sex differences in substance abuse: 1976–1979

The International Journal of the Addictions, 18(1), 71-87, 1983

Sex Differences in Substance Abuse: 1976-1979

Paul E. Ryser, PhD

IMS America Ltd. Ambler, Pennsylvania 19002

Abstract

Drug abuse patterns are examined for 326,6 11 males and females who abused drugs and were treated at a hospital emergency room or died. The data reveal a marked percentage difference between male and female mentions of heroin, PCP, and diazepam. A significantly larger proportion of females than males indicated their motivation for drug abuse to be a suicide attempt or gesture. Diazepam, alcohol-in- combination, and aspirin are the most frequently mentioned drugs by those whose motivation is suicidal. However, the percentage difference between males and females for these three drugs is less than 6%. The data were collected during the years 1976-1979.

INTRODUCTION

The purpose of this paper is to examine the pattern of drug abuse by males and females as reported to the Drug Abuse Warning Network (DAWN). DAWN is a nationwide project initiated as a pilot study in 1972 and activated as an on- going reporting system in 1973. The Drug Enforcement Administration (DEA) initiated the project with IMS America Ltd. as the original and continuing contractor for DAWN. In 1976 the National Institute on Drug Abuse (NIDA) joined with DEA to cosponsor DAWN. The goals of DAWN are:

0 To identify drugs currently being abused and/or associated with harm to the individual and society.

7 1

Copyright 0 1983 by Marcel Dekker, Inc. 0020-773X/83/1801-007 1 $3.50/0

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7 2 RY SER

To the extent feasible, to determine existing patterns of drug abuse and to monitor changing trends, including the detection of new abuse entities and new combinations. 70 vrovide current drug abuse data which are relative to assessing the relative hazards to health, both physiological and psychological, and the relative potentials for abuse of different substances. To provide data needed for the rational control and scheduling of both presently existing and new substances of potential abuse.

The DAWN system is comprised of hospital emergency room and medical cxaminer/coroner offices located in 26 major metropolitan centers, with an additional panel of hospital emergency rooms randomly selected outside the 26 major metropolitan centers. There are presently 803 facilities that report drug abuse information to DAWN. (The DAWN annual and quarterly reports describe the overall system in detail and display data for a wide range of drugs reported to DAWN. Copies of these annual reports may be obtained from the Drug Enforcement Administration or the National Institute on Drug Abuse. In addition, Peyson [1976], Retka and Tester [1979], and Swisher and Hu 119811 present information on the DAWN system.)

DAWN data are collected from reports of drug and alcohol abuse episodes in hospital emergency rooms, and from medical examiners and coroners. Of these three data sources, hospital emergency rooms contribute the largest share of data (97%). Hospital emergency rooms eligible for participation are nonfederal, short-term general hospitals that are open 24 hours a day, 7 days a week, and have at least 1,000 emergency room visits a year. Alcohol abuse episodes are presently reported to DAWN only when alcohol has been ingested with some other drug or chemical substance.

In each patient record there are 18 data elements containing facility data, patient data, and drug data. The drug substance data reported to DAWN include the substance(s) abused, the form in which the substance was acquired. route of administration, source of the substance, and methods used to identify the substance. The most important data element in the DAWN system is the substance abuse data. Drug abuse is defined as the nonmedical use of a substance for any of the following three reasons: psychic effects, dependence, or self- destruction. The substances include ethical pharmaceutical drugs used incon- sistently or contrary to intended medical purposes, plus all illicit or nonmedical substances. such as heroin, marijuana, PCP, glue, aerosols, etc. In its first 8 years of operation DAWN has accumulated approximately 7,000 different substances mentioned in incidents of drug abuse. These 7,000 substances have been used in more than 60,000 combinations.

Because many DAWN reporting facilities reported every day for a 4-year period, DAWN data provide a unique national data base to examine patterns

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SEX DIFFERENCES IN SUBSTANCE ABUSE 73

of drug abuse over time. Data discussed in this paper were collected between January 1, 1976, and December 31, 1979.

FI NDl NGS

Considerable attention in the drug abuse literature has been given to differences in the pattern and extent of drug abuse by males when compared to abuse by females. Various studies (Cooperstock, 1971; Greene and Ryser, 1978; Fejer and Smart, 1972; Mellinger et al., 1971; Mitchell et al., 1976; Parker et al., 1980; Rosenberg et al., 1974) have shown that men and women differ in their rate and pattern of drug abuse. The DAWN data presented here confirm the differential pattern of drug abuse. However, that pattern is not consistent for all drugs. Table 1 displays the rank order of the top 10 drugs reported to DAWN.

PATTERN OF ABUSE: TOP 10 DRUGS

The top 10 drugs account for slightly less than 50% of the drug mentions counted in the total DAWN system. The examination of the rank order of the top 10 drugs provides a gross picture of stability and change in the leading drugs since 1975. Table 1 shows that 15 different substances have been ranked in the top 10 at least once during the 4 years covered by these data. Six of the drugs ranked in the top 10 in 1976 are ranked in the top 10 in each successive year. Methadone, secobarbital, phenobarbital, and chlordiazepoxide are not included in the top 10 in 1979 for either sex. The rank for methadone for males and females in 1976 is fourth and tenth, respectively. However, methadone was not mentioned a sufficient number of times by patients to rank in the top 10 in 1977, 1978, and 1979 for either sex. Marijuana and PCP/PCP combinations have been listed in the top 10 drugs since 1976 and 1977, respectively. Acetaminophen is the most recent drug to rank in the top 10. Acetaminophen ranks tenth for males and sixth for females. The significant changes in drug mentions are clearly noted in Fig. 1. (More complete data displays containing percentages for the top 10 drugs may be obtained from the author.)

Table 2 reveals the drugs most frequently reported to DAWN by males and females during the 4 years covered by these data. Heroin/morphine and alcohol- in-combination are more frequently reported by males than females, whereas females are more likely than males to mention diazepam. The percent of aspirin mentions by females is consistently 11%. PCP/PCP combinations are more likely to be mentioned by males than females. The number of mentions of PCP/PCP combinations was insufficient prior to 1977 to rank PCP in the top 10 drugs.

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SEX DIFFERENCES IN SUBSTANCE ABUSE 7 5

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Fig. 1 . Top three drugs, by sex by year.

The one compelling observation of similarity is the consistency concerning the top 10 drugs. The same drugs are mentioned in sufficient numbers to be ranked in the top 10 for each sex. While there are differences within the ranks, the pattern of use is not sufficiently diverse to disturb the consistent inclusion of a drug in the top 10 for each sex during the 1976-1979 time period. The

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most marked percent decrease is that of heroin/morphine mentions by males, a decrease from 27% in 1976 to 12% in 1979. The disparity noted in 1976 between male and female abuse of heroin/morphine is reduced significantly by 1979.

DRUGS USED ALONE OR IN COMBINATION

Examination of Figs. 2 and 3 reveals several differences between the sexes. Diazepam is most likely to be used alone by females, whereas heroin/morphine is clearly most likely to be used alone by males. However, the percentage of males abusing heroin/morphine alone decreases from 53% in 1976 to 26% in 1979. That decrease is countered by the increase in the mentions of PCP/PCP combinations alone by males in 1978 and 1979. The examination of drugs used in combination reveals that both sexes consistently mention alcohol-in- combination more frequently than the multiple use of other substances. The percent of mentions by males is consistently larger than the percent of mentions by females. In addition, the percents increase for both sexes, from 42% to 48% for males and from 33% to 40% for females, during the 4-year period.

MOTIVATION FOR TAKING DRUGS

Figure 4 presents data for the total DAWN system with respect to motivation for drug abuse. Drugs are clearly most frequently mentioned as a means to self-destruction, either a suicide gesture or suicide attempt. Approximately one-fifth of the patients who enter the DAWN system do not divulge their motivation, or that datum is missing from the patient record. However, the sizable number of patients for whom motivation can be ascertained merits a cursory examination.

Figures 5 through 8 display the percentage of drug mentions by sex, 1976 and 1979, by individuals who reportedly were motivated by drug dependence. The most dramatic percent change noted in Figs. 5 through 9 is the decrease in heroin/morphine-dependent mentions. During this 4-year time period there is a decrease of 29% for males and 24% for females. The decline in male methadone mentions merits note. Methadone is listed in the top 10 drugs in 1976, but the decrease in mentions eliminates methadone for listing in the top 10 in 1979. In contrast, there is an increase in the percent mentions of alcohol in combination with drugs by both sexes.

Examination of Figs. 9 through 12 reveals a change in the leading drug of abuse for psychic effects by males. In 1976 alcohol-in-combination is the leading drug, whereas in 1979 PCP/PCP combinations are most likely to be mentioned.

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RYSER

-

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1976 1977 1978 1979

- __ - H e r o i n , Male - Oiazepam, Male P C P , Male __ .- H e r o i n , Female - -Diazepam, Female PCP, Female

Fig 2. Leading drugs used alone, by sex, 1976-1979.

Female use of PCP/PCP combinations is not as great, but these are mentioned sufficiently to be one of the leading drugs of abuse by females. It is clear that the choices of drugs reported to DAWN by those motivated by psychic effects reflect a narrow choice of drugs: PCP, marijuana, diazepam, and alcohol in combination with drugs.

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SEX DIFFERENCES IN SUBSTANCE ABUSE

40

35

79

/ /

- /

/ /

/ / - / - - - -

PERCENT -

50

t

0 I I

1976 1977 1978 1979

Alcohol-In-Combination, Male Diazepam, Male

_ - Alcohol-In-Combination, Female Diazepam, Female

Fig. 3. Leading drugs used in combination, by sex, 1976-1979.

The percents for male and female ingestion of drugs for self-destructive purposes are similar for the leading drugs mentioned (data not shown here). The leading drugs for both sexes, in order of percent of mentions, are diazepam, aspirin, and alcohol-in-combination. These three drugs account for at least 50% of a11 drug mentions by those who ingested a drug for self-destructive purposes.

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80

PERCENl

RYSER

100

90

80

70

60

50

40

30

20

10

0

1976 1977 1978

YEAR A B C

PSYCHIC SU IC l D E EFFECTS DEPENDENCE OTHER

1979

D

Fig. 4. Motivation for taking drugs, b y year (episodes).

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OTHER (10%) I ALCOHOL-IN.COMB0. (5 %1

TI 4ADONE 116%)

HEROIN

Fig. 5. Leading drugs of abuse by males: motivation dependence, 1976.

HEROIN/MORPIi IN E

(21%)

3mb0.

OTHER (10%)

Fig. 6 . Leading drugs of abuse b y males: motivation dependence, 1979.

81

(21%)

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82 RYSER

OTHER (13%) DIAZEPAM (9%)

THADONE (15%)

HEROlN/MORPHlNE (63%)

Fig. 7. Leading drugs of abuse by females: motivation dependence, 1976.

DIAZEPAM (31%)

OTHER (15%)

:OHOL-IN-COMBO. (15%)

HERO I N/MOR PH IN E (39%)

Fig. 8. Leading drugs of abuse by females: motivation dependence, 1979.

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SEC

HEROINIMORPI

8 3

.COMBO.

i INE (25%) OTHER (19%) ---

Fig. 9. Leading drugs of abuse by males: motivation psychic effects, 1976.

ALCOHOL-IN-COMBO; (21%)

Fig. 10. Leading drugs of abuse by males: motivation psychic effects, 1979.

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84 RYSER

HER,OINIMORPHINE (10%)

OTHER (3C

ASPIRIN (10%)

L A/LCOHOL-IN-C (20%)

1%)

:0m60

DIAZEPAM (30%)

Fig. 11. Leading drugs of abuse by females: motivation psychic effects, 1976.

OTI

Fig. 12. Leading drugs of abuse b y females: motivation psychic effects, 1979.

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D I SCUSSl ON

We have presented data for 326,611 individuals, 97% of whom were admitted to hospital emergency rooms during the period 1976-1979. These individuals are those selected from the total DAWN system of more than 700,000 individuals who abused drugs and required emergency medical treatment or died. The selection criteria for inclusion in this paper were based on the rank order of the top 10 drugs mentioned during treatment or discovered during an autopsy. The aggregate total number of mentions of substances abused and reported to the DAWN system reveals an ever present substance abuse problem. Substance abuse episodes that require emergency medical treatment highlight the adverse consequences of chemical dependence and the ingestion of legal drugs with alcohol.

Examination of the various tables reveals some dissimilar patterns of abuse by males as compared to females. This differential pattern is not consistent for all drugs nor for each drug within the time periods examined. The most marked percent differences are noted for heroin/morphine abused alone (1 6% difference or greater), PCP/PCP combinations abused alone (1 9% difference), diazepam abuse alone (13% or greater), and diazepam abused with motivation for psychic effects (12% or greater). Many of the male/female percent com- parisons tend to be similar even though the magnitude of the percent changes. We do not see any marked inverse percent change in drug abuse by the different sexes in the data reported in this paper.

These data do support the evidence that shows differential patterns of drug abuse by males and females. This evidence, however, is misleading if it is generalized without specification of certain conditions. For example, it is clear that the percent differences are minimal for 9 of the 15 drugs examined in this paper when we control for the effect of year of the episode, use alone or in combination, or motivation for abusing drugs. We suspect that if we had additional sociodemographic variables to use as controls, we might both augment some of the percents and diminish others. The important consideration is that the argument of wholesale differential patterns of drug abuse based on sex is not tenable.

These facts aside, the important consideration focuses upon treatment and prevention. The publicly announced heroin epidemic of the late '60s fostered a national concern as a response to the heroin epidemic. That response carried into the '70s with a nationwide network of federal, state, and locally funded drug and alcohol treatment centers. Many treatment programs are structured to recruit and treat the hard drug users. This effort is appropriate for some drug users but may not provide a milieu for treatment for those individuals whose problems are associated with polydrug use, use of tranquilizers, and alcohol

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86 RYSER

in combination with drugs; or whose use is motivated by suicide gesture or attempt. Table 2 shows that tranquilizers and alcohol-in-combination are the dominant drugs of abuse reported to DAWN. The pattern of drug use displayed in the various tables and figures points to a use pattern of licit drugs that poses a serious consequence to the health of the user and a burden on the emergency room.

Individuals who need emergency help for drug abuse are confronted with a personal health crisis that demands immediate intervention. The intervention provided by hospitals utilizes expensive and often scarce human resources to treat the episode. The DAWN data show the disposition of the drug abuse episodes treated in hospital emergency rooms to be 28% treated and referred, 27% treated and released, 36% admitted to the hospital, and 5% left against medical advice.

There needs to be developed a closer working relationship between drug/ alcohol treatment centers and hospital emergency rooms so that they act as leam members in the health field to ameliorate the adverse consequences of substance abuse. Parochialism in health care treatment and prevention is maintained at the expense of the victims of drug abuse/misuse. Education, prevention, treatment, and health care policy must be cognizant of the widespread phenomena and accommodate the reality that single-focus episodic treatment may not fit the widespread pattern of the use of legal and illegal substances. An effective drug/ alcohol treatment and prevention program, clearly identified as a direct adjunct to our health care system, may be an important step in the reduction of the extensive utilization of expensive health care resources for treatment that is important but may not independently alter the situation that motivated the episode nor prevent a repetition of the experience.

ACKNOWLEDGMENTS

The data presented in this paper were collected under contract to the Drug Enforcement Administration and the National Institute on Drug Abuse. The views expressed herein are those of the author.

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sex differences in substance abuse: 1976–1979

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