1996.
  • Weiss, R.D.; Martinez-Raga, J.; Griffin, M.L.; Greenfield, S.F.; and Hufford, C. Gender differences in cocaine dependent patients: A 6 month follow-up study. Drug and Alcohol Dependence 44(1):35-40, 1997.
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