Ethical issues in practice with older women who misuse substances

Older women who misuse substances represent a growing population within the United States. Yet, helping professionals lack guidance in addressing ethical issues that arise in working with these older women. The purpose of this article is to (a) examine what we know about older women who misuse substances, (b) address professional ethical dilemmas and other ethical issues that emerge in treating and delivering services to older women, (c) identify barriers for treatment, and (d) propose practice recommendations. Specifically, the authors examine the overarching professional ethical dilemma or tension between client autonomy and professional beneficence that emerges in treating and delivering services to older women. Implications are delineated for professional education, gender-and age-sensitive substance misuse services, and research and policy efforts.     

Long-term outcomes of adolescents treated for substance misuse

INTRODUCTION: Little is known about the long-term outcome of substance misuse by teenagers, this is especially true for gender specific consequences. OBJECTIVES: To examine the prevalence of death, physical illnesses related to substance misuse, mental illness, substance misuse, criminality, and poverty in adulthood among two cohorts of individuals who as adolescents had consulted for substance misuse problems, to estimate the effect of sex on adverse outcomes, and to compare cohort effects. METHODS: Individuals who had consulted a substance misuse clinic as adolescents during 1968-1971 and 1980-1984 were followed until 2002. Adverse outcomes were documented using information from Swedish national registers. RESULTS: In the older cohort followed to age 50, only one-in-five escaped all six adverse outcomes, while over half of subjects experienced at least two or more. Sex and the severity of adolescent substance misuse and delinquency were predictors of adverse outcomes. More women than men experienced physical illness and poverty in the older cohort while more men than women were convicted of criminal offences in both cohorts and presented continued substance misuse in the younger cohort. Men in the younger as compared to the older cohort had higher rates of substance misuse and criminal convictions. CONCLUSIONS: Adolescents seeking help for substance misuse problems are at elevated risk for multiple adverse outcomes later in life. Outcomes differ for women and men and by severity of adolescent misuse and delinquency. Few cohort differences in adult outcomes exist.     

Ethical, economic, and professional issues in home health care

Important ethical, economic, and professional issues in home health care (HHC) are identified and discussed. Patient services issues in HHC involve the ethics of providing high-technology feeding therapies to terminally ill patients and the controversies surrounding drug products, such as the appropriate amount of drug to be dispensed, the appropriate individual to compound home-care drug products, acceptable types of product packaging, and the impact of a switch in venders on the drug products supplied to patients. Economic issues include reasonable profit for HHC services, methods used to charge for products and services, payments to physicians for patient referrals, and pharmacies owned and operated by the HHC industry. Pharmacy relations issues center on the influence of nonpharmacists on pharmacy-based HHC services and the effect of HHC services on intraprofessional relations. How pharmacists resolve the many ethical, economic, and professional issues in HHC will determine the quality of services provided to patients, the nature of the working relationships between pharmacists and other health professionals, and the direction that pharmacy HHC services will take in the future.     

In the absence of hard data,Is soft data better than no data at all?

Where total anonymity and confidentiality were previously respected in drug research, a tendency towards the provision of “hard” data such as verifiable personal details seriously disadvantages researchers working with “hidden groups” who use drugs in a relatively problem free way. This particularly applies to those who use substances generally regarded as highly addictive and problematic, such as heroin. Funding for a follow-up to an earlier research project was sought; the original investigated non-problematic heroin users, whereas the chief aim of the follow-up was to examine “resilience” to the problems commonly associated with the use of heroin. An illustration of attempting to put the gathering of “hard” verifiable data into action is presented here along with the immediate consequences. Unsurprisingly, the response of potential participants to the idea of providing personal details was largely negative, as the perceived consequences of being “outed” as a heroin user were generally regarded as worse than any of the issues associated with the use of the drug itself. An irony of the situation is that this “resilience” may be due to participant refusal to compromise their anonymity. This raises some obvious ethical issues. A number of potential longer term consequences on substance use/misuse research are also discussed.     

Regular past year cannabis use in women veterans and associations with sexual trauma

IntroductionThis study sought to describe the prevalence of regular past year cannabis use (i.e., at least monthly use) in women veterans, to characterize women veterans reporting this level of use, and to examine the independent contributions of sexual trauma across the lifespan on regular past year cannabis use.MethodsA national online survey on women veterans' health, with targeted oversampling of lesbian and bisexual women, collected data from US armed forces women veterans, 18 or older, living in the US (N = 636).ResultsEleven percent of women reported regular cannabis use (5% heterosexual women; 21% lesbian/bisexual women). In bivariate analysis, identifying as a sexual and/or racial ethnic minority, younger age, being unmarried, reporting lower income, receiving VA services, smoking tobacco, and screening positive for alcohol misuse were positively associated with regular cannabis use. Additionally, a greater percentage of cannabis users reported experiencing childhood and adult sexual trauma and screened positive for posttraumatic stress disorder (PTSD) when compared to peers who did not use any drugs. In a multivariate model, the number of life eras women endorsed experiencing sexual trauma was significantly associated with regular cannabis use even when adjusting for demographic variables and PTSD symptoms.ConclusionsAmong women veterans, regular cannabis use is fairly common among those who are sexual and racial/ethnic minorities, younger, unmarried, receiving VA services, and reporting alcohol or tobacco use, PTSD symptoms, and/or multiple sexual traumas across the lifespan. Screening and assessment may be important to consider in healthcare settings serving this veteran population.     

The relationship of childhood abuse history and substance use in an Alaska sample

This study confirms a strong link between childhood abuse history and substance misuse based upon data obtained from an ethnically diverse (largely Alaska Native) sample of 192 pregnant women in substance misuse treatment in the mid-1990s. Nearly three-quarters of the women reported childhood victimization. Compared to women with no abuse history, abused women were significantly younger at the age of onset of substance misuse, used substances more frequently, had experienced more blackouts, had more family members with substance-misuse concerns, were more likely to have been raped, revealed more psychological problems, and had less formal education. Risk patterns differed slightly for women with physical versus sexual abuse histories, with the experience of physical violence having a stronger relationship with adulthood problem behaviors than the experience of sexual molestation. Overall, findings suggest an interactive cycle of violence and substance misuse that begins very early in childhood, especially for women who were physically abused, and continues in adulthood, though no cause-end-effect conclusions can be drawn. Treatment and prevention implications of these findings are discussed.     

Intervention Strategies for Children Vulnerable for School Failure Due to Exposure to Drugs and Alcohol

Children and youth exposed in utero to drugs and alcohol and/or who are growing up in a family in which these substances are misused are vulnerable for failure at all age levels, prenatally through adulthood. This article reviews developmental issues presented by children and youth vulnerable for school failure either due to the biological effects of prenatal exposure to drugs and/or environmental issues resulting from growing up in a family in which misuse of drugs and alcohol occurs. Characteristics and needs of these students with recommendations for educational and community-based system of services to them and their families are discussed. Model programs serving children and youth prenatally through school age are identified. [Translations are provided in the International Abstracts Section of this issue.]     

Pharmacy support staff involvement in,and attitudes towards,pharmacy‐based services for drug misusers

Objective This study aimed to examine involvement of pharmacy support staff in delivering services to drug misusers; to quantify their participation in related training; and to examine relationships between attitudes, practice experience and training. Methods The setting was a random sample of 10% of UK community pharmacies (n = 1218) using a postal questionnaire with two reminders. Pharmacy managers were used as gate‐keepers to access pharmacy support staff, which included dispensary technicians and medicines counter assistants. Key findings Six hundred and ninety (56.7%) pharmacies responded, and 1976 completed questionnaires were returned from 610 (50.1%) pharmacies. A further 80 (6.6%) opted out. Three‐fifths of staff had no input into decisions about whether their pharmacy provided services for drug misusers. One‐third working in pharmacies that provide services were uncertain or negative about whether their pharmacy should do so. Staff were more involved in needle exchange (91%) and decisions to sell needles (95%) than supervising consumption of therapies (64%) or handing out dispensed medicines to drug misusers (73%), suggesting managers perceive needle exchange and sales as appropriate roles. Three‐quarters of those working in pharmacies that provide services had not received any training to do so. Those who had undertaken training and who worked in pharmacies that provided services had significantly more positive attitudes compared to those had not undertaken training but also worked in pharmacies that provided services, or those who had undertaken training but did not provide services. Conclusions Pharmacy support staff were involved extensively in drug‐misuse services but the majority had not been trained to do so. Attitudes were more positive in those who were involved in service provision and had undertaken training. The findings suggest a need for more extensive training and for further exploration of the views of managers on appropriate roles, particularly the clinical versus supply nature of needle exchange. This is timely given the recent publication of guidelines by the National Institute of Health and Clinical Excellence (NICE) on needle exchange.     

THE RELATIONSHIP OF CHILDHOOD ABUSE HISTORY AND SUBSTANCE USE IN AN ALASKA SAMPLE

This study confirms a strong link between childhood abuse history and substance misuse based upon data obtained from an ethnically diverse (largely Alaska Native) sample of 192 pregnant women in substance misuse treatment in the mid-1990s. Nearly three-quarters of the women reported childhood victimization. Compared to women with no abuse history, abused women were significantly younger at the age of onset of substance misuse, used substances more frequently, had experienced more blackouts, had more family members with substance-misuse concerns, were more likely to have been raped, revealed more psychological problems, and had less formal education. Risk patterns differed slightly for women with physical versus sexual abuse histories, with the experi-ence of physical violence having a stronger relationship with adulthood problem behaviors than the experience of sexual molestation. Overall, findings suggest an interactive cycle of violence and substance misuse that begins very early in childhood, especially for women who were physically abused, and continues in adulthood, though no cause-end-effect conclusions can be drawn. Treatment and prevention implications of these findings are discussed.     

Receptivity to alcohol-related care among U.S. women Veterans with alcohol misuse

Previous research indicates women Veterans have a potentially large, unmet need for alcohol-related care but are under-represented in treatment settings. The purpose of this study was to identify factors associated with women Veterans' receptivity to a recommendation for alcohol-related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. Semi-structured interviews were conducted from 2012–2013 with 30 women Veterans at two VA facilities who screened positive for alcohol misuse during a primary care visit and discussed their alcohol use with their primary-care provider. Qualitative analyses identified 9 themes women used to describe what affected their receptivity to a recommendation for alcohol-related care (i.e., VA specialty substance use disorder services). The most common themes positively associated with women's receptivity included self-appraisal of their drinking behavior as more severe, the provider's presentation of treatment options, availability of gender-specific services, and worse physical and mental health. The themes identified here may have important implications for the clinical strategies providers can use to present alcohol-related care options to women Veterans to facilitate their use of care. These strategies include educating women about the health effects of alcohol misuse and increasing providers' knowledge about available care options (within the care organization or the community), including the availability of gender-specific services.     

Substance Misuse Services in Primary Health Care

Introduction: Substance misuse remains the largest cause of preventable morbidity and mortality in the UK. As the first port of call for advice and care, the Primary Health Care (PHC) setting offers an ideal opportunity for prevention of substance misuse. The most basic activity is to ask patients whether they use specific substances.

Methods: All practices within four Health Authorities across South London were targeted. A self-completion questionnaire for PHC staff was designed for demographic information and previous training on substance misuse. Information on services provided by the practice was requested from the Practice Manager only.

Results: Twenty-five per cent (104/417) of the practices responded. Seventy-four per cent reported providing smoking, 76% alcohol and 81% drug services, and 67% reported providing all three. There was no significant association between services provided and PHC professionals' training in substance misuse.

Discussion: Less than half the practices reported screening their patients for smoking and drinking, and less than a third for drug use; a much greater number reported referring to specialist services for alcohol and drug use. This indicates that PHC professionals tend to engage with this health concern when the problem has escalated and specialist referral is required. A methodological limitation to this study is the low response rates and the possibility of a response bias in those who did respond.     

Substance Misuse Services in Primary Health Care

Introduction: Substance misuse remains the largest cause of preventable morbidity and mortality in the UK. As the first port of call for advice and care, the Primary Health Care (PHC) setting offers an ideal opportunity for prevention of substance misuse. The most basic activity is to ask patients whether they use specific substances. Methods: All practices within four Health Authorities across South London were targeted. A self-completion questionnaire for PHC staff was designed for demographic information and previous training on substance misuse. Information on services provided by the practice was requested from the Practice Manager only. Results: Twenty-five per cent (104/417) of the practices responded. Seventy-four per cent reported providing smoking, 76% alcohol and 81% drug services, and 67% reported providing all three. There was no significant association between services provided and PHC professionals' training in substance misuse. Discussion: Less than half the practices reported screening their patients for smoking and drinking, and less than a third for drug use; a much greater number reported referring to specialist services for alcohol and drug use. This indicates that PHC professionals tend to engage with this health concern when the problem has escalated and specialist referral is required. A methodological limitation to this study is the low response rates and the possibility of a response bias in those who did respond.     

Increasing the appeal and utilization of services for alcohol and drug problems: what consumers and their social networks prefer

BackgroundA large gap exists in the United States between population need and the utilization of treatment services for substance-related problems. Surveying consumer preferences may provide valuable information for developing more attractive services with greater reach and impact on population health.MethodsA state-level telephone survey using random digit dialling sampling methods assessed preferences for available professional, mutual help, and lay resources, as well as innovative computerized and self-help resources that enhance anonymity (N = 439 households in Alabama).ResultsRespondents preferred help that involved personal contact compared to computerized help or self-help, but were indifferent whether personalized help was dispensed by professional or lay providers. Attractive service features included lower cost, insurance coverage, confidentiality, rapid and convenient appointments, and addressing functional problems and risks of substance misuse. Respondents in households with a member who misused substances rated services more negatively, especially if services had been used.ConclusionThe findings highlight the utility of viewing substance misusers and their social networks as consumers, and the implications for improving the system of care and for designing and marketing services that are responsive to user preferences are discussed.     

Parenting and Maternal Substance Addiction: Factors Affecting Utilization of Child Protective Services

The purpose of this study is to identify which personal, familial, environmental, and social factors are associated with the utilization of child protection services, including parental support programs, by mothers who misuse illicit substances. Participants are 56 mothers with substance use and addiction-related problems, of whom 32 were receiving, voluntarily or otherwise, child protection services while 24 mothers had psychotropic drug use-related problems but were receiving no psychosocial services. Data were collected in the province of Quebec, Canada, between August 1998 and August . Results indicate that mothers who receive services are younger, have fewer interpersonal resources, live in lower socioeconomic conditions, and have greater family dysfunction (less parental supervision and more inconsistent discipline) than mothers who do not receive services from child protection agencies. However, there are no significant differences between groups with regards to maternal childhood trauma, psychological distress, antisocial behavior and the quality of the parent–child bond. The results of this study suggest that although both groups misuse drugs and have personal difficulties, some mothers will not need support from social services to take care of their children. Implications of these findings for prevention are discussed. The study's limitations are noted.     

Substance Use Among Women Veterans: Epidemiology to Evidence-Based Treatment

An increasing percentage of women are U.S. Military Veterans. We review the substance misuse rates and comorbidities and the risk factors for and consequences of substance use among women Veterans. Women Veterans may have higher rates of substance misuse and comorbid psychiatric and medical disorders than male Veterans and women who are not Veterans. Studies support the AUDIT-C as a scaled marker of alcohol-related risk among female Veterans, but validated drug screening instruments are needed. We discuss evidence-based approaches in terms of treating women Veterans’ substance misuse in primary and specialty care settings, along with knowledge gaps and potential research priorities to improve care in this special population.     

Co-morbid substance misuse in psychiatric patients: prevalence and association with length of inpatient stay

Improved management of mental illness with co-morbid substance misuse is an important clinical objective. This study aimed to assess the prevalence of substance misuse in psychiatric inpatients, and to examine the relationship between alcohol misuse and length of hospital admission. A prevalence study conducted over four months, examined rates of co-morbid substance misuse in patients admitted for psychiatric inpatient care. Demographic details and length of hospital stay were collected for all patients and those who gave informed consent were screened for levels of alcohol and substance misuse. Two hundred and thirty-eight patients were admitted during the study period in which 178 (74.8%) consented to take part in the study. A group of 44 (50.6%) men and 26 (29.2%) women were screened positive for alcohol misuse (chi(2) = 8.7, P = 0.003). Cannabis use was acknowledged by 31 (35.2%) men and 10 (11.2%) women (chi(2) = 13.5, P < 0.0001). Presence of co-morbid alcohol misuse was associated with a significantly shorter hospital admission (z = 3.34, P = 0.0008). Co-morbid substance misuse (including alcohol) was reported significantly more frequently by men than women. Overall, patients with co-morbid alcohol misuse had shorter hospital admissions, suggesting different patterns of presentation and progress in hospital. Hospital admission presents an opportunity to identify substance misuse and evaluate treatments for co-morbid conditions within a safe environment.     

Substance Misuse Among Women Attending Family Planning Clinics in a Rural Area in Britain: prevalence and associated problems

Objectives: Little research has been carried out focusing on women who misuse substances, although existing evidence suggests that they represent a distinctive group. The aims of the current study are to determine prevalence of tobacco, alcohol and other drug use in women attending family planning services in a rural area and to investigate preferred sources of help-seeking. Methods: A prospective study using a self-completed questionnaire assessing use of tobacco, alcohol, other drugs, associated problems and sources of help-seeking. The sample included women attending family planning clinics in a rural area of southern England. Results: Fifty-three percent were current smokers,thirty-five percent misused alcohol and fourteen and a half percent had used other drugs in the last year. Those using each of the substances were significantly more likely to be 21 years or under. Not all those using substances indicated problems and sources of help varied with the presence of problems. Conclusions: Women attending family planing clinics are a self-selected group with a high level of substance use compared to the general population. This suggests that they may have a lifestyle incorporating more risky behaviours, including unsafe sexual behaviour. Once problems have occurred due to substance use, help needs to be more accessible.     

Substance use in the general hospital

INTRODUCTION: People misusing substances are overrepresented in health settings. Substance misuse can also be an underlying factor complicating medical diagnosis and management. AIMS: (i) To establish the prevalence of substance misuse in the general hospital inpatient population; and (ii) to examine the relationship between medical diagnosis and substance misuse problem as identified by screening tools. METHOD: This study adopted a three-step screening approach including a prospective questionnaire survey, interview, and case note review. Subjects included all adult patients admitted to a London teaching hospital over a 1-week period. RESULTS: Seventy percent completed the questionnaire. Twenty-three percent was currently smoking, 14% was rated positive for alcohol misuse, and 12% positive for drug misuse. Only 65% of patients was screened for smoking, 54% for alcohol, and 9% for other substances. CONCLUSIONS: People misusing one substance were more likely to be misusing others, hence the importance of screening all patients for all substances. Doctors were screening a small percentage of patients and they identified and intervened with only the severe ones.     

“They Gave Me Life”: Motherhood and Recovery in a Tribal Community

Objective: This study explored factors related to substance misuse and recovery among Native mothers in a Pacific Northwest tribe, focusing on motherhood as a motivating factor in seeking treatment and sustaining recovery. Method: Using a community-based participatory research approach, we conducted a thematic analysis of 20 in-depth interviews and one focus group (N = 12) with Native women 18 years and older living on or near the reservation. Results: Qualitative findings highlighted challenges, motivations and strategies for seeking treatment and recovery in four major themes: (a) the close relationship between interpersonal violence and substance misuse; (b) traditional healing in recovery; (c) community-specific challenges to recovery; and (d) the motivating role of motherhood in seeking treatment and successful recovery. Conclusions: A central finding of this work is that pregnancy and motherhood may be underexplored factors in Native women's substance use. Results support previous work suggesting that Native women are at high risk of interpersonal trauma and that trauma contributes to substance misuse. Findings offer several rich implications for treatment and recovery among Native mothers in tribal communities including the necessity of trauma-informed treatment, community and culturally-based interventions, more integration of treatment services with Child Protective Services, and drawing on motherhood as a motivation for seeking and succeeding in recovery.