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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Psychiatr Clin North Am. Author manuscript; available in PMC 2011 June 28.
Published in final edited form as:
PMCID: PMC3124962
NIHMSID: NIHMS304257

Substance Abuse in Women

Shelly F. Greenfield, MD, MPH,a,* Sudie E. Back, PhD,b Katie Lawson, MA,b and Kathleen T. Brady, MD, PhDb

EPIDEMIOLOGY

Gender differences in rates of substance abuse have been consistently observed in the general population and treatment-seeking samples, with men exhibiting significantly higher rates of substance use, abuse, and dependence.1-3 However, recent epidemiologic surveys suggest that this gap between men and women has narrowed in recent decades.3,4 For example, surveys in the early 1980s estimated the male/female ratio of alcohol-use disorders as 5:1,5 in contrast to more recent surveys that report a ratio of approximately 3:1.6

Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093), the largest and most recent study of substance use and other psychiatric disorders, showed that men were 2.2 times more likely than women to have drug abuse, and 1.9 times more likely to have drug dependence.1 Data regarding prescription drugs are less consistent. Although several studies indicate that rates of nonmedical prescription drug use are higher among women than men, particularly for narcotic analgesics and tranquilizers,7 other studies report equivalent or higher rates among men.8

Telescoping

Telescoping is a term used to describe an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment.9-11 The phenomenon has been consistently observed in investigations of gender and substance-use disorders, with studies typically reporting an accelerated progression among women for opioids, cannabis, and alcohol.9 Thus, when women enter substance abuse treatment they typically present with a more severe clinical profile (eg, more medical, behavioral, psychological, and social problems) than men, despite having used less of the substance and having used the substance for a shorter period of time compared with men.

BIOLOGICAL ISSUES

Neuroactive Gonadal Steroid Hormones

Ovarian steroid hormones (eg, estrogen, progesterone), metabolites of progesterone, and negative allosteric modulators of the γ-aminobutyric acid A (GABA-A) receptor, such as dehydroepiandrostenedione (DHEA), may influence the behavioral effects of drugs.12,13 In human studies, the follicular phase of the menstrual cycle, in which estradiol levels are high and progesterone low, is associated with the greatest responsivity to stimulants.14 A study investigating response to cocaine administration found that women in the luteal phase reported lower ratings of feeling high than women in the follicular phase or men.14 Whether observed differences are accounted for by enhancing effects of estradiol or attenuating effects of progesterone remains unclear. However, one study found that progesterone attenuates the subjective response to smoked cocaine in women, but not men.15 Studies of nicotine show a potential greater saliency in the luteal phase of the cycle,12,16 although the effect of gonadal steroids on responses to alcohol is less clear than for other substances of abuse.17

Sex Differences in Stress Reactivity and Relapse to Substance Abuse

Sex differences in neuroendocrine adaptations to stress and reward systems may mediate women’s susceptibility to drug abuse and relapse.18 Several studies have examined sex differences in stress response (eg, subjective, autonomic) and relapse.18,19 Among substance-dependent subjects, attenuated neuroendocrine stress response in women (ie, blunted adrenocorticotropic hormone and cortisol) has been shown following exposure to stress and drug cues.20 This hypothalamic-pituitary-adrenocortical (HPA) dysregulation in women may be one key to enhanced vulnerability to relapse in response to negative affect, as it may be associated with greater emotional intensity at lower levels of HPA arousal.21

ROLE OF CO-OCCURRING DISORDERS

Mood and Anxiety Disorders

Lifetime rates of mood and anxiety disorders are significantly higher among women than men, with and without substance-use disorders.22 A recent study by Goldstein23 using the wave 1 NESARC (n = 24,575) found that the 12-month prevalence rates of mood and anxiety disorders among women with substance-use disorders were 29.7% and 26.2%, respectively. The most common mood disorder was major depressive disorder (15.4%) and the most common anxiety disorder was specific phobia (15.6%).

Given this high co-occurrence, a comprehensive psychiatric assessment is critical. Because chronic alcohol or drug use may enhance vulnerability for these disorders, or lead to organic changes that manifest as a mood or anxiety disorder, careful assessment is necessary to differentiate substance-induced, transient symptoms from a disorder that warrants treatment. One way to do this is to carefully monitor symptoms during a period of abstinence from alcohol or drugs. A family history of mood/anxiety disorders, onset of mood/anxiety symptoms before the onset of the substance-use disorder, and sustained mood/anxiety symptoms during periods of abstinence all point toward an independent mood or anxiety disorder.24

If an independent mood or anxiety disorder is diagnosed, evidence-based treatment that will adequately address both conditions is warranted. Few investigations have examined gender differences in response to psychotherapeutic or pharmacotherapeutic treatments for mood and anxiety disorders among individuals with co-occurring substance-use disorders, and studies examining agents targeting substance use, such as naltrexone or disulfiram, as add-on treatment of individuals with co-occurring mood or anxiety disorders is under explored. One study25 examined gender differences among alcohol-dependent outpatients in the effectiveness of sertraline among type A and B alcoholics, of whom 57.9% had major depression. Type A alcoholic men, but not women, responded more favorably to sertraline than placebo (ie, longer time to relapse, fewer days drinking). No gender differences among type B alcoholics were observed.

Eating Disorders

Ninety percent of the cases of anorexia nervosa (AN) and bulimia nervosa (BN) are found in women. Eating disorders (EDs) are estimated to be 2 to 3 times higher in women than men.26 Among women with substance-use disorders, high rates of EDs, in particular the purging subtypes of bulimia, have been reported. In their review of clinical populations, Holderness and colleagues27 reported that lifetime ED behaviors co-occurred with substance-use disorders in up to 40% of women. Among women with BN or binge-eating disorder, rates of substance abuse are greater among those with, compared with without, a history of sexual or physical abuse.28

Treatment is complex and requires a multidisciplinary approach including, for example, nutritional counseling and medication supervision.29 Evidence-based behavioral treatments for EDs include cognitive behavioral therapy and interpersonal therapy, and pharmacotherapy for EDs has focused on antidepressant medications. At present, no integrated, evidence-based treatments for EDs and substance-use disorders are available.30 Like many co-occurring psychiatric conditions, individuals presenting to treatment with substance-use disorders and EDs typically receive treatment in programs specializing in substance-use disorders or EDs. They rarely receive services for both disorders. A recent national survey of screening and treatment practices at 351 addiction treatment programs revealed that only half (51%) screen for EDs at intake or assessment, and only 29% admit patients who screen positive for EDs.30

Posttraumatic Stress Disorder

The prevalence of posttraumatic stress disorder (PTSD) is 1.4 to 5 times higher among individuals with, compared to those without, co-occurring substance-use disorders.31 Similarly, data from the Australian National Survey of Mental Health and Well-being found that 34.4% of respondents with PTSD also had at least 1 substance-use disorder.32 Among treatment-seeking women with substance abuse, rates of physical or sexual abuse are high, ranging from 55% to 99%,33 with many of these women manifesting trauma-related symptoms consistent with a diagnosis of PTSD.

Consensus is lacking regarding the best treatment approach for co-occurring PTSD and substance-use disorders; however, accumulating data confirm the efficacy (ie, significant before and after decreases in PTSD and substance-use symptoms) of integrated interventions that address both conditions simultaneously.34-37 Addressing trauma-related symptoms early in treatment may provide the opportunity for improved likelihood of recovery from substance-use disorders, as many individuals report using alcohol or drugs in response to symptoms of PTSD (eg, sleep impairment, flashbacks, nightmares, avoidance of trauma reminders, hyperarousal). Selective serotonin reuptake inhibitors are the pharmacological treatments of choice for PTSD. However, only 3 published studies have examined their use among patients with co-occurring alcohol- or drug-use disorders, and all of these studies have examined the use of sertraline.38-40 The findings suggest that the medication-responsive group tended to have onset of PTSD preceding the onset of the substance-use disorder (ie, primary PTSD), highlighting the potential relationship between temporal order of onset and treatment outcome.

SPECIFIC SUBSTANCES

Alcohol

Although men consume and misuse alcohol at significantly higher rates than women, this gender gap has decreased over time3 and has been well documented in several large epidemiological studies. For example, the 2001 to 2002 NESARC, which sampled more than 42,000 individuals, found that sex differences in rates of alcohol use and abuse or dependence were smallest for younger cohorts (with cohorts ranging from 1913–1932 to 1968–1984).3 In a similar vein, examination of changes in the age of initiation of alcohol use in the past 50 years shows significant narrowing of the gender gap.3,41 In the 1950s, the male/female ratio of initiation in the 10- to 14-year-old age group was 4:1, and by the early 1990s it was 1:1.

Compared with men, women experience significantly shorter time intervals between the initiation of alcohol use and the onset of significant alcohol-related problems and treatment entry.9 This accelerated course, known as telescoping, may be attributed to a variety of biological, socioeconomic, psychological, and cultural factors that affect women. For example, compared with men, women may be more adversely affected by alcohol because of the lower percentage of total body water, decreased first pass metabolism because of lower levels of alcohol dehydrogenase in the gastric mucosa, and slower rates of alcohol metabolism.42,43

Gender differences in motives for alcohol use have been observed, with women being more likely than men to consume alcohol in response to stress and negative emotions. In contrast, men seem more likely than women to consume alcohol to enhance positive emotions or to conform to a group.44 Compared with men, women with alcohol-use disorders are significantly more likely to have co-occurring psychiatric disorders22,23,27 that may serve to impede substance-use treatment efforts. Thus, prevention and treatment intervention efforts should incorporate these gender differences in motives and co-occurring psychiatric conditions to enhance effectiveness.45

Women are less likely than men to seek treatment, and more likely to face gender-specific treatment barriers.46 Various factors, such as childcare responsibilities, transportation, financial status, and social stigma, may help explain this finding. To enhance treatment seeking and retention, programs should consider offering childcare, prenatal care, women-only treatment, and services specific for women’s issues.47 Interventions specifically designed for women-only groups show promise, indicating that women-only treatment is associated with fewer relapses and higher treatment satisfaction ratings.48,49

Stimulants

Although rates of stimulant use are similar among men and women,50 preclinical and clinical studies suggest that women may be particularly vulnerable to the reinforcing effects of stimulant drugs.51,52 Recent public health monitoring indicates that methamphetamine use is increasing, with an estimated 5.8% of individuals aged 12 years and older in the United States endorsing lifetime methamphetamine use.53 According to the Treatment Episode Dataset (TEDS), admissions for methamphetamine between 1995 and 2005 more than doubled from 3.7% to 9.2%.54 Increased use among pregnant women has also been observed. Among pregnant women admitted to federally funded substance abuse treatment centers in 1994, 8% were admitted for methamphetamine dependence; that proportion rose to 24% in 2006,55 leading the study’s investigators to conclude that methamphetamine is the primary substance of abuse for which pregnant women seek care.

The reinforcing effects of stimulants may be strongly influenced by women’s hormonal milieu. Basic and clinical studies show that estrogen increases, and progesterone decreases, the reinforcing effects of stimulants for women.14,15,51,56 In response to cocaine administration, women have been found to report increased subjective feelings of high and increased heart rate during the follicular phase, when levels of estrogen are high and progesterone levels are low.14,15 Moreover, exogenous administration of progesterone among women has been shown to result in attenuated subjective responses to cocaine administration among women.15

Cognitive behavioral therapy has been shown to be as effective in treating stimulantuse disorders among women as among men.57 Modified therapeutic community programs may also be effective for methamphetamine-using women.58 At present, there are no approved pharmacotherapy treatments for cocaine dependence. However, preclinical studies suggest that baclofen, a GABAergic drug, may help reduce cocaine use among women, in particular.59 In contrast, studies using naltrexone to reduce cocaine use,60 and bupropion to decrease methamphetamine use,61 indicate that these pharmacotherapies may be more effective for men than for women.

Opioids

Prescription opioids

The use of prescription opioids has soared in the past 2 decades. For example, from 1992 to 2003, a 141% increase in prescription opioid abuse was reported.62 Two large epidemiological surveys found that women engage in the nonmedical use of prescription opioids more often than men.7 In contrast, other studies suggest that rates of nonmedical use are similar for men and women,53 or higher among men.63 Gender differences in prescription opioid use may also occur within specific age groups. Regarding prescription opioid abuse or dependence, data from the 2002 to 2004 National Survey on Drug Use and Health (NSDUH) found that women aged 12 to 17 years had higher rates than men, but that men aged 18 to 25 years had higher rates than women.64

Gender differences in motives for use and aberrant drug-taking behaviors have also been observed. Among college students, McCabe and colleagues65 found that men were significantly more likely than women to use prescription opioids for experimentation (35.3% vs 18.4%) or to get high (39.4% vs 24.4%). A recent study of 121 chronic pain patients found that women were significantly more likely than men to hoard unused medications and to use additional drugs (eg, sedatives) to enhance the effectiveness of prescription opioids.66

Heroin and intravenous drug abuse

Approximately 0.2% of the population of the United States aged 12 years and older endorses lifetime heroin use.50 One study (N = 408) found that, compared with men, women use smaller amounts of heroin, use heroin for shorter periods of time, and are less likely to inject heroin.67 A recent study of 111 individuals who were opioid-dependent and not in treatment found that women, compared with men, had more severe vocational impairment and used significantly more cocaine.68

Research indicates that women’s injection of drugs may be particularly influenced by their sexual partner’s injection risk behavior.69 Powis and colleagues67 found that women who injected heroin were significantly more likely than men to have a sexual partner who also injected heroin (96% vs 82%). In addition, women are also more likely than men to be introduced to injection by their sexual partners.67 Powis and colleagues67 reported that 51% of the female heroin users were first injected by their male sexual partner, whereas 90% of men were injected the first time by a friend. Compared with men who inject, women who inject report being more influenced by social pressure and by sexual partner encouragement.70

Risks of sharing needles or preparation equipment include enhanced vulnerability to numerous physical diseases, including hepatitis B and C, as well as human immunodeficiency virus (HIV).70 To date, it is unclear whether there are significant sex differences in injection risk behaviors. Frajzyngier and colleagues70 failed to observe sex differences in sharing needles during the first injection. However, women were significantly more likely than men to share preparation equipment. Other results suggest that, although women may be more likely to share needles,71,72 women are also more likely than men to engage in risk-reducing behaviors such as carrying clean syringes.72

Treatment

Less than one-fourth of individuals with opioid-use disorders receive treatment.73 Preliminary findings for a manual-based, 12-session group treatment of women using methadone suggests that this may be an effective way to treat opioid dependence in women.74 Regarding opioid agonist therapies, Jones and colleagues75 found that men and women remained in treatment for a significantly longer period of time when given methadone as opposed to l-α acetylmethadol (LAAM). Although buprenorphine, LAAM, and methadone reduced drug use for all participants, results suggest that sex differences may occur in the effectiveness of these pharmacologic agents. Specifically, buprenorphine was associated with significantly fewer positive urine samples and less self-reported opioid use than methadone among women. LAAM was associated with less drug use than buprenorphine among men.

Cannabis

Marijuana is the most commonly used illicit drug in the United States. According to the 2004 NSDUH, approximately 96.6 million Americans (40.2%) have tried marijuana.76 Compared with women, men are more likely to use marijuana daily (2.0% vs 0.7%),77 have more initial opportunities to use marijuana,78 and initiate marijuana use at a younger age (16.4 years vs 17.6 years).79

Unlike other substances, such as stimulants, a relationship between the menstrual phase and women’s use of,80 or response to, marijuana (eg, mood, pulse rate)81,82 has not been observed. However, marijuana use may be related to the menstrual cycle for women who have severe premenstrual syndrome or premenstrual dysphoric disorder.82

Attention processes and memory may be affected by marijuana use for up to 7 days following use.83 The effects of marijuana use on neuropsychological processes may differ by sex. In a study of heavy versus light marijuana users, Pope and colleagues84 reported that visual-spatial memory was impaired for women who smoked heavily, compared with women who were light smokers. However, no such difference was observed for men.

Research suggests that women enter treatment for marijuana-use disorder after significantly fewer years of use than men do (ie, telescoping effects).9 Because of the low numbers of women in treatment, no studies have been published regarding gender differences in the effectiveness of treatment of marijuana-use disorders. However, research suggests that cognitive behavioral therapy, contingency management treatments, motivational enhancement therapies, and administering oral tetrahydrocannabinol (THC) and nefazodone are effective treatments for marijuana dependence.85-88 However, a limitation of these studies is that they were predominately conducted with male participants.

Nicotine

In 2008, approximately 28.4% citizens of the United States reported being current nicotine users. Men use nicotine at higher rates than women (34.5% vs 22.5%),50 but women may be at an increased risk for health problems caused by smoking. Women who smoke are twice as likely as men to have heart attacks,89 women experience faster lung deterioration than men, and are at increased risk for chronic obstructive pulmonary disease90 and lung cancer.91 Smoking may also cause women to commence menopause earlier, experience increased menstrual bleeding, have difficulty becoming pregnant, or to experience spontaneous abortion.

Pharmacological and nonpharmacological factors influence nicotine use. Non-pharmacological factors are stimuli that are often paired with nicotine. Such stimuli can be proximal (eg, the smell of a cigarette) or distal (eg, people associated with smoking).92 Compared with men, women seem to be less influenced by nicotine factors93,94 and more influenced by proximal cues.95 These gender differences in underlying motivations or triggers for use may help inform etiologic understanding of nicotine use and help improve the design of gender-sensitive treatment approaches.

Compared with men, women may have more difficulty quitting smoking. A study conducted by the Centers for Disease Control and Prevention,96 which surveys more than 100,000 citizens of the United States, indicates that more than 1 million fewer women than men older than 35 years are able to quit smoking.97 Gonadal steroid hormones may be associated with women’s success at smoking cessation.12,16 Women who attempt to quit during the first 14 days of their menstrual cycle (ie, the follicular phase) seem more likely to succeed than women who attempt to quit in the second half of the cycle (ie, the luteal phase).12,16 Another obstacle to smoking cessation is women’s concern about weight gain. Women worry twice as much about weight gain caused by smoking cessation than men,98 and relapse 3 times more often than men because of weight gain.99

Sex differences in the efficacy of nicotine replacement therapy (NRT) may exist, but research to date is inconclusive. For example, a meta-analysis of 11 placebo-controlled NRT patch trials found that NRT is equally effective for men and women.100 More recently, Perkins and Scott101 added 3 placebo-controlled trials to this meta-analysis. The findings revealed that NRT is significantly more effective for men than women. Studies examining non-nicotine medication (eg, bupropion, varenicline) report equal effectiveness in men and women up to 12 weeks after treatment,102,103 and bupropion may be a particularly effective method for women because it has been found to also help relieve depression.103 Although medications are the standard treatment approach, therapy and counseling enhance the efficacy of medication treatment and may be more effective in women than men.104 Interventions that teach women how to cope with cues and address co-occurring mood and anxiety disorders may be particularly helpful.

A pertinent nicotine-related concern for women is smoking during pregnancy.105 Behavioral treatment approaches are particularly important for smoking cessation during this time, as many medications are contraindicated in pregnancy. Modifications may be made to therapy to tailor it for pregnant women (eg, incentives for cessation, such as vouchers that can be exchanged for baby supplies) while women are pregnant and after delivery. These modifications should continue after the baby has been delivered, because the majority (65%) of women who quit smoking during pregnancy relapse within 6 months of delivery.106

TREATMENT OUTCOME FOR WOMEN WITH SUBSTANCE-USE DISORDERS

Data from the TEDS, which captures data on national treatment admission rates, report that the overall proportion of men to women within the treatment system has remained fairly constant from 1995 to 2005 at 2:1.107 A recent review of the literature between 1975 and 2005 concluded that women are less likely to enter substance abuse treatment than men.46 However, once women enter treatment, gender itself is not a predictor of treatment retention, completion, or outcome.46 Several gender-specific predictors of outcome, and patient characteristics and treatment approaches can affect outcomes differentially by gender.46 Some characteristics have been shown to be associated with more favorable outcomes for men and women, such as greater financial resources, fewer mental health problems, and less severe drug problems.46,108 Studies in women-only samples have found associations between certain characteristics and retention, including better psychological functioning, higher levels of personal stability and social support, lower levels of anger, treatment beliefs, and referral source.46,109,110

Gender differences in treatment referral sources have been documented, highlighting the differential pathways by which women and men enter substance abuse treatment facilities. For example, significantly more men than women are referred to treatment through the criminal justice system (40% men vs 28% women). Approximately twice as many women as men (15% women vs 6% men) are referred from other community agencies, such as welfare, mental health, and other health care providers.107,111 The number of female prisoners in the United States is growing rapidly (eg, 53% since 1995), which means that the criminal justice system is increasingly becoming more relevant to the lives of women with substance-use disorders.112 This increase in the number of female prisoners is largely the result of changes in sentencing for drug-related charges that have disproportionately affected women, particularly women of color.112

In treatment seeking for women, their relationship with and responsibility for children is particularly important. Most women who enter substance abuse treatment are mothers, and at least half have had contact with child welfare.113,114 One study of methadone maintenance treatment found that women who were residing with their children were significantly more likely than women not residing with their children to enter treatment.115 For some women, residing with their children may serve as an impediment to treatment entry if they fear they may lose custody of their children.116 Once in treatment, women who are able to keep their children with them or retain custody of their children while in treatment are more likely to stay in treatment.117

Differences in the sources of payment for substance abuse treatment have also been reported. Significantly more men than women report self-pay (26% men vs 18% women) and more women than men report being dependent on public insurance (26% women vs 12% men).107 This finding suggests that women may be more vulnerable to changes in insurance-related benefits and coverage because of their greater reliance on public insurance to pay for treatment. In addition to childcare and financial issues, other factors may present as impediments to women’s treatment seeking and use. Social stigma, lack of awareness regarding treatment options, concerns about confrontational approaches that were pervasive in male-dominated traditional substance abuse treatment, co-occurring mental disorders or a history of trauma and victimization, as well as homelessness all present possible barriers for women.

Gender-specific Treatment of Women with Substance-use Disorders

To date, most substance abuse treatment models have been designed for men and based predominantly on male norms.46,118 However, gender-specific interventions that are designed to deliver information and services tailored for women are beginning to emerge in response to mixed-gender programs, which often fail to address women’s specific needs, such as childcare assistance, pregnancy, parenting, domestic violence, sexual trauma and victimization, psychiatric comorbidity, housing, income support, and social services.46,118-120

It is unclear at this point whether gender-specific treatments are superior.46,47,121 However, this research is severely limited because only a few randomized clinical trials have examined the relative effectiveness of comparable women-only versus mixed-gender interventions.49 In a meta-analysis examining single-gender substance abuse treatment of women, Orwin and colleagues119 concluded that single-gender treatment was effective, but its strongest effect was on pregnancy outcomes, psychological well-being, attitudes/beliefs, and HIV risk reduction. One study that randomized women (N = 1573) to women-only versus mixed-gender treatment found no significant differences in retention.122 In contrast, another study that randomized cocaine-dependent women to a women-only day treatment program or a mixed-gender outpatient program found that participants in the women-only program had significantly higher retention rates123 (60.2% vs 46.1%). More recently, treatment outcomes and costs of women-only and mixed-gender day treatment programs were compared among 122 women randomized to a women-only program or 1 of 3 standard mixed-gender programs.124 Compared with the hospital-based program, participants in the women-only program showed significantly lower total abstinence during the follow-up. Limitations included a small sample size and the focus on only day treatment programs.46

In a recent stage I behavioral development trial, Greenfield and colleagues49 developed a manual-based, 12-session women’s recovery group (WRG; n = 16) and compared WRG with mixed-gender group drug counseling (GDC; n = 7), an effective manual-based treatment of substance-use disorders. During the 12-week treatment phase, WRG and GDC were equally effective in reducing substance use, but WRG showed significantly greater improvement in reductions in drug and alcohol use during the 6-month follow-up phase. In addition, women were significantly more satisfied with WRG than GDC.49 Secondary analyses revealed a 3-way interaction effect of treatment condition, time, and baseline Brief Symptom Inventory scores, indicating that women with greater baseline psychiatric severity had greater reductions in substance use during treatment and follow-up if they were in the WRG rather than the GDC condition.125 Furthermore, women with low self-efficacy showed improved treatment outcomes if assigned to WRG compared with the GDC group.126

Behavioral Couples Treatment

For women, the risk of consuming alcohol secondary to marital discord, divorce, negative emotional states, and interpersonal conflict is higher than for men.44,127 Similarly, having a partner who abuses alcohol or drugs is more strongly related to relapse for women than for men.114 Because of this, treatment interventions designed specifically to address these dyadic issues may be particularly beneficial. Behavioral couples therapy (BCT) is founded on 2 fundamental assumptions: (1) family members, specifically spouses or other intimate partners, can reward abstinence; and (2) a reduction of relationship distress and conflict leads to improved substance-use outcomes by reducing possible antecedents to relapse and heavy use. Participation in BCT results in significantly less partner violence, higher rates of marital satisfaction, lower substance-use severity, greater improvements in psychosocial functioning of children living with parents, and better cost benefit and cost-effectiveness compared with traditional individual-based treatments (IBTs).128 In one study of 138 married or cohabiting women, Fals-Stewart and colleagues128 randomly assigned subjects to: (1) BCT, (2) IBT, or (3) a psychoeducational attention control treatment (PACT) condition. The findings showed that women who received BCT, compared with IBT or PACT, had significantly fewer days drinking and higher levels of dyadic adjustment during a 1-year follow-up period.128

CONCLUSIONS AND FUTURE DIRECTIONS

Gender differences in substance-use disorders and treatment outcomes for women with substance-use disorders have been a focus of research in the last 15 years. The initiation, use patterns, acceleration of disease course, and help-seeking patterns are affected by gender differences in biologic, psychological, cultural, and socioeconomic factors. Important gender-specific factors also predict women’s substance abuse treatment entry, retention, and outcomes. Understanding the basic biological mechanisms that underlie these gender differences in vulnerability and responsiveness to substances will enhance the development of gender-specific treatments. Additional research is also necessary to elucidate gender differences in response to specific pharmacologic and behavioral treatments, to identify subgroups of women who can benefit from single-gender versus mixed-gender treatments, and to improve understanding of the effectiveness and cost-effectiveness of gender-specific versus standard treatments.

Acknowledgments

The authors would like to acknowledge support from grant K24DA019855 (SFG), K23DA021228 (SEB) and K24 DA00435 (KTB) from the NIH/NIDA, and P50 DA016511 (KTB) from NIAMS/ORWH.

REFERENCES

1. Compton WM, Thomas YF, Stinson FS, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64:566–76. [PubMed]
2. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27. [PMC free article] [PubMed]
3. Grucza RA, Norberg K, Bucholz KK, et al. Correspondence between secular changes in alcohol dependence and age of drinking onset among women in the United States. Alcohol Clin Exp Res. 2008;32(8):1493–501. [PMC free article] [PubMed]
4. Wagner FA, Anthony JC. Male-female differences in the risk of progression from first use to dependence upon cannabis, cocaine, and alcohol. Drug Alcohol Depend. 2007;86:191–8. [PubMed]
5. Helzer JE, Burnam A, McEvoy LT. Alcohol abuse and dependence. In: Robins LN, Regier DA, editors. Psychiatric disorders in America: the epidemiological catchment area study. The Free Press; New York: 1991. pp. 81–115.
6. Hasin DS, Stinson FS, Ogburn E, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830–42. [PubMed]
7. Simoni-Wastila L, Ritter G, Strickler G. Gender and other factors associated with the nonmedical use of abusable prescription drugs. Subst Use Misuse. 2004;39(1):1–23. [PubMed]
8. Blanco C, Alderson D, Ogburn E, et al. Changes in the prevalence of non-medical prescription drug use and drug use disorders in the United States: 1991–1992 and 2001–2002. Drug Alcohol Depend. 2007;90(2–3):252–60. [PubMed]
9. Hernandez-Avila CA, Rounsaville BJ, Kranzler HR. Opioid-, cannabis-, and alcohol-dependent women show more rapid progression to substance abuse treatment. Drug Alcohol Depend. 2004;74(3):265–72. [PubMed]
10. Hser YI, Anglin MD, Booth MW. Sex differences in addict careers: 3. Addiction. Am J Drug Alcohol Abuse. 1987;13(3):231–51. [PubMed]
11. Randall CL, Roberts JS, Del Boca FK, et al. Telescoping of landmark events associated with drinking: a gender comparison. J Stud Alcohol. 1999;60:252–60. [PubMed]
12. Newman JL, Mello NK. Neuroactive gonadal steroid hormones and drug addiction in women. In: Brady KT, Back SE, Greenfield SF, editors. Women and addiction: a comprehensive handbook. Guilford Press; New York: 2009. pp. 35–64.
13. Doron R, Fridman L, Gispan-Herman I, et al. DHEA, a neurosteroid, decreases cocaine self-administration and reinstatement of cocaine-seeking behavior in rats. Neuropsychopharmacology. 2006;31(10):2231–6. [PubMed]
14. Sofuoglu M, Dudish-Poulsen S, Nelson D, et al. Sex and menstrual cycle differences in the subjective effects from smoked cocaine in humans. Exp Clin Psychopharmacol. 1999;7(3):274–83. [PubMed]
15. Evans SM, Foltin RW. Exogenous progesterone attenuates the subjective effects of smoked cocaine in women, but not in men. Neuropsychopharmacology. 2006;31(3):659–74. [PubMed]
16. Perkins KA, Levine M, Marcus M. Tobacco withdrawal in women and menstrual cycle phase. J Consult Clin Psychol. 2000;68(1):176–80. [PubMed]
17. Holdstock L, de Wit H. Effects of ethanol at four phases of the menstrual cycle. Psychopharmacology. 2000;150:374–82. [PubMed]
18. Sinha R. How does stress increase risk of drug abuse and relapse? Psychopharmacology. 2001;142:343–51. [PubMed]
19. Sinha R, Fox H, Hong KI, et al. Sex steroid hormones, stress response, and drug craving in cocaine-dependent women: implications for relapse susceptibility. Exp Clin Psychopharmacol. 2007;15(5):445–52. [PubMed]
20. Back SE, Waldrop AE, Saladin ME, et al. Effects of gender and cigarette smoking on reactivity to psychological and pharmacological stress provocation. Psychoneuroendocrinology. 2008;33(5):560–8. [PMC free article] [PubMed]
21. Fox HC, Hong KA, Paliwal P, et al. Altered levels of sex and stress steroid hormones assessed daily over a 28-day cycle in early abstinent cocaine-dependent females. Psychopharmacology. 2008;195(4):527–36. [PMC free article] [PubMed]
22. Conway KP, Compton W, Stinson FS, et al. 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. J Clin Psychiatry. 2006;67:247–57. [PubMed]
23. Goldstein RB. Comorbidity of substance use with independent mood and anxiety disorders in women: results from the National Epidemiologic Survey on Alcohol and Related Conditions. In: Brady KT, Back SE, Greenfield SF, editors. Women and addiction: a comprehensive handbook. Guilford Press; New York: 2009. pp. 173–92.
24. Greenfield SF. Assessment of mood and substance use disorders. In: Westermeyer J, Weiss RD, Ziedonis D, editors. Integrated treatment for mood and substance use disorders. Johns Hopkins University Press; Baltimore (MD): 2003. pp. 432–67.
25. Pettinati HM, Dundon W, Lipkin C. Gender differences in response to sertraline pharmacotherapy in type A alcohol dependence. Am J Addict. 2004;13(3):236–47. [PubMed]
26. Hudson JI, Hiripi E, Pope HG, et al. The prevalence and correlated of eating disorders in the National Comorbidity Survey Replication Study. Biol Psychiatry. 2007;61:348–58. [PMC free article] [PubMed]
27. Holderness CC, Brooks-Gunn J, Warren MP. Co-morbidity of eating disorders and substance abuse: review of the literature. Int J Eat Disord. 1994;16:1–34. [PubMed]
28. Dohm FA, Striegal-Moore R, Wilfley DE, et al. Self harm and substance use in a community sample of black and white women with binge eating disorders or bulimia nervosa. Intl J Eat Disord. 2002;32:389–400. [PubMed]
29. Bowers WA, Andersen AE, Evans K. Management of eating disorders: inpatient and partial hospital programs. In: Brewerton TD, editor. Clinical handbook of eating disorders: an integrated approach. Marcel Dekker; New York: 2004. pp. 349–76.
30. Gordon SM, Johnson JA, Greenfield SF, et al. Assessment and treatment of co-occurring eating disorders in publicly funded addiction treatment programs. Psychiatr Serv. 2008;59:1056–9. [PMC free article] [PubMed]
31. Cottler LB, Compton WM, Mager D, et al. Post-traumatic stress disorder among substance users from the general population. Am J Psychiatry. 1992;149:664–70. [PubMed]
32. Mills KL, Teesson M, Ross J, et al. Trauma, PTSD, and substance use disorders: findings from the Australian National Survey on mental health and well-being. Am J Psychiatry. 2006;163:652–8. [PubMed]
33. Najavits LM, Weiss R, Shaw S. The link between substance abuse and posttraumatic stress disorder in women: a research review. Am J Addict. 1997;6(4):237–83. [PubMed]
34. Brady KT, Dansky BS, Back SE, et al. Exposure therapy in the treatment of PSTD among cocaine-dependent individuals: preliminary findings. J Subst Abuse Treat. 2001;21:47–54. [PubMed]
35. Back SE, Dansky BS, Carroll KM, et al. Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures. J Subst Abuse Treat. 2001;21(1):35–45. [PubMed]
36. Hien DA. Trauma, posttraumatic stress disorder and addiction among women. In: Brady KT, Back SE, Greenfield SF, editors. Women and addiction: a comprehensive handbook. Guilford Press; New York: 2009. pp. 242–56.
37. Najavits LM. Seeking safety: a treatment manual for PTSD and substance abuse. Guilford Press; New York: 2002.
38. Brady KT, Sonne SC, Roberts JM. Sertraline treatment of comorbid posttraumatic stress disorder and alcohol dependence. J Clin Psychiatry. 1995;56:502–5. [PubMed]
39. Brady KT, Sonne S, Anton RF, et al. Sertraline in the treatment of co-occurring alcohol dependence and posttraumatic stress disorder. Alcohol Clin Exp Res. 2005;29(3):395–401. [PubMed]
40. Labbate LA, Sonne SC, Randal CL, et al. Does comorbid anxiety or depression affect clinical outcomes in patients with post-traumatic stress disorder and alcohol use disorders? Compr Psychiatry. 2004;45(4):304–10. [PubMed]
41. Keyes KM, Grant BF, Hasin DS. Evidence for a closing gender gap in alcohol use, abuse, and dependence in the United States population. Drug Alcohol Depend. 2008;93:21–9. [PMC free article] [PubMed]
42. Brady KT, Randall CL. Gender differences in substance use disorders. Psychiatr Clin North Am. 1999;22:241–52. [PubMed]
43. Frezza M, Pozzato G, Chiesa L, et al. Abnormal serum gamma-glutamyltrans-peptidase in alcoholics. Clues to its explanation. Neth J Med. 1989;34(1–2):22–8. [PubMed]
44. Annis HM, Graham JM. Profile types on the Inventory of Drinking Situations: implications for relapse prevention counseling. Psychol Addict Behav. 1995;9:176–82.
45. Stewart SH, Gavric D, Collins P. Women, girls, and alcohol. In: Brady KT, Back SE, Greenfield SF, editors. Women & addiction. Guilford Press; New York: 2009. pp. 341–59.
46. Greenfield SF, Brooks AJ, Gordon SM, et al. Substance abuse treatment entry, retention, and outcome in women: a review of the literature. Drug Alcohol Depend. 2007;86:1–21. [PMC free article] [PubMed]
47. Ashley OS, Marsden ME, Brady TM. Effectiveness of substance abuse treatment programming for women: a review. Am J Drug Alcohol Abuse. 2003;29:19–53. [PubMed]
48. Dahlgren L, Willander A. Are special treatment facilities for female alcoholics needed? A controlled 2-year follow-up study from a specialized female unit (EWA) versus a mixed male/female treatment facility. Alcohol Clin Exp Res. 1989;13:499–504. [PubMed]
49. Greenfield SF, Trucco EM, McHugh RK, et al. The Women’s Recovery Group Study: a stage I trial of women-focused group therapy for substance use disorders versus mixed-gender group drug counseling. Drug Alcohol Depend. 2007;90:39–47. [PMC free article] [PubMed]
50. Substance Abuse and Mental Health Services Administration (SAMHSA) Results from the 2008 National Survey on Drug Use and Health: national findings. US Department of Health and Human Services; Rock-ville (MD): 2009. Office of Applied Studies, NSDUH Series H-36, HHS Publication No. SMA 09-4434.
51. Lynch WJ. Sex differences in vulnerability to drug self-administration. Exp Clin Psychopharmacol. 2006;14(1):34–41. [PubMed]
52. Westermeyer J, Boedicker AE. Course, severity, and treatment of substance abuse among women versus men. Am J Drug Alcohol Abuse. 2000;26(4):523–35. [PubMed]
53. Substance Abuse and Mental Health Services Administration the NSDUH report. Office of Applied Studies; Rockville (MD): 2007. Methamphetamine use.
54. Della Grotta S, LaGasse LL, Arria AM, et al. [Accessed January 28, 2010];Patterns of methamphetamine use during pregnancy: results from the Infant Development, Environment, and Lifestyle (IDEAL) Study. Matern Child Health J. 2009 Available at: http://www.springerlink.com/content/l70457522w85q525/fulltext.html. [PMC free article] [PubMed]
55. Terplan M, Smith EJ, Kozoloski MJ, et al. Methamphetamine use among pregnant women. Obstet Gynecol. 2009;113:1285–91. [PubMed]
56. Sofuoglu M, Mitchell E, Kosten TR. Effects of progesterone treatment on cocaine responses in male and female cocaine users. Pharmacol Biochem Behav. 2004;78(4):699–705. [PubMed]
57. Hser YI, Evans E, Huang YC. Treatment outcomes among women and men methamphetamine abusers in California. J Subst Abuse Treat. 2005;28(1):77–85. [PubMed]
58. Rowan-Szal GA, Joe GW, Simpson DD, et al. During-treatment outcomes among female methamphetamine-using offenders in prison-based treatments. J Offender Rehabil. 2009;8:388–401. [PMC free article] [PubMed]
59. Campbell UC, Morgan AD, Carroll ME. Sex differences in the effects of baclofen on the acquisition of intravenous cocaine self-administration in rats. Drug Alcohol Depend. 2002;66(1):61–9. [PubMed]
60. Pettinati HM, Kampman KM, Lynch KG, et al. Gender differences with high-dose naltrexone in patients with co-occurring cocaine and alcohol dependence. J Subst Abuse Treat. 2008;34(4):378–90. [PMC free article] [PubMed]
61. Elkashef AM, Rawson RA, Anderson AL, et al. Bupropion for the treatment of methamphetamine dependence. Neuropsychopharmacology. 2008;33(5):1162–70. [PubMed]
62. Center on Addiction and Substance Abuse at Columbia University [Accessed September 15, 2008];Under the counter: the diversion and abuse of controlled prescription drugs in the U.S. 2005 July; Available at: http://www.casacolumbia.org/absolutenm/articlefiles/380-Under%20the%20Counter%20-%20Diversion.pdf.
63. Tetrault JM, Desai RA, Becker WC, et al. Gender and non-medical use of prescription opioids: results from a national US survey. Addiction. 2008;103:258–68. [PubMed]
64. Colliver JD, Kroutil LA, Dai L, et al. Misuse of prescription drugs: data from the 2002, 2003, and 2004 National Surveys on Drug Use and Health. Substance Abuse and Mental Health Services Administration, Office of Applied Studies; Rockville (MD): 2006. DHHS Publication No. SMA 06-4192, Analytic Series A-28.
65. McCabe SE, Cranford JA, Boyd CJ, et al. Motives, diversion and routes of administration associated with nonmedical use of prescription opioids. Addict Behav. 2007;32(3):562–75. [PMC free article] [PubMed]
66. Back SE, Payne R, Waldrop AE, et al. Prescription opioid aberrant behaviors: a pilot study of gender differences. Clin J Pain. 2009;25:477–84. [PMC free article] [PubMed]
67. Powis B, Griffiths P, Gossop M, et al. The differences between male and female drug users: community samples of heroin and cocaine users compared. Subst Use Misuse. 1996;31(5):529–43. [PubMed]
68. Kelly SM, Schwartz RP, O’Grady KE, et al. Gender differences among in- and out-of-treatment opioid-addicted individuals. Am J Drug Alcohol Abuse. 2009;35(1):38–42. [PMC free article] [PubMed]
69. Bryant J, Treload C. The gendered context of initiation to injecting drug use: evidence for women as active initiates. Drug Alcohol Rev. 2007;26:287–93. [PubMed]
70. Frajzyngier V, Neaigus A, Gyarmathy VA, et al. Gender differences in injection risk behaviors at the first injection episode. Drug Alcohol Depend. 2007;89:145–52. [PubMed]
71. Breen C, Roxburgh A, Degenhardt L. Gender differences among regular injecting drug users in Sydney, Australia, 1996–2003. Drug Alcohol Rev. 2005;24:353–8. [PubMed]
72. Montgomery SB, Hyde J, De Rosa CJ, et al. Gender differences in HIV risk behaviors among young injectors and their social network members. Am J Drug Alcohol Abuse. 2002;28(3):453–75. [PubMed]
73. Grant BF, Moore TC, Shepard J, et al. Source and accuracy statement for Wave 1 of the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions. National Institute on Alcohol abuse and Alcoholism; Bethesda (MD): 2003.
74. Najavits LM, Rosier M, Nolan AL, et al. A new gender-based model for women’s recovery from substance abuse: results of a pilot outcome study. Am J Drug Alcohol Abuse. 2007;33(1):5–11. [PubMed]
75. Jones HE, Fitzgerald H, Johnson RE. Males and females differ in response to opioid agonist medications. Am J Addict. 2005;14:223–33. [PubMed]
76. Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey of Substance Abuse Treatment Services (N-SSATS) Department of Health and Human Services; Rockville (MD): 2005.
77. Substance Abuse and Mental Health Services Administration The NSDUH Report: daily marijuana users based on the 2003 National Survey on Drug Use and Health: national findings. U.S. Department of Health and Human Services; Rockville (MD): 2004. Office of Applied Studies, NSDUH Series H-25, DHHS Publication No. SMA 04-3964.
78. Van Etten ML, Anthony JC. Comparative epidemiology of initial drug opportunities and transitions to first use: marijuana, cocaine, hallucinogens, and heroin. Drug Alcohol Depend. 1999;54:117–25. [PubMed]
79. Gfroerer JC, Wu LT, Penne MA. Initiation of marijuana use: trends, patterns, and implications. Substance Abuse and Mental Health Administration, Office of Applied Studies; Rockville (MD): 2002. DHHS Publication No. SMA 02-3711, Analytic Series: A-17.
80. Griffin ML, Mendelson JH, Mello NK, et al. Marijuana use across the menstrual cycle. Drug Alcohol Depend. 1986;18:213–24. [PubMed]
81. Lex BW, Mendelson JH, Bavli S, et al. Effects of acute marijuana smoking on pulse rate and mood states in women. Psychopharmacology. 1984;84:178–87. [PubMed]
82. Terner JM, de Wit H. Menstrual cycle phase and responses to drugs of abuse in humans. Drug Alcohol Depend. 2006;84:1–13. [PubMed]
83. Pope HG, Gruber AJ, Hudson JI, et al. Neuropsychological performance in long-term cannabis users. Arch Gen Psychiatry. 2001;58:909–15. [PubMed]
84. Pope HG, Jacobs A, Mialet JP, et al. Evidence for a sex-specific residual effect of cannabis on visuospatial memory. Psychother Psychosom. 1997;66:179–84. [PubMed]
85. Budney AJ, Higgins ST, Radonovich PL, et al. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol. 2000;68:1051–61. [PubMed]
86. Haney M, Hart CL, Ward AS, et al. Nefazodone decreases anxiety during marijuana withdrawal in humans. Psychopharmacology. 2003;165:157–65. [PubMed]
87. Haney M, Hart CL, Vosburg SK, et al. Marijuana withdrawal in humans: effects of oral THC or divalproex. Neuropsychopharmacology. 2004;29:158–70. [PubMed]
88. Marijuana Treatment Project Research Group Brief treatments for cannabis dependence: findings from a randomized multisite trial. J Consult Clin Psychol. 2004;72:455–66. [PubMed]
89. Prescott E, Hippe M, Schnohr P, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. Br Med J. 1998;316:1043–7. [PMC free article] [PubMed]
90. Dransfield MT, Davis JJ, Gerald LB, et al. Racial and gender differences in susceptibility to tobacco smoke among patients with chronic obstructive pulmonary disease. Respir Med. 2006;100:1110–6. [PubMed]
91. International Early Lung Cancer Action Program Investigators Women’s susceptibility to tobacco carcinogens and survival after diagnosis of lung cancer. JAMA. 2006;296:180–4. [PubMed]
92. Conklin CA. Environments as cues to smoke: implication for human extinction-based research and treatment. Exp Clin Psychopharmacol. 2006;14:12–9. [PubMed]
93. Perkins KA, Jacobs L, Sanders M, et al. Sex differences in the subjective and reinforcing effects of cigarette nicotine dose. Psychopharmacology. 2002;163:194–201. [PubMed]
94. Perkins KA, Doyle T, Ciccocioppo M, et al. Sex differences in the influence of nicotine and dose instructions on subjective and reinforcing effects of smoking. Psychopharmacology. 2006;184:600–7. [PubMed]
95. Perkins KA, Gerlach D, Vender J, et al. Sex differences in the subjective and reinforcing effects of visual and olfactory cigarette smoke stimuli. Nicotine Tob Res. 2001;3:141–50. [PubMed]
96. Centers for Disease Control and Prevention Cigarette smoking among adults—United States, 2005. MMWR Morb Mortal Wkly Rep. 2006;55:1145–8. [PubMed]
97. Rodu B, Cole P. Declining mortality from smoking in the United States. Nicotine Tob Res. 2007;9:781–4. [PubMed]
98. Pirie PL, Murray DM, Luepker RV. Gender differences in cigarette smoking and quitting in a cohort of young adults. Am J Public Health. 1991;81:324–7. [PubMed]
99. Swan GE, Ward MM, Carmelli D, et al. Differential rates of relapse in subgroups of male and female smokers. J Clin Epidemiol. 1993;46:1041–53. [PubMed]
100. Munafo M, Bradburn M, Bowes L, et al. Are there sex differences in transdermal nicotine replacement therapy patch efficacy? A meta-analysis. Nicotine Tob Res. 2004;6:769–76. [PubMed]
101. Perkins KA, Scott J. Sex differences in long-term smoking cessation rates due to nicotine patch. Nicotine Tob Res. 2008;10:1245–51. [PubMed]
102. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an a4b2 nicotinic acetylcholine receptor partial agonist, vs. sustained-release bupropion and placebo for smoking cessation. J Am Med Assoc. 2006;296:47–55. [PubMed]
103. Scharf D, Shiffman S. Are there gender differences in smoking cessation, with and without bupropion? Pooled and meta-analyses of clinical trials of Bupropion SR. Addiction. 2004;99:1462–9. [PubMed]
104. Cepeda-Benito A, Reynoso JT, Erath S. Meta-analysis of the efficacy of nicotine replacement therapy for smoking cessation: differences between men and women. J Consult Clin Psychol. 2004;72:712–22. [PubMed]
105. England LJ, Grauman A, Qian C, et al. Misclassification of maternal smoking status and effects on an epidemiologic study of pregnancy outcomes. Nicotine Tob Res. 2007;9:1005–13. [PubMed]
106. McBride CM, Pirie PL. Postpartum smoking relapse. Addict Behav. 1990;15:165–8. [PubMed]
107. Office of Applied Studies, Substance Abuse and Mental Health Services Administration Treatment Episode Data Set (TEDS) highlights-2005 national admissions to substance abuse treatment services: 1995–2005. SAMHSA; Rockville (MD): [Accessed November 8, 2007]. 2006. Available at: http://oas.samhsa.gov/teds2k5/TEDSHi2k5.htm.
108. Green CA, Polen MR, Dickinson DM, et al. Gender differences in predictors of initiation, retention, and completion in an HMO-based substance abuse treatment program. J Subst Abuse Treat. 2002;23:285–95. [PubMed]
109. Kelly PJ, Blacksin B, Mason E. Factors affecting substance abuse treatment completion for women. Issues Ment Health Nurs. 2001;22:287–304. [PubMed]
110. Loneck B, Garrett J, Banks SM. Engaging and retaining women in outpatient alcohol and other drug treatment: the effect of referral intensity. Health Soc Work. 1997;22:38–46. [PubMed]
111. Schmidt L, Weisner C. The emergence of problem-drinking women as a special population in need of treatment. In: Galanter M, editor. Recent developments in alcoholism: alcoholism and women. Plenum Press; New York: 1995. pp. 309–34. [PubMed]
112. Harrison PM, Beck AJ. Prisoners in 2004 (BJS Bulletin, NCJ 210677) Bureau of Justice Statistics, US Department of Justice; Washington, DC: [Accessed October 10, 2006]. 2005. Available at: http://www.ojp.gov/bjs/abstract/p04.htm.
113. Conners NA, Bradley RH, Mansell LW, et al. Children of mothers with serious substance abuse problems: an accumulation of risks. Am J Drug Alcohol Abuse. 2004;30(1):85–100. [PubMed]
114. Grella CE, Scott CK, Foss MA, et al. Gender differences in drug treatment outcomes among participants in the Chicago Target Cities Study. Eval Program Plann. 2003;26:297–310.
115. Lundgren LM, Schilling RF, Fitzgerald T, et al. Parental status of women injection drug users and entry to methadone maintenance. Subst Use Misuse. 2003;38(8):1109–31. [PubMed]
116. Haller DL, Miles DR, Dawson KS. Factors influencing treatment enrollment by pregnant substance abusers. Am J Drug Alcohol Abuse. 2003;29(1):117–31. [PubMed]
117. Chen X, Burgdorf K, Dowell K, et al. Factors associated with retention of drug abusing women in long-term residential treatment. Eval Program Plann. 2004;27:205–12.
118. Greenfield SF, Grella CE. Alcohol & drug abuse: what is “women-focused” treatment for substance use disorders? Psychiatr Serv. 2009;60:880–2. [PMC free article] [PubMed]
119. Orwin RG, Francisco L, Bernichon T, Center for Substance Abuse Treatment Effectiveness of women’s substance abuse treatment programs: a meta-analysis. SAMHSA; Arlington, Virginia: 2001.
120. Volpicelli J, Markman I, Monterosso J, et al. Psychosocially enhanced treatment for cocaine-dependent mothers: evidence of efficacy. J Subst Abuse Treat. 2000;18:41–9. [PubMed]
121. Smith WB, Weisner C. Women and alcohol problems: a critical analysis of the literature and unanswered questions. Alcohol Clin Exp Res. 2001;24:1320–1. [PubMed]
122. Condelli WS, Koch MA, Fletcher B. Treatment refusal/attrition among adults randomly assigned to programs at a drug treatment campus. The New Jersey Substance Abuse Treatment Campus, Seacaucus, NJ. J Subst Abuse Treat. 2000;18:395–407. [PubMed]
123. Strantz IH, Welch SP. Postpartum women in outpatient drug abuse treatment: correlates of retention/completion. J Psychoactive Drugs. 1995;27:357–73. [PubMed]
124. Kaskutas LA, Zhang L, French MT, et al. Women’s programs versus mixedgender day treatment: results from a randomized study. Addiction. 2005;100:60–9. [PubMed]
125. Greenfield SF, Potter JS, Lincoln MF, et al. High psychiatric severity is a moderator of substance abuse treatment outcomes among women in single vs. mixed gender group treatment. Am J Drug Alcohol Abuse. 2008;34:594–602. [PMC free article] [PubMed]
126. Cummings A, Gallop R. Self-efficacy and substance use outcomes for women in single gender versus mixed-gender group treatment. J Groups Addict Recover. 2010 in press. [PMC free article] [PubMed]
127. Connors GJ, Maisto SA, Zywiak WH. Male and female alcoholics’ attributions regarding the onset and termination of relapses and the maintenance of abstinence. J Subst Abuse. 1998;10:27–42. [PubMed]
128. Fals-Stewart W, Birchler GR, Kelley ML. Learning sobriety together: a randomized clinical trial examining behavioral couples therapy with alcoholic female patients. J Consult Clin Psychol. 2006;74:579–91. [PubMed]