Natalie Davies has gathered some of the latest academic research papers and commentaries about women and addiction. From representations of drinking in women’s magazines to preventing overdoses among sex workers, these articles give insight into women’s distinctive experiences of substance use and substance use interventions, and what more equitable and gender-responsive services could look like. 

1. Overdoses among sex workers in Vancouver

The literature underscores an urgent need for structural reforms to laws and policing practices to reduce barriers to harm reduction and mitigate risk of overdose for women sex workers who use drugs (Elena Argento and colleagues)

A study set in British Columbia examined the risk factors associated with sex workers having a first non-fatal overdose. Dr Elena Argento and colleagues accessed a database with information about over 900 street and off-street sex workers in Vancouver, and then identified a sub-sample of 273 women who used drugs but had never overdosed. In line with the wider literature, they found that this population had a high prevalence of illicit drug use. Over half (60%) reported using opioids in the previous six months, and almost all (96%) reported recent use of stimulants. Recent benzodiazepine use was reported by 8% and recent heavy drinking was reported by 15%.

Nearly a quarter (23%) reported their first non-fatal overdose during the initial six-month follow-up, and there was an estimated 57% risk that a woman in this population would experience her first non-fatal overdose over a nine-year period.

Half of the participants (46%) reported experiencing barriers to harm reduction strategies due to ‘police presence’ in the last six months, and this was significantly higher among those who had a first non-fatal overdose at follow-up compared to those who did not (62% vs. 41%). Problems with police presence included police confiscating drugs or drug use equipment, and women resorting to rushing their drug use.

Nearly half of the participants (40%) reported police harassment without arrest in the previous six months. Examples of police harassment included being threatened with arrest/detainment, searched, moved to another location, physically assaulted, coerced into providing sexual favours, and verbally harassed.

Original article: Increasing trends and incidence of nonfatal overdose among women sex workers who use drugs in British Columbia: the role of criminalization-related barriers to harm reduction. By Elena Argento and colleagues. Published in Drug and Alcohol Dependence (2023)

2. Factoring alcohol dependence into FASD prevention messages

If we are serious about FASD prevention, we must recognise for whom, how and when prevention activity is a barrier to help-seeking (Susan Evans)

Dr Susan Evans examined the public health message that fetal alcohol spectrum disorder (FASD) is ‘entirely preventable’, and argued that the message may be misleading, and may also be exacerbating barriers to getting help for women with alcohol dependence.

People familiar with research and prevention efforts in this area will know that a considerable number of pregnancies are unplanned, and in many cases, women will continue to drink alcohol before they know they are pregnant. This makes FASD prevention difficult but has led many to the conclusion that health professionals should ‘double down’ on the message that women should avoid drinking if they could get pregnant. The commentary by Dr Evans challenged the dominant approach by unpacking the implications of the ‘FASD is entirely preventable’ message for women who cannot simply ‘stop drinking’.

Women who are already struggling with a dependence on alcohol and then become pregnant will likely feel a great deal of shame about their drinking, especially in the context of FASD prevention efforts, and this may cause them to avoid healthcare altogether during pregnancy, or to try and conceal their alcohol use from midwives. Among this group, current FASD prevention messages may run counter to the aims of reducing the risk of FASD and helping diagnose children with FASD. The author suggested that a more advisable message for this group may be, “If you are pregnant and having trouble quitting alcohol you are not alone and there is help.”

Original article: Women with alcohol dependence and FASD prevention. By Susan Evans. Published in Drug and Alcohol Review (2023).

3. Moving towards trauma-informed substance use research

By enhancing research representation of [women who use drugs], a trauma-informed framework holds promise to improve applicability, relevance, and trust in evidence-based interventions (Kaye Robinson and Dr Sarah Ickowicz)

Trauma is a common experience among women who use drugs, and a known barrier to women accessing substance use support services. It may also lead to a diverse range of women who use drugs feeling excluded from substance use research. In an article published in the Journal of Addiction Medicine, Kaye Robinson and Dr Sarah Ickowicz explored what it would look like to apply trauma-informed practice to the ‘knowledge-production process’.

The authors summed up the merits of using a trauma-informed framework in substance use research with the four core principles of trauma-informed practice: trauma awareness; safety and trustworthiness; choice, collaboration and connection; and a focus on strengths and skill-building. Collectively, they said, these principles would promote safety and inclusion in research.

One of their recommendations was to emphasise participants’ strengths, rather than their shortcomings. This concept is already accepted in many recovery support services, but in this case, was extended to the choice of substance use outcomes in research. Embracing strengths-based outcomes would mean that researchers would opt for measures such as quantity and frequency of substance use, and use of harm reduction strategies, over abstinence-based measures such as whether people ‘pass’ or ‘fail’ urine drug screens.

Original article: Research with women who use drugs: applying a trauma-informed framework. By Kaye Robinson and colleague. Published in the Journal of Addiction Medicine (2022).

4. The risks of needle-sharing

Interventions for risk reduction should balance the protective effects of injecting in groups with strategies to reduce needle sharing (Katherine M Rich and colleagues)

Researchers in the US investigated the relationship between gender and needle-sharing, using survey data from 7,678 people who reported injecting drugs between 2010 and 2019. Sharing needles can expose people who inject drugs to injecting-related harms such as blood-borne viruses and skin and soft tissue infections, and prior work has suggested that women may be at greater risk of these kinds of adverse events due to unequal power dynamics when injecting in groups or with a sexual partner. One theory, for example, is that women are more likely to ‘go second on the needle’ when injecting with their male partners.

The data in this study revealed that one in five respondents (20%) reported using a needle that had previously been used by another person (known as ‘receptive needle-sharing’), and 19% reported giving someone a needle that they had previously used (‘distributive needle-sharing’). Two-thirds (66%) of those who received a needle from another individual reported distributing the same needle following injection, and about a third of all participants (37%) reported reusing their own needle during their last injection.

Analysing the data by gender, Katherine M Rich and colleagues found that the odds were 34% higher that women would engage in receptive needle-sharing, and 67% higher that they would engage in distributive needle-sharing. These findings support prior research that women who inject drugs are more likely to share needles, which should be used to inform harm reduction efforts. However, the authors stressed that the risks associated with social injecting need to be balanced against the protective effects of social injecting (e.g. the latter may mitigate the risk of physical violence and fatal overdoses).

Original article: The association of gender with receptive and distributive needle sharing among individuals who inject drugs. By Katherine M Rich and colleagues. Published in Harm Reduction Journal (2022).

5. Representations of alcohol in women’s magazines

An important component … was a focus on celebrity diet and appearance … in which sobriety was discussed as [a way to achieve] weight loss and maintain… a desired body shape (AM Atkinson and colleagues)

Women’s magazines are potential sources for disseminating public health messages about alcohol. However, an analysis of 20 printed magazines found that articles sent mixed messages about alcohol, and when they did discuss alcohol-related harms, tended to do so in ways that overlooked the structural causes of alcohol-related harms and reproduced regressive gender norms and expectations.

The study explored how alcohol and drinking were depicted in UK women’s magazines over a six-month period between August 2020 and January 2021. Dr AM Atkinson and colleagues found that around a quarter of alcohol-related texts referred to the effects and consequences of drinking. However, these messages were arguably overshadowed by the 36% of texts promoting alcohol, including through direct brand adverts, reviews of new alcohol products, and drink recipes.

Across the board, alcohol was discussed in gendered ways. Pro-alcohol and commercial messages, for example, highlighted pink products and low-calorie options. And health messages, including the benefits of not drinking, were underpinned by unequal expectations of women around beauty, domestic responsibilities, and public behaviour.

Original article: Magazines as contradictory spaces for alcohol messaging: a mixed method content and thematic analysis of UK women’s magazine representations of alcohol and its consumption. By AM Atkinson and colleagues. Published in Drugs: Education, Prevention and Policy (2022).

by Natalie Davies

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