Substance Abuse

Overview

What Is It?

Substance abuse may involve alcohol, tobacco or over-the counter, prescription or illicit drugs. There are three primary risk factors for substance use disorder: genetics; age of first use and duration of use; and victimization.

Substance use disorders are complicated illnesses that present unique threats to women's health. Medical research finds that women who consume alcohol, tobacco or other drugs may develop substance use disorders and/or substance-related health problems faster than men.

Recent surveys show that alcohol consumption is most common among:

• women in their 20s and early 30s
• women who are divorced or separated, women who are unmarried and living with a partner or women who never married

Before discussing problems with the use of alcohol, it is important to understand the different levels of drinking. Alcohol consumption occurs across a continuum related to risk and levels of consumption. At the low end is abstinence, or avoidance of alcohol altogether.

Low-risk drinking is defined as drinking within the recommended limits published by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). For men up to the age of 65, these limits are no more than four drinks in one day AND no more than 14 drinks in a week. For nonpregnant women up to the age of 65, and for both healthy men and women over the age of 65, the recommended limits are no more than three drinks in one day AND no more than seven drinks in a week. The NIAAA also recommends having some days when you do not drink. If you drink within these limits, you will reduce your chances of developing an alcohol use disorder and related health problems.

Those who drink above the NIAAA limits are engaged in what is often termed risky or hazardous use, which is a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others. Harmful use is alcohol consumption that results in consequences to physical and mental health. Finally, alcohol dependence is a disorder that includes three or more of the following symptoms: tolerance, withdrawal, inability to limit amount consumed or time spent drinking, desire or unsuccessful attempts to reduce drinking, great deal of time spent drinking or recovering from effects of alcohol, neglect of important life activities because of drinking, and continued drinking despite the realization that alcohol is causing or making worse a physical or psychological problem.

For most women, responsible drinking is the consumption of no more than one standard drink per day. A standard drink contains about 14 grams of alcohol (0.6 fluid ounces or 1.2 tablespoons), which is equivalent to one 12-ounce bottle of beer or wine cooler; 8 to 9 ounces of malt liquor; one 5-ounce glass of wine; or 1.5 ounces of 80-proof distilled spirits. Keep in mind that the alcohol content of different types of beer, wine and distilled spirits can vary quite substantially.

This is intended to measure the amount consumed on a single day and does not represent an average over several days. (In other words, if you don't drink all week and then drink seven drinks on Saturday, it's not the same as having one drink a day.)

The limits for women over 65 are intended for healthy women. Women who have chronic health conditions or take certain medications may have increased risks from drinking alcohol. Additionally, health care providers are less likely to detect increased alcohol use in men and women over age 65.

According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), women are more vulnerable to alcohol-related organ damage, trauma and interpersonal difficulties:

• Liver damage: Women develop alcohol-induced liver disease faster than men even if they consume less alcohol. Plus, women are more likely than men to develop alcoholic hepatitis and die from cirrhosis (liver disease).
• Brain damage: Studies of brains via magnetic resonance imaging (MRIs) show that women may be more vulnerable to alcohol-related brain damage than men.
• Heart disease: Among heavy drinkers, women develop heart disease at the same rate as men, despite the fact that women consume 60 percent less alcohol than men over their lifetimes.
• Breast cancer: There is emerging evidence of a link between moderate or heavy alcohol consumption and an increased risk for breast cancer.
• Violence: College women who drink are more likely to be the victims of sexual abuse than those who don't. And high school girls who drink are more likely to be the victims of dating violence than those who don't.
• Accidents: After having just one drink, a 140-pound woman reaches a blood alcohol level that increases her risk of being killed in a single-vehicle crash.
• Women are more likely than men to use a combination of alcohol and prescription drugs.
• Women may begin to abuse alcohol and drugs following depression, to relax on dates, to feel more adequate, to lose weight, to decrease stress or to help them sleep at night.

Poor self-esteem is a major issue for most women who develop problems with drugs and alcohol. The following factors may also increase a woman's risk for developing substance use disorders:

• A history of physical or sexual abuse. Physical and sexual violence against women is common when one or both partners have been drinking or using drugs. Women also are more likely to drink or use drugs when their partners do.
• Depression, panic disorder and post-traumatic stress disorder. Women who abuse alcohol also have much higher rates of eating disorders.
• Family history. Researchers know that there is a strong family (genetic) component to addiction. If you have a family history of addiction, you should be aware of your risk for developing dependency, especially during stressful periods in your life.

So, why are women more vulnerable to the effects of alcohol?

Women develop serious alcohol problems more rapidly than men, and at lower doses, a process called "telescoping." This is partially because women's bodies absorb alcohol faster than men's because of a difference in the way a key enzyme works. The enzyme, alcohol dehydrogenase (ADH), breaks down alcohol before it enters the bloodstream. But this enzyme is less active in women than in men. Also, women have a smaller ratio of water to fat than men. That means there's less water to dilute the alcohol and more fat to capture it. One positive difference: Women seem to eliminate alcohol from their bodies faster than men.

Hormonal fluctuations in women may affect how alcohol is metabolized. Some women report feeling the effects of alcohol more quickly or strongly when they drink at certain times during their menstrual cycle.

Alcohol affects almost every organ in your body. Serious health problems associated with excessive alcohol use include but are not limited to:

• brain damage
• cancer
• pancreatitis
• increased risk for sexually transmitted diseases
• liver disease
• high blood pressure and other forms of heart disease
• malnutrition (specifically thiamine deficiency)
• anemia
• heavy menstrual flow, irregular cycles or premenstrual pain
• premature menopause
• osteoporosis
• diabetes
• circulation problems
• respiratory disease
• alcohol poisoning
• sexually transmitted diseases

Alcohol poisoning occurs when high quantities of alcohol are consumed in one session. It can lead to coma and death. The lethal dose for alcohol is about .35 to .40 percent, or about five times the legal limit (0.08) in most states. However, death can occur from alcohol poisoning at lower levels, especially for women. For a 120-pound man or woman drinking very quickly, it would only take eight to 10 drinks in an hour to reach the lethal level.

Alcohol Use and College Students

For women, binge drinking is consuming four or more drinks in one session, usually within about two hours. It is most common among women between the ages of 18 to 25. This type of heavy, episodic drinking causes most of the alcohol-associated harm occurring on campuses and in students' lives. Collegedrinkingprevention.gov, an organization supported by the NIAAA, reports the following statistics concerning alcohol use and college students:

• Each year, 1,825 college students between the ages of 18 and 24 die, and 599,000 are injured as a result of alcohol-related incidents, including car crashes.
• About 696,000 students between the ages of 18 and 24 are assaulted each year by a fellow student who has been drinking.
• About 97,000 students between ages 18 and 24 are victims of sexual assault or rape each year due to alcohol consumption.
• Each year, 400,000 students have unprotected sex and more than 100,000 students report having been too intoxicated to know whether or not they consented to sex.
• About 25 percent of college students suffer academically because of their drinking habits.
• More than 150,000 college students develop alcohol-related health problems every year, and between 1.2 percent and 1.5 percent of students say they tried to commit suicide within the past year as a result of drinking or drug use.
• More than 3.3 million students between the ages of 18 and 24 report driving drunk each year.

Substance Use and Older Women

Substance use, including cigarettes, alcohol and misuse of psychoactive prescription drugs (sedatives, tranquilizers and other drugs that affect the mind or behavior), is also a problem for American women 60 years old and older.

Older women are at greater risk for substance use disorders in part because tolerance levels decrease as people age. Some studies suggest that older women are at greater risk for developing a substance use disorder even if they use smaller amounts than younger women. Yet this is often a hidden problem, going undetected by health care professionals, family and friends. Substance abuse symptoms in older women are often erroneously attributed to other factors, such as anxiety or depression.

Also, older women are less likely to discuss their alcohol use or misuse of prescription drugs with their health care professional, in part because of the stigma their generation attached to alcoholism and mental disorders. Additionally, health care professionals are less likely to address addiction problems in this population.

There are different types of excessive alcohol use in the elderly: early onset and late onset. Those who have been using alcohol at levels above the recommended limits for many years and reached age of 65 are called "hardy survivors" and belong to the early onset group; those who begin abusing alcohol later in life belong to the late onset group.

This distinction is particularly important in women since those who have early onset are at higher risk for alcohol-related health issues. Both groups are at increased risk for injury however, especially falls, and for depression, suicide and malnutrition.

Alcohol and Pregnancy

The damaging effects of alcohol on pregnant women and their unborn babies are well documented. Like many other drugs, alcohol easily passes from a mother to her baby through the placenta. Prenatal alcohol exposure is the single greatest preventable cause of mental retardation.

One of the greatest risks of alcohol use during pregnancy is fetal alcohol spectrum disorder (FASD) and fetal alcohol syndrome (FAS), the most severe form of FASD. Low birth weight, congenital anomalies, severe behavioral and neurological problems and learning and physical disabilities are some symptoms experienced by infants and children exposed to alcohol in the uterus.

Children diagnosed with FAS suffer the severest damage related to alcohol exposure, including facial changes and mental retardation.

For the mother, alcohol use during pregnancy has been associated with high blood pressure, miscarriage, premature delivery, stillbirth and anemia.

There is no safe level of alcohol consumption during pregnancy. Women who are planning to become pregnant or who are sexually active and might become pregnant should refrain from alcohol use, since damage can occur before a woman realizes she is pregnant.

Prescription and Over-the-Counter Drug Use and Women

Misuse of, abuse of and dependence on prescription drugs are major health problems for women. Two-thirds of all tranquilizers, such as diazepam (Valium), chlordiazepoxide (Librium) and alprazolam (Xanax), are prescribed to women. Other examples of prescription drugs used frequently by women include sedatives such as triazolam (Halcion) and estazolam (ProSom); analgesics like meperidine (Demerol) or other types of painkillers such as oxycodone mixed with aspirin (Percodan) or guaifenesin mixed with codeine (Brontex); and stimulants such as methylphenidate (Ritalin), sibutramine (Meridia) and dextroamphetamine (Dexedrine).

When used to treat the medical conditions for which they were approved at the recommended dose, these drugs are safe and effective, rarely leading to addiction or abuse. But when not used properly, they can lead to addiction and death, especially when used in combination with alcohol or other drugs.

Women are more likely to use narcotic pain relievers for nonmedical use than men, and they are more likely to mix prescription drugs with alcohol.

Many women start taking a medication for a health problem, such as anxiety, muscle spasms or pain, but then use it longer and in greater amounts than intended or without close supervision by a health care professional. In most cases, developing a physical dependence on a certain drug causes your body to build up tolerance to it, requiring more of the drug to have the same effect.

In these cases, abruptly stopping use of the drug may result in rebound withdrawal signs. This doesn't necessarily mean you were abusing the drug or developed an addiction to it, because sometimes long-term use is appropriate. That's why it's so important that you only take prescription drugs under the supervision of a health care professional.

Misuse of prescription drugs can cause a variety of health problems in addition to physical dependence, including headaches, confusion, drowsiness, fainting and lowered or elevated blood pressure.

For some prescription drugs, adverse effects increase dramatically if you mix them with alcohol. This combination increases the risk of injuries from falls and car accidents and can be deadly. Be sure to consult with your health care provider or pharmacist about the use of alcohol when taking any prescription drug.

Over-the-counter (OTC) pain relievers and fever reducers can also cause health problems if used with alcohol. If you have three or more alcoholic drinks a day, you may be at increased risk for liver damage or stomach bleeding if you take these medications.

Illicit Drug Use and Women

Studies have found that more than 4 million women need treatment for drug problems. The health risks of illegal drug use go beyond the effects of the drugs themselves. Illicit drug use (such as heroin, cocaine or marijuana) often leads to behavior that puts women at increased risk for HIV, hepatitis and other sexually transmitted diseases (STDs).

Heroin

Also known on the street as smack, horse, H, junk or scag, heroin is the most commonly abused narcotic. Narcotics are drugs that produce an insensibility or stupor. The term narcotic is most often used to refer to derivatives of the opium poppy (an annual poppy cultivated as the source of opium) or chemically similar synthetics created in a lab. Heroin was a commonly prescribed medicine in the early 20th century, until its addictive potential was realized. It breaks down to morphine in the body.

Narcotics act on the nervous and digestive systems to control pain, relieve diarrhea and suppress coughing. When prescribed for pain relief, narcotics are usually taken by mouth. Narcotics slow body functions such as circulation, breathing and digestion. They cause your blood vessels to relax and your heart rate to slow, lowering blood pressure. Narcotics make you feel drowsy, groggy and confused. A common characteristic of heroin use is "nodding," a semiconscious state in which the person may appear to be nodding off to sleep.

Like most other drugs that are abused, narcotics can make you feel a sense of euphoria, contentment and physical relaxation. The "high" usually lasts about three to four hours. When heroin is injected or smoked, the abuser experiences an instant period of intense pleasure known as a "rush." The more you use narcotics, the more tolerant your body becomes, requiring higher doses to achieve the same results. Eventually, the user reaches a plateau at which no amount of the drug is sufficient. When the user reaches this level, the person administers the drug just to delay withdrawal sickness.

Street heroin is sold in powder form and has a bitter taste. Heroin is generally inhaled or injected and sometimes smoked. There is a high prevalence of hepatitis C, HIV and AIDS among heroin users due to sharing of contaminated syringes, which has resulted in a decline in the number of intravenous (IV) users. Today, many heroin addicts sniff the powder into their nostrils or heat it on foil to inhale the vapors. Heroin is also sometimes mixed with tobacco or marijuana and smoked in a pipe or cigarette.

The consequences of heroin use include:

• dry, itchy skin, skin infections and abscesses
• constipation and loss of appetite
• menstrual irregularity
• fluctuating blood pressure and slow or irregular heartbeat
• dependence, addiction
• hepatitis B and C and HIV/AIDS caused by use of dirty needles
• stroke and heart attack caused by blood clots
• cardiac arrest, coma and death from accidental overdose

Cocaine

Cocaine is one of the oldest known drugs. In the early 19th century, this stimulant was used as an ingredient for many types of tonics prescribed to treat a variety of illnesses. However, the source of cocaine—coca leaves—has been ingested for thousands of years in mountainous regions of Peru and Bolivia where the coca bush is found. Though it can be prescribed by physicians today as a local anesthetic, cocaine is a commonly abused drug and was very popular in the '80s and '90s.

Cocaine comes in two chemical forms: hydrochloride salts (the powdered form) and "crack" (a smokable "freebase" form produced through a reaction with an alkaline substance such as baking soda). The powdered form can be injected into a vein after it's dissolved in water, or inhaled. When sold by drug dealers, the powdered form of cocaine is often diluted with sugar, starch or other substances. The freebase form of cocaine can be smoked.

Cocaine stimulates the nervous system, causing your heart rate and blood pressure to increase and your blood vessels to constrict, which is why abusers often suffer heart attacks and strokes. The initial effects of cocaine use are increased alertness, energy, self-confidence and loss of appetite. However, as these effects wear off, the user is left feeling depressed, fatigued, jumpy, fearful and anxious.

Crack is the slang name for the highly potent form of freebase cocaine processed from powdered hydrochloride into a substance that can be smoked. Crack looks like white chunks, rocks or chips and "cracks" when it is smoked. Crack is less expensive to produce and buy than cocaine. It is typically smoked in a pipe, and users inhale the fumes.

The effects of crack are similar to other forms of cocaine, only more intense and more immediate. Users seem to become addicted to it more quickly than to other forms of cocaine.

The consequences of cocaine abuse are:

• irregular heartbeat, heart attack and heart failure
• strokes and seizures
• fluid in the lungs and other lung disorders
• paranoia, depression, anxiety disorders and delusions
• aggressive, violent behavior
• an increased risk of hepatitis and HIV for users who inject the drug intravenously
• increased and indiscriminate sexual activity often accompanies use and addiction, further increasing risk of HIV and other STD infection.

Pregnant women who use cocaine have a higher risk of miscarriage and premature labor. Its use has also been associated with low birth-weight babies and developmental problems.

Marijuana

"Pot" is by far the most commonly used illegal drug. It may also be the most insidious drug, because most people don't realize how dangerous it is. Since the 1990s, most marijuana contains significantly more THC (delta-9-tetrahydrocannabinol, the active ingredient in the drug) than marijuana used in the 1960s and 1970s. Thus, the effects of smoking part of a single 21st-century marijuana cigarette produces more profound and debilitating effects than smoking several marijuana cigarettes in the 1970s would have.

Marijuana is usually smoked, either in a pipe or a loosely rolled cigarette known as a "joint." Joints are infrequently (and usually unknown to the user) laced with the potent hallucinogen PCP or other drugs that substantially alter the effects of marijuana. Marijuana can also be brewed into tea or mixed in baked products like cookies or brownies.

The effects of smoking are usually felt in a few minutes and peak in 10 to 30 minutes. They include dry mouth and throat, increased heart rate, impaired coordination and balance, delayed reaction time and diminished short-term memory. Marijuana can impair driving and lead to accidents, and its effects may be worse in combination with alcohol. Larger doses can cause more intense reactions such as paranoia.

The most familiar long-term effect of marijuana use is impaired learning ability. Research shows that marijuana use limits your ability to absorb and retain information. In testing, users often show a reduced ability to memorize information and demonstrate lower math and verbal skills.

Aside from the mind-altering effects of marijuana, it also carries consequences similar to cigarette smoking. According to some studies, if you smoke one joint, it is thought that you are exposed to the same amount of cancer-causing chemicals as if you smoke five tobacco cigarettes, and smokers can experience frequent respiratory infections, including chest colds, bronchitis, emphysema, asthma and sinusitis. A novice marijuana user is more likely to experience anxiety, panic attacks and paranoia.

The health consequences of associated with heavy marijuana use include:

• delayed onset of puberty and reduced sperm count of men
• dbnormal menstrual cycles and irregular ovulation for women
• impaired perception, diminished short-term memory, loss of concentration and coordination, impaired judgment and decreased ability to judge distance and speed—all of which lead to increased risk of accidents
• damage to respiratory, reproductive and immune systems

Methamphetamine

Also known as speed, crank, meth, crystal-meth and glass, methamphetamine is a powerful stimulant that produces increased alertness and elation. Its effects are similar to cocaine but last longer. Easily made with inexpensive over-the-counter ingredients in makeshift laboratories, methamphetamine is cheaper to produce than cocaine.

Methamphetamine can be swallowed, smoked, snorted or injected. In powder form, it can be mixed with water and injected in the veins or sprinkled on tobacco or marijuana and smoked. Chunks of clear, high-purity methamphetamine are called ice, crystal or glass. It looks like rock candy and is smoked like crack cocaine.

Women use methamphetamine at the same rate as men, and almost half of methamphetamine users are women, unlike with other illicit drugs, such as heroin and cocaine. Additionally, methamphetamine use is seen among women in rural areas and among middle-class women, unlike cocaine and heroin users, who are more often from poor urban populations. Treatment is often less available in rural areas.

Women may be more attracted to methamphetamine for its promise of weight loss and treatment of depression symptoms.

Low doses of methamphetamine can make you feel alert and energetic. With continued use, however, the pleasurable feelings can disappear. The user soon needs to take higher doses more often to achieve the same effects. Someone using methamphetamine is easily agitated. One minute she is calm and content, the next she is angry and fearful. Addicts may pick at imaginary bugs on their skin and become obsessed with repetitive actions.

The crash that follows a methamphetamine binge involves agitated depression and an intense craving for more of the drug. These feelings soon give way to exhaustion and long, deep sleep—again followed by severe depression. During this last phase, the potential for suicide is very high.

The consequences of methamphetamine use include:

• nausea, vomiting, diarrhea and dramatic weight loss to the point of emaciation
• insomnia and sleep disturbances
• severe damage to the teeth
• skin sores and infections as a result of picking at imaginary bugs
• psychotic symptoms such as anxiety, paranoia, depression, hallucinations including the sensation of bugs crawling on the skin and feelings of hopelessness (These symptoms can sometimes last for months or years after methamphetamine abuse has ceased.)
• permanent damage to the heart that can result in increased blood pressure, chest pain, headaches and increased risk for stroke and heart attack
• severe structural and functional changes in areas of the brain associated with emotion and memory that may be partially reversible
• increased risk of sexually transmitted diseases, such as HIV and hepatitis

Methamphetamine causes different health consequences in women than in men and requires different approaches. This is particularly true with pregnant women and women with young children.

Methamphetamine use during pregnancy can increase the mother's blood pressure and heart rate. This can result in an increased risk of premature delivery or miscarriage, restricted fetal growth and increased lethargy in newborns. Additionally, methamphetamine constricts blood vessels in the placenta. This means there is less blood flow to the fetus, and the baby receives less oxygen and nutrients. The drug can also pass through to the placenta, which increases the fetus's blood pressure. This can result in stroke or heart damage, as well as slow fetal growth.

Ecstasy

Also called MDMA (3,4-methylenedioxymethamphetamine), Ecstasy use has, in recent years, become increasingly popular with teenagers in club or dance settings. It is a synthetic, illegal drug that has characteristics of both stimulants and hallucinogens. It is typically produced in capsule or tablet form and is usually taken by mouth, although health care professionals have documented cases in which people injected or snorted the drug. Researchers have found that women may experience more intense psychoactive effects of Ecstasy than men. Ecstasy interferes with learning and memory and may produce damaging changes in brain structures and chemistry. It increases heart rate and blood pressure and can disable the body's ability to regulate its own temperature.

There is now a large body of evidence that links heavy and prolonged MDMA use to confusion, depression, sleep problems, persistent elevation of anxiety and aggressive/impulsive behavior. Because of its stimulant properties, when used in club or dance settings, it enables users to dance vigorously for extended periods but can also lead to severe rises in body temperature (hyperthermia), as well as dehydration, hypertension and even heart or kidney failure in susceptible people.

Researchers at the University of Amsterdam studying brain blood flow patterns in male and female chronic users of Ecstasy found that women who use the drug may be more likely to develop neurological problems than men.

The consequences of MDMA use include:

• confusion
• depression and severe anxiety
• sleep problems
• drug craving
• increased heart rate and blood pressure
• involuntary teeth clenching
• nausea, blurred vision, faintness and chills or sweating

In high doses, MDMA can interfere with the body's ability to regulate temperature. Rarely, this can lead to a sharp increase in body temperature, which can result in liver, kidney and cardiovascular system failure or even death.

Recent research suggests that MDMA may also impair some types of cognitive or memory tasks.

Screening

It may be difficult to know if your alcohol or other substance use is putting you at risk for a substance use disorder. However, readily available screening instruments can help you determine if your substance use may be harmful.

If you suspect you may have a problem with alcohol use, you might want to ask yourself the following question:

How many times in the past year have you had four or more drinks in a day (five or more for men)? If you answer one or more, you may be at risk for alcohol-related problems.

You can also complete the following screening test:

Alcohol Use Disorders Identification Test (AUDIT)

Please circle the answer that is correct for you. Give yourself the number of points indicated for each response:

1. How often do you have a drink containing alcohol?
   • (0) Never (skip to questions 9 and 10)
   • (1) Monthly or less
   • (2) 2–4 times a month
   • (3) 2–3 times a week
   • (4) 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?
   • (0) 1 or 2
   • (1) 3 or 4
   • (2) 5 or 6
   • (3) 7 to 9
   • (4) 10 or more
3. How often do you have six or more drinks on one occasion?
   • (0) Never
   • (1) Less than monthly
   • (2) Monthly
   • (3) Weekly
   • (4) Daily or almost daily
4. How often during the last year have you found you were not able to stop drinking once you started?
   • (0) Never
   • (1) Less than monthly
   • (2) Monthly
   • (3) Weekly
   • (4) Daily or almost daily
5. How often during the last year have you failed to do what was normally expected from you because of drinking?
   • (0) Never
   • (1) Less than monthly
   • (2) Monthly
   • (3) Weekly
   • (4) Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
   • (0) Never
   • (1) Less than monthly
   • (2) Monthly
   • (3) Weekly
   • (4) Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?
   • (0) Never
   • (1) Less than monthly
   • (2) Monthly
   • (3) Weekly
   • (4) Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
   • (0) Never
   • (1) Less than monthly
   • (2) Monthly
   • (3) Weekly
   • (4) Daily or almost daily
9. Have you or someone else been injured as a result of your drinking?
   • (0) No
   • (2) Yes, but not in the last year
   • (4) Yes, during the last year
10. Has a relative, friend, doctor or any other health worker been concerned about your drinking or suggested you cut down?
    • (0) No
    • (2) Yes, but not in the last year
    • (4) Yes, during the last year

Scoring AUDIT

Add up your scores from questions 1 to 10. The maximum score is 40. A total score of 8 or more on the questionnaire suggests that you have a pattern of hazardous or risky alcohol consumption. If so, talk with your health care provider or contact a local clinic or agency. The Substance Abuse & Mental Health Services Administration can help you locate a treatment facility through its online site at www.samhsa.gov/or its Helpline at 1-877-SAMHSA-7.

The Drug Abuse Screening Test (DAST)

The Drug Abuse Screening Test (DAST) is one of the two standard screening tools that health care providers use to screen a person for a possible drug use disorder.

Answer YES or NO to the following questions:

1. Have you used drugs other than those required for medical reasons?
2. Have you abused prescription drugs?
3. Do you abuse more than one drug at a time?
4. Can you get through the week without using drugs (other than those for medical reasons)?
5. Are you always able to stop using drugs when you want to?
6. Do you abuse drugs on a continuous basis?
7. Do you try to limit your drug use to certain situations?
8. Have you had "blackouts" or "flashbacks" as a result of drug use?
9. Do you ever feel guilty about your drug abuse?
10. Does your spouse (or parents) ever complain about your involvement with drugs?
11. Do your friends or relatives know or suspect you abuse drugs?
12. Has drug use ever caused problems between you and your spouse?
13. Has any family member ever sought help for problems related to your drug use?
14. Have you ever lost friends because of your use of drugs?
15. Have you neglected family because of your use of drugs?
16. Have you ever been in trouble at work because of drug abuse?
17. Have you ever lost a job because of drug abuse?
18. Have you gotten into fights when under the influence of drugs?
19. Have you ever been arrested because of unusual behavior while under the influence of drugs?
20. Have you ever been arrested for driving while under the influence of drugs?
21. Have you engaged in illegal activities in order to obtain drugs?
22. Have you ever been arrested for possession of illegal drugs?
23. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)?
25. Have you ever gone to anyone for help for a drug problem?
26. Have you ever been in a hospital for medical problems related to your drug use?
27. Have you ever been involved in a treatment program specifically related to drug use?
28. Have you been treated as an outpatient for problems related to drug abuse?

A score of 1 is given for each "yes" response, except for items 4, 5 and 7, for which a "no" yields a score of 1. If you scored 6 or higher, you may be at risk for a substance abuse problem. If you are concerned that you may have a substance abuse problem or be at risk for one, talk with your health care provider or contact a local clinic or agency. The Substance Abuse & Mental Health Services Administration can help you locate a treatment facility through its online site at www.samsha.gov or its Helpline at 1-877-SAMHSA-7.

Reducing risk

If you meet the criteria for hazardous drinking but are not actually dependent on alcohol, you can get support to help you cut down on your drinking. Your health care provider will be able to help you with suggestions on how to drink responsibly. If you are unable to cut back on your drinking, you should seek further assistance, including the support of a health care provider with experience in substance abuse and/or a self-help group such as Alcoholics Anonymous or Women for Sobriety.

Diagnosis

For women who screen positive for a substance abuse disorder, it is important to see a health care professional for further assessment. If you receive a diagnosis of alcohol or drug dependence, it is important that you seek treatment.

Since substance use disorders are chronic illnesses, treatment includes not only the initial therapy aimed at achieving abstinence from the substance, but long-term management to promote health and prevent further consequences. If you are diagnosed with substance use dependence, you are at risk for relapse throughout your life.

But substance dependence can be treated and the risk of relapse reduced using tested interventions. Researchers find that treatment issues differ between women and men. At one time, treatment programs were designed to address only the patterns and reasons behind men's substance dependency issues, since men comprised the majority of any treatment group. Women's issues, such as emotional, psychological or physical abuse, lack of self-esteem and family responsibilities, tended to slip through the cracks.

Yet depression and anxiety disorders are more common in women than men and are also risk factors for alcohol and drug abuse, including cigarette smoking. Thus, treating depression and anxiety disorders in women can be key to their recovery. Also, women are often reluctant to admit they have a problem and to seek or enter treatment, fearing they will lose their children or won't be able to take care of them.

Given these differences, single-sex programs are becoming more available. Although evidence is still inconclusive as to whether women-only treatment programs are more effective than mixed-gender programs, many women prefer them. Some programs offer child care, parenting classes and therapy for children of substance users.

Treatment

Women for Sobriety (WFS) is an alternative to the well-known Alcoholics Anonymous 12-step program. Founded in 1976, WFS is based on the belief that women require a different kind of recovery program than those used primarily by men. Thirteen positive "statements" guide the WFS program. This program differs from AA in that it doesn't include a religious focus, doesn't ask members to examine their pasts and provides women with a female-only environment in which to express their hopes and fears.

The "New Life" WFS program encourages independence, self-reliance and leaving the past behind.

Finding a support group or therapy that feels "right" can take some time. Doing whatever it takes to stay drug-free is the goal. The key to successful treatment is that it should be individualized, because each woman's issues are different. Lifestyle changes that reduce exposure to drug abusers and access to the drug are often critical. Similarly, emotional problems and disorders such as depression, anxiety and insomnia should be treated to improve the chances of recovery.

Behavioral therapy and in some cases medication are used to treat addiction. The use of medication is effective for many people, especially when used together with counseling and other behavioral therapies. In fact, combining these approaches can be critical to their success. Behavioral therapies include counseling, psychotherapy, support groups and family therapy. Medications offer help in suppressing withdrawal symptoms and drug craving and in blocking the effects of drugs. For long-term heroin use, pharmacotherapy with medications such as methadone is effective.

The following medications may be used to treat substance use disorders. They are most effective under a program of medical management directed by a health care professional. In some cases, they may also be more effective as part of an overall program that includes counseling, support group meetings and other treatment recommended by your health care professional.

• Methadone is a synthetic opioid drug, generally a pill or liquid, used mainly in the treatment of heroin addiction. Studies show that treatment for heroin addiction with methadone combined with behavioral therapy reduces death rates and many health problems associated with heroin abuse.
• Buprenorphine (Subutex, Suboxone) is the most recently approved medicine for treating heroin and related opioid disorders. It is related to morphine but does not produce the same high, dependence or withdrawal syndrome as morphine. It is long-lasting, less likely to cause respiratory depression and well-tolerated. Buprenorphine is now available in office-based settings. To find doctors trained and certified to use the medication, check with the Substance Abuse and Mental Health Services Administration (SAMHSA) at www.samhsa.gov.
• Disulfiram (Antabuse) is a prescription medication used to help people avoid alcohol and thus overcome addiction to or dependence on alcohol. If a person uses disulfiram and drinks alcohol, the medication causes severe symptoms that can last several hours, including flushing, rapid or irregular heartbeat, dizziness, nausea, vomiting, difficulty breathing and headache. When taken according to the prescribed schedule, the medication is used to discourage someone from resuming drinking once they've stopped. It has been in use since the 1940s, but its long-term effectiveness has not been established.
• Naltrexone (Revia) is used to help narcotic addicts and alcoholics. Naltrexone works by blocking the effects of narcotics, especially the "high" feeling that makes you want to use them. When used with behavioral treatments, it can reduce the craving for alcohol and drugs and help people avoid relapse. It does not, however, block the effects of these substances.
• Acamprosate (Campral) is approved to prevent people who have already stopped drinking from starting again. Campral is thought to work by regulating the brain chemicals that have been altered by long-term alcohol use. For Campral to work, people taking it must be alcohol-free before they take their first dose and must be prepared to follow a complete alcohol treatment plan including mental and behavioral counseling.
• Vivitrol, a version of naltrexone, is the first FDA-approved injectable drug to treat alcohol dependence. It is injected by a health care professional once a month. The injectable version of the drug may be preferable for some people recovering from alcohol dependence because it is easier to use consistently.

Clonidine (Catapres), a drug used to treat high blood pressure, can be used to ease opioid withdrawal symptoms but is not used to manage long-term recovery.

In general, the more treatment pursued, the better the results. If you are working to overcome an addiction, you may require other services as well, such as medical and mental health services and HIV prevention services.

The ultimate goal of all treatment is to enable you to return to a productive life. When you begin treatment for a substance use disorder, you receive assistance in meeting your immediate goals, such as reducing your alcohol or drug use and improving your ability to function while minimizing the medical and social complications of your drug abuse.

There are several types of treatment settings:

• Inpatient treatment is recommended for people with other medical conditions or those in danger of withdrawal. These usually involve a three- to six-week inpatient treatment phase following detoxification.
• Intensive outpatient treatment, which usually involves daily treatment in a controlled setting.
• Outpatient treatment for shorter periods on a weekly basis.
• Therapeutic communities, or TCs (also called inpatient long-term drug rehabs). These are highly structured programs in which you stay at a residence for six to 12 months or longer. Those in TCs include those with relatively long histories of drug dependence, involvement in serious criminal activities or seriously impaired social functioning. The focus of the TC is to help you transition to a drug-free, crime-free lifestyle.

Even after the formal treatment ends, the risk of relapse is high. But a trained health care professional can help you develop strategies to prevent relapse. Thus, if you're trying to recover from substance abuse you should be prepared for a lifelong commitment to avoiding the pressures that lead to drug use. Many women have successfully completed treatment and now lead productive lives.

Prevention

Since research finds a strong family component to addiction, women with a family history of addiction should be aware of their increased risk for dependency, especially during stressful periods. There are three primary risk factors for substance use disorders:

• Genetics: This risk factor is still being studied and further research is required. But we know that if a woman has a grandparent, parent or sibling with an addiction, she is significantly more likely to develop an addiction than a woman with no such family history.
• Age of first use and duration of use: About 40 percent of women who began drinking as teenagers, specifically before the age of 15, and continue to drink will be diagnosed as alcohol dependent at some point in their lives. Women who began drinking at age 21 or older have a much lower chance of developing alcohol dependence.
• Victimization: Women who have been sexually abused in childhood are more likely than other women to have alcohol-related problems. And women who seek alcoholism treatment are significantly more likely to report childhood sexual abuse and father-to-daughter verbal aggression or physical violence. One study found that women who were neglected as children but not abused were at greater risk of having alcohol-related problems regardless of any other life experience, including poverty, parental alcohol abuse, race or age.

Responsible use of alcohol—up to one drink per day, or the equivalent of one 12-ounce bottle of beer or wine cooler; 8 to 9 ounces of malt liquor; one 5-ounce glass of wine; or 1.5 ounces of 80-proof distilled spirits (NIAAA guide)—is not harmful for most women as long as they are not pregnant or trying to become pregnant. (Keep in mind that the alcohol content of different types of beer, wine and distilled spirits can vary quite substantially.) If you feel the need to increase your use of alcohol, you may be at risk for alcohol-related adverse health consequences including the possibility of developing an alcohol use disorder. Talk to your health care professional about your use of alcohol and how to drink responsibly.

The best way to prevent risky or harmful substance use is to recognize the potential for it. Alcohol and marijuana use are particularly insidious substances due to their perceived harmlessness. Also, the effects of each may be worse when used together. Although alcohol is socially acceptable when used by women above the recommended limits, it increases the risk of alcohol use disorder and serious alcohol-related health consequences, such as breast cancer. If you plan to drink, it's important you make a conscious effort to drink responsibly.

Marijuana is the most widely used illegal drug. Although it is commonly believed to be a safe, nonaddictive recreational drug, it carries many health risks, including occupational injury and automobile accidents.

The growing increase of methamphetamine use by women is a major health issue affecting rural and middle-class women. Methamphetamine use can result in permanent adverse health consequences.

Another issue for women is the abuse of prescription drugs that are potentially addictive. The following steps can help you and your health care professional prevent an addiction to a prescription drug:

• Ask your health care professional to prescribe only quantities appropriate for your condition.
• Talk about why the medication is being prescribed, how to use it correctly and what side effects you may experience.
• Talk about addiction and how tolerance to a drug is developed.
• Follow up with your health care professional when the medication is finished.

Unfortunately, many health care professionals have little or no training in substance abuse or addiction. If in doubt, call the American Society of Addiction Medicine at 301-656-3920 or www.asam.org to find a doctor certified in addiction medicine in your area or contact the International Nurses Society on Addiction at (877) 6-INTNSA (646-8672) or www.intnsa.org to find a registered nurse certified in addiction. The National Institute on Drug Abuse (www.drugabuse.gov) and the National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov), both part of the National Institutes of Health (NIH), can also provide literature and other forms of guidance.

Facts to Know

1. In 2008, nearly 13.4 million women (or 11.5 percent of adult women) ages 18 and older reported using an illicit drug within the past year, according to the U.S. Department of Health and Human Services.
2. The NIDA also reports that almost half of all women ages 15 to 44 have used illegal drugs at least once in their lifetime. Of these women, nearly 2 million have used cocaine and more than 6 million have used marijuana within the past year. Most women drug abusers use more than one drug.
3. Women use methamphetamine at about the same rate as men, and almost half of methamphetamine users are women, unlike with other illicit drugs, such as heroin and cocaine. Additionally, methamphetamine use is seen among women in rural areas and among middle-class women, unlike cocaine and heroin users, who are more often from poor urban populations.
4. The NIAAA recommended limit for alcohol consumption for women of all ages is no more than three standard drinks in one day AND no more than 7 standard drinks in a week. Pregnant women or women who may become pregnant should not consume any alcohol. A standard drink is equivalent to one 12-ounce bottle of beer or wine cooler; 8 to 9 ounces of malt liquor; one 5-ounce glass of table wine; or 1.5 ounces of 80-proof distilled spirits. Keep in mind that the alcohol content of different types of beer, wine and distilled spirits can vary quite substantially.
5. Women who use alcohol and drugs develop substance abuse related health problems faster than men.
6. Women are more likely than men to use a combination of alcohol and prescription drugs.
7. Women often begin to abuse alcohol and drugs following depression, to relax on dates, to feel more adequate, to lose weight, to decrease stress or to help them sleep at night.
8. These conditions may increase your risks for developing a substance use disorder: a history of physical or sexual abuse; depression, panic disorder or anxiety; and a family history of substance abuse.
9. Alcohol is absorbed faster in women's bodies because women's stomachs absorb alcohol more rapidly than men. And, women who drink tend to have more concentrated levels of alcohol in their bloodstream than men. Monthly hormonal fluctuations in women may affect how alcohol is metabolized.
10. According to the NIAAA, an estimated 5.3 million women in the United States drink in a way that threatens their health, safety and general well-being. Heavy drinking is more risky for women than men.
11. According to the NIAAA, despite the fact that drinking is illegal for anyone under the age of 21, the reality is that many teenage girls drink. About 37 percent of ninth-grade girls report drinking in the past month, a rate slightly higher than that for teenage boys. And about 17 percent of these same young girls report having had five or more drinks on a single occasion during the previous month. Teenagers who drink are more likely to be sexually active and not protect themselves against sexually transmitted diseases.
12. According to the 2010 National Survey on Drug Use and Health, prepared in part by the Substance Abuse and Mental Health Services Administration, full-time college students were more likely to use alcohol in the past month, binge drink and drink heavily than young people of the same age who were part-time college students or not enrolled in college. Among full-time college students in 2010, 63.3 percent were current drinkers, 15.6 percent were heavy drinkers and 42.2 percent were binge drinkers. Among those not enrolled in college full-time, 52.4 percent were current drinkers, 11.9 percent were heavy drinkers and 35.6 percent were binge drinkers.
13. Having more laws restricting underage drinking or governing the volume of sales and consumption of alcohol is associated with less drinking among underage students.
14. Women of any age who drink are more likely to be the victims of violence, to attempt suicide or overdose than those who do not drink.
15. Substance abuse and addiction to cigarettes, alcohol and psychoactive prescription drugs (tranquilizers and other drugs that affect the mind or behavior) are a problem for a significant number of American women 60 years old and older. Older women are more susceptible to alcohol or drug addiction because tolerance levels decrease as people age.

Questions to Ask

Review the following Questions to Ask about alcohol and drug abuse and dependence so you're prepared to discuss this important health issue with your health care professional.

1. Are any of the medications I am currently taking addictive?
2. Is my use of alcohol affecting my health?
3. How can I tell if I am drinking too much or too often?
4. Given my risk factors, what can I do to avoid experiencing adverse health consequences related to the use of alcohol or other drugs?

Questions to Ask if You're Concerned about Your Alcohol or Drug Use

1. What treatment options are available in my community?
2. Should I reduce my alcohol consumption or quit completely?
3. Can you recommend any support groups for me?
4. What type of treatment should I seek for my problem?
5. How can I include my family in my treatment program?
6. How can I balance work and treatment for my addiction?

Key Q&A

1. How much alcohol consumption is considered acceptable?
   According to the NIAAA, for men up to the age of 65, these limits are no more that four drinks in one day AND no more than 14 drinks in a week. For nonpregnant women up to the age of 65, and for both healthy men and women over the age of 65, the recommended limits are no more than three drinks in one day AND no more than seven drinks in a week. Pregnant women or women who may become pregnant should not consume any alcohol. A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). This is equivalent to one 12-ounce bottle of beer or wine cooler; 8 to 9 ounces of malt liquor; one 5-ounce glass of table wine; or 1.5 ounces of 80-proof distilled spirits. Keep in mind that the alcohol content of different types of beer, wine and distilled spirits can vary quite substantially.
2. Can I be an alcoholic even if I don't drink hard liquor?
   Alcoholism has little to do with the kind of alcohol you drink. Each type of alcoholic beverage has a different amount of alcohol. For example a 12-ounce can of beer is roughly equal to 1.5 ounces of hard liquor. If you are currently drinking more than the recommended limits (no more than one standard drink per day and seven per week), you may need to cut back. If you find it difficult to cut back, you may want to seek help from a health care professional.
3. I only get drunk during holidays or stressful times in my life, so that means I don't have a problem with alcohol, right?
   Drinking more than four alcoholic drinks for women or five for men in one sitting, usually in about two hours, is usually termed heavy episodic drinking or binge drinking. This type of consumption pattern is consistent with hazardous or risky alcohol use and may place you at increased risk for developing an alcohol use disorder. It also puts you at risk for other health issues such as injury, motor vehicle crashes and sexually transmitted diseases. If you find it difficult to reduce your drinking to three or fewer drinks at a time AND less than seven drinks in a week, you may want to seek help from a health care professional.
4. What is alcohol abuse?
   Alcohol abuse is a clinical diagnosis that differs from alcoholism (alcohol dependence) in that it does not generally include an extremely strong craving for alcohol, loss of control or physical dependence. In addition, alcohol abuse is less likely than alcoholism to include tolerance (the need for increasing amounts of alcohol to get "high"). Alcohol abuse is defined as a pattern of drinking that is accompanied by one or more of the following situations within a 12-month period:
   • Failure to fulfill major work or home responsibilities
   • Drinking in situations that are physically dangerous, such as while driving a car or operating machinery
   • Recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol
   • Continued drinking despite having ongoing relationship problems that are caused or worsened by the affects of alcohol
5. When I am feeling stressed or nervous, I have a few drinks. Is there any harm in that?
   Yes. Women often begin to abuse alcohol and drugs following depression, to relax on dates, to feel more adequate, to lose weight, to decrease stress or to help them sleep at night. Any time the number of drinks consumed exceeds the recommended limit, it becomes a problem, and it is important to get help with the issue that is creating the pressure to drink as well as guidance to help avoid such drinking.
6. My 17 year-old daughter has begun drinking socially. Should I be concerned?
   Yes. Underage drinking is illegal. Your daughter could be arrested, and you could be held legally responsible for her actions under the influence of alcohol. Also, drinking puts your daughter at risk for being sexually active and less likely to protect herself from sexually transmitted diseases. She is also at increased risk for becoming a victim of violence, motor vehicle crashes, attempted suicide, overdosing and date rape.
7. Should I worry that my elderly mother has begun drinking more than one drink a day?
   Yes. More than one drink a day puts her above the recommended limit of no more than seven drinks in a week for women. Your mother may have a problem, and her health care provider should be consulted if her alcohol consumption is exceeding the recommended limits of no more than three standard drinks in one day AND no more than seven standard drinks per week. Tolerance levels decrease as people age, and some studies indicate that older women get addicted faster using smaller amounts than any other group. As noted by NIAAA, individual responses to alcohol vary, and drinking at lower levels may be problematic for those who are older or have coexisting medical conditions or take medications that should not be used in conjunction with alcohol.
8. I started taking painkillers after back surgery six months ago. I have been increasing my dosage in order to manage the pain, and I am afraid of letting my prescription run out. Could I be addicted?
   You may have developed a physical dependence on and tolerance to your medication. You should talk to your health care professional immediately about your concerns. He or she can help determine if this treatment is best for you, or if an alternative treatment should be tried. You can also contact the American Pain Society or American Society for Addiction Medicine if you have questions about your treatment, how to manage your pain and whether you are addicted.
9. Is it OK for me to have just a few drinks while I am pregnant?
   No. There is no known safe level of alcohol use during pregnancy. If you feel you cannot resist drinking while you are pregnant, seek the help of a health care professional.

Organizations and Support

For information and support on Substance Abuse, please see the recommended organizations, books and Spanish-language resources listed below.

AddictionResource
Website: https://addictionresource.com/

Al-Anon Family Groups
Website: https://al-anon.org/
Address: 1600 Corporate Landing Parkway
Virginia Beach, VA 23454
Hotline: 1-888-425-2666
Phone: 757-563-1600
Email: wso@al-anon.org

Alcoholics Anonymous
Website: https://www.aa.org/
Address: A.A. World Services, Inc.
475 Riverside Drive at West 120th St. - 11th Floor
New York, NY 10115
Phone: 212-870-3400

American Association for Marriage and Family Therapy
Website: https://www.aamft.org
Address: 112 South Alfred Street
Alexandria, VA 22314
Phone: 703-838-9808
Email: https://networks.aamft.org/contactus

American Psychological Association
Website: https://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1-800-374-2721
Phone: 202-336-5500

Campaign for Tobacco-Free Kids
Website: https://www.tobaccofreekids.org
Address: 1400 I Street, Suite 1200
Washington, DC 20005
Phone: 202-296-5469
Email: info@tobaccofreekids.org

Drug Free America Foundation, Inc.
Website: https://www.dfaf.org
Address: 5999 Central Avenue, Suite 301
St. Petersburg, FL 33710
Phone: 727-828-0211
Email: https://www.dfaf.org/contact-us/

Moderation Management
Website: https://www.moderation.org
Address: 2885 Sanford Ave SW #36026
Grandville, MI 49418
Email: mm@moderation.org

National Association for Children of Alcoholics
Website: https://www.nacoa.org
Address: 10920 Connecticut Avenue, Suite 100
Kensington, MD 20895
Hotline: 1-888-55-4COAS (1-888-554-2627)
Phone: 301-468-0985
Email: nacoa@nacoa.org

National Institute of Alcohol Abuse and Alcoholism
Website: https://www.niaaa.nih.gov
Address: 5635 Fishers Lane, MSC 9304
Bethesda, MD 20892
Phone: 301-443-3860
Email: niaaaweb-r@exchange.nih.gov

National Institute of Drug Abuse: Drugs + HIV - Learn the Link
Website: https://www.drugabuse.gov/news-events/public-education-projects/learn-link-drugs-hiv

National Institute on Drug Abuse
Website: https://www.drugabuse.gov/
Address: 6001 Executive Boulevard, Room 5213
Bethesda, MD 20892
Phone: 301-443-1124
Email: information@nida.nih.gov

Partnership for a Drug-Free America
Website: https://www.drugfree.org
Address: 633 Third Avenue, 19th Floor
New York, NY 10011
Phone: 212-922-1560

Students Against Destructive Decisions (SADD)
Website: https://www.sadd.org
Address: 1440 G Street
Washington, D.C. 20005
Hotline: 508-481-3568
Email: https://sadd.org/contact

Women for Sobriety, Inc.
Website: https://www.womenforsobriety.org
Address: P.O. Box 618
Quakertown, PA 18951
Phone: 215-536-8026
Email: contact@womenforsobriety.org

Books

Educating Yourself About Alcohol and Drugs: A People's Primer
by Marc Alan Schuckit

How Alcoholics Anonymous Failed Me: My Personal Journey to Sobriety Through Self-Empowerment
by Marianne Gilliam

Kicking Addictive Habits Once & For All: A Relapse Prevention Guide
by Dennis C. Daley

Mother's Survival Guide to Recovery: All About Alcohol, Drugs and Babies
by Laurie L. Tanner

My Mama's Waltz: A Book for Daughters of Alcoholic Mothers
by Eleanor Agnew

Sex, Drugs, Gambling, & Chocolate: A Workbook for Overcoming Addictions
by A. Thomas Horvath

Staying Sober: Tips for Working a Twelve Step Program of Recovery
by Meredith Gould

Stop the Chaos: How to Get Control of Your Life by Beating Alcohol & Drugs
by Allen A. Tighe

The Therapy Sourcebook
by Francine M. Roberts

Spanish-language resources

Medline Plus: Drugs and Young People
Website: https://www.nlm.nih.gov/medlineplus/spanish/drugsandyoungpeople.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Medline Plus: Alcoholism
Website: https://www.nlm.nih.gov/medlineplus/spanish/alcoholism.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov