“The pain pills came, you know, very quickly and I had bottles at home anyway,” she said. “And then it became energy for me. It became the way I coped with life.” Today Almada, 44, is a peer recovery specialist at Wheeler Clinic in Plainville, where she helps women get off opioids.

Americans are using opioids at record rates. Between 1999 and 2015, the number of prescriptions written for opioids in the United States nearly quadrupled, as did the number of opioid overdose deaths, according to the U.S. Centers for Disease Control and Prevention (CDC). In Connecticut, the CDC has tracked a high toll: Fatal overdoses from synthetic opioids increased 125 percent between 2014 and 2015.

In our podcast, sponsored by Wheeler Clinic,  Stephanie Almada reflects on her journey to recovery and Wheeler Clinic’s Jessica Smith discusses the difficulties women face with overcoming addiction.

Over the past two years, the deaths of 423 women in the state were related to drug use. Nationally, more women than men are initiating opioid use, according to the Substance Abuse and Mental Health Services Administration. Women are often prescribed opioids in high doses over longer periods of time, which often results in addiction progressing quickly, experts say. And women usually face a variety of barriers that keep them out of treatment.

Female Addiction Vulnerability

Jessica Smith, senior director of adult outpatient services at Wheeler Clinic, describes a perfect storm that makes women vulnerable to opioid addiction. An estimated 50 million American women suffer from some form of chronic pain, according to Smith, and women are more likely to seek treatment for those problems than men. Their experiences in the health care system are different too. Women are prescribed opioids at higher dosages for longer periods than men typically are, Smith said.

Opioids can lead to rapid addiction, according to Patricia Rehmer, senior vice president at Hartford HealthCare and president of the Behavioral Health Network.

In as little as two weeks— a common prescription duration—addiction can take hold, Rehmer said. Middle-aged white women are “pretty good doctor shoppers,” she said. So they can get new prescriptions, even in damaging combinations. For example, benzodiazepines, such as Xanax, are commonly prescribed to women to manage menopausal symptoms. Taking them with certain opioids can be fatal, Rehmer, the former commissioner of mental health and addiction services, said.

Women also are prone to something called the “telescoping effect,” Smith said. They suffer physical harm from these drugs more quickly, just as female alcoholics progress into heart damage and cirrhosis of the liver faster than men.

Patricia Rehmer

Habitual users build up a tolerance, meaning they will need a higher and higher dose of the same drug to experience pain relief. If the prescriber stops the flow of drugs to the patient, she has three choices: addiction treatment; buying the pills on the street at exorbitant rates; or heroin.

Jack Malone has been in the addiction treatment business for 22 years, serving a population with little to no resources. For most of that time, the heroin addicts he served were young men of color raised in poverty.

But the past decade has seen growth in heroin use by white suburbanites—teens and women—who started with prescription pills either snuck out of the household medicine cabinet or prescribed by a clinician, said Malone, who is executive director of the Southeastern Council on Alcoholism and Drug Dependence. When money for pills runs out, people turn to “the disgraceful thing that you never thought you’d do, and that’s stick a needle in your arm.”

Opioids are a family of drugs that bind to opioid receptors, blocking pain signals and producing a high. Along with a number of prescription pain relievers, the class of drugs includes heroin.

The rise in opioid use follows a shift in how Americans as a whole and the medical profession view pain. “It seems that we’re a society that expects not to feel any pain,” Rehmer said.

The Centers for Medicare and Medicaid Services (CMS) now tracks how hospitals manage pain, Rehmer said. CMS is the nation’s largest payer of health care services and has enormous influence over practice. Hartford Healthcare’s addiction programs offer alternative ways to cope with pain, such as yoga and meditation, she said. Insurance pays for medication but generally not for these complimentary therapies. So either the patient or the provider takes a financial hit if this safer route to pain treatment is taken.

Barriers To Care

Women seeking to quit heroin or opioid addiction have generally suffered more harm than men, according to Malone. “Women who show up for treatment have far more needs and far more problems,” he said. “If you’re living in that world, you’ve probably been abused sexually, physically, financially and psychologically.” Treatment for women must be trauma-informed.

Even a woman whose addiction is confined to pills enters treatment carrying a heavy load, according to Smith. “She’s got complex medical conditions. She’s got co-occurring psychiatric conditions with the substance use disorder. Attention needs to be paid to all of those in an environment that understands who women are,” she said. A 2011 study showed that women being treated for opioid addiction had significantly more current and past medical problems than male addicts.

Jessica Smith

Women wait longer to get treatment because of their role as caregivers, particularly as mothers. Sometimes the barriers are logistical, such as having no one to watch the children during a multi-day stay in detox. Often custody is the issue. “They believe their children may be taken away because they have a problem,” Smith said, “a problem that started simply with having a physical health condition.”

For Almada, fear of losing her children led her to treatment. When she showed up high to pick up her daughter from daycare, the state Department of Children and Families got involved. “DCF saved my life,” she said.

Almada entered a program at Wheeler exclusively for women. That mattered, she said. “I started hearing all those women with the same hurts I had, the same barriers.”

She described herself as a “high functioning addict,” who could keep up appearances while using. But toward the end of her active addiction, relationships suffered. Connecting with other women helped her get and stay clean.

Today she embraces continuing her education, taking pride in her daughters’ schoolwork and walking with other women toward a life beyond opioids. “I found my recovery community,” she said.

If you missed our forum, Working Women: The New Face of Addiction, you can view it here thanks to CT-N Connecticut Network. 

An analysis of the report shows that the state’s rate of potentially preventable deaths from accidental injuries jumped 97 percent – the sixth- highest increase nationally, after Maryland, Massachusetts, New Jersey, New York and Virginia. Nationally, preventable deaths from accidents – namely, overdoses from prescription and illicit drugs, as well as falls – rose 23 percent.

Connecticut had 1,142 unintentional injury deaths in 2014— the second highest in New England, after Massachusetts. About half (568) were accidental drug intoxication deaths, according to the Office of the Chief Medical Examiner. The number of such deaths is expected to surpass 850 in 2016, Chief Medical Examiner Dr. James Gill projected earlier this year.

Gill said he was not surprised that the CDC report showed a sharp increase.

“The 97 percent increase in potentially preventable accidental deaths is disappointing, and from our own data, the drug intoxication deaths are certainly a big part of it,” he said Monday. He said the office’s overall autopsy numbers “are not decreasing, and we are still investigating a high number of drug intoxication deaths each week. Today alone, we had five.”

The CDC report estimated preventable deaths using a formula comparing the number of expected deaths with the number of observed deaths in 2010 and 2014.

Jack Malone, executive director of the Southeastern Council on Alcoholism and Drug Dependence, said the report reflected what his organization saw from 2010 to 2014 – “a spate of overdose deaths happening with scary frequency.”

He said that, unlike the men and women in their 30s and 40s who have historically come in seeking help to quit alcohol and drugs “with their hands up,” heroin users are younger and usually are “chased into treatment” by the courts or family members.

“If they make it to 35, they’re enormously lucky,” Malone said. Those whose lives are spared by Narcan (naloxone), an opioid overdose antidote, often go right back to using drugs, he added.

“You can’t knock Narcan, but you also can’t look at it as the problem-solver,” he said. “This is a very challenging population.”

Gary Mendell, founder and CEO of Shatterproof, a non-profit organization that advocates for addiction treatment and prevention, praised Gov. Dannel Malloy and state lawmakers for tightening prescription monitoring, expanding access to Narcan, and making other changes to reduce overdose risks. But he said, “There’s no question that more can be done,” and he urged the state to adopt the CDC’s recent recommendations for opioid prescribing for patients with chronic pain.

Among the recommendations are that primary care providers treat patients with non-opioid therapy, whenever possible; start patients on the lowest effective dose of opioids; prescribe three days or fewer of opioids for treatment of acute pain; and avoid concurrent prescribing of opioids and benzodiazepines. State adoption of the guidelines “would be a big step to saving lives and reducing the (overdose) number substantially,” Mendell said.

Meanwhile, on other causes of death, the CDC report includes some good news for Connecticut.

Potentially preventable deaths from heart disease fell 51.6 percent in the state – far more than the national average decrease of 4 percent. Preventable deaths from cancer declined 87 percent – greater than the national drop of 25 percent. Avoidable deaths from stroke in Connecticut fell more than 100 percent — significantly more than the 11 percent drop nationally. Preventable deaths from chronic lower respiratory disease (CLRD) increased slightly, as they did nationally.

The CDC report includes national and state-specific death rates for people under the age of 80 for the five leading causes of death, which represented 63 percent of all deaths in 2014. The CDC estimates that 15 percent of those cancer deaths, 30 percent of heart-disease deaths, 43 percent of unintentional-injury deaths, 36 percent of CLRD deaths, and 28 percent of stroke deaths were preventable.

“Fewer Americans are dying young from preventable causes of death,” CDC Director Dr. Tom Frieden said in releasing the report. “Tragically, deaths from overdose are increasing . . . and there are still large differences between states in all preventable causes of death, indicating that many more lives can be saved through use of prevention and treatment available today.”

The report cites progress in early detection and treatment, as well as a 12-percent decline in the age-adjusted death rate from lung cancer, as key drivers in reducing preventable cancer deaths. Similarly, it credits improvements in care and reductions in risk factors such as hypertension for the decline in death rates from heart disease and stroke.

Of the increase in preventable accidental deaths, the report cites efforts in some states to reduce drug overdoses by enhancing prescription drug monitoring programs; increasing access to naloxone; and tightening opioid prescribing guidelines – as Connecticut has done.

Connecticut recently was awarded $5 million in federal money to increase access to medication-assisted treatment for opioid addiction and to strengthen prevention efforts. The treatment grant targets states based on rates of treatment admission for heroin and opioids, prioritizing those that have seen the largest recent increases.

The increases put Connecticut’s drinking rates above the national average, with survey data from some counties showing that more than one in five adults are binge drinkers — defined as consuming more than four drinks a day for women and five for men on at least one occasion in the past 30 days.

Heavy drinking and binge drinking rates were highest in Litchfield and Middlesex counties and lowest in New Haven and Hartford counties. All of the state’s counties exceeded the national rate for any alcohol consumption – 65.3 percent of adults statewide, compared to the national rate of 56 percent.

While Connecticut had higher-than-average rates in 2012, so did a number of other states in the Northwest, Midwest, and New England. Connecticut’s increases in binge and heavy drinking mirrored a national trend, but were higher than the U.S. average increases.

“I think what we’re seeing is that (problem drinking) is everywhere, not just in poor communities,” said Patricia Rehmer, senior vice president for behavioral health for Hartford HealthCare and former state commissioner of mental health and addiction services.

She said the increase in women drinkers was not a surprise.

“We’re seeing the same thing in Connecticut with opioids,” she said. “Women have increasing responsibilities at work and home — they want to do it all, and they’re under pressure. A glass of wine at night can become a bottle very quickly.”

The study – the first to track trends in alcohol use at the county level — found large variations in rates of excessive drinking among adults ages 21 and older across the country. Heavily Mormon Madison County, Idaho, had the lowest levels of binge drinking in 2012—5.9 percent — while Menominee, Wisconsin, home of the Menominee Indian Reservation, had the highest rates of binge drinking, at 36 percent.  Connecticut’s rate of binge drinking – 19.1 percent – fell in the middle.

For heavy drinking, Hancock County, Tennessee, had the fewest heavy drinkers — 2.4 percent—while Esmeralda County, Nevada, recorded the largest proportion, 22.4 percent. Connecticut’s rate was 8.6 percent, slightly higher than the national average of 8.2 percent.

The study, published in the American Journal of Public Health, was led by the Institute for Health Metrics and Evaluation at the University of Washington. Ali Mokdad, a lead author of the report, said the study shows “some very alarming trends in alcohol overconsumption, especially among women. We also can’t ignore the fact that in many U.S. counties, a quarter of the people, or more, are binge drinkers.”

Nationally, women showed a much faster escalation in binge drinking than men, with rates rising 17.5 percent between 2005 and 2012. Among men, rates of binge drinking increased 4.9 percent.

Those increases were steeper in Connecticut, where the prevalence of binge drinking among women rose nearly 21 percent, and among men, 10 percent.

By county, Litchfield saw the biggest increase in binge drinking rates among women – nearly 30 percent. Heavy drinking rates among women went up the most in Tolland County – 36.4 percent. “Heavy” drinking is defined as an average consumption of more than one drink per day for women or two drinks per day for men in the past 30 days.

Nationwide, heavy drinking increased 17.2 percent since 2005. The increase among women was 28.2 percent.

In Connecticut, 10.8 percent of women were identified as binge drinkers in 2005. That increased to more than 13 percent in 2012, slightly higher than the national average. The rate of binge drinking among men in the state remains significantly higher, at 25.4 percent.

Rehmer noted that the national focus has been on combatting binge drinking among college students and underage drinkers, rather than adults. She said there is a stigma associated with heavy drinking among women, especially those in affluent communities who have children.

Catching problem drinkers early, through screening and brief interventions — at primary care appointments and other settings – is key, she said.

“We need to do more early screening and educating around risk factors – family history, stress, genetics – to open up the conversation,” she said.

Jack Malone, director of the Southeastern Council on Alcoholism and Drug Dependence, said the Connecticut numbers were not surprising, given “the prevalence of alcohol, the advertising of alcohol, and the freedom with which we accept alcohol as part of our culture.”

Photo Courtesy of SCADD.

Jack Malone, director of SCADD.

“We show our young people that alcohol is used for celebratory occasions, or to help deal with stress. I don’t think we educate them enough that there’s a serious downside,” he said. “When you binge drink, it increases the possibility that you will cross the line into addiction.”

Malone said his agency has served an increasingly younger and more affluent clientele, with “more and more women” addicted to opioids – pain medications and heroin.

While Litchfield and Middlesex counties had the highest proportion of heavy drinkers in 2012 – 10.8 percent of adults – New Haven and Hartford counties had the lowest – less than 8 percent. Fairfield County had 9 percent.

Similarly, while the prevalence of binge drinking among adults in Litchfield and Middlesex counties topped 21 percent, the lowest binge drinking rates were in New Haven and Hartford counties – about 18 percent.

Overall drinking rates – the percentage of adults who reported at least one alcoholic drink in the last 30 days – remained relatively flat from 2005 to 2012 in Connecticut and nationally. The proportion of adult drinkers was highest in Middlesex County – 69.6 percent of the population – and lowest in Windham County – 61.2 percent.

Nationwide, overall drinking is highest in some affluent areas, led by suburban Falls Church, Va., where 78.7 percent of adults drink, and several counties in Colorado that include ski resort areas.

Binge drinking is commonly associated with a higher risk for serious bodily harm, such as injuries, alcohol poisoning and acute organ damage. Heavy drinking is considered a risk factor for longer-term conditions, such as liver cirrhosis and cardiovascular disease.