Women Veterans and Substance Use Disorders Jen McDonald, MD

Women Veterans and Substance Use Disorders Jen McDonald, MD DATE/MONTH 2011 Objectives Develop an understanding of the unique issues women veterans Understand treatment options of women veterans with substance use disorders 1 1

Women Veterans - Activity Women and the Military Women make up about 16% of the entire active duty force (U.S. Department of Defense, 2017). Women currently make up about 9% of the total number of veterans, which is approximately 6 million (National Center on Veterans Analysis and Statistics, 2016). The median age of women veterans is 49 years old (HRSA, 2013). A total of 49.9% of women veterans are married compared to 65% of male veterans (HRSA, 2013). The majority of today s women veterans (53%) served between the Vietnam era and September 11, 2001 (Patten & Parker, 2011). 2

Characteristics of Women Veterans/Service Members Women veterans are more racially and ethnically diverse than their male counterparts: o 67% are White, non Hispanic; for men that number is 80% o 18% are African American; African American males are 10% o 8.2% are Hispanic; Hispanic males are 6.4% (Source: National Center for Veterans Analysis and Statistics, 2016) Women with military experience often have higher education levels than nonveteran women. Experiences of Women in the Military Post 9/11 era women veterans more likely to have seen or engaged in active combat, to have been engaged in hostile fire, or to have seen or known someone killed by enemy fire. Women are increasingly serving in traditional male roles, placing them at increased risk of experiencing hostile enemy fire (Meyers, 2009). DOD has opened all military roles to women (Bradner, 2015). 3

Protective Factors against SUDs Strong social and family supports before, during, and after deployment (Eisen et al., 2014; Street et al., 2009) Low exposure to combat stressors, including being fired upon, firing upon an enemy, or exposure to human remains Higher levels of reintegration supports (Street et al., 2009) Greater levels of access to services, including health care (Street et al., 2009) Sense of community Women Veterans and SUDs Of the women veterans screened at Department of Veterans Affairs clinics, the past year rates (2014 2015) of documented diagnoses found: o Alcohol use disorder (AUD): 3% to 10% o Drug use disorder (DUD): 1% to 6% o Substance use disorder (SUD): 3% to 16% (AUD and DUD combined total) The types of substances being used included alcohol, sedatives, opioids, and amphetamines. Women veterans aged 35 and older were found to have higher rates of SUDs than their non veteran counterparts. (Hoggatt et al., 2015) 4

SUD and Suicide Rates Studies indicate that women veterans with an SUD diagnosis have higher rates of suicide than their nonveteran peers. Women veterans are five times more likely to commit suicide than non veteran women. Women veterans with an opioid use disorder commit suicide at a rate of 98.6 per 100,000 a higher rate than the suicide rate for veterans without an SUD diagnosis. (Bohnert et al., 2017) Co-occurring Disorders Women veterans with SUDs generally had higher rates of other issues, including: trauma exposures psychiatric comorbidities some medical comorbidities (Hoggatt et al., 2015) 5

Women Veterans and Trauma Women veterans have much higher rates of interpersonal trauma than male veterans, including much higher rates of military sexual trauma (MST) and intimate partner violence (IPV) (Zinzow et al., 2007; U.S. Department of Veterans Affairs, 2011b). One study places the prevalence of trauma histories among women veterans at 81% to 93% (Zinzow et al., 2007). Studies have shown that exposure to trauma is associated with other challenges (Hamilton et al., 2011; Washington et al., 2010). Military Sexual Trauma Among women veterans, 1 in 4 report having experienced military sexual trauma (MST) (VA, 2010, 2015). MST is an experience, not a diagnosis or a mental health condition. Reactions to MST vary and are affected by: o role of the perpetrator o type of assault o duration and whether it occurred once or multiple times o response from others if it was reported o her prior history of trauma (U.S. Department of Labor, 2010) 6

Women Veterans, Poverty, and Homelessness More women veterans live in poverty than their male counterparts: 9.4% compared to 6.7% (National Center for Veterans Analysis and Statistics, 2016). A total of 15.3% of disabled women veterans live in poverty compared to 9.4% of male veterans (National Center for Veterans Analysis and Statistics, 2016). Women veterans are overrepresented in the homeless population when compared to nonveteran women, though the number of women vets experiencing homelessness is lower than male veterans. Women Veterans and Chronic Pain 50% of all veterans have at least one pain diagnosis Women veterans are more likely to suffer from chronic pain than their male peers Wider range of chronic pain conditions Greater severity of pain Longer lasting pain More frequent pain Hurley, 2008; LeResche 2010 7

Women are prescribed more opioids than men Women are more likely to be prescribed opioids Women are more likely to be prescribed opioids in conjunction with benzodiazepines Women are prescribed higher doses of opioids than their age matched male peers Middle aged women (44 59) are twice as likely to be prescribed opioids as men Campbell 2010; USND 2017 Needs of Women Who Have Served Trauma, and the resulting effects and coping strategies, often result in the need for behavioral health or substance use treatment. Following their time in service, women veterans may be faced with other challenges, such as: o single parenthood o lack of child care o higher rates of unemployment o homelessness 8

What Can We Do? 16 What Can We Do? Relationship Building Stabilization and Skills Building Mission Meaning Mindfulness Self Care Strengths 9

Relationship Building: The Power of YOU Implications for Care: The Power of YOU 19 10

Implications for Care: The Power of YOU Use your relationship as a tool Find ways to structure your work that promote a sense of control Provide predictable, consistent, and respectful interactions Model power sharing and positive regard in relationships Discuss what need might be driving a given reaction or behavior Evaluate the pros and cons of meeting the need in this particular way Explore whether there are alternative ways to meet this need that may interfere less with living the life the Veteran wants Stabilization and Skills Building 11

Implications for Care: Stabilization and Skills Building Imagine trying to read a book that has no plot. There are no organizing themes, no recurrent patterns. Each page has a new and unpredictable set of events that seem unconnected to the events on the previous page and there is no way of guessing, much less predicting, what will happen next. At first the book might seem entertaining and even exciting, but eventually it just seems like too much effort to read. Now imagine that book is your life. Nothing makes sense and you cannot plan or take control of even the simplest activities. (Harris & Fallot, 2001, p.14) Implications for Care: Stabilization and Skills Building 12

Stabilization: Finding Mission 24 Stabilization: Meaning 25 13

What s the matter with you? What matters to you? 14

Skills Building: Mindful Awareness A way of being in the present moment. on purpose. nonjudgmentally Self Care 15

Implications for Care: Focus on Self Care Prioritize self care For our veterans who have often forgotten the how to put themselves first And for us as providers: The emotional demands of working with veterans with SUD and our strengths as providers empathy, ability to care genuinely about others, and capacity to go difficult places leave us vulnerable to depletion For all it is important to remain grounded in what is meaningful, gratifying, and enjoyable to us 31 16

Focus on Strengths Deficit Model 17

A Strengths-Based Approach 34 Paying Attention to Different Things What s going right? What are strengths? What really matters? 18

Conclusion Women veterans have unique needs and require unique treatment approaches for SUD. A focus on relationship building, stabilization, skills, self care and strengths often results in the best chance of recovery. Recommendations for Providers Serving Women Veterans 1. Engage women veteran peers for peer support activities to support treatment and recovery. 2. Include screening and assessment questions that address military experience and recognize a woman s military contributions. 3. Create a trauma informed organization that is welcoming to women veterans. 4. Offer, or provide referrals to, trauma specific/trauma informed interventions and services. 5. Ensure that intake personnel, clinicians, administrative support personnel, and others are aware of and understand the unique culture and experiences of women veterans. 19

Recommendations for Providers Serving Women Veterans 6. Accommodate women veterans with children by providing secure places for children to be while moms are being treated. 7. Provide treatment/recovery services that address individual and family needs. 8. Provide access to safe and affordable housing for a woman veteran and her children. 9. Develop integrated care models and care coordination models that can assist women veterans so they receive the services they need in an effective and safer way. 10.Assist women with understanding and accessing their full benefits, including VA/military related education (Post 9/11 GI bill), employment training, healthcare benefits, Medicaid, and other supports. (Tang et al., 2012) Resources For more information about women veterans and services available to them, see the following: Department of Veterans Affairs Center for Women Veterans at https://www.va.gov/womenvet/ National Veterans Technical Assistance Center at https://www.nvtac.org/ United States Department of Labor at https://www.dol.gov/vets/womenveterans/ Substance Abuse and Mental Health Services Administration Veterans and Military Families at https://www.samhsa.gov/veterans military families 20

References Bradner, E. (2015, December 3). U.S. military opens combat positions to women. Retrieved from http://www.cnn.com/2015/12/03/politics/u s military women combat positions/ Bohnert, K., Ilgen, M., Louzon, S., McCarthy, J., & Katz, I. (2017). Substance use disorders and the risk of suicide mortality among men and women in the US Veterans Health Administration. Addiction. DOI: 10.1111/add.13774 Campbell, J., Garza, M., Gielen, A., Campo, P., Kub, J., & Dieneman, J. Jafar, E. (2003). Intimate partner violence and abuse among active duty military women. Violence Against Women, 9(9), 1072 1092. Eisen, S. V., Schultz, M. R., Glickman, M. E., Vogt, D., Martin, J. A., & Osei Bonsu, P. E. Elwy, A. R. (2014). Postdeployment resilience as a predictor of mental health in Operation Enduring Freedom/Operation Iraqi Freedom returnees. American Journal of Preventive Medicine, 47(6), 754 761. Hamilton, A., Poza, I., & Washington, D. (2011, July August). Homelessness and trauma go hand in hand: Pathways to homelessness among women veterans. Women's Health Issues, 21(4Suppl), 203 209. Health Resources and Services Administration. (2013). Women veterans. Retrieved from https://mchb.hrsa.gov/whusa13/population characteristics/p/women veterans.html Henry, M., Cortes, A., Shivji, A., & Buck, K. (2014). The 2014 annual homeless assessment report (AHAR) to Congress. Washington, DC: The U.S. Housing and Urban Development Office of Planning and Development. Retrieved from https://www.hudexchange.info/resources/documents/2014 AHAR Part1.pdf References - 1 Hoggatt, K. J., Jamison, A. L., Lehavot, K., Cucciare, M. A., Timko, C., & Simpson, T. L. (2015). Alcohol and drug misuse, abuse, and dependence in women veterans. Epidemiologic Reviews, 37, 23 37. Khadduri, J., & Culhane, D. (2010). Veteran homelessness: A supplemental report to the annual homeless assessment report to Congress. Washington, DC: U.S. Department of Housing and Urban Development, Office of Community Planning and Development. Retrieved from http://www.va.gov/homeless/docs/2010aharveteransreport.pdf Meyers, S. (2009, August 16). Women at arms: Living and fighting alongside men, and fitting in. The New York Times. Retrieved from http://www.nytimes.com/2009/08/17/us/17women.html?_r=0 National Center on Homelessness Among Veterans. (2016). Women veterans and homelessness: Homeless evidence and research roundtable series. Retrieved from https://www.va.gov/homeless/nchav/research/hers3_women.asp National Center for Veterans Analysis and Statistics. (2016). Profile of women veterans: 2014. [PowerPoint slides]. Washington, DC: U.S. Department of Veterans Affairs. Retrieved from http://www.va.gov/vetdata/docs/specialreports/women_veterans_2014.pdf Office on Women s Health. (2009). Action Steps for Improving Women s Mental Health. Retrieved from https://store.samhsa.gov/shin/content/owh09 PROFESSIONAL/OWH09 PROFESSIONAL.pdf Patten, E., & Parker, K. (2011). Women in the U.S. Military: Growing share; distinctive profile. Washington, DC: Pew Research Center. Retrieved from http://www.pewsocialtrends.org/2011/12/22/women in the u s military growing share distinctive profile/ 21

References -2 Street, A. E., Vogt, D., & Dutra, L. (2009). A new generation of women veterans: Stressors faced by women deployed to Iraq and Afghanistan. Clinical Psychology Review, 29(8), 685 694. Substance Abuse and Mental Health Services Administration. (2012). Behavioral health issues among Afghanistan and Iraq U.S. war veterans. HHS Publication No. (SMA) 12 4670. Rockville, MD: Author. Tang, Z., Claus, R. E., Orwin, R. G., Kissin, W. B., & Arieira, C. (2012). Measurement of gender sensitive treatment for women in mixed gender substance abuse treatment programs. Drug and Alcohol Dependence, 123(1 3), 160 166. U.S. Department of Defense. (2017). Table of active duty females by rank/grade and service. Washington, DC: Author. Retrieved from https://www.dmdc.osd.mil/appj/dwp/dwp_reports.jsp U.S. Department of Housing and Urban Development. (2015, October). HUD 2015 continuum of care homeless assistance programs homeless populations and subpopulations. Retrieved from https://www.hudexchange.info/resource/reportmanagement/published/coc_popsub_natlterrdc_2015.pdf U.S. Department of Labor. (2017). Employment situation of veterans summary. Retrieved from https://www.bls.gov/news.release/vet.nr0.htm U.S. Department of Labor, Women s Bureau. (2010). Trauma informed care for women experiencing homelessness: A guide for service providers. Retrieved from https://www.dol.gov/wb/trauma/wbtraumaguide2011.pdf References - 3 U.S. Department of Veterans Affairs. (2011a). Educational attainment of veterans: 2000 to 2009. Retrieved from https://va.gov/vetdata/docs/specialreports/education_final.pdf U.S. Department of Veterans Affairs. (2011b). National Center for PTSD: Intimate partner violence. Retrieved from https://www.ptsd.va.gov/public/types/violence/domestic violence.asp U.S. Department of Veterans Affairs. (2010). Top 10 things all healthcare & service professionals should know about VA services for survivors of military sexual trauma. Retrieved from https://www.mentalhealth.va.gov/docs/top_10_public.pdf U.S. Department of Veterans Affairs, National Center for PTSD. (2015). Military sexual trauma. Retrieved from https://www.ptsd.va.gov/public/types/violence/military sexual trauma general.asp U.S. Department of Veterans Affairs, Office of Inspector General. (2012). Homeless incidence and risk factors for becoming homeless in veterans. Washington, DC: Author. Retrieved from http://www.va.gov/oig/pubs/vaoig 11 03428 173.pdf Vasquez, S. (2011). Homelessness among women veterans. U.S. Department of Veterans Affairs. Retrieved from http://www.va.gov/womenvet/docs/2011summit/vasquezfinal.pdf Washington, D., Yano, E. M., McGuire, J., Hines, V., Lee, M., & Gelberg, L. (2010). Risk factors for homelessness among women veterans. Journal of Health Care for the Poor and Underserved, 21, 82 91. Zinzow, H., Grubaugh, A., Monnier, J., Suffoletta Malerie, S., & Freuh, B. (2007). Trauma among female veterans: A critical review. Trauma, Violence, & Abuse, 8, 384 400. 22