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Addiction and Pregnancy Intentions

University of Florida Institutional Repository
Permanent Link: http://ufdc.ufl.edu/UFE0021879/00001

Material Information

Title: Addiction and Pregnancy Intentions Understanding the Why behind the What
Physical Description: 1 online resource (252 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: abuse, addiction, alcohol, contraception, drugs, fertility, reproduction, treatment, violence, women
Anthropology -- Dissertations, Academic -- UF
Genre: Anthropology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Addiction and fertility are complex, multifaceted phenomena, which affect individuals, families and societies. They are biological and cultural and have huge economic and political influences and impacts. This dissertation explores addiction and fertility through a review of the literature and original qualitative and quantitative research in a population of women in residential treatment for Substance Use Disorders (SUDs). The purpose of this dissertation is to describe and explain women's experiences of addiction through life history interviews and to explore and analyze demographic, reproductive, contraceptive and substance use characteristics in this population. These results are then compared to national surveys related to substance use and reproduction. Women with SUDs have often been victims of child abuse and domestic violence. Many have co-occurring psychiatric, medical and socioeconomic problems. Substance abuse is related to a number of reproductive health risks including rape, risky sexual behavior, sexually transmitted infections and unintended pregnancies. Substance use during pregnancy can cause numerous adverse pregnancy outcomes. Drug and alcohol use are commonly associated with cases of child abuse and neglect. Total fertility rates among women with SUDs are much higher than rates in developed countries around the world. But addiction conflicts with and interferes with reproduction and parenting. Addiction and fertility are discussed and examined through the lens of several theories and frameworks including a human behavioral ecology perspective, life history theory and life history narratives. While there is a great need to reduce the number of children adversely affected by substance abuse and addiction, coerced abortions, sterilizations, termination of parental rights and incarceration are not solutions to this problem. When addiction prevention and delayed or protected sexual activity have failed, early interventions, education and treatment are required to reduce current harm and possibly break the cycle for future generations.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Burns, Allan F.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0021879:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021879/00001

Material Information

Title: Addiction and Pregnancy Intentions Understanding the Why behind the What
Physical Description: 1 online resource (252 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: abuse, addiction, alcohol, contraception, drugs, fertility, reproduction, treatment, violence, women
Anthropology -- Dissertations, Academic -- UF
Genre: Anthropology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Addiction and fertility are complex, multifaceted phenomena, which affect individuals, families and societies. They are biological and cultural and have huge economic and political influences and impacts. This dissertation explores addiction and fertility through a review of the literature and original qualitative and quantitative research in a population of women in residential treatment for Substance Use Disorders (SUDs). The purpose of this dissertation is to describe and explain women's experiences of addiction through life history interviews and to explore and analyze demographic, reproductive, contraceptive and substance use characteristics in this population. These results are then compared to national surveys related to substance use and reproduction. Women with SUDs have often been victims of child abuse and domestic violence. Many have co-occurring psychiatric, medical and socioeconomic problems. Substance abuse is related to a number of reproductive health risks including rape, risky sexual behavior, sexually transmitted infections and unintended pregnancies. Substance use during pregnancy can cause numerous adverse pregnancy outcomes. Drug and alcohol use are commonly associated with cases of child abuse and neglect. Total fertility rates among women with SUDs are much higher than rates in developed countries around the world. But addiction conflicts with and interferes with reproduction and parenting. Addiction and fertility are discussed and examined through the lens of several theories and frameworks including a human behavioral ecology perspective, life history theory and life history narratives. While there is a great need to reduce the number of children adversely affected by substance abuse and addiction, coerced abortions, sterilizations, termination of parental rights and incarceration are not solutions to this problem. When addiction prevention and delayed or protected sexual activity have failed, early interventions, education and treatment are required to reduce current harm and possibly break the cycle for future generations.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (Ph.D.)--University of Florida, 2008.
Local: Adviser: Burns, Allan F.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0021879:00001


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ADDICTION AND PREGNANCY INTENTIONS:
UNDERSTANDING THE WHY BEHIND THE WHAT




















By

KIMBERLY FROST-PINEDA


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2008

































2008 Kimberly Frost-Pineda

































To my Parents and my Children









ACKNOWLEDGMENTS

I thank my committee for all of their advice, support and feedback throughout my years as

a student in the doctoral program. I am especially grateful for mentoring received from Dr.

Mark S. Gold, Distinguished Professor and Chief of Addiction Medicine at the University of

Florida who provided employment, encouragement, recommendations and opportunities and

directly influenced my decision to work toward the PhD. I would also not have come this far

without Dr. Allan Burns, Professor of Anthropology and Chairman of my committee, who taught

me and provided guidance and suggestions through the many different research ideas and

proposals. Ultimately, the life history interviews, which Dr. Bums recommended, were the most

valuable and memorable experience of my PhD research. I acknowledge and thank Dr. Connie

Mulligan, Associate Professor of Anthropology, for reviewing and providing useful suggestions

on early drafts and Dr. John Krigbaum, Assistant Professor of Anthropology, and Dr. Mark

Lewis, Professor of Psychiatry and Neuroscience, at the University if Florida for their kind

support and positive encouragement.

I thank my parents, Thomas Frost, Patricia Frost and Rose Marie Faunt, for the influences

they had on who I am today. I appreciate the encouragement I have received from friends,

colleagues, and other family members, including Grandma Adams who helped support my

undergraduate studies. I am especially grateful to my four children, Daniel, Joshua, Isaiah and

Racheal, who through these past few years sacrificed their time and forwent activities with me so

that I could get his done. I appreciate my new husband, Christopher, who came into my life as

my sister Deanna Frost passed into the next, on May 6th 2007. I thank him for his help with my

children and for his patience.

I am grateful to Dr. Candice Hodgkins and her colleagues who opened doors for this

research. I acknowledge the National Institutes of Health (Loan Repayment Program) for their









support during this research. I am also grateful to all of my new colleagues in Clinical

Evaluation at Philip Morris USA, especially Dr. Paul Mendes, Dr. Hans Roethig, Dr. Mohamadi

Sarkar and Dr. Sunil Kapur, for giving me time and encouragement to finish this dissertation and

I thank Dr. Qiwei Liang and Mr. Lonnie Rimmer for their advice on statistical analysis and

reporting. Lastly, I would like to acknowledge my deep appreciation to the women who

participated in this research and who shared their lives with me.









TABLE OF CONTENTS

page

A CK N O W LED G M EN T S ................................................................. ........... ............. .....

L IST O F T A B L E S .................................. ........................ ................................. 11

LIST OF FIGURES ................................. .. .... ..... ................. 14

ABSTRAC T ............................... ..................... 19

CHAPTER

1 INTRODUCTION AND REVIEW OF THE LITERATURE .............. ............... 21

In tro du ctio n ................... ...................2...................1..........
P purpose of the R research ........................................................................................... 2 1
R review of the Literature ............................... ..... .. ...... ................. ....... ........ ... 24
How Does Anthropology Contribute to Our Understanding of Addiction,
Reproduction and V violence? ......................................................... ............... 24
W hat is A addiction? ........................................................ .. .... ......... .... ..... ...... 27
D rug and drug addiction history......................................... .......................... 28
M odem disease .......................................... ...................................... 29
Defining substance use disorders: Substance abuse and dependence................... 30
W hat are the Theories of Addiction?................ ...... ... ................ ..... .................31
Initiation, continuation, transition from use to abuse and dependence,
cessation, relapse ....................................................... ............. 31
Selected addiction theories and examples....... ........ ........................................ 32
Biological, cultural, environmental, and psychological................. ........... .....33
How do W omen Experience Addictions? ............................... ... ....................... 36
Epidemiology of substance use among women ................................................. 37
Substance use during pregnancy ......................... ..................... ............... .... 38
What is the Role of Violence in Addicted Women's Lives? ........... ........................40
C hild abuse and neglect........... .................................... .............. .. .... ...... 40
D om estic violence .................. .......................................... .......... .. 41
Substance abuse and violence .................... .. ............................................... 41
What Special Issues Surround Addiction and Pregnancy?.............................. .....41
U intended pregnancy .......................................... .................... ............... 4 1
Effects on the fetus ................. ............... ...................... ........... 42
Child w welfare and legal im plications.................................................. .................43
What Pregnancy Planning/Contraceptive Strategies do Women with SUDs use?..........44
How do Fertility Theories and Other Factors Explain Fertility Rates?...........................48
F fertility th eories .................. ....................................... ................ ........... ...... 4 8
Other factors affecting fertility.................................................................. ......... 49
Can Human Behavioral Ecology and Life History Theory Partially Explain
Reproductive and Addictive Behavior? ............................................ ............... 50



6









What Are the Common Themes in Life Histories/Narratives of Addiction? ..................52
Can the Cycle be Changed? Is Survival Possible? ................................................. 52
Prevention and intervention: Pre-conception and early prenatal care...................52
Treatment for pregnant women and women with children ....................................53
Integrating fam ily planning .................. ................... .............................53
Key components of a comprehensive treatment program ........... ..............54

2 M A TER IA L S A N D M ETH O D S ........................................ .............................................59

Study D design Sum m ary ........................... ........................ .. ........... ........... 59
H um an Subjects Protection ..................................... ............. ............. ........................59
R e se arch S ettin g ................................................................................................6 1
Study Population and Size ................................................................. ............... 62
Q ualitative M materials and M ethods.............................................................. .....................63
Interview G uide D evelopm ent ............................................................. .....................63
D a ta .................. ... ... .. ... ............................ ................................ ........... 6 4
Qualitative Data Reporting and Analysis......................................... ...............65
Q uantitative M materials and M ethods............................................................ .....................65
Q questionnaire D evelopm ent ..................................... ............. ............... ..................... 65
A naly sis V ariables........... ...................................................................... ...... .. ....... .. 68
Survey D ata A analysis ........................ .................... ... .... ...... .... ....... 69

3 LIFE H ISTORY IN TERVIEW S .................................................. .............................. 74

Intro du action ................... .......................................................... ................ 74
S a ra ............................................................................7 4
M a ry ............ ....................................................................................8 6
J a c k ie .............................................................................9 6
T ra cy ................................................................................................. 10 2
P am ela............... ............................................................109
C onclusions.....................................................................120

4 SURVEY RESULTS: DESCRIPTIVE STATISTICS ................. ................. .........122

Survey Data Collection and Data Entry ................................ ........................ .....122
R e su lts ................... ...................1.............................3
A g e ...........................................................................1 2 3
Race and Ethnicity ................................................................ ............... 123
M arital Status and Living Arrangem ents ........................................ ............... 123
E m ploym ent and Incom e ......................................................................................... 124
E education ..... ............. ....... ......... ........................... ........ 124
Current Health and History of Abuse and Violence ..................................................... 124
Pregnancy, Pregnancy Outcomes, Planning and Intentions ........... .. ............. 125
Future Pregnancy Intentions ............................................................. ............... 126
Age of First Intercourse and Pregnancy Prevention ................................................. 126
Pregnancy and Offspring .......................................... ................. .......... 126
Surgical Sterilization ............................................................. ... ......... 127









Past Pregnancy Prevention Strategies ........................................ ....................... 128
Potential Barriers to using Methods to Prevent Pregnancy ................ .... ........... 131
S u b sta n c e U se .......................................................................................................... 1 3 2
T o b a c c o ...................................................................................................... 1 3 2
A lc o h o l ....................................................................................................... 1 3 2
M ariju an a ...............................................................13 3
C o c a in e ........................................................................................1 3 3
C ra c k ..............................................................................1 3 3
Pain relievers ................................................................... .... ......... 133
Other drugs of abuse ... .......... ........... .... ................ 134
H igh sugar and high fat foods ....................................................... 134
Most Prevalent Drugs of Abuse .................................................. 134
Age of First U se .................. ........................................... ......... ......... 135
Sum m ary and N ext Step s ........................................................................................ 135

5 STATISTICAL ANALYSIS AND COMPARISONS TO NATIONAL DATA ................. 142

In tro d u ctio n ................... ...................1.............................2
Frequencies........................... .................................... 143
Use of one or m ore contraceptive m ethods ...........................................................143
Contraceptive use by past substance use .......................................................143
C ontraceptiv e u se by age.................................................................................. 144
Contraceptive status by marital status ............... ........... ...............144
Comparisons by Race ................................................................. ... ........ 145
Demographic characteristics ................................................... 145
Pregnancy, childbirth and pregnancy intentions ..................................... 145
Contraceptive history ................................................ 146
Discontinuation of contraceptive method ................ .................... 146
Sub stance u se history ...........................................................147
R eg ressio n A n aly sis ................................................................................................ 14 8
O ordinary regression results............................................................................... 149
Logistic regression results .............................................................. ..............150
N national Substance A buse D ata ........................................ .... ..... ................ 155
Comparisons of Current Survey and National Survey Demographic Characteristics... 156
G e n d e r ......................................................................................................1 5 6
A g e ...............................................................1 5 6
Race/Ethnicity ......................................... .................. .... ........ 156
Socioeconom ic status ....................................................................................... 157
National Survey Drug Use Characteristics Compared to Women in Treatment for
S U D S .......... .................................................................. 1 5 7
A ge of initiation ... ........ ................................................ ...... ..... ............ ....157
Prevalence of substance use ............ ...... ...................158
National Survey of Family Growth (NSFG) Comparisons ............. ..................159
S u m m a ry .................... .. .... ......... .. .. ..................................................................... 1 6 1

6 DISCUSSION AND CONCLUSIONS .................... .....................................178



8









Introduction ............... .............. ...................................................................178
Life History Themes .................. .......................................... .......... 178
Family history of addiction ..................................... ............... 178
Availability of drugs and alcohol ................................ ................... ...... ....... 179
Dom estic violence .................. .................................... ........ ............ 179
Sexual abuse and rape ................................. ... .. ..... .............. 180
C hild abu se and neglect................. .............................. .................. 18 1
Early substance use and progression to addiction...............................182
Substance use by partners ................... ........................................ ............... 183
Loss through disease, accidents, death and estrangement.................................... 183
L o ss o f ch ild ren ............................................................................... 184
Fam ily care of children ................................................ .............................. 184
N orth-South transitions ................................................ .............................. 185
S secrets .............. ....... ..................................................... .......... 18 5
Promiscuity, prostitution and arrests ....................................... ...............186
D e n ia l ..............................................................................1 8 7
R elap se ........................... .......................................................................18 7
Illness, injuries and near-death experiences..........................................................188
Isolation ............................................................... ..... ..... ........ 189
Sharing and connecting to others ........................................ ....................... 189
S p iritu a lity ...................................................................................................1 9 0
Treatm ent and recovery .......................................................... ............... 190
Sum m ary of Life H history Them es..................................................................... ...... 192
Treatment Environment and Treatment Process ...................................................192
Life History Themes and Survey Results in Relation to Selected Addiction
Theories and Previous R research ..................................................... ...... ......... 194
Stages of change ................................................... ......... .. ...... ... 194
B io lo g ic al ...............................................................19 5
C u ltu ra l ......................................................................................................1 9 6
Environm mental ......................................... .................. .... ........ 197
P sy ch olog ical ...............................................................19 7
A addiction and Pregnancy ................. .... ........... ........................198
Life History Themes and Survey Results in Relation to Selected Fertility Theories
and Previous Research ................................. ........................... ... ......201
Fertility theories ........................................... .......... 201
Behavioral ecology/Life history theory............................................203
L ife history n arrativ es ...................................................................................... 2 07
L im itatio n s ................................................................................ 2 0 9
R ecom m endations ...............................................................2 10
C onclusions.....................................................................2 12

APPENDIX

SUPPORTIN G D OCUM EN TS ..............................................................215

IRB A application ............................................ 215
Informed Consent Form ............. ...... ............................................ 217


9









L better of Support ................. ................................................................ ........ 2 19
Family Planning and Contraception Survey ................................. .....................................220
L ife H history Interview G uide........................................................................ ..................229

L IST O F R E F E R E N C E S ............................................................................. ..........................232

B IO G R A PH IC A L SK E T C H ............................................................................. ....................252
















































10









LIST OF TABLES


Table page

1-1. T theories of A addiction ......... ............ ......................................................................... 55

1-3. Percentages of Females Aged 15 to 44 Reporting Past Month Use of Alcohol, by
Pregnancy Status and Age (1999-2000) ........................................ ........................ 56

2-1. Examples of Services Provided by SafeFree............................... ..................72

2-2 Interview T opics ..................................................................73

2-3. Family Planning and Contraceptive Methods .............................. ...............73

4-1. Past Y ear Incom e .............................................................. ............ 135

4-2. Past 30 Day Use of M ethods to Prevent Pregnancy ......................... .............. .............. 136

4-3. Percent Reporting Frequency of Condom or Other Method in Last 12 Months............... 136

4-4. Reported Use of Methods to Prevent Pregnancy in Last Three Months, Last 12 Months
and Ever in Lifetim e .......................... ...... ..................... .................... 136

4-5. Reported Future Intentions to Use Methods to Prevent Pregnancy ....................................137

4-6. Reasons for Discontinuation, Methods and Number of Women Reporting ........................138

4-7. Percentage Reporting Past Substance Use and Age of Initiation ............ .............. 138

5-1. Frequency Reporting Past Year and Recent Substance Use and Number and Percent
Reporting No Contraceptive M ethod.......................... ......... .................... 166

5-2. Percentage of Women Reporting Illicit Drug Use in Lifetime, Past Year, Past Month
and Day before Treatm ent by Race ...........................................................................166

5-3. Regression for Age in Years and Year of Education ..................................................... 166

5-4. Regression for Age in Years and Number of Years Since Surgical Sterilization .............166

5-5. Regression for Age in Years and Age of First Contraceptive Use.................................. 167

5-6. Regression for Age in Years and Years Between Oldest and Youngest Child ................... 167

5-7. Regression for Age in Years and Age of Cocaine Initiation .........................................167

5-8. Regression for Age in Years and Age of Crack Initiation ......... ................................... 167

5-9. Regression for Education in Years and Age at First Intercourse .....................................167









5-10. Regression for Education in Years and Number of Pregnancies................. .......... 168

5-11. Regression for Education in Years and Age at Last Childbirth .....................................168

5-12. Regression for Education in Years and Years Since Surgical Sterilization ......................168

5-13. Regression for Age at First Intercourse and Age at First Childbirth..............................168

5-14. Regression for Age at Contraceptive Use and Age at First Childbirth .............................168

5-15. Regression for Number of Not Planned/Not Wanted Pregnancies and Number of
A abortions ............................... ........................... .............. ................. 169

5-16. Regression for Number of Pregnancies and Number of Births................... ............... 169

5-17. Regression for Age at First Birth and Number of Births ..................... ................. 169

5-18. Regression for Age at First Birth and Years Between Youngest and Oldest Child..........169

5-19. Regression for Age at Last Birth and Number of Births ........................................169

5-20. Regression for Age at Inhalant Initiation and Age at Tobacco Initiation........................170

5-21. Regression for Age at Alcohol Initiation and Age at Tobacco Initiation..........................170

5-22. Regression for Age at Alcohol Initiation and Age at Marijuana Initiation .......................170

5-23. Regression for Age at Alcohol Initiation and Age at Stimulant Initiation........................170

5-24. Regression for Age at Marijuana Initiation and Age at Tobacco Initiation ....................170

5-25. Regression for Age at Marijuana Initiation and Age at Cocaine Initiation .......................171

5-26. Regression for Age at Crack Initiation and Age at Cocaine Initiation .............................171

5-27. Regression for Age at Cocaine Initiation and Age at Tranquilizer Initiation.................. 171

5-28. Regression for Age at Cocaine Initiation and Age at Stimulant Initiation........................171

5-29. L ogistic R egression for A ge ............................ ............... ....................................... 171

5-30. Logistic R egression for R ace......... .................... ........ ..................... ............... 172

5-31. Logistic Regression for Last Year Employment .......................................... 172

5-32. Logistic Regression for History of Abuse .............................................172

5-33. Logistic Regression for History of Domestic Violence.........................................173

5-34. Logistic Regression for Surgical Sterilization............................................. 173









5-35. Logistic Regression for Number of Pregnancies............... .......................................... 173

5-36. Logistic Regression for Total Number of Births.................................173

5-37. D rugs U sed Prior to A dm ission............................................... .............................. 173

5-38. Percentages of Females Using Illicit Drug Use in Lifetime, Past Year, and Past
Month: Women with SUDS (WSUD) and Women NSDUH, 2005 (NSDU)................74

5-39. Comparison of NSDUH and MTF Prevalence Estimates (Young Adults, 2005) and
Lifetime, Past Year, and Past Month Prevalence in Women with SUDs ......................174









LIST OF FIGURES


Figure page

1-1. Stages of Change in Addiction. Based on Prochaska and DiClemente's Model (1992).......56

1-2. Primary Substance of Abuse among Women Aged 15 to 44 Admitted to Treatment, by
Pregnancy Status: 1999 (SAMHSA Treatment Episode Data Set (TEDS))....................57

1-3. Florida Domestic Violence Offences and Relationship of Victim to Offender. (Florida
Department of Law Enforcement Uniform Crime Reports, 2007).
http://www.fdle.state.fl.us/FSAC/UCR/2006/CIF_annual06.pdf................................57

1-4. Baseline Alcohol Intake Among Women and Choices for Reducing Risk of an Alcohol
Exposed Pregnancy (Centers for Disease Control 2003)..........................................58

4-1. Percentage of Women Who Reported Chance of Feeling Less Physical Pleasure with
C on d om U se ......................................................................................... 13 9

4-2. Percentage of Women Who Reported Chance of Feeling Embarrassed to Discuss
C ondom U se w ith N ew Partner. ........................................................... .....................139

4-3. Percentage Who Reported Chance of Appreciating Use of Condom by New Partner........140

4-4. Types and Percentages of M ethods Discontinued........................................................... 140

4-5. Percentage of Women Reporting Specified Reasons for Discontinuation of Method ........141

5-1. Age of Illicit Drug Use Initiation among Women with SUDS by Race..............................175

5-2. Primary Substance of Abuse at Admission: TEDS 1995-2005. (Office of Applied
Statistics 2006) ............... ........... .......................... ............................175

5-3. Mean Age at First Use for Specific Illicit Drugs among Past Year Initiates Aged 12 to
4 9 : 2 0 0 5 ........................................................................................17 6

5-4. Age of Illicit Drug Use Initiation among W omen with SUDS ..........................................176

5-5. Most Commonly Reported Methods of Contraception Ever Used in the NSFG (1982,
1995 and 2002) and Among W omen with SUDs ....................................... ............... 177

5-6. Percentage of US Women by Contraceptive Status (Last Three Months) (NSFG 2002) ....177

5-7. Percentage of Women in Treatment for SUDs by Contraceptive Status (Last Three
M months) ............... .... ........................... ..................................177

6-1. Total Fertility Rates Overall and by Race/Hispanic Ethnicity: The United States, 2000 ...214









LIST OF ABBREVIATIONS

AA Alcoholics Anonymous

AAA American Anthropological Association

AIDS Acquired Immune Deficiency Syndrome

APA American Psychiatric Association

ASAM American Society of Addiction Medicine

0 Logistic regression coefficient

BAL Blood Alcohol Level

CASA Center on Addiction and Substance Abuse

CDC Centers for Disease Control

CI Confidence Interval

CSAP Center for Substance Abuse Prevention

DAWN Drug Abuse Warning Network

DCF Department of Children and Families

DEA Drug Enforcement Administration

DHHS Department of Health and Human Services

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

FAS Fetal alcohol syndrome

FDLE Florida Department of Law Enforcement

HIV Human Immunodeficiency Virus

HS High School

IDU Injection Drug User

IOM Institute of Medicine

IRB Institutional Review Board

IUD Intrauterine Device









LOTAD

MSA

MTF

N

NA

NAAAPI

NIDA

NSDUH

NSFG

OAS

OB/GYN

ONDCP

OPPAGA

OR

PTSD

Prob/p

R

R-squared/R2

SAMHSA

SD

SE

STD

STI

SUD

TEDS


Length of time between onset of abuse and dependence

Master Settlement Agreement

Monitoring the Future

Number

Narcotics Anonymous

National Association of African Americans for Positive Imagery

National Institute of Drug Abuse

National Survey of Drug Use and Health

National Survey of Family Growth

Office of Applied Statistics

Ob stetrics/Gynecology

Office for National Drug Control Policy

Office of Program Policy Analysis and Government Accountability

Odds Ratio

Post Traumatic Stress Disorder

p-value

Correlation Coefficient

Coefficient of determination

Substance Abuse and Mental Health Services Administration

Standard Deviation

Standard Error

Sexually Transmitted Disease

Sexually Transmitted Infection

Substance Use Disorder

Treatment Episodes Data Set









TFR Total Fertility Rate

U.S. United States

UCR Uniform Crime Reports

WSUDs Women with Substance Use Disorders

x Independent variable/explanatory or predictor variable

y Dependent or criterion/response variable


































































18









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

ADDICTION AND PREGNANCY INTENTIONS:
UNDERSTANDING THE WHY BEHIND THE WHAT

By

Kimberly Frost-Pineda

May 2008

Chair: Allan Burns
Major: Anthropology

Addiction and fertility are complex, multifaceted phenomena, which affect individuals,

families and societies. They are biological and cultural and have huge economic and political

influences and impacts. This dissertation explores addiction and fertility through a review of the

literature and original qualitative and quantitative research in a population of women in

residential treatment for Substance Use Disorders (SUDs). The purpose of this dissertation is to

describe and explain women's experiences of addiction through life history interviews and to

explore and analyze demographic, reproductive, contraceptive and substance use characteristics

in this population. Results are then compared to national substance use and reproduction surveys.

Women with SUDs have often been victims of child abuse and domestic violence. Many

have co-occurring psychiatric, medical and socioeconomic problems. Substance abuse is related

to a number of reproductive health risks including rape, risky sexual behavior, sexually

transmitted infections and unintended pregnancies. Substance use during pregnancy can cause

numerous adverse pregnancy outcomes. Drug and alcohol use are commonly associated with

cases of child abuse and neglect. Total fertility rates among women with SUDs are much higher

than rates in developed countries around the world. But addiction conflicts with and interferes

with reproduction and parenting.









Addiction and fertility are discussed and examined through the lens of several theories and

frameworks including a human behavioral ecology perspective, life history theory and life

history narratives. While there is a great need to reduce the number of children adversely

affected by substance abuse and addiction, coerced abortions, sterilizations, termination of

parental rights and incarceration are not solutions to this problem. When addiction prevention

and delayed or protected sexual activity have failed, early interventions, education and treatment

are required to reduce current harm and possibly break the cycle for future generations.









CHAPTER 1
INTRODUCTION AND REVIEW OF THE LITERATURE

Introduction

The dissertation consists of six chapters. The first chapter introduces background literature

on addiction and pregnancy intentions and describes the theoretical underpinnings of this

research. The second chapter describes the materials and methodology used. The third chapter

includes the results of the life history interviews. The fourth chapter describes the survey results.

The next chapter includes an analysis of the survey results and makes comparisons to national

data. The sixth (final) chapter synthesize the data and assesses these finding through theories

and frameworks discussed in this chapter. The final chapter also includes recommendations for

future research and programs.

Purpose of the Research

There are two hypothesis explored by this research. First, that there are barriers to

effective contraceptive use among women with substance use disorders (SUDs). The second

hypothesis is that the lived experience of women with addictions can provide insight into the

proximate and distal causes of addiction. Examining contraceptive needs and perceived barriers

in a population of substance abusing women, could help to identify areas where programs and

services are needed to reduce child and prenatal drug exposure and other forms of child

maltreatment. Exploring the life histories of women with addiction provides information that

may have a significant impact on treatment considerations and on changing the cycle and

reproduction of addiction and abuse. The research described in subsequent chapters includes a

wealth of information reported by women in treatment for SUDs. The ethnographic component

documents women's experiences of living with addiction in a life history format, in an attempt to

answer some of the "why" questions surrounding addiction and fertility. The goal of the survey









was to further describe women in treatment and identify issues related to effective contraceptive

use and family planning among women with substance use disorders. The survey attempts to

answer the "what" question regarding the prevalence and types of past, current and future family

planning practices in a population of women in treatment for SUDs. It also investigates

perceived barriers to contraceptive use, substance abuse history, demographics and history of

violence. References to national survey data are made for comparison.

There are scores of theories and models of addiction, most of which consider addiction as a

chronic, relapsing, life-long disease. Drug experimentation and abuse usually begin in childhood

and adolescence and while not everyone who uses a drug of abuse becomes addicted, the

pathway to addiction always includes substance exposure. Some individuals may be more prone

or less at risk for developing addiction due to biological traits and genetic factors. However

behavioral, emotional, learning, and environmental factors are also important. Addiction affects

the individual, the family, the work environment and it has huge societal costs. The economic

cost of drug abuse was close to $181 billion in 2002 (Office for National Drug Control Policy

2004). Like the cycle of violence, which is often linked to drug and alcohol use, there is a cycle

of addiction, such that children who are genetically predisposed and those who are exposed to

addictive behavior and stress in the home environment are at greater risk for addiction. Without

intervention, drug addiction can lead to numerous severe consequences, including poverty,

arrests, family destruction, morbidity and death.

Addiction may lead to additional consequences for females, who have the ability to bear

children and who traditionally bear the primary responsibility for caring for children and other

family members. While women are now able to regulate their fertility through the use of

contraception and family planning services, the number of unintended and unwanted pregnancies









remains high in the United States. Addiction can impair a woman's ability to consent to sexual

relationships, can make regulating fertility more difficult and may also impact her ability to

protect and care for her children. In addition to economic and medical consequences of

addiction, there are serious social consequences. Substance abuse is a common factor in cases of

child abuse and neglect. Sometimes these children are permanently removed from their homes,

parental rights are terminated, and these children may spend years waiting for a new home. The

wait is especially long for children with special needs, defined by the U.S. Department of Health

and Human Services as a child who is part of a sibling group which is to be adopted together,

above the age of eight, minority race, and those with a mental, physical or emotional disability.

Many children are never adopted and once they age out of the foster care system, many end up

homeless. Without family ties and social support, the outlook is bleak for these children.

Although there is a great need to reduce the number of children adversely affected by

addiction, coerced abortions and sterilizations are not a solution to this problem. When addiction

prevention has failed, early interventions and addiction treatment are required to reduce current

harm and possibly break the cycle for future generations. It may also prove useful to increase

family planning education and effective contraceptive use among sexually active girls and young

women before drug experimentation. In addition, there should be efforts made to overcome

barriers to effective contraceptive use among women with substance use disorders (SUDs).

The following sections set the foundation and address some of the important questions

related to the research conducted for my dissertation. Because the discipline of anthropology

draws from history, philosophy and epistemology as part of its perspective, some of these

questions are more philosophical than practical.









Important Questions

* How does anthropology contribute to our understanding of addiction, reproduction and
violence?
* What is addiction?
* What are some theories of addiction?
* How do women experience addictions?
* What is the role of violence in addicted women's lives?
* What special issues surround addiction and pregnancy?
* What are the pregnancy planning/contraceptive strategies used by women with substance
use disorders (SUDs)?
* How do fertility theories and other factors explain fertility rates?
* Can behavioral ecology and life history theory partially explain reproductive and addictive
behavior?
* What are the common themes in life histories/narratives of addiction?
* Is there existence beyond the disease? Is survival possible?

Review of the Literature

These questions are addressed in this chapter through a selected review and analysis of

relevant literature. In Chapter 6, addiction and fertility are examined through the lens of some of

the theories described here with a special emphasis on life history theory and life history

narratives.

How Does Anthropology Contribute to Our Understanding of Addiction, Reproduction
and Violence?

Simply put, anthropology is the study of humankind. Anthropologists study human

origins, biological characteristics, cultural and physical development, and social mores and

beliefs (Dictionary.com Unabridged 2007). Anthropology contributes to our understanding of

addiction, reproduction and violence in a number of ways. Archeology and forensic sciences are

used to better understand and explain these experiences. Anthropologists often analyze historical

factors related to addiction, reproduction and violence and they may study these issues from a

human behavioral ecology or provide evidence of genetic influences. They may also examine

these issues from an emic perspective (understanding from an insider's view), compare









phenomena cross-culturally or use or develop theories to explain addiction, fertility and violence.

Anthropology is about using and relating multiple methods from multiple disciplines. It is not

just about theory; it is also about surveys and life histories. Anthropology may be the discipline

that pulls all the research and researchers together to better understand and address human issues.

Anthropological methods are often used to gather data, which can be used in prevention,

intervention, treatment and policy recommendations. To review all of the anthropological

literature on addiction, reproduction and violence is beyond the scope of this chapter, however a

number of examples are provided below.

Archeologists have studied the prevalence of violence in past populations by identifying

signs of trauma in human remains, looking at the material culture and examining population

density, available resources and environmental conditions (Torres-Rouff & Costa Junqueira

2006). Forensic anthropologist may determine whether injuries were intentional or accidental

and whether self-inflicted or due to homicide (Falsetti 1999). Forensic sciences have also been

useful in determining patterns of drug use and exposure in at risk groups (Kintz et al. 2005).

Historical and political aspects of addiction have been analyzed by a number of researchers

including Aurin's (2000) manuscript on opium use in the United States and Agar and Reisinger

(2002a; 2002b) who describe aspects of the heroin epidemic of the 1960s. Genetic studies have

contributed to the understanding of protective and risk factors for alcoholism (Mulligan et al.

2003). Anthropologists have also explored environmental aspects of substance use, such as the

influence of the workplace on alcohol use (Ames 1990).

Historical analysis of production and reproduction, such as that by Lamphere on women's

changing roles in an industrial setting is also present in the anthropological literature (Lamphere

1986). Some anthropologists have examined the role of stable food sources on fertility and child









survival (Pennington 1996), while others have used an evolutionary perspective to examine

genetic and other factors in reproduction, such as rate of conception and length of gestation (Gill

1997). Ethnographic descriptions of reproduction have been published, including a recent

review of five examples by Taylor (2004). Numerous examples of cross-cultural studies on

reproduction can also be found in the anthropological literature (Zelman 1977; Sobo 1993;

Whittemore & Beverly 1996).

Anthropologists have used ethnography to describe things such as use of substances by

indigenous peoples (Hanna 1974) and drug user decision-making (Agar 1975). Other examples

of anthropological research include biocultural studies, such as that conducted by Lende (2005),

which incorporated findings from neurobiological research into ethnographic methods to better

understand the role of wanting in a sample of Columbian adolescent drug users. Researchers

have used in-depth interviews with addicted sex workers to gain insight into the relationship

between childhood sexual abuse and later risk of HIV (Dickson-G6mez et al. 2006).

Anthropologists have also analyzed drug use (crack) trends to inform theory (Agar 2003).

Studies of violence and child abuse are well represented in the literature. Two examples

cross-cultural studies of violence include Snajdr's study of domestic violence among Muslim

women (2005) and Van Vleet's examination of discourses and practices of violence in a

community in the Bolivan Andes (2002). Anthropological perspectives on violence include

analyses by Nancy Scheper-Hughes whose work has documented the impact of violence among

the poorest and most vulnerable populations (Scheper-Hughes 1987; Scheper-Hughes 1993;

Scheper-Hughes & Sargent 1998). Studies of child abuse and neglect include Jill Korbin's work,

with publications on this issue spanning more than two decades (Korbin 1981; Korbin 2004;

Korbin 2006). While working within the field of anthropology or as part of an interdisciplinary









team, anthropologists have made numerous contributions to understanding addiction, fertility and

violence. In addition to contributing to understanding these issues, anthropologists also

recognize the importance of influencing policy decisions, as evidenced by recommendations

regarding ratification of the World Health Organization Framework Convention on Tobacco

Control (Society for Medical Anthropology 2007) and a recent public policy statement on the

rights of children (Society for Medical Anthropology 2007).

What is Addiction?

Addiction, in its broadest context, can include any number of behaviors including alcohol

or drug dependence, pathological gambling, binge eating, problematic internet use and sex

addiction. While addiction is sometimes used to describe attachment to activities such as

shopping, puzzles or a particular television program, addiction generally refers to a pathological

attachment. Addictive behaviors impact the brain reward system. Initially, there is a "high" or

euphoric feeling when the drug reaches the brain, when the slots hit the jackpot, when highly

palatable food is consumed and when orgasm is reached during masturbation or other sexual

experiences. However, for someone who becomes addicted, there is a loss of control over the

behavior and they may continue to seek that initial high despite the fact that they now need to lie

and steal to obtain the drug and avoid withdrawal. The pathological gambler may spend his or

her life savings and have to declare bankruptcy, the binge eater may become obese and diabetic

and the sexual addict may get sexually transmitted diseases and destroy relationships with their

partners. Regardless of what the addiction is, there are often physical, emotional and economic

personal and social consequences.

In the following sections, addiction is primarily used to describe drug addiction, although

co-occurring addictions may also be explored in later chapters. Not all substances have the same

abuse and addiction potential. As mentioned previously, some substances affect the brain and









are thus considered to be "psychoactive." Drugs of abuse produce a brain reward and are self-

administered by animals in the laboratory and by humans. We have learned a lot about addiction

and the brain in the last few decades, but addiction is not a new concept. The next section

reviews some historical examples of drug addiction.

Drug and drug addiction history

The history of psychoactive substance use goes back thousands of years. The Drug

Enforcement Agency has documented this history in an oral transcript (Drug Enforcement

Agency 2007), which is summarized in the paragraphs below.

Many drugs of abuse come from natural sources such as the poppy flower (morphine,

opium and heroin), tobacco, cannabis and the coca plant. Early routes of administration included

chewing, eating or drinking and then smoking and inhalation. Many of these flowers and plants

had medicinal uses. Opium, for example was described in medical text from China dating back

to the 8th century. Opium was used as an anti-diarrhea agent at a time when infections diseases

could lead to a quick and early death. Refined opium and pure alcohol were combined in the 16th

century to form laudanum and its use later became widespread in the US. People began smoking

opium in the early 1700s, especially in China, but by the mid 1800s, there were opium-smoking

dens in all the major U.S. cities. Morphine, which is much more potent than opium was

discovered in the early 1800's and with the invention of the hypodermic needle in the 1860s the

drug was injected directly into the blood stream. Cocaine was discovered in the second half of

the 19th century and like morphine and later heroin it was advertised in part as a treatment for

other addictions. Addiction to opium-based drugs became a huge problem for middleclass

women in the late 19th century as these drugs were used by physicians for childbirth, cramps,

pre-menstrual syndrome and were even available over the counter.









At the start of the industrial revolution, there were patent medicines containing these drugs

that were given to children, which sometime resulted in death. Substance abuse and addiction

became such a problem that legislation was enacted, which included the Pure Food and Drug Act

of 1906, the Opium Exclusion Act and the Harrison Narcotics Act (which is the foundation of

drug law enforcement at the federal level). The Department of Justice's Drug Enforcement

Agency (DEA) was created in 1973, but its roots go back to the Bureau of Prohibition in the

1920s and the Federal Bureau of Narcotics in 1930.

With legislation, The Depression and World War II, drug use declined in the United States

so that by 1960, prevalence was very low. Use increased in the late 1960's and President Nixon

was the first President to declare a "War on Drugs". The Controlled Substances Act was enacted

and the Drug Enforcement Agency was formed in 1973. Because the United States government

was focused on heroin, distribution systems and use of cocaine increased substantially in the

1970s, including international organized crime. Cocaine and crack use led to increased violence

in many cities, especially during the cocaine/crack epidemics of the late eighties and nineties.

While there have been some reductions in the prevalence of tobacco and illicit drugs use,

substance abuse and dependence continues to be a significant problem with huge societal costs.

Modern disease

Addiction is well established as a chronic, relapsing illness with both physical and

psychological components in the medical and behavioral sciences. Addiction has also been

described as a disease of the emotions, of relating to others and of the spirit (American Society of

Addiction Medicine 2007). The great-great-grandson of Charles Darwin, William Pryor, who

was once addicted to heroin, calls addiction a "love substitute." He writes that, "At the root of

all addiction is pain, just as it is at the root of being human..." (Pryor 2004, p.1). Addiction is

much more than simply physical dependence; otherwise, detoxification would cure addiction.









Tolerance and withdrawal, markers of physical dependence, are just two of the seven diagnostic

criteria physicians use to diagnose substance dependence (defined below). For a clinical

diagnosis of substance dependence, three or more criteria must be present in a one-year period.

Defining substance use disorders: Substance abuse and dependence

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

(American Psychiatric Association, 1994), substance abuse is defined as a maladaptive pattern of

substance use, leading to clinically significant distress or impairment marked by one (or more) of

the following, in the same 12-months:

* recurrent substance use resulting in a failure to fulfill major role obligations at work,
school or home.

* recurrent substance use in situations in which it is physically hazardous

* recurrent substance-related legal problems

* continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance.

The DSM-IV definition and criteria for substance dependence (American Psychiatric

Association, 1994) are included below:

Drug dependence is defined as a maladaptive pattern of substance use, leading to clinically

significant distress or impairment marked by three (or more) of the following, in the same 12-

months:

* tolerance -a need for more of the drug to achieve intoxication or desired effect or decreased
effect with continued use of the same amount.

* withdrawal -in which the characteristic withdrawal syndrome appears in the absence of the
substance or the same or a similar substance is taken to relieve or avoid withdrawal.

* the drug is taken in larger quantities or over a longer period than was intended.

* there is a persistent desire or unsuccessful efforts to cut down or control use.

* a significant amount of time is spent in obtaining, using or recovering from use.









* important social, occupational, or recreational activities are reduced or stopped because of
use.

* continued use despite adverse consequences.

What are the Theories of Addiction?

Initiation, continuation, transition from use to abuse and dependence, cessation, relapse

There are scores of theories of addiction, many of which were described in a monograph

published by the National Institute on Drug Abuse in 1980 (U.S. Department of Health and

Human Services 1980). In Tablel-1, numerous theories of addiction are listed as well as their

relationship to self, others, society and nature (U.S. Department of Health and Human Services

1980). Examples of these theories include Coping Theory and Bad-Habit Theory (focused on

internal factors which influence addiction), Family Theory and Drug Subcultures Theory (which

focus on relationships to others), Learned Behavior and Role Theory (which describe and explain

societal influence) and Genetic Theory and Social Neurobiological Theory (which emphasize the

role of biology and nature). With the exception of the Metabolic Deficiency Perspective, all of

these theories address the first component of addictive behavior, which is initiation of substance

use. After initiation, the cycle of addiction includes continuation of substance use, the transition

from use to abuse and dependence, cessation of substance use and relapse. It is beyond the scope

of this chapter to review all theories of addiction, however, a number of theories and examples

are provided in the next section.

Once someone becomes addicted to a substance it is very difficult to discontinue use.

Prochaska and colleagues have developed a model to describe stages of change in addiction

(Prochaska & DiClemente 1982; Prochaska, DiClemente & Norcross 1992). As illustrated in

Figure 1-1, the stages are precontemplation, contemplation, preparation, action, maintenance and

relapse. Prochaska and DiClemente's model makes it easier to understand why change takes









time and relapse is so common among addicts; because it is part of the change process. Someone

may spend years as an addict in the pre-contemplation phase or may try to change dozens of

times before long-term success. Some individuals exit the model by death. Once an individual

reaches maintenance, continued abstinence is generally considered a recovery phase which leads

some to long-term recovery (and exiting from the model), while others relapse.

Selected addiction theories and examples

Some theories of addiction have focused on the neurobiology of addictive behavior, such

as Robinson and Berridge who have examined the neurological foundation of craving for drugs

in what they describe as the incentive-sensitization theory of addiction (Robinson & Berridge

1993). The "Gateway" theory is another popular theory, which suggests that early use of licit

drugs like tobacco and alcohol or "softer" drugs like marijuana may lead to exposure to and use

of "harder" drugs like cocaine and opiates (Kandel, Yamaguchi & Chen. 1992). Learning to

inhale one drug may also be a gateway to inhalation of other substances (Gold & Frost-Pineda

2006). Use of certain substances may increase the risk of developing psychiatric symptoms and

disorders, such as chronic heavy marijuana use; which increases the risk of developing psychotic

symptoms and schizophrenia (Ferdinand et al. 2005) and alcohol related depression (Gold &

Aronson 2003). Theories of co-occurring disorders/dual diagnoses have been used to describe

high rates of addiction and mental illness, which often occur together (Bachmann & Moggi

1993). Gold et al. recently proposed a theory of chronic low-level exposure to opiates in the

operating room and brain sensitization which may increase the risk for opiate addiction among

anesthesiologists (Gold et al. 2004; Gold et al. 2006). Addiction is complex, with biological,

psychological, emotional and cultural influences. Some examples from the literature under the

broad categories of biological, cultural, environmental and psychological are explored below.









Biological, cultural, environmental, and psychological

Biological. The effects of drugs on the brain appear to be related to complex interactions

with a number of neurotransmitter systems, including dopamine, serotonin and opioid systems.

All drugs of abuse have an effect on the brain reward pathway, but not all drugs are equally

addictive. The strength, amount, route of administration (how quickly it reaches the brain) and

individual metabolism all play a role, as do individual susceptibility differences. Drugs that

reach the brain more quickly, such as smoked cocaine or tobacco and injected heroin, are more

immediately rewarding than drugs that are absorbed through the skin or digestive system. Some

researchers have suggested that those who are at greater risk of addiction may have a Reward

Deficiency Syndrome and proposed that this may be due to a genetic defect in their reward

pathway neurotransmitters (including dopamine, serotonin, GABA norepinephrine, opioid and

cannabinoid) (Comings & Blum 2000). Genetic factors account for 40-60% of the risk of

alcohol dependence (Kendler et al. 1997; Schuckit 2002). In fact, there is a three to five times

greater risk of developing alcohol dependence if there are alcoholics in your genetic family and

the risk is greater with increasing number and closeness of the genetic relatives (Schuckit 2002).

Genetic factors may be responsible for the level of response to a drug, enhanced brain reward,

and how the drug is metabolized (Schuckit 1998; Hwang et al. 1999; Risinger, Doan & Vickrey

1999; Roberts et al. 2000, Thiele et al. 1998; Bowers et al. 1999; Yagi, Yasuda & Nicki 2000;

Engel & Allan 1999).

Recent studies have looked at addiction liability and the transition from abuse to

dependence. Dr. Cottler and her colleagues have examined the length of time between onset of

abuse and dependence (LOTAD) in attempts to elucidate liability to addiction among individuals

and groups and addictive liability of drugs (Ridenour et al. 2005). Use of opiates and cocaine had

the shortest LOTADs regardless of the characteristics of the group of analysis (Ridenour et al.









2005). Early substance use and females also had shorter LOTADs, but there were no differences

between African-Americans and Caucasians in the length of time between onset of abuse and

dependence (Ridenour et al. 2005).

Cultural. Peer groups and peer pressure influence substance initiation and maintenance,

especially among teens (Kandel 1978). Parents and siblings also have a strong influence on the

decisions teenagers make about whether or not to use drugs (CASA, 2002). Children of one or

more addicted parents may have impulse and behavioral problems. Conduct problems can lead

to rejection by peers at school and failing grades, which makes it more likely they will seek out

peers where risky behavior and drug use are accepted (Cadoret et al. 1995).

Substance use may be a way that individuals say something about themselves or others.

For example one recent study found gender differences in how smokers are perceived, with

female smokers being perceived as "slutty and out of control" and male smokers described as

"manly, relaxed, and in control" (Nichter et al. 2006, p. 215). Culture also plays a role in what

drugs are available (indigenous, imported, processing and supply chain, laws), where drugs are

used (crack houses, bars, homes), who uses drugs and with whom (age of user, use with other

users, peers, partners and family) and how drugs are used (i.e. route of administration, quantity,

what drugs are used together). Culture also influences the perceived effects drugs, including

medications (George et al. 2006).

Environmental. Environmental exposure to drugs of abuse comes in many forms.

Sometimes, drug use is prevalent in the home or neighborhood and exposure cannot be avoided.

On the other hand, it could be the workplace that influences alcohol (Ames 1990) or other drug

use. Media also influences substance use. Before the Master Settlement Agreement (Wilson et

al. 1999), billboards and other forms of outdoor advertising promoting tobacco use were









widespread. Alcohol advertising continues to be widespread including television, radio and

print. Even with restriction, tobacco advertising continues with ads such as that for Newport

cigarettes, which says to "FIRE IT UP", a message that could also be promoting marijuana use

(National Association of African Americans for Positive Imagery 2007)

Exposure may also happen inadvertently, such at house painters who after exposure to

alcohol in paint and had higher rates of alcohol abuse and dependence and physicians,

particularly anesthesiologists, who have higher rates of prescription misuse, abuse, and

dependence (Vaillant, Brighton & McArthur 1970; Gold, Frost-Pineda & Pomm 2005). In

addition to access to potent opiates, higher rates of addiction among anesthesiologists may be

related to occupational exposure in the operating room (Gold et al. 2004). For example, Gold

and colleagues (2004) found that opiates, such as fentanyl, could be detected in the operating

room air. Long-term exposure to opiates could sensitize the brain leading to higher rates of

addition among doctors who later use these drugs (Gold et al. 2004; Gold et al. 2006).

Psychological. Antisocial personality disorder, bipolar disorder, panic disorder and

schizophrenia all increase the risk of a substance use disorder (Schuckit 2000). One model of a

pathway to alcohol dependence suggests that some individuals drink to control internal distress

(Conrod, Pihl & Ditto 1995). Some children have more anxious and depressed feelings than

other children. When these individuals begin to drink alcohol, they may initially feel better,

leading them to drink more often in larger quantities. Drugs of abuse may be more rewarding

when taken in stressful situations and stress is considered to be a significant factor in relapse (Liu

& Weiss 2002).

Substance use disorders and Post Traumatic Stress Disorder (PTSD) occur so often

together that there may be a relationship between these disorders (Jacobsen et al. 2001). The risk









of SUDs may be four times greater in those with PTSD (Chilcoat & Breslau 1998). Usually, the

traumatic events) and symptoms of PTSD (avoidance, hypervigilance, re-experiencing the

trauma, exaggerated startle response, and trouble sleeping) precede the development of substance

abuse and dependence (Saxon et al. 2001) which may be a way to escape or self-medicate to

reduce PTSD symptoms (Khantzian 1985; Chilcoat & Breslau 1998).

How do Women Experience Addictions?

There is evidence that suggests women's experience of addiction may be different than

men's experience of addiction. There may also be special issues in recovery for women.

Women are more likely to be victims of childhood sexual abuse and are more likely than men to

be victims of domestic violence and this victimization places them at increased risk for substance

dependence (Miller 1996). Substance use also places these women at increased risk of further

victimization (Miller 1996). Women are disproportionately affected by certain psychiatric

disorders, such as binge eating, anxiety and depression, which are often co-morbid with

substance abuse and dependence (National Institute on Drug Abuse & American Psychiatric

Association 2004). And women with substance use disorders are more likely to experience

depression, eating disorders, panic disorders and post-traumatic stress disorder (Becker

&Walton-Moss 2001; Brienza & Stein 2002).

While females often begin using substances at a later age than males, the progression to

addiction and negative consequences happens much more rapidly among females (CASA 2003).

There is also evidence that drugs may have different effects during different phases of the

menstrual cycle (National Institute on Drug Abuse & American Psychiatric Association 2004).

Some gender differences may make it more difficult for women to stop using a substance, to

remain in treatment and to avoid relapse after treatment.









Epidemiology of substance use among women

In public health and preventative medicine, epidemiology is the field that studies the

incidence, prevalence and determinants of disease or health condition in populations. While

many of the determinates of addiction were explored in the previous section of addiction

theories, in the following paragraphs estimates of the incidence and prevalence of substance use,

abuse and dependence among women of child bearing age is elucidated.

The actual prevalence of substance abuse by women of child bearing potential is unknown.

Drug use is clearly recognized as dangerous and many substances of abuse are illegal so there is

a tendency to under report use. Among nonpregnant women ages 15 to 44, 49.8% used alcohol

and 20.5% were binge drinkers (Substance Abuse and Mental Health Services Administration

2002). Alcohol use patterns before pregnancy often predict drinking during pregnancy (U.S.

Department of Health and Human Services 2000). Data from the National Household Survey on

Drug Use and Health, show that self-reported illicit drug use among all 18-to-25-year-olds

climbed from 14.7 percent in 1997 to 18.8 in 1999 (Substance Abuse and Mental Health Services

Administration 2005). Prevalence of drug use is highest among young adults (18 to 30). Most

pregnant women also fall in this age group. Results of the 2003 National Household survey

estimated that approximately 4 percent of married females aged 18 to 49 were dependent on or

abusing alcohol or an illicit drug compared with 11 percent of females who were divorced or

separated and 16 percent of females who had never been married. Five and one-half percent of

females between the ages of 18 to 49 years old who reported living with one or more children

were dependent on or abusing alcohol or an illicit drug in 2003 (Substance Abuse and Mental

Health Services Administration 2005).

Another measure of substance use is Emergency room visits related to drugs. The Drug

Abuse Warning Network reported the following close to 290,000 Drug ED visits for women in









2005 (See Table 1-2). Females had a higher rate of drug-related suicide visits (55 visits per

100,000 population) than males (34 per 100,000) in 2005. (Substance Abuse and Mental Health

Services Administration 2007). The national Treatment Episode Data Set (TEDS) for 2005

included 590,759 females who were admitted to treatment substance abuse and dependence

(Substance Abuse and Mental Health Services Administration 2007).

Substance use during pregnancy

Prevalence data on past month alcohol use by age and pregnancy status is provided in the

table below. As detailed in Table 1-3, younger pregnant females are more likely to report binge

and heavy alcohol use than older pregnant women (Substance Abuse and Mental Health Services

Administration, Office of Applied Studies 2002a). Binge alcohol use (defined for women as four

or more alcoholic drinks on a single occasion) is less likely to be reported by Hispanic pregnant

women (1.4%) than by pregnant white women (4.1%) or pregnant Black women (5.6%)

(Substance Abuse and Mental Health Services Administration, Office of Applied Studies 2002a).

In their 1999 survey, the Centers for Disease Control found similar rates of alcohol use among

pregnant women (see rates above for women over 25), with 12.8% of pregnant women reporting

alcohol use and 3.3% binge drinking (Centers for Disease Control 2002). The survey also

reported that pregnant women over 30 years old, who were unmarried and employed were more

likely to report alcohol use, binge drinking, and frequent drinking (Centers for Disease Control

2002). Women over 30 years of age may be less likely to reduce or eliminate alcohol use when

pregnant due to alcohol dependency (Ebrahim et al. 1999; Grant & Douison 1998). In other

surveillance reports, women with a high school education or less, those with low incomes,

younger (<25 years) women, white women, non-Hispanic women and American Indian women

have higher rates of smoking during pregnancy, while for alcohol use during pregnancy, those









who are >35 years, with higher incomes and those with more than a high school education have

higher rates of drinking during pregnancy (Phares et al. 2004).

While a standard drink in the United States is defined as 12-ounces of beer, 8-ounces of

malt liquor, 5-ounces of wine or 1.5-ounces or a "shot" of 80-proof distilled spirits or liquor,

(U.S. Department of Health and Human Services 1995; Centers for Disease Control 2007), one

study of pregnant women found the median self-defined drink was 22-ounces of malt liquor, 8-

ounces of fortified wine and 2-ounces of spirits (Kaskutas 2000). When asked about their alcohol

use in the 12 months before they became pregnant, 88% of fortified wine drinkers, 75% of spirits

drinkers, 53% of malt liquor drinkers, 50% of wine drinkers and 48% of beer drinkers

underestimated how much alcohol they consumed (Kaskutas 2000). Past month cigarette

smoking is reported by about 20% of pregnant women.

The National Pregnancy Health Survey found that an estimated 5.5 percent of pregnant

women reported using an illegal drug while they were pregnant (U.S. Department of Health and

Human Services & National Institute on Drug Abuse 1996). This equates to about 221,000 drug-

exposed infants. Based on 1992 data, the National Institute on Drug Abuse estimated the

number of infants exposed prenatally to one or more illegal drugs at between 625,000 to 729,000

per year (about 15 to 18 percent). Rates of drug-exposed pregnancies vary by hospital, from a

few to more than 30 percent. In one recent study, 11% of the mothers admitted to illicit

substance use, but 43% of the 3000 infants tested positive for illicit substances (Lester et al.

2001). Pregnant women are less likely to report current substance abuse than non-pregnant

women, but women report pre-pregnancy levels of use after they give birth (U.S. Department of

Health and Human Services & National Institute on Drug Abuse 1996).









In 2001, young pregnant women aged 15 to 17 had rates of illicit drug use that were

similar to rates for non-pregnant females in the same age group, 15.1% and 14.1% respectively.

Rates of illicit drug use in 2001 were similar among white, Black and Hispanic pregnant women.

In 1999, pregnant women aged 15 to 44 were more likely to enter treatment for cocaine abuse

followed closely by alcohol and then opiates, while non pregnant females had the highest rates of

treatment admissions for alcohol (Substance Abuse and Mental Health Services Administration,

Office of Applied Studies 2002b) (See Figure 1-2). In 1999, about 28% of pregnant women

admitted to treatment were referred through the criminal justice system, 28% were self- referrals

and 11% were referred by a health professional (Substance Abuse and Mental Health Services

Administration, Office of Applied Studies 2002b).

What is the Role of Violence in Addicted Women's Lives?

There is a relationship between violence and substance abuse. Women with SUDs have

often witnessed family violence and have been victims of traumatic events as children and in

their adult relationships. Children who are victims of abuse are more likely to abuse substances

and have other risky behaviors during adolescence. Substance abuse, domestic violence and

poverty are often present in families in which there are reports of child abuse and neglect.

Child abuse and neglect

Women who were physically abused as children are about twice as likely to abuse alcohol

than non-abused adults. Childhood abuse is a significant risk factor for later alcohol and

substance abuse (Schuck & Widom 2001). In Florida, there were more than 235,800 reports to

its Florida Abuse Hotline of suspected child abuse/neglect cases in fiscal year 1999-2000 (Office

of Program Policy Analysis and Government Accountability 2001). The Department of Children

and Families determined investigation was required for 164,464 cases and determined that

76,494 children were victims of abuse and neglect during that year (Office of Program Policy









Analysis and Government Accountability 2001). In the United States, domestic violence co-

occurs with child abuse/neglect in at least half of the cases reported to child protective services.

Domestic violence

Many cases of domestic violence go unreported. However, data that are available indicate

that domestic violence is a widespread problem. Figure 1-3 presents statistics on domestic

violence offences reported to law enforcement in Florida during 2006 (Florida Statistical

Analysis Center 2007a; 200b). As documented by the Florida Department of Law Enforcement

(See Figure 1-3), there were 8,175 cases in which the victim was the child of the offender. The

majority of these cases were categorized as simple assaults, aggravated assaults and forcible sex

offenses. There were close to 30,000 domestic violence crimes against spouses and over 35,000

offenses reported among cohabitants in 2006 (Florida Statistical Analysis Center 2007a; 200b).

Substance abuse and violence

Anxiety, depression, panic attacks, post-traumatic stress disorder and substance

dependence are common psychological consequences of traumatic/violent events (Smith et al.

1990; Galea et al. 2002; Schuster et al. 2002). These consequences may develop in those who

experience the violence/trauma as victims and those who witness these events. In one study,

27% of females with a history of PTSD also had a lifetime history of SUDs, while those the

prevalence of lifetime SUD among those without PTSD was estimated to be about 8% (Kessler

et al. 1995).

What Special Issues Surround Addiction and Pregnancy?

Unintended pregnancy

According to the Office of Disease Prevention and Health Promotion and U.S. Department

of Health and Human Services, most women are unaware that they are pregnant until after they

are already 6 weeks pregnant (2005). Overall, about 57% of all pregnancies are unintended at









the time of conception and the proportion of unintended pregnancies is much higher among

women who abuse illegal drugs and alcohol (Institute of Medicine 1995).

Effects on the fetus

Substance abuse during pregnancy is associated with increased risk of miscarriages,

stillbirths, pre-term deliveries, low birth weight, and perinatal death. Nationally in 1997, 11.4%

(436,600) births were pre-term, 7.5% were low birth weight (291,154), 1.4% (54,973) births

were very low birth weight, and 27,968 infants died in their first year of life. Without

intervention, women who have one child with Fetal Alcohol Syndrome (FAS) due to alcohol use

during pregnancy, have a 75% risk of having another child with FAS for each pregnancy (Burd

et al. 2000). However only 1% of OB/GYN doctors report that they ask patients about alcohol

use at every prenatal care appointment (Diekman et al. 2000). Infant mortality and child

morbidity caused by substance use disproportionately affects the poor and those who receive late

or no prenatal care (Pollard 2000).

Documenting long-term effects of maternal substance abuse is a challenge because

following this population may be especially difficult (moving, arrests, lack of telephone,

controlling/abusive partners, homelessness, treatment, shelters, kids removed from home,

confidentiality issues, legal issues), as is delineating what effects are the results of prenatal

exposure, and which are related to the early childhood environment. Children of parents who

abuse drugs are more likely to have an addiction as adults (McGinnis & Foege 1999).

Additional consequences for these children may include increased risk of HIV infection and a

higher risk of abuse, neglect and abandonment (Belew & Morrison-Rodriguez 2005). More than

half all pediatric AIDS cases in the United States are related to injection drug use, either by the

mother or her sex partner. In one large study, almost 10% of adverse pregnancy outcomes









(stillbirths, neonatal deaths, premature delivery, small head circumference, small for gestational

age) were linked to maternal smoking (Kallen 2001)

The effects of drugs are exacerbated in children who are poor or have less than optimal

care giving environments (Eyler & Behnke 1999). Drug use has a negative effect on children's

health when they are exposed in the home. Children whose parents abuse alcohol and drugs are

three to four times more likely to be abused or neglected (Jaudes & Voohis 1995). An estimated

10 million children in this country have one or more addicted parents, with serious mistreatment

affecting 675,000 of these children (Belew & Morrison-Rodriguez 2005).

Children who are the result of unwanted pregnancies have poorer health outcomes

(Institute of Medicine 1995). Contraceptive choices should be available and affordable for

women who do not wish to become pregnant. If substance-abusing women are identified early,

and receive prenatal care and drug abuse treatment, they have a reduced risk of pre-term

delivery, intrauterine growth retardation, and having a low birth weight infant (Substance Abuse

and Mental Health Services Administration 1995). Outcomes for women who start drug

treatment and prenatal care after the first trimester still have better outcomes that those who do

not receive these services (Substance Abuse and Mental Health Services Administration 1995).

Child welfare and legal implications

Addiction does not make a person into a bad mother (Boyd 1999) and many mothers with

substance use disorders feel guilty about the effects of drug use on their children (Harding &

Richie). However, addiction can, and often does, impair the ability to appropriately parent a

child and may lead to child abuse and neglect. In a survey of child welfare professionals, 71.6%

of 915 professionals said substance abuse was one of the top three reasons for the rise in child

abuse and neglect reports (The National Center on Addiction and Substance Abuse 1999). It is









estimated that substance abuse is involved in 30% to 90% of confirmed child abuse cases and

75% of child abuse related deaths (Belew & Morrison-Rodriguez 2005).

Reports in the media of child abuse and neglect related to substance abuse and mental

illness are numerous. A particularly horrific example of child neglect was reported in the news

in November of 2005 (ABC News Original Report 2005) when the proposal for my research was

being developed. In this case, a mother of seven was found passed out among garbage and more

than 300 empty beer cans. Her blood alcohol level (BAL) was .40 (a BAL of .08 is considered

intoxicated in most states). Of the three youngest children that lived with her, the youngest two

(ages 6 weeks and 16 months) starved to death after not being fed for days (ABC News Original

Report 2005).

Even when services are available, pregnant women and mothers with SUDs may fear

losing their children if they seek treatment. (Ayyagari et al. 1999). Their concern is not

unreasonable considering that substance use during pregnancy has led to arrests and prosecutions

for child abuse and other charges. In 2006, 15 states and Washington, DC statutes includes

reporting requirements for suspected prenatal substance abuse and almost all of those states,

including Florida, include language on drug use during pregnancy in their definition of child

maltreatment (Child Welfare Information Gateway 2007). Many states also have other statutes

related to drug use or drug paraphernalia around children.

What Pregnancy Planning/Contraceptive Strategies do Women with SUDs use?

Women with Substance Use Disorders (SUDs) face a number of reproductive health risks

including risky sexual behavior and unintended pregnancy. There are a number of factors that

may make access and use of contraceptives difficult for women with SUDs.

Female cocaine smokers, for example, may have more frequent sex with multiple partners

either by coercion or while impaired, which may prevent adequate contraceptive use (Richard,









Bell & Montoya 2000). In a study of women who have HIV or are at risk of HIV, researchers

found that crack, cocaine, and injecting drug use were associated with inconsistent condom use

(Wilson et al. 1999). Unintended and unwanted pregnancy is an additional stress that women

with SUDs are ill equipped to handle. While a number of studies have focused on condom use,

especially in terms of protection against HIV, few studies have examined family planning and

contraceptive use among women with SUDs.

Substance use can place women at higher risk for contracting a sexually transmitted

disease because impaired judgment makes them less likely to use condoms or other forms of

contraceptive and more likely to have sex with multiple partners. (Kaiser Family Foundation,

2002) Women with SUDs appear to be less likely to use contraception, despite the risk of

pregnancy and sexually transmitted diseases. In a study of heroin-addicted women in the 1980s,

only 25.8% used contraception compared to 48.5% of women nationally (Ralph & Spigner

1986). In a more recent study, researchers used cross-sectional interviews with opiate-

dependent women enrolled in a drug treatment program to determine contraceptive use.

Morrison et al. reported that 44.2% of sexually active women at risk of becoming pregnant did

not use a contraceptive method (Morrison, Ruben & Beeching 1995). Contraceptive use is more

prevalent in France, but is still significantly different among drug users compared to the general

population. One study that compared contraceptive practices of injecting drug users (IDUs) to

national survey data in France, found that women IDUs age 25 to 34 were less likely than

women in the national sample to use contraceptives, 77% and 84% respectively (Vidal-Trecan et

al. 2003). However, condom use was much higher, reported by 64% of women IDUs and 10%

of women in the national survey. In another study of IDUs, researchers examined sexual

decision-making and contraceptive use and found that 15-27% of these women said that they did









not participate in decisions about when to have sex, use condoms or contraception (Harvey et al.

2003). Those who did report decision making were 20 times more likely than others to use

contraceptives. In this study, women were less likely to use condoms and other forms of

contraceptives if they were in longer relationships (Harvey et al. 2003).

Researchers have reported that there are ethnic differences in attitudes and behaviors

related to contraceptive use among person in substance abuse treatment (Gutierres & Barr 2003).

Gutierres and Barr report that history of abuse also impacts contraceptive use. Native American

and Mexican American women with histories of abuse and a concern about pregnancy were

more likely to use contraceptives, but European American women with similar histories and

concerns were less likely to use contraceptives (Gutierres & Barr 2003). These authors

recognize the importance of reducing unintended pregnancies among drug users and addicts

(Gutierres & Barr 2003).

Other studies have promoted increasing the use of contraceptives to decrease alcohol

exposure (Ingersoll et al. 2003). Ingersoll and colleagues reported on 143 women who used

alcohol and did not use contraceptives at the start of the study. The women received one

contraceptive counseling session and four motivational counseling sessions and were followed

for six months. Among these high-risk women, 56% were using contraceptives at the six-month

follow-up (Ingersoll et al. 2003).

Barriers to contraceptive use

Cabral and colleagues note the importance of designing prevention and intervention

programs that fit women's lives (Cabral et al. 2001). In their study, women from drug treatment

facilities, homeless shelters, and public housing developments were recruited for a prospective

study of condom use, however the authors found at baseline that about 25% of these women









wanted to have a baby and over 40% believed their partner wanted them to have a baby and this

significantly impacted consistent use of condoms during the study (Cabral et al. 2001). Harding

and Richie found that among women in treatment for opiate addiction, women who had a low

perceived risk of pregnancy were less likely to use contraceptives (2003). Among 974 homeless

women, availability and cost were reported to be the most common barriers to contraceptive use,

but alcohol use in this population was found to impact use of contraceptive services (Wenzel et

al. 2001).

In a study of over 200 homeless women who were at risk of pregnancy, Gelberg and

colleagues reported perceived deterrents to contraceptive use (Gelberg et al. 2002). They found

the most common deterrents to contraceptives were cost, side effects, partner's dislike, fear of

health risks, and not knowing how or which method to use. Sexual partners have a significant

influence on women's reproductive health including use of contraceptives, but it is often difficult

to determine the conditions of use, reasons for use, and actual behaviors relative to what partners

think about contraception, especially cross culturally. In Gelberg and colleagues' study, not

knowing which method to use, how to use it, and cost of contraceptives were the most common

deterrents among women with a history of substance abuse (Gelberg et al. 2002).

There is strong evidence to suggest that preventive programs that include family planning

are warranted in drug treatment settings. In a prospective study of 1,155 drug-using women

whose infants were removed from them at birth and placed in foster care, researchers found that

among the 926 drug-using women available at follow-up, 22% had given birth to another infant

who was also placed in foster care (Lewis et al. 1995). Another study, which included 1,576

newborns in foster care due to maternal substance abuse, documented that 60% of the infants

already had one or more siblings in foster care (Children's Defense Fund 2000). Child welfare









programs that do not address substance abuse, and substance abuse programs that do not address

family planning, may lead to an increasing number of children who have been exposed to toxic

substances, increased cases of child abuse and neglect and removal of children because of abuse

and neglect.

Pregnancy and parenting may represent barriers to treatment seeking, availability of

services, or completing treatment. As mentioned previously, women may fear losing their

children or legal prosecution if they admit to drug use or are identified by a positive drug test.

The number of women in need of treatment far exceeds to number of beds available in treatment.

Cost of treatment may be another barrier, since most addicts "hit bottom" before seeking or

being referred to treatment. Women often take the primary responsibility for children, which can

also make it difficult to receive treatment and parent simultaneously. Responsibility for children,

along with inability to obtain child care services, is one of the most significant treatment barriers

among women (van Olphen & Freudenberg 2004).

How do Fertility Theories and Other Factors Explain Fertility Rates?

Fertility and reproduction are complex phenomena. They are both biologically based and

culturally significant. Reproductive rates have varied across time and places and this

significantly impacts population size and structure. Throughout history demographers have

noted transitions where initially fertility and mortality are high, but after transition, fertility and

mortality are lower.

Fertility theories

One theory used to explain fertility rates is the Natural Fertility Theory (Henry 1961),

which focuses on physiological mechanisms which impact the ability to reproduce, such as

length of time between menarche and first pregnancy, time spent breastfeeding and length of

post-partum a menorrhea. Understanding natural fertility is important in studies that look at









ways that fertility is controlled, such as through cultural norms and practices related to sexual

intercourse and contraception (Coale & Trussell 1974).

Two predominate theories of changes in reproductive behavior and fertility rates, Demand

Theory and Diffusion of Norms Theory, focus on changes fertility due to changes in the demand

for children related to the costs and benefits of having children and changes in fertility due to the

cultural diffusion of lower or higher fertility norms (Davis 1963; Caldwell 1980; Becker 1981;

Pollack & Watkins 1993). Other theories suggest that resources available to parents (such as

childcare, time off from work) influence the choice to have children.

Other factors affecting fertility

Aspects of fertility that are controlled by biological mechanisms include the sex of

offspring and maternal age and its impact on possibility of conception (Dunson, Columbo &

Baird 2002; Markus et al. 1998) however these factors are important socially as well.

Reproduction is also full of symbols; which can vary from culture to culture. It may be about

love and other emotions and in some cultures it is tied to what it means to be female (Westfall &

Benoit 2004). It is also about connectedness, kinship and relationships within communities

(Feldman-Savelsberg 1995).

While many theorists have focused on demand for children, not all women that desire

children are able to become pregnant and/or maintain pregnancy and not all women who want to

limit the number or timing of pregnancies and child-births are able to do so (Quesnel-Vallee &

Morgan 2004; Bongaarts 1991). Choices regarding reproduction are not solely individual

decisions. Sometimes who bears children and when is influenced by politics and sometimes it is

about power relations (Basu 1997; King & Meyer 1997). In the United States, more and more

legal restrictions are being placed on abortion in the last decade. Poor women may have access

to free or low cost contraception through programs such as Medicaid or health department









clinics, but are unlikely to have access to treatment for infertility, while for middle class women,

insurance plans may cover infertility treatments but not contraception (King & Meyer 1997).

Internationally, forces outside the individual and family also control women's fertility.

Some countries limit the number of children per family, like China, with its one-child policy

(Barett & Tsui 1999). Another example of the political economy of fertility is the international

aid provided to developing counties in order to control fertility (Richey 2004) and limit

population growth. Political policies, economic forces and changing cultural norms have had a

significant impact on global fertility. In the early 1950's the median total fertility rate (TFR) was

5.4 children per woman and only one country had a total fertility rate below the replacement

level of about 2 children per woman (United Nations 1999). However estimates for 2000

indicate that the median is now close to two and 40% of people live in countries where the rate is

below two children per woman. Sixty-three percent of people lived where the TFR was above

4.8 in the early 1950's, compared to today where only 10% of people live in areas where TFR is

above 4.8 (United Nations 1999).

Can Human Behavioral Ecology and Life History Theory Partially Explain Reproductive
and Addictive Behavior?

Human behavioral ecology uses the principles of evolutionary theory to study human

behaviors and cultures. Human behavioral ecology can be used to explain behavioral variations

and adaptations to competitions between life-history demands such as reproduction and parental

care and mate acquisition (Borgerhoff Mulder 2003). For example, Hill and Reeve have used the

principles of behavioral ecology to explain the inverse relationship between wealth and fertility

(2005). A behavioral ecology perspective also provides a useful framework to analyze how

inheritance, individual variation and the functionality of certain traits may play a role in

substance use (Lende & Smith 2004). Specifically, Lende and Smith have described potentially









evolved traits such as the genetic basis of drug abuse, variations in personality and physiological

responses, and the adaptiveness of craving and withdrawal.

Life history theory is another framework used in evolutionary anthropology and other

disciplines, which proposes that many behaviors and physiological traits can be explained by

maturational and reproductive features that are key in the life course, such as age of

menstruation, age of first sexual intercourse and age first childbirth. Life history theory has been

used in the analysis of early childhood sexual abuse (Vigil, Geary & Byrd-Craven 2005), human

reproductive behavior (MacDonald 1997), fertility (Bock 2002) and risky drinking (Hill & Chow

2002). Bock suggests that using life history theory can help explain fertility related issues that

demographers have had difficulty in understanding, such as

[C]onflicts of interest between parents and children and between men and women, the
allocation of resources to competing and/or alternative forms of investment in reproduction
and parenting, resource flow within the household, demographic transitions and
particularly the fertility transition associated with economic development, and variation in
life history characteristics such as fertility and mortality across populations (Bock 2002, p.
145).

Vigil and colleagues describe social correlates of life history events and then reports on the

impact of a history of childhood sexual abuse on age of menarche, sexual activity and timing of

first childbirth (Vigil, Geary & Byrd-Craven 2005). Hill and Chow analyze the impact of

environmental instability on risk-taking behaviors (2002). MacDonald focuses on how stressful

environments, both physical and psychological, can delay reproduction (1997). MacDonald also

describes how the ability to move up in society can result in delayed reproduction, increased

investment in children and lower overall fertility (MacDonald 1997). Some of these life history

events, including contextual and environmental influences, is discussed further in the final

chapter to obtain a better understanding of the reproductive lives and addictive behaviors of

women in treatment for substance use disorders.









What Are the Common Themes in Life Histories/Narratives of Addiction?

Hurwitz and colleagues have reviewed several examples of personal accounts of drug

addiction written by women including The Agony of Ecstasy (Gordon 2004), More, Now, Again:

A Memoir (Wurtzel 2002), Go Ask Alice (Anonymous 1972), I Never Saw the Sun Rise: Diary

of a Recovering Chemically Dependent Teenager (Donlan 1977), The Party's Over" Diary of a

Recovering Cocaine Addict (Hendrick 1992), How to Stop Time: Heroin from A to Z (Marlowe

1999), Women and Cocaine: Personal Stories of Addiction and Recovery (Greenleaf 1989),

Drinking: A Love Story (Knapp 1996). Hurwitz and co-authors also review accounts of

women's addiction to food and sexual addiction (2007). These life histories are in the form of

biographies and memoirs that have been analyzed as narratives of addiction (Hurwitz, Tapping &

Vickers 2007). In the addiction story, environmental characteristics are often minimized, while

the spiritual aspects are emphasized (Hurwitz, Tapping & Vickers 2007). Accounts of addiction

often take the form of a confessional narrative of illness or as a quest for recovery and health.

Medical professional can use narratives to gain a better understanding of a patient's experience

and their illness. The lived experience of women in treatment for substance use disorders, which

are presented as a collection of life histories in Chapter 3 is discussed further in the final chapter.

In this discussion, themes of the drug experience, illness, suffering, spirituality and recovery

within the life histories are explored.

Can the Cycle be Changed? Is Survival Possible?

Prevention and intervention: Pre-conception and early prenatal care

The best ways to decrease the prevalence of substance abuse by pregnant women are to

reduce substance use by women of child bearing potential (through prevention, intervention and

treatment) and to increase contraceptive use by women who use drugs and alcohol. Improving

child health starts before conception. Women of reproductive potential should receive pre-









conception care prior to becoming pregnant. At routine office visits they could be screened for

substance abuse and could be given advice about contraception, nutrition, the importance of

early pre-natal care, and other periconceptional health issues (Morrison 2000). Methods to

reduce harm among substance abusing women have included reducing or stopping drug use,

prenatal care, lifestyle changes, and substituting other drugs or attempting to counteract the

effects of the drug (Rosenbaum & Irwin 2005).

Treatment for pregnant women and women with children

Treatment interventions have include "hospitals, clinics, emergency rooms, drug hotlines,

schools, psychiatric counseling, jail and prison, social worker counseling, mental health clinics,

drugs for drugs, AA and NA 12-step programs, rehabilitation, acupuncture, removal of children

and placement in foster care, proposed orphanages for drug exposed children, and therapeutic

communities" (Belew & Morrison-Rodriguez 2005). Nationally it is estimated that only 20% of

the women who need treatment receive it (Substance Abuse and Mental Health Services

Administration 2002). Despite the various types of intervention and treatment, one survey found

that only 11% of pregnant women receive the drug treatment services they need (Center for

Substance Abuse Prevention 2005).

Integrating family planning

There have been reports of efforts to integrate family planning programs into drug

treatment. In one of these, preliminary assessments indicated that only 38% of women in

treatment who were sexually active in the past month had used a contraceptive (Armstrong,

Kenen & Samost, 1991). In their drug treatment population of 599 women, 81% already had at

least one child and 76% reported that their last pregnancy had been unintended (Armstrong,

Kenen & Samost 1991). Misinformation about contraceptives and perceived negative health

effects (that they caused bleeding, blood clots, cancer, headache, mood swings, water retention









and weight gain) were the main barriers reported by Armstrong and colleagues (1991). Some

authors have promoted linking primary care, family planning, and addiction treatment (Wenzel et

al. 2001). Brief intervention and motivational interviewing can help reduce risk of alcohol-

exposure during pregnancy (Babor et al. 2000). The Centers for Disease Control has reported

that motivational interviewing can reduce the risk for alcohol-exposure during pregnancy by

decreasing alcohol consumption, increasing contraception use, or both (Centers for Disease

Control 2003) (Figure 1-4). In this study, risk was reduced in 69% of high-risk women. (Centers

for Disease Control 2003)

Key components of a comprehensive treatment program

The Substance Abuse and Mental Health Services Administration has described numerous

components for substance abuse treatment to meet the needs of women (Brady & Ashley 2005).

These components are summarized below

* Services to improve access such as child care or transportation services

* Services to address needs, such as prenatal and pediatric care, psychosocial education,
human immunodeficiency virus (HIV) prevention and risk reduction, and mental health
services, especially those that address post traumatic stress disorder, since many of these
women have a history of trauma and abuse.

* Programs designed for women only, a treatment environment that is more focused on
women's issues, and which may provide a more supportive, nonconfrontational approach
to treatment.

In the concluding chapter, addiction and fertility are further explored and examined

through themes that emerged from the interviews, and then through a discussion of the literature

and several theories presented in this chapter. The final chapter concludes with recommendations

for current programs and future research.









1-1. Theories of Addiction
Theory Theorist Relationship to
Achievement-Anxiety Theory Misra Society
Adaptational Theory Hendin Society
Addiction-to-Pleasure Bej erot Nature
Addictive Experiences Theory Peele Others
Availability and Proneness Theory Smart Self
Bad-Habit Theory Goodwin Self
Biological Rhythm Theory Hochhauser Nature
Cognitive Control Theory Gold Self
Combination-of-Effects Theory McAuliffe and Gordon Others
Conditioning Theory Wikler Others
Coping Theory Milkman and Frosch Self
Cyclical Process Theory van Dijk Others
Defense Structure Theory Wurmser Self
Developmental Stages Theory Kandel Others
Disruptive Environment Theory Chein Others
Drug Subcultures Theory Johnson Others
Ego/Self Theory Khantzian Self
Existential Theory Greaves Self
Family Theory Stanton Others
General Addiction Theory Lindesmith Self
Genetic Theory Schuckit Nature
Hyperactive Adolescents Theory Loney Others
Incomplete Mourning Theory Coleman Others
Interactive Framework Huba, Wingard and Bentler Others
Learned Behavior Theory Frederick Society
Life Theme Theory Spotts and Shontz Self
Metabolic Deficiency Perspective Dole and Nyswander Nature
Multiple Models Theory Gorsuch Self
Natural History Perspective Robins Society
Personality-Deficiency Theory Ausubel Self
Perceived Effects Theory Smith Self
Role Theory Winick Society
Self-Derogation Theory Kaplan Others
Self-Esteem Theory Steffenhagen Others
Social Deviance Theory Hill Others
Social Neurobiological Theory Prescott Nature
Source: U.S. Department Of Health And Human Services (1980). Theories On Drug Abuse: Selected Contemporary
Perspectives. NIDA Research Monograph 30. DHHS publication number (ADM) 80-967. Available online at
http://www.nida.nih.gov/pdf/monographs/30.pdf Last accessed on August 16, 2007.








1-2. Number of Female Emergency Department Drug Mentions, 2005
Drug Number of Mentions (females)
Cocaine 155,985
Heroin 55,503
Marijuana 80,597
Stimulants 54,419
MDMA 4,419
LSD 251
PCP 2,913
All illicit drugs 288,960
Source: SAMHSA Drug Abuse Warning Network (2007)


1-3. Percentages of Females Aged 15 to 44 Reporting Past Month Use of Alcohol, by Pregnancy
Status and Age (1999-2000)


15 to 17 18 to 25 25 to 44
Use Last Pregnant Not Pregnant Not Pregnant Not
Month pregnant pregnant pregnant

Alcohol 8.6 26.1 10.1 53.6 14.0 50.2
Binge
Alcohol 7.0 15.4 4.8 29.6 3.1 17.1
Heavy
Alcohol 2.0 3.3 0.9 7.5 0.5 3.0


Source: Office of Applied Studies (2002b)


Pre-
contemplation


Contemplation


^ ;r


Relapse


Preparation


/Maintenance


Action


1-1. Stages of Change in Addiction. Based on Prochaska and DiClemente's Model (1992).


" I











Pregnant


Olher
4%


Cocaine
27%


Nonpregnant


Other
Stimulants 4%
%


Cocaine
20%


Marijuana
11%


Opiates
19%


38%coho
38%


1-2. Primary Substance of Abuse among Women Aged 15 to 44 Admitted to Treatment, by
Pregnancy Status: 1999 (SAMHSA Treatment Episode Data Set (TEDS)).


Domestic Violence

by Offense Type to Victim's Relationship to Offender

REL noNSfHI 1C nB TO OFFEDER
OFFENSES
Other
Total Sppi Parent Child 5iblin Familr C(oQ bia u Otber A;rrt

M. :61 49 12 5 1 34 16 82
Iasuhtr 1w 2 3 9 1 1 1 1 13
v. rcbl Sff 0e~ s- I 173 I 5- 2 709 229 289 S4
1rmrrF1 148 4I 2210 98 2 15 174 42S
T:'. 14 a 99 69 114 2T 42
Faotcitj Fr;-4 11 4. 315 113 47 73 22)
a a 3 1 S64 1.796 1.903 1i 5. 95 3.263 13.021
d s 92 8 4 4 s18 6 7 1'4
Si le iAs S 1: 2l.58 9.311 .61 46S2 '. .4 10.814 .
TaEl'Eriab4t 3BW 1.116 -\ 16I 11I 309 645 Q!; 680
:uy.t. ; c; .": 132 1,i .h 6 9 81 S: 124

TOTU OFENSS 115l 2.129 11.6"2 .1? S94 ".339 35.401 15.460 6."S"

1-3. Florida Domestic Violence Offences and Relationship of Victim to Offender. (Florida
Department of Law Enforcement Uniform Crime Reports, 2007).
http://www.fdle.state.fl.us/FSAC/UCR/2006/CIF_annual06.pdf


Stimulants
12%


Marijuana
14%


Alcohol
24%










100


80 &- Ielduced risk









20-



Low Medium High
Baseline aWohd intake risk level



1-4. Baseline Alcohol Intake Among Women and Choices for Reducing Risk of an Alcohol
Exposed Pregnancy (Centers for Disease Control 2003).









CHAPTER 2
MATERIALS AND METHODS

Study Design Summary

In this chapter the research methods used are described. Details regarding human subjects

protections, the research setting, study population and size, and materials and methods utilized

are provided. The materials and methods in this chapter are divided into two sections, a

qualitative section and a quantitative section, and explain how the interview guide and

questionnaire were developed and details about analysis variables and types of analysis. A two

pronged research design was used in this research in attempt to qualitatively answer some of the

"why" questions related to addiction and fertility behind the "what" quantitative data that were

collected by the survey. Ethnographic data was collected through life history interviews to

provide a context and background for the results of the survey on contraceptive use and barriers

to using contraceptives in a population of women in residential treatment for Substance Use

Disorders (SUDs). After approval by my PhD committee and the University of Florida

Institutional Review Board 02 (Protocol # 2006-U-0439), life history interviews were conducted

in the summer of 2006 and questionnaires were administered between June and December of

2006.

Human Subjects Protection

To ensure the protection of human subjects in this research, the study was reviewed and

approved by the University of Florida Institutional Review Board 02 (IRB application included

in the Appendix, Protocol # 2006-U-0439) and the administration of the addiction treatment

center. (See Appendix for letter of approval). To further protect the identity of the women who

participated in this research, the addiction treatment provider will be referred to as "SafeFree".

This name is fictitious and was chosen in recognition that these women were safe and drug free









during this research. Additional information about SafeFree and the study population are

included in the Research Setting and Study Population sections of this chapter.

As is described in the IRB application, the Principal Investigator explained the purpose of

the study including any risks and potential benefits. One hundred consecutive adult women in

treatment for substance use disorders were asked to complete the contraceptive survey. Women

were asked individually and in groups. Staff at SafeFree assisted with the research by locating

potential participants, introducing the researcher to clients, scheduling time, providing meeting

space and assisted with collecting completed surveys. Potential participants were given a copy

of the IRB approved informed consent document to read and any questions were answered

before participation (See Appendix for a copy of the IRB approved informed consent form).

Informed consent was documented before any of the research questions were asked.

Signed informed consent forms were stored separately from the anonymous questionnaires

and life history interviews so that there would be no link to connect responses on the

questionnaire to individual respondents. No identifying information was collected on the survey.

This was to ensure that responses were completely anonymous. Participants were informed that

their questionnaire data would be stored and reported in an anonymous and summarized form.

No compensation or other incentive was provided to those who completed the survey.

Five adult women participated in the life history interviews. It was anticipated that some

of these women may have had interactions with the child welfare system and they were reminded

not to discuss any unreported incidents of child abuse because of state mandatory reporting laws.

They were also told they could discontinue participation at any time. In the interviews, names

and dates were modified to protect the privacy of respondents. Each woman received a $10 Wal-

Mart gift card at the end of each interview. There was a maximum of five interviews and $50









per person. Since one participant was not available for her last interview, her last gift card was

given to a staff member to give to her.

As previously mentioned, there was no direct benefit to participants in the survey,

however, the data collected may have the potential to improve services at SafeFree. Sharing

personal life history can be therapeutic, but it also has the potential to bring up painful memories.

Counselors and psychiatrists were available if anyone experienced distress after sharing their

story.

Research Setting

Participants in this research were recruited at SafeFree residential treatment facility in a

large city in Florida and all data was collected at this site. SafeFree is the one of the largest non-

profit organization offering alcohol abuse, substance abuse and related behavioral health services

in Florida. They offer a number of services including detoxification and specialized residential

addiction treatment services for women with substance use disorders and those with dual

diagnosis (See Table 2-1). SafeFree serves one of the largest cities (in square miles) in the

United States. The 2000 U.S. Census data indicate that 65% percent of the population is

Caucasian, 29% is African American and 4% is Hispanic or Other. This research site was

selected because of its proximity to the University and because of SafeFree's interest in this

research.

Substance abuse and child abuse and neglect are critical problems in the metropolitan area

served by SafeFree. According the Florida Uniform Crime Report this city averaged nearly

8,500 drug arrests and 3,400 DUI arrests per year in the years between 1998 and 2002, (Florida

Statistical Analysis Center 2007a; 2007b). In 1999, the Florida Department of Children and

Families (DCF) did a statewide survey of protective supervision cases to obtain baseline data on

substance abuse (Office of Program Policy Analysis and Government Accountability 2001). In









this area, 57.65% of child abuse and neglect cases required substance abuse treatment as part of

the case plan, while statewide 52% of case plans identified the need for substance abuse

treatment (Office of Program Policy Analysis and Government Accountability 2001). There

were more than 12,900 reports of child maltreatment in one of the areas served by SafeFree

between July 1, 2002 and June 30, 2003 and in fiscal year 2004-2005, there were more than

11,000 reports of child abuse or neglect (Department of Children and Families 2005). The

monthly reported rate of child abuse and neglect in the area surrounding SafeFree is 3.8 per

1,000 children, which is higher than the statewide rate of 3.6 per thousand children.

Study Population and Size

SafeFree has a maximum of 30 inpatient beds for women at any given point and it is

anticipated that on average each woman receives 45-60 days of residential treatment. For the

qualitative component, five women were selected from the population in residential treatment

during the summer of 2006. Women learned about the research interviews through participation

in the survey and the first five volunteers were asked to come to the first interview. Two of the

first five women were not available for the first interview and so two additional women were

asked to participate. These five women were interviewed on 4-5 different occasions for

approximately two hours per interview during the summer of 2006. The interview guide is

included in the Appendix and is described further in the next section of this chapter.

For the quantitative component of this research, a "N" of 100 was selected. This N was

selected based on a number of factors including, the exploratory nature of the research, the

feasibility of collecting the data within the period of IRB approval and it was in line with

feedback received from Dr. Mark Yang, Professor of Statistic at the University of Florida. The

N in this study was not a random sample of women whose responses were used to make

inferences to all women in treatment for substance use disorder, rather the N represents the









women who were in treatment at the time the data were collected with the goal of describing

characteristics and relationships between variables in this group of women. Had it been a

random sample of a large or unknown population size, the sample size needed in this study

would have been 96 at the 95% confidence level with a margin of error of +/-10. This sample

size is calculated as follows ((1.96)2*(.5)*(1-.5))/(. 1)2, where 1.96 represents the z value for the

95% confidence level, under normal distribution .5 represents the proportion picking a choice

and .1 represents the confidence interval of +/-10 expressed as a decimal (Creative Research

Systems 2007). However, as preciously mentioned the purpose of the survey was to capture data

on the characteristics of the population of women who were in treatment for substance use

disorder at the time of the research, not to make inferences from a random sample.

The questionnaire that was developed to conduct this survey is included in the Appendix

and is described in further detail later in this chapter. Although it was expected that women in

residential treatment are inherently different to a nationally representative sample of the U.S.

population in terms of numerous factors such as age, gender, income, and substance use history,

to have a better understanding the results of this survey in light of national surveys, several

questions from national surveys were included in the questionnaire developed for this research.

Details on questionnaire development and analysis variables are described under the heading

Quantitative Materials and Methods.

Qualitative Materials and Methods

Interview Guide Development

The qualitative portion of the research was designed to provide a context and background

for the survey research and was also intended to provide a better understanding of some of the

"why" questions behind the "what" information found in the literature and in the survey results.

Although five life histories cannot provide definitive answers that are generalizable to all women









with substance use disorder, an examination of these life histories allows for identification of

themes which can be analyzed within the context of this research and previous studies and

theories that are found in the literature. In-depth semi-structured interview, a commonly used

method in anthropology (Bernard 1994), was the selected method of qualitative data collection.

It was expected that the narratives of these women would include basic information about ages

and places and also give us insight into the their individual life histories and specifically how

addiction has impacted their lives. In addition, it was hoped that these interviews would provide

us with a better understanding of the human face and social context of fertility and addiction.

Life history interviews with five women were selected as the method for collecting these

women's stories. An interview guide was developed and is included the Appendix. The

interview guide was developed in consultation with my committee Chairman, Dr. Burns, to

ensure a successful interview experience. Informants were able to talk about their life story in

the order and detail that they preferred. The interviews were open ended in terms of what the

women could talk about and the guide was used as a starting point for discussion and to provide

some consistency in the type of data collected. These in-depth, in-person interviews were

conducted to provide a more detailed and personal account of the relationship between trauma,

substance abuse, family planning and child welfare issues. For each life story, approximately five

separate two-hour interviews were conducted. Each woman received a ten-dollar Wal-Mart gift

card for each completed interview. Information about the treatment environment and treatment

process was also collected to provide another ethnographic dimension to this study.

Data

The interview methods and interview guide were reviewed and approved by the University

of Florida Institutional Review Board (Protocol # 2006-U-0439) prior to the conduct of the

research. The qualitative data were collected by note taking during the interviews and are









presented in Chapter 3 in an ethnographic life story format. Topical areas included in the

interview guide are summarized in Table 2-2. The interviews were not video or audio recorded

in order to protect privacy.

Qualitative Data Reporting and Analysis

Field notes were taken during the interviews. These detailed notes were recorded as the

participant described their individual histories on five separately scheduled interviews.

Sometimes abbreviations were used to capture the full details of her descriptions. After each

interview, field notes were reviewed and any areas in need of further clarification were addressed

at the next scheduled interview. After the interviews were completed, the notes were reviewed

again and then transcribed into an electronic format. In transcribing these notes, names and dates

were changed to protect confidentiality. The life history interviews were sent to several

reviewers and to my thesis committee members for review and comments. To provide a more

seamless story, references to where interviews began and finished were deleted as well as some

mentions of items that participants brought in to share during interviews. The complete set of life

histories is included in Chapter 3. The histories were reviewed and re-read numerous times to

identify life history themes and areas for discussion in the final chapter.

Quantitative Materials and Methods

Questionnaire Development

In order to develop a questionnaire that was relevant to this research project, numerous

nationally representative surveys were reviewed and several questions and topical areas were

selected from the National Family Growth Surveys (Centers for Disease Control) and other

national and treatment surveys such as The National Survey of Drug Use and Health, Treatment

Episodes Data Set, the Drug Abuse Warning Network and Monitoring the Future surveys which

are conducted or sponsored by the Substance Abuse and Mental Health Administration









(SAMHSA) or the National Institute on Drug Abuse (NIDA). This questionnaire was developed

to collect a variety of information regarding demographic characteristics, health and abuse

history, pregnancy related information, number of children, types of contraceptives used in the

past and future intentions to use methods to prevent pregnancy, reasons for stopping use and

questions related to substance use.

Because one goal of the research was to compare selected data collected to national

prevalence figures some of the family planning and contraceptive survey questions (See

Appendix) were selected from the National Survey of Family Growth (NSFG)(Centers for

Disease Control) and were asked according to specific timeframes that are used in the

Monitoring the Future Studies (MTF) (Johnston, O'Malley & Bachman 2002; National Institute

on Drug Abuse) and the National Survey on Drug Use and Health (NSDUH) (Substance Abuse

and Mental Health Administration). For examples, women were asked about the same types of

methods to prevent pregnancy (birth control pills, condoms, withdrawal, etc.) and periods used

(last 3 months, last year, ever) that were asked about in the NSFG and questions about

substances used included the times frames of last month, last year and ever as does the MTF and

the NHSDUH.

Standard demographic questions were also included (age, race, marital status, education,

general health status) as well as questions that seemed pertinent to the research based on the

review of the literature (number and wantedness of pregnancies, number and ages of children,

history of abuse and domestic violence, potential barriers to contraceptive use and about use of

substances prior to entering treatment). Contraceptive data from the National Surveys of Family

Growth (1982, 1995 and 2002 [Centers for Disease Control]) were used for general comparisons.









The questionnaire was designed to collect data on a number of variables in a condensed

format. The survey itself was self-administered, so that after informed consent, women could

read and answer the questionnaire in the time that they needed. The final questionnaire was six

double-sided pages. The questionnaire included mostly closed ended questions with multiple

choices for responses. For example, two of the questions are provided below.

Would you say your general health is

a. excellent

b. very good

c. good

d. fair

e. poor

Thinking back over the past 12 months, would you say you used a condom with your partner for
sexual intercourse

a. Every time

b. Most of the time

c. About half the time

d. Some of the time

e. None of the time

Respondents were able to write in responses to questions that asked "how old" or "how many",

for example, how old are you? and how many times have you been pregnant?

Questions that had an "other" category among the possible response choices also included space

for a written response, such as, where do you live most of the time? e. other: Race

was also open-ended, such that participants were asked, what race do you consider yourself?

Check boxes were used for contraceptive use questions (See multiple examples in Appendix) and









a matrix format was used to collect information about history of substance use and age at first

use (See sixth/last page of the survey).

With the exception of the contraception terminology that was included, the questionnaire

was developed so it could be easily comprehended at the eighth grade reading level. It was also

designed to be easy to use so that respondents could answer hundreds of questions in six double-

sided pages. Related questions (such as questions about past contraceptive use and questions

about future intentions) were usually grouped together in sections and respondents could check

appropriate responses or circle all that applied from lists. Prior to implementing the survey,

feedback on the full questionnaire was sought from my supervisory committee, colleagues in the

UF Division of Addiction Medicine, UF medical students, undergraduate students and women at

SafeFree. Suggestions were incorporated before finalization of the survey. The final draft of the

survey was reviewed and approved by the supervisory committee and the Institutional Review

Board prior to conducting the research.

Analysis Variables

The Family Planning and Contraception Survey included demographic variables such as

age, marital status, education, employment, and income. It also included questions about the

subjects' health, history of abuse, pregnancy status, pregnancy history, pregnancy planning, age

and number of children, age at first intercourse, and about their intentions to become pregnant.

The survey included questions about the types of contraceptives (see Table 2-1) that were used in

past month, where methods were obtained and a series of questions about condom use.

Contraceptive use in the last three months, the last year and lifetime history of use of

approximately twenty different methods were also explored. Data on future plans to prevent

pregnancy in the next month and next year and reasons why they may have stopped using a

method were collected. The last series of questions asked about twelve specific substances or









categories of drugs of abuse (tobacco, alcohol, marijuana, cocaine, crack, heroin, hallucinogens,

inhalants, pain relievers, tranquilizers, stimulants, sedatives) and also included an "other drug"

category, high sugar foods and high fat foods. For each of these, data regarding if they had ever

used, used in the last 12 months, used in the last 30 days or on the day before treatment was

collected. They were also asked to indicate the age they were when they began using the

substance

Survey Data Analysis

Descriptive Statistics. For the variables described above, frequencies were generated for

categorical (i.e., dichotomous yes/no responses and income categories) variables (N or % with

each response and N missing) and descriptive statistics (i.e., N and N missing, mean, median,

standard deviation, minimum and maximum) were calculated for continuous variables (i.e. age,

number of pregnancies, number of children, years since surgical sterilization, age at first sexual

intercourse, age of children and age at first use of drugs and alcohol). These results are presented

in Chapter 4.

Additional analysis, regressions and comparisons. Frequency tables were used to examine

the relationship between type and frequency of substances) used (past year and before entering

treatment) and effective contraceptive use/failure to use in past year and past three months.

These tables are included in Chapter 5. Comparisons by age and race are also included in

Chapter 5.

Since this was an observational study and not an experimental design, regression analysis

was chosen for further analysis of the data. This method does not examine cause-effect

relationships, but does allow for examination of relationship between two variables. Regression

analysis is a commonly used method to test the relationship between variables, such that a model

can be made to make predictions about one variable based on another variable (Darlington









1990). While often used to analyze the relationship between two quantitative variables, such as

weight and blood pressure, it can also be used when there is a dichotomous variable such as

yes/no or use/not use. In other words, it can be used to describe the relationship between age (x,

the independent variable/explanatory or predictor variable) and contraceptive use (y, the

dependent or criterion/response variable). In the results presented in Chapter 5, ordinary and

logistic regressions were used. SigmaPlot (Version 9, Systat Software Inc, San Jose, CA) was

used for the ordinary regression analysis and SAS (SAS Institute Inc, Cary, NC) was used to

conduct the logistic regressions.

Ordinary regression was used to find the relationship between continuous data, such as the

number of years since surgical sterilization method or age of substance use initiation (dependent

variables) and demographic characteristics such as age and years of education (independent

variable). When the response variable was "use" or "not use", logistic regression was used.

Using contraceptive methods as the dependent variable and demographic characteristics as

independent variables, logistic regression method was used to find the relation between the past

and planned use of contraceptive methods and demographic characteristics. Independent

variables included in the analysis and presented in Chapter 5 are age, race, ever married, past

year employment, education and history of abuse or domestic violence. Additional details about

the variables of analysis are included in Chapter 5.

In the ordinary regression results, the size of the regression coefficient for the independent

variable indicates the size of the effect that variable has on the dependent variable. A negative

coefficient indicates a negative relationship and a positive coefficient indicates a positive effect.

For example when examining the effect of age on number of years since sterilization, a positive

coefficient indicates that the number of years since sterilization is expected to increase when age









increases by one. For the results reported in Chapter 5, a correlation coefficient of less than .30 is

considered weak, .30 to .59 as moderate and .60 or greater as strong. The square of the

correlation coefficient between the dependent and independent variable is presented as the R2.

This is the fraction of the variation in the dependent variable that is predicted by the independent

variable. The p-values, which indicates confidence that the independent variable is in someway

correlated with the dependent variable, was considered statistically significant at p <.05. The

significant results of the logistic regression are summarized with the odds ratio and 95%

confidence interval for the odds ratio included in the text and additional details in the

corresponding tables. For the logistic regression results, if the 95% confidence interval for the

odds ratio includes "1" or the p-value is .05 or greater, the results are not considered statistically

significant.

In Chapter 5, the survey data was also compared to summarized data in the 2002 NSFG,

previous NSFG surveys and other national survey reports. When available comparisons were

made in terms of age, race/ethnicity, past and current contraceptive use and types of methods

used, rates of surgical sterilization, age at admission and primary substance of abuse, education,

employment, ages of specific substance initiation, and prevalence of substance use in past month,

past year and ever. The life histories of women in treatment for substance use disorders may be

useful in understanding some of the survey results and differences between these results and

national estimates. Therefore, before the survey results are presented, the life history interview

results are provided in Chapter 3 to provide a context and background for the subsequent

chapters.









2-1. Examples of Services Provided by SafeFree
Type of Service Examples
Prevention Children of alcoholics
Community education
Web-based educational intervention services
Intervention Help for family members
Reduce risks associated with substance abuse
Prevent further abuse
Assessment Psychiatric evaluation
Treatment referral
Detoxification Assessment, detoxification, and stabilization
Secure environment
Twenty-four hour medical coverage
Outpatient Services Aftercare
Crisis intervention
Co-dependency services
Dual diagnosis
Family therapy
Individual and group therapies
Intensive outpatient services
Random drug screening during treatment
Relapse prevention
Juvenile Justice Behavior management
Case management
Dual Diagnosis
Halfway Housing 12-step groups
Employment assistance
Life skills
Personal support
Residential Treatment 12-step recovery model
Dual diagnosis
Child Development Center
Individual and group therapies
Infants and children can stay with mother
Family counseling
Links to community resources
Parenting skills
Medication management
Trauma recovery









2-2. Interview Top
Life Periods
Childhood




Adolescence




Adult




Pregnancies,
contraception
and children

Future
Intentions


ics
Ar


eas Discussed


Number of siblings, memories of her parents, relationship with mom
and dad and, grandparents, role of her grandmothers, memories of
where she lived, school experiences, were drugs and alcohol used at
home, memories of holidays, birthdays, was she a "tomboy", what
types of activities did she enjoy.
Relationships with her family, relationships with peers, first menstrual
cycle, other physical changes, first boyfriend, sexual experiences,
substance use, school experiences, was she a risk-taker, and if so,
what were those risks, did others think she was a risk taker, did her
friends take risks, hobbies/activities she enjoyed.
Work experiences, relationships with her family, intimate
relationships, substance use/ treatment experiences, financial/legal
issues, would she describe herself as a risk-taker, in what ways,
religious/spirituality influences, positive/happy memories of these
years.
History of pregnancies, planned/wantedness, number and ages of
children, contraception, past and current perceived barriers to use,
perceived benefits to use, impact of having childrenn, child care
issues, ask her to tell me something special about her childrenn.
Her plans for her life post-treatment, her intentions regarding future
pregnancies, her plans to use contraception, child care/employment
plans, how she will use her treatment experience in the future, how
she will try to avoid relapse, what she hopes to accomplish tomorrow,
in the next week, the next month and the next year.


2-3. Family Planning and Contraceptive Methods
Methods
Birth Control Pill Female Condom, Vaginal Pouch
Condoms Foam
Vasectomy Jelly/Cream without Diaphram
Withdrawal/Pulling Out Cervical Cap
Depo-Provera, Injectables Suppository/Insert
Norplant Implant Today Sponge
Rhythm/safe period by calendar IUD (Intrauterine Device)
Natural Family Planning Lunelle, (once-a-month Injectable)
Emergency Contraceptives Contraceptive Patch
Diaphragm Any Other Method









CHAPTER 3
LIFE HISTORY INTERVIEWS

Introduction

This chapter includes the life histories of five women in treatment for addiction who

shared their stories with me. An interview guide was used (See Appendix), but these women

could tell their stories in the order and level of detail that they wished. Each interview begins

with a brief introduction. Only names and some dates were change to protect the privacy of

these women. Inconsistencies were not edited. The interviews are presented as follows:

* Sara
* Mary
* Jackie
* Tracy
* Pamela


While these women had diverse backgrounds, there are many commonalities in their

stories. Themes and areas of concordance and dissonance are presented in Chapter 6. The text

that follows is their words.

Sara

Sara is a 50-year-old African-American woman. She has a strong voice, filled with

wisdom. She has no children but has helped raise her siblings and her sister's daughter and

grand-nephew. She tells me:

I was born in Jacksonville, but moved when I was 15 after my father died. I moved to
Georgia about thirty-three years ago. In 1979, I went to Princeton, NJ after mom died and
lived mostly there until December of 2005. I had a job as a nanny. I'm not sure why I
took that job because I never liked kids or housework, but I was fired so I went to stay with
my niece in Pennsylvania. I was having a massive addiction to painkillers. They (my niece
and her son and my sister) had an intervention and bought me a train ticket. I never
imagined I would be in this city again. I am estranged from my sister here. I was brought
here and I brought my addiction with me. It sat right next to me on the train on the way
here. I had this medicine dispenser. It was horrifying. I was passing out and sleeping all
the time.









When I first started as a nanny it was great. I just needed the pain meds for pain, but it
became an addiction. I found a doctor that would write me prescriptions anytime. The
doctor was a pusher, a drug pusher. I overcame street drugs. I smoked lots of marijuana
over the years. One day someone gave me marijuana laced with crack. It was only with
the grace of God that I was turned around. I remember I had to... had to get high. I used
to bargain with God for Wednesday because I needed to get high on Monday and Tuesday.
I was going to my drug dealer crying. I cried and I prayed "I love it and don't want to
stop, but I can't take it anymore." The next day that black switch turned off. There was no
more obsession. God took that away. It was very difficult to accept such a blessing. It
was a horrible way of living. God is a loving and understanding God.

I thought I would try to fool God. If God could let me do this for three more months, and
then I could say the same prayer. And I heard a voice that He could promise, but I would
not be sure if it will be one day or three years to answer. It took me almost 6 years to stop.
I have learned that one does not tease that drug (crack).

I took pills for two or three years. I lost my coping skills and did not know how to live. I
didn't know how to pay bills anymore. I lived on the bare necessities, but I had an
expensive dope habit. Even thought I was not using crack, I forgot how to manage money.
I would be extravagant and go on expensive shopping trips. I didn't pay bills. Well I paid
the motor vehicle bills. I didn't need to get high anymore. There was no desire.

I was in a lot of pain though, pain from osteoarthritis. I also have a degenerative joint
disease that required lots of surgeries. I had knee problems and knee pain. I suffered a lot.
I was scared to give into the pain. I started a routine of moving from one township to
another... so I could go to new hospitals. At first I was very honest about the pain. At first
they gave me Dilantin. It was like "wow" they believed me. At first I was a sincere
person in pain.

The first time I went into treatment in Princeton, there was a therapist, a nurse who cried
through the whole thing as I told my story. She was a godsend. This was my first
addiction after my other addiction. This addiction was to the pain pills that they had
started prescribing after my shoulder surgery. I never told them about the weed laced with
crack. No human force or program could help with that. I was smoking it while I was in
treatment. The therapist did ask me about other drug use once.

Their program was a revolving door. There was a pill for everything. An anti-psychotic, a
sleeping pill, an anti-anxiety medication. We were falling asleep in detox. My therapist,
she just had me for a patient. I had one roommate that was thirty years old and had been in
treatment 27 times! It wasn't unusual to see the same people 5 or 6 times. There was no
12-Steps, no idea of sponsors. The therapist would just encourage meetings.

Going to the ER (emergency room) started for pain. The doctor said for them to give me a
shot of Dilantin, but I felt absolutely nothing. The nurse had never given me the shot!
When I went back I felt the prick and the drug, and it was "Oh my God!" I never felt it the
first time they said to give me the shot.









I had a ritual. On Fridays I would get off from work and then go to the ER at about
1:00am in a suburban beautiful hospital. I would tell them about my rheumatoid arthritis
and would tell them that yes, I had had the blood test for it. I would have a panic attack
and they would give me something intravenously. I thought I had died and gone to
heaven. I would leave the hospital with a prescription. There was one 24 hour pharmacy I
used to go to until I was red flagged. I did have a medical history of pain and so I went to
another pharmacy. It had been about three years since I was doing all of this. I would go
back to another hospital and get oral Percocet. I could persuade them. My addiction was
screaming but the pain was there. I would get morphine in one place, Dilantin in the next.
I would go to one place on Friday and another on Saturday. I would juggle prescriptions.

I met a woman through the ER. She gave me a morphine patch. It was 50mg and I took it
because I needed something for the pain. I was taking 100 mg by the following week.
Then I remember I was at a pizza place with the family I worked for and something was
happening with the patch. I went to the car and took off the patch. It was supposed to be
worn for 72 hours but I extended it. I first bought one patch and then a whole box of them.
They worked well for a while and I cut back on the pills I was taking. I used them for
three months, but then they stopped working. The lady I got them from told me to go see
the doctor. When I went to the doctor's office it was filled with poor Hispanics and Blacks.
I thought to myself "Are all of these people here for the same reason I am?" The office
staff was very compassionate. There was a great big sign that said if you want any of the
major pain pills that you were in the wrong place. But the doctor prescribed them. He
gave me 40 Tylenol #4 with codeine. I was feeling lightheaded now. After he got my
medical history he gave me Percocet. I got a month supply, which I took in 2 weeks.
Then I asked for 10s instead of 5s. When the doctor first asked me if I wanted to try
Oxycontin, the addict in me said "Yes!" but the other person in me said no.

Then I was taking the Oxycontin, Percocet and some other drug and it almost killed me. I
remember that I had to get in a cold shower and I prayed, "God, please not like this." I
remember I would have to jump around. I was surprised when I woke up. I had taken the
pills too close together. I was so afraid I was going to die.

I put myself out of my job. I was paying cash for $200 prescriptions because insurance
would have caught on. And, oh how dumb I would play with the pharmacist about the
strength. I would never run out of my supply. Addicts, we see things differently. For
example, I took some Percocets from the medicine cabinet of my employer. I actually
went through her bedroom into her bathroom while she was sleeping to get them. Well she
caught me and asked what I was doing. I told her I needed them for the pain. She was a
lawyer and told me I was breaking the law and threw the remaining pills in the garbage.
Well the next day I went through the garbage to find them. I just couldn't believe that she
didn't understand the pain.

As an addict I felt like "I am invisible" even if there are fifty people around who could see
what I was doing. I felt like "how dare you question me when I know that I am in pain."
When I came to Jacksonville in 1987 it was to bury my middle sister. She was murdered.
That was when I was first introduced to marijuana with crack. It numbed the pain. This
place reminds me of my sister. I miss her so much.









I have another sister. She is the youngest. She is not a spiritual person but uses God and
the Bible to judge people. What happened before returning here this time was my doctor
had given me a whole stack of prescriptions to last a while. In December of 2005, my
sister had an intervention for me with medical people and church people. I didn't think
people were watching. My sister communicated very little with me. When my pills got
low and I asked her to help me get more she said "no." My sister made calls and they
referred me to here. They said I could come in that very same day at 10am, but I took the
pills that were packed and then took the rest of them and then went into detox on Dec. 19th
I didn't want to feel withdrawal.

I had gone to treatment in Princeton three or four times for withdrawal. In this city, I
didn't know anyone that would leave and want to come back again. Detoxification in here
was substandard; just the basics. Detoxification here was not a place you want to keep
coming back to...unless you were on the streets. I was cold, crying and sad. I spent
Christmas and New Years day here in detox.

Thinking back, I didn't celebrate my 50th birthday either. Because my addiction was so
powerful that I did not celebrate anything, except by maybe taking some extra pills. There
were many times that I would just not show up to celebrations.

I chose not to have children because I wanted to party all night. I loved it, the partying.
However, I did care for my niece for my sister who was murdered and I also have a grand-
nephew who is nine years old. On holidays, I was still getting high and even when I
wasn't high there was something missing. Now, I am getting coping skills. I am learning
all over again how to pay bills, how to live on my own. I used to be able to do that back in
my twenties and thirties, but then the addiction took it over.

Some of the most positive experiences of my life were when my niece graduated from
college and the birth of my grand-nephew. I'm in the extended program here, which
includes stages and phases. I am at the highest level and can now use a cell phone so I can
keep my connection with him.

My niece came to live with me when she was 14. I was very cold to her initially. I didn't
realize it, but part of me died with my sister. I would freeze when my niece hugged me.
But I learned. And she learned that with me there was no cursing, no name-calling, no
clamor and no disrespect. Her son doesn't know any of it either and for that I am thankful.

When I grew up there was a lot of verbal and physical abuse. My mother was an alcoholic
and my middle sister was an addict. She was abusive to her daughter. My niece was very
fearful at first and always afraid of consequences. But I was able to help her break the
cycle of abuse and now her son rarely gets spanked. It was unusual to hear voices raised
when we lived together.

Another positive thing is that my grand-nephew's dad had once had an alcohol problem
and was verbally abusive, but now he has gotten his life together, got his GED and is now
almost done his BS. My niece will be graduating from college too.









I told the two of them that they cannot be selfish and don't put their son in the middle of it.
They don't use him as a pawn. I helped them with this and talked to them. I told my niece
not to deny the father. He had grown up in foster care. They are both very involved. I
hope that I have helped to stop that abuse from passing down. My nephew feels safe. I
couldn't, I didn't feel safe. My niece is very grounded and stable. She puts her kids first.
We had many long talks where I tried to share some wisdom.

I went to college. I got caught shoplifting when I was 19. I did it for the thrill of it. I tried
to take something impossible. My mother called the priest, an Episcopalian priest. He was
a pervert. My punishment was to go to college. I would be sleeping in the classroom with
my pen in my hand and my coffee. Eventually they told me not to come back. But I did
go back to college in my thirties and forties. Then an A- was not good enough for me. I
was very active and involved when I went back on my own.

Look I brought some pictures of my grandnephew, his dad and my niece. This was on a
trip to Baltimore.

I don't think I told you this. I was born in Jacksonville. I had a twin sister, but she died
when I was just 19 months old. My mother exaggerated, but my sister may have had some
sort of leukemia. My middle sister was born on the same day that my twin died. She was
called a present. And here I am, still grieving even though I was just 19 months old when
she died. I've always felt like my twin was my guide.

I had two brothers and three sisters. Now I just have one brother and one sister. I am
estranged from each of them.

My family always seemed to struggle. Even though we had the store and the nightclub,
called the Red Room. We had a duplex house. Our family lived downstairs and we rented
the rooms upstairs. My dad had our house, an apartment building and three other houses.
We used to play on what we called "the lot." We would play "War". There were lots of
kids. We looked like we were privileged. But it was my Aunt and Uncle that sent us to
private Catholic schools.

Dad was a mamma's boy. He had a gambling problem. I remember he had this Cadillac
he would drive on Sundays we called it "leaping Lenora." My mother was from Georgia.
Dad must have been a tough guy. He carried a gun. She was 24 and he was 49. Dad
drove through town, they met and got married. Mom may have been pregnant with my
oldest brother. Dad always treated him different.

I loved my dad. He was an older man. I think the stress from the marriage to a woman
from a very dysfunctional family made it worse. This was his second family. I was 13
when he died. His children were as old as my mom. He did some time in prison.
Everyone called him "Doc". He went to jail a couple of times. It could have been related
to gambling or meds. Dad was tough and men treated him with respect. I would sit on
his lap and love my dad. I am a bit like him. He was a hustler. I have his survival skills. I
never give up. I know this, how things are now, does not have to be. We should have
been upper middle class, but I remember the lights being out sometimes. He would ask my









grandmother, his mother, for money. She helped him out. Even at 60 his mother would
tell him to tuck his shirt in his pants.

I remember when there were five of us. Mother had a stillborn when I was 8. We were
sent to Connecticut that summer. There was a housekeeper Ms. Ida and Mr. Bill. They
stayed in one of dad's houses. When you love someone, you don't really notice, but that
house had a strange smell. Dad sold bootleg liquor in the Red Room. I turned my nose up
at the drunk and disgusting people. Ms. Ida told me my mother was a drunk. When I
asked my mother what was wrong this shield would come down and then she would read
this Wizard of Oz book. I hated her when she was drunk. I still remember how they
smelled. Dad always wore suit clothes, or a white dress shirt and gray slacks. You would
bring him his stuff, his food and his coffee. He was very loving toward the girls, but not
towards my brothers.

My brother Anthony, we used to call him Mr. Blackie. He was darker than everyone else.
He had long hair. We used to call him saddle head, too. Anthony was friends with the
kids next door. They convinced him to take dad's moneybag. He gave it to Lee. Dad took
Anthony to the Red Room, stripped him, tied him too a chair and whipped him with a razor
strap. Dad was friends with the police, but he still had to spend a night in jail for that.

Dad's niece, Tanya, was mom's best friend. Tanya and Anthony were both killed in a car
accident on Jan 2nd 1965. It was a drunk driver. It was a rainy cold day. They were on
their way to father's first wife's funeral. Anthony was 12 years old and he DID NOT want
to go. He hid his shoes. He missed the first car. He begged mom, "please don't let me
go!"

They didn't let the girls go, but I thought if I hurry I can go with them. But I could not get
out of bed that day. We missed mass that morning. When I got up, mother had called a
Taxi. I saw him wave from the back of the cab. There was so much guilt and pain that
followed.

Mom made a big dinner that day. There was a large woman who lived next door who
would eat with her hands. I remember it was around seven or eight that night when two
hearses came to the house. I don't know why they came to the house. After that dad came
home. They passed the accident. It looked like Tanya's car, but they didn't stop.

Mom ran down the street screaming. This was 40 years ago, but I remember so clearly.
Dad got up, held his chest and said get coffee. Mom just screamed and screamed. I was
afraid to look in his room when I was making the coffee.

By then the family became dysfunctional. No one paid any attention to my oldest brother
Shawn. He started using drugs at 15. He should have been Valedictorian. He would make
us cartoon books. I have no idea where he is. After he started drugs he was no longer a
part of the family.

My father got sick after we lost my brother and we moved to the other side of town into a
smaller house. My dad would drive to work. My mother was an odd woman. She never
went grocery shopping or to a store to buy a dress. She never went to see a movie. Well,









maybe she did with Tanya. My mother would give me a list for the store when I was just
eight years old and I had to know what to buy and how to select foods. Maybe that's why I
never wanted kids.

In our store we had a jukebox and pinball and ice cream. Sometimes we would find mom
passed-out drunk behind the counter. My dad sold properties too. He ended up having a
heart attack and then got sick. He ended up leasing the store. When he got sick, we lost
everything. I'm not sure if we went on assistance. Mom went to work outside the home
for the first time. They gave her $40/week. Other women got $85/week, but maybe they
gave her liquor.

I was 12 when mom went to work. Every morning when I woke up I would shave, clean
and feed my dad. I would go play and then go back to see what he was doing. I had to
help him with his urinal, but he was sick and I had to do it.

My mother was a violent drunk and she knew how much I loved him. I was closest to him.
Once when I was 11 or 12, I was sitting in his lap and she accused us of doing something.
She slapped him and his glasses flew off. She called us both all kinds of names. It has
been 37 years since he died. I knew I would be on my own when he dies. It was a
Wednesday in 1969. My brother told me and they were taking him out in a sheet when I
got there. From that day, I was raising my sisters. They would come to me hungry and I
would steal to feed them.

After my dad died, my mother brought this man Stan in the house. I could hear them
having sex. My sister told me he was peaking at our little sister in the bathtub. I would sit
up all night with a knife in my hand watching over my sisters. I was taking care of kids at
9 and 10 years old.

At 14, I went to work for this woman named Marcy. My sister Deborah started watching
them first, but she got pregnant. At first, I just started working a day or two. At 14, I was
taking care of an 8 and 9 year old. Marcy bought all my school clothes. My Grandma and
Aunt were a safe haven for us. We would lay in bed with Grandma. She was strict. They
did not like my mother.

Marcy would call my mother at 10:00 or 11:00 pm and send a cab for me. I think she may
have been a prostitute. She was beautiful and lavish. She would brush her teeth with
bleach because she chewed tobacco. I watched her kids for about a year.

I always had lots of friends, and one or two best friends. It made my life bearable. My
mom would chase away boyfriends because she thought they could take me away. I could
never take anyone home. People talked about my sister being fast. And she was fast and
fiery! She was born during a hurricane. They allowed her to get away with a lot.
Especially since my twin's death.

At 14 or 15, my mother's mom died from a stroke. My mother's cousin took her home and
she arrived drunk. My uncle beat my mother in front of everyone. No one helped her. I
never forgave him. My mother got sick after that. Mom was in her 40's. She lived
vicariously through her kids. When she wasn't drinking it was wonderful talking to her.









She always had a sweet smell. When she was drunk she had a look of rage. I remember
beatings with broomsticks at 1:00 or 2:00 am that started while I was sleeping. I remember
going to school with scratches and bruises, saying it was the cat that did it.

At 15 or 16, I moved to Georgia. I remember a total of 3 or 4 birthdays with cake and ice
cream. At my 8th birthday, I cried. I was mourning the loss of my twin. I had a party when
I was 16. I never remembered any parties for the other kids.

When I was about 5 or 6 years old, we had a ritual, we never had enough ice. We went to
bed early, around six o'clock, so we would have our pajamas on. It was my job to go
upstairs to get the ice. This one time, someone put his hand over my mouth and eyes and
he put his hand in my underwear and fondled me. I was in a daze. I don't remember ever
telling anyone about that.

Growing up I was always running from men. I had best friends, everyone would just
appear on the street. The girl next door used to get beat with the extension cord by her
grandma. One friend's uncle used to threaten me all the time. He threatened to rape me.
He died in a car accident. I was never so happy.

In Ms. Ida's back yard, she would have us in our underwear. Robert would chase me.
Men would expose themselves to me. In my entire life, I have had experiences with nine
men. I have trust issues.

As an adult I was a bartender and had plenty of supplies of liquor, but I never had the
desire to drink. I would taste it with a spoon. I don't like the feeling of alcohol. Alcohol
can wake up the desire for other drugs. I tended bar for a University President and met
famous people like the Clintons and Toni Morrison. I did bartending until I got sick with
pain. I did private parties. I would hire staff. I learned as I went along, delegating
responsibilities.

I taught myself to bartend. At this last minute party on a New Year's Eve, I was mixing
Black Russians. They had cocaine at the party with the whole family there. They were
nice people but something was wrong. There were lines that I didn't cross. I remember
when they passed the cocaine to the grandmother and she did some too. I was about 40
then.

It is only through the grace of God that I have never been arrested. Ninety to ninety-five
percent of the women here now have been arrested. I remember one time I had a car with
no insurance, no registration and was driving while my license was suspended. The last
thing on my mind was eating, but I stopped to get some chicken. I was pulled over after
stopping at KFC. I got pulled over by the police and he took me home. I was loaded with
drugs, but he never patted me down. You can't negotiate with heroin.

I'm in the aftercare program now. So where was I? I told you I was serving alcohol at
private parties? Oh, yes. I remember, I was telling you about Ms. Ida. Back to Ms. Ida.
After my brother died we moved on the East side. We always lived in houses we owned
until I was an adult. After my father died, I had to take care of my sisters.









When I was 15 we moved to Georgia. I had to change schools in the 11th grade. It was a
quaint town, almost like Princeton. To the south was Jekyll Island and St Simon. I liked
being near the islands. I grew to love my new school. It was a very good school. I liked
high school a lot. It was sad to graduate. I was in the chorus. We would go to Ms.
Marie's house for choir.

I had a close friend from high school to my thirties. After my sister died we had a falling
out. I lost lots of friends because of my addiction. After school was done most of my
friends went to New Jersey. Mom died in 1977, no 1978. It was New Years Day. I left
Georgia in 1979. I only stayed a year after her death.

I moved to Princeton and stayed there for close to 28 years. I stayed friends for years with
the people from Georgia. By 1987-88, I was in so much pain that friends were starting to
disrespect me. I am sure I was the topic of many conversations. One of my friends was an
opera singer. I couldn't face her, even when she got married, I did not go.

Before my addiction, they would want to embrace me. They didn't reach out to me, but I
didn't want them to. Margaret and I were best friends. I thought everyone should have a
best friend. I have had a few and I have hurt them. I didn't value what it really means.

It always came so natural to make friends. I had the studious friends and then the ones I
would do the other stuff with parties, shoplifting. Every time I woke up, there was
someone I could have to spend time with. In my late teens I thought, how could anyone be
home on a Friday and Saturday night? For many years, I always had a buddy.

Before I had the drugs, I remember that Linda and I would get high and go to Atlantic
City. She introduced me to speed and cocaine. We were big Diana Ross fans and we went
everywhere we could to see her. I always went to work though. I lost contact with my
friends. When drugs took over, they replaced people. I couldn't pick up the phone
anymore. I lost my communication with people. I was lonely and didn't know it. Drugs
became more important than men and relationships.

For 20 years, I smoked marijuana every night. But after it was laced with something else it
was never the same. One day I looked over and saw 21 roaches left in the ashtray. I knew
not all marijuana was the same, but I was not knowing it was laced with crack. I started
having to go out for marijuana for the first time. I used to buy it in bulk, but then I had to
get the marijuana that was laced with crack or some kind of cocaine. I remember I used to
pass the crack dealers to get to the marijuana dealers. Crack is like a loaded gun. You
play with it until you accidentally hit the trigger.

I went to Princeton to work and to go to school. We would make between $175-$200 a
day at DJ's Pancake house. They were a fun loving people. It was money. We partied.
There was so much money! I did what I was supposed to do. It was a landmark. I
remember when one of the Kennedy's came in.

I lived in a house that I shared with other students. I had the attic room. It was beautiful. I
was crying a lot over the loss of my mother. I was 25 and so tired of crying. Laurie sold
me some pot, but I didn't know what to do with it. I told some guy we were having a party









and he rolled some. I later became a professional. I could clean and roll it. It was the first
time I felt... I felt peace and fell asleep after smoking it. It became a ritual every night.

The first time I smoked pot was at 19. There were two men I had a crush on, Patricia's
husband and her brother. She was a teacher at the college for the summer. They became
like a family to me and we became good friends. I was so afraid at 19 that I didn't inhale.
I didn't like the feeling. I smoked a couple more times with people I worked with, but I
could take it or leave it. Back then it wasn't taboo. It was cool. If you were cool you did
it.

By 25, I needed the pot. I had dealers all over Princeton. Laurie moved and I followed
her. I was her best customer. I always bought in bulk. I started hanging with this older
group of women. They would tease me because I never really liked cocaine. I knew if it
was stepped on, it wasn't very good.

I had a classic MG sports car when I was 27. I was making a lot of money but there was
emptiness. I moved from my room in the attic to a loft that had paintings. I was truly
miserable. I never looked in the mirror. I hated myself. I hated my ethnicity. I had
problems with intimacy. And then there were the drugs. I had a hole, emptiness in my
heart.

I tried self-help, intermittent therapy, searching for God. I knew I didn't have a
relationship with God. I denounced my Catholicism. It was superficial. I left that 45-
minute Mass feeling more empty that when I went in. I tried Christian Science-God is
Love. I found some churches were too white. I also went to some churches where they
were laying hands and speaking in tongues. This one time I remember I took off my $100
shoes and walked home. I cried on the way home, I was in so much pain. And then I went
to get high.

There was a time when all that was available was what was in the pies and cookies. New
York had a dry spell for marijuana. We pooled out money and went to Jamaica to get
drugs. We didn't go to the beach or buy souvenirs. They had huge big trash bags full of
marijuana. We got lots of it there. They loved women. We packed our bodies with
marijuana. We went to the mountains to get high with the Rastafarians. That was good
cocaine. When the plane landed in NY we were loaded with marijuana but we didn't get
caught. Some Jamaicans had brought fruit and goat meat and it distracted the dogs and the
guards. I was so scared. That was the last trip for me, but one of the women got caught
with drugs on a later trip.

At this point in my life, I believe that anything I want to do, that I can do it. I no longer
have limits on life.

I have been here for six months now and there has never been a day where I have hated
being here. I have prayed for purpose, order and disciple. Just showing up and being
accountable is important. Some things take more time, but I have accomplished a lot. I
have peace in knowing that each day I accomplish something, I do something a little
different. I appreciate my awareness and that I have desire now.









Before, as an addict, I stayed in my comfort zone. Now I have sponsors and wise women
in recovery and they show me the possibilities in life. What I love about being here is that
it is about having a full and meaningful life and being a person of character. It is not just
about not using.

In 1999 I got pregnant. I was very heavy into my addiction. I almost thought drugs were a
birth control method. In the past I had used contraceptives. I never wanted to be in a
relationship. Because then you would know the real me and all my secrets. So he (the guy
I was with when I got pregnant) and others were just sex partners.

I got sick before Thanksgiving. I started a new job. Even when I started having some of
the pregnancy changes, all of my money went to drugs. The day I got pregnant was the
day my health insurance started. I got an STD (sexually transmitted disease) and from that
had gotten PID (pelvic inflammatory disease). I remember the nurse pulling the curtain
back, telling me, "your pregnant" and then she walked away. And I thought, "not for
long."

They admitted me that night. I told them that I used cocaine. I thought that would follow
me. I was in the hospital for a long time. They couldn't get my fever down. I remember
counting 31 IVs and then I stopped counting. I had this restless leg thing at night. They
would soak my feet in hot water. I spent 17 days in the hospital. I wanted to go home for
Thanksgiving. I went home, but I miscarried, so I didn't have to get an abortion.

I wanted no connection to the dad, in or out of me. I never attached to the child. I never
had any emotion about it. In the last 12 to 15 years, once, maybe one time, I had a
glimmer of sadness. I would pray, "please don't let me get pregnant." I have used birth
control a few times.

I always had so much responsibility as a child. I was always an old child. I was always
thinking and watching out for someone. I was always the one with the hard shoulders. I
always took things to heart.

When my sister had her baby, I was the one they called on for milk and diapers and for her
first pair of shoes. I was about 18 or 19. They always called on me for money. I never
expected it back. If they ever needed, I was always there for them.

I have a sister here but I'm estranged from her. We had a better relationship when I was in
New Jersey, but the conversation was very one-sided. I wanted her to listen to me. But to
her, I am being "selfish" and "unreasonable." I sent her $500 after her husband left her.
Now, I don't feel like I could ask for, nor has she offered, even $5.

I choose to grow. I surrounded myself with love here. I know I could not live with her.
Even off drugs I couldn't live with her. I made up my mind not to call. Now I can't hold
anger and resentment.

But, I am human. Now I have sadness toward her. She is just down the street. I used to
ask her, "when can you come?" But something was always going on. I cannot forget that
she cannot be there. If it hadn't happened, if she hadn't been murdered, even though it has









been 18 years since then, my sister Deborah, I know she would have brought me meals and
would visit me.

Spirituality is so important. I have peace. I know God is in my life.

In addiction, God's plans are postponed. Now it will happen, what I didn't let God do. I
searched hard for a relationship with God. I know He is there.

I am the phone monitor here for the primary and aftercare clients. Usually you can only
get a call if you are on the list. So it might be 2 out of 20 or 30 calls. We are supposed to
only use the payphone (or not) every day. I have turned away maybe one or two people. I
am a peer. I have been fooled by people calling others, but I cannot be a dictator with that
or use that power.

I am happy. It comes from that I know this is God's plan, allowing him to direct my life. I
genuinely care about the people here. I don't harbor anger. There is a blueprint for living
the 12-steps. Any wrong I do shows God that I am not grateful.

I need to leave that sister alone for now. I don't want my hurt to get in the way of loving
her and her children.

I had a need. I didn't know how my need would be met or where it would come from and
then God provided.

If telling my story can help, especially if it can help another 50 year-old, to know that they
can have 20 more years. At 50, I am still teachable. The only fear I have is that it will take
a little longer to kick start that change. I talk to people, I make small changes.

In the program I am in, I can stay as long as needed. My disability limits me. Ijust got a
insurance card and I am going to see a PCP (primary care provider) because I need to get a
referral to an orthopedic surgeon.

After a year of sobriety, I can work here. I can also go to school. I will probably move to
one of the aftercare houses.

Last year, no one told me I would be in treatment here. Drugs gave me a false sense of
safety. This place has offered me recovery. I had to be in dire straits to take this. If I had
anything, I would have tried to run back to it. I wasn't completely spiritually bankrupt. I
felt like I am going to get though this. That is faith. But I was scared to call it faith. I
didn't trust myself to have faith in me. But I had an unspoken faith in God and now I
realize in myself. And what God has to offer I would take.

I want to help people in addiction. I want the emphasis on a better life. If He can do it for
me, He can do it for you.

Sara's early life experiences included abuse and exposure to addicted family members.

She experienced a number of losses including the death of her twin, the accidental death of her









brother and then her father's death. Her mother died when she was a young adult and then her

sister was murdered. Her early life experiences and responsibilities as a provider for her siblings

may have influenced why she did not want to have children. Sara appears to be doing very well

in her recovery. She is very spiritual and articulate. Sharing her insights and experiences of

addiction and parenting may help younger women in treatment.

Mary

Mary is a very petite thin woman with a strong Irish catholic background. She has a

surprisingly strong voice and despite the numerous traumatic events of her life she has survived.

She survived childhood illness, rapes and the beatings from a number of abusive relationships.

She has no children. She looks like her addiction has taken a toll on her physically. She begins

her story by telling me:

I was born in 1957, in San Francisco, CA. My dad was a chemical engineer and my mom
was a homemaker. I have three older sisters and one younger brother. When I was five we
moved back to the East Coast, to Delaware. My dad had a position at a pharmaceutical
company. My parents were both from Philadelphia.

When I was eighteen months old, I was given seafood and went into anaphylactic shock.
This was in 1958. The doctors gave me Prednisone, which was considered a miracle drug
at the time. They kept me on it for 12 years. Do you believe in reincarnation? I'm reading
this book about it, it's by Sylvia Browne, called "Life on the Other Side."

Anyway, I was raised in an Irish catholic home. When I was five, my father traveled a lot.
He would bring me presents. I remember the time that dad brought me four teddy bears. I
had gotten a fever and ended up going into a coma. They found fluid in my brain from
long-term Prednisone. They had to do a spinal tap. I still remember that. I remember
screaming, the pain was so bad! I remember mom was there. I was afraid of the blood
work they had to do too. I came out of the coma to find myself in an oxygen tent. They
did surgery on me to release the fluid.

My family life was sort of chaotic. There were so many of us and dad was gone a lot.
Both of my parents were alcoholics and my sisters helped to raise me. Kate helped me to
learn how to read. I was so sick that I did not go to kindergarten. When I went to the first
grade it was a catholic school and I was smaller than everyone. I remember the nuns were
mad when they learned I knew how to read. They were going to move me up to the second
grade but I was so small. I loved my second grade teacher when I did get there.









Not only was I small, but I had eczema and allergies. I was taking Prednisone and
Benadryl and at some point, other meds. I had to use so many creams and had to take
oatmeal and tar baths.

I always had a thirst for learning though. In the third grade I remember plays and learning
to dance the waltz. I don't have any major memories of the 4th-6th grade. My dad was a
good provider, but he traveled a lot. I was close to my mom.

Around the 5th or 6th grade they realized that I was not growing. I was taking allergy shots.
The allergist thought that I wasn't growing because of the Prednisone. So they took me
out of school and they took me off the Prednisone. My sisters would bring me home the
work to do. It was not a good time for a month or two. I was very depressed and
emotional. I did go back to school and then was active in the Catholic Youth
Organization. I was in spelling Bs. I was a cheerleader and did lots of acting too. I wrote a
speech in the 7th grade and won a contest where I went on to a State competition. It was a
speech about Martin Luther King.

Between 12 and 13 years old, I started drinking alcohol. It was always in the house and
my parents would throw parties. Me and my friends would buy orange extract and we
would steal vodka from my parents and then we would go to the woods to get drunk. I
didn't get sick using alcohol.

When I was 13 they realized I was not growing. They took me to the Children's Seashore
House after the 8th grade. It was in New Jersey and was affiliated with CHOP (Children's
Hospital of Pennsylvania). They took me off the 5mg of Prednisone when they realized I
was not developing sexually or growing. The Seashore house, it was a rehabilitation place
for children. After three months, I was supposed to start St. Marks High School.

I had had a nervous breakdown. I had scratched my legs until they were bleeding. They
ended up putting me on Valium and Thorazine. I remember my parents driving me to
CHOP. The three months tuned into nine months. I became suicidal and depressed. I did
have a teacher there that became a good friend. Her name was Sue and she was a resident
doc. Sue didn't know what was going on with me and she sent me to a psychiatrist that
was affiliated with CHOP. The psychiatrist said I was emotionally disturbed and brought
the whole family in. My sister who is a social worker said he should have never been a
child psychiatrist.

So in February of 1972, I started attending a new school. The nuns told the other kids to
be sensitive to me. I acclimated quickly, however I was still on Thorazine and Valium. I
remember falling asleep a lot in algebra, but I still got a B. I couldn't participate in
physical education classes.

I remember we would vacation in Avalon NJ, and Cape May. In the summer of 1974, my
father was drunk and noticed the difference in my personality and he took my meds away
and then I started drinking. I remember my dad beat the shit out of me while mom just
watched. I asked my mom to call the police but she didn't. After be beat me, he wanted to
take a walk on the beach. My father would beat mom a lot. I would hide in the closet or









sometimes I would get in-between them. I remember all the lies about the black eyes. I
often felt overwhelmed.

I played the lead role in "The Bad Seed" which was a lot of fun. When I graduated in
1975, I went to Temple and wanted to be an art therapist. But when I went to college, all
hell broke loose. It was my junior year of high school the first time I smoked pot. It was
the end of high school or first year of college that I had started smoking cigarettes. My
first time getting high was when I was 16 on hash. There was a speed doctor in
Philadelphia who had flat beauties and pink hearts. In 1975 and 1976, I had an easy time
making friends. We would do MDA and acid at discos. I smoked a lot of pot but I always
went to class and I had a B-C average. But there was lots of drinking and drugging during
that time.

I was raped by a fraternity guy. That was my first sexual experience. My friends were so
upset. Joe, the resident assistant, flushed the guy's head down the toilet nine times.

They had told me that I would stop growing when I got my period. That was when I was
17. I am four feet, nine inches tall.

I had to transfer from Temple because my parents couldn't pay out-of-state tuition after
putting my three sisters through school. So when I met up with my friends from high
school in Delaware, there were a lot of drugs: lots of hallucinogens, angel dust, crystal
meth, powder speed, pot, and drinking. I got the urge to go to the West Coast and at the
time they had these drive away cars. So there was me, and five friends in a Pinto with
$200 in my pocket.

We ended up in Oregon and there I got a fake ID from someone to get alcohol. We got a
house together and we got food stamps and ajob. There was a bunch of people in that
house and we were all vegetarian. We started hanging out at this gay bar. I loved to dance
and I felt safe in a gay bar. There was a lot of drinking. We also did magic mushrooms
and peyote and always pot and alcohol. I can't remember the first time I used cocaine.

I had two summer jobs when I was in college. One summer I worked in the Seashore
house. I worked on the kids unit as a ward clerk. That was when my friend with CF died.
Another summer I worked on a pier in Atlantic City. I remember on the ward there was a
baby that was born addicted to heroin. The baby was suffering. I was so angry at the
mom. I never did do heroin.

When I worked on the steel pier in Atlantic City, I had gotten an apartment with two
friends from college. We were selling hash and we got ripped off. I remember the
hurricane that came and destroyed half of the steel pier. I met this guy on the boardwalk
and I agreed to date him. I am not sure why I agreed to date him. I didn't have any real
dating experience. He forced me to perform oral sex on him and then he wouldn't leave
me alone. He kept coming around to my apartment.

I met my husband in the gay bar in Oregon. He was bisexual. I was dating two people
then. He appeared gentle and kind. He was older than me and taught me a lot. I had my
first orgasm with him. He was an alcoholic and a heroin addict. I moved with him to









Venice Beach, CA in 1979. He was Jewish. I agreed to marry him when he asked but I
didn't tell my parents. The first year of my marriage I was very happy. I would go
swimming a lot and roller-skating.

After the first year, my husband became very controlling and abusive. He didn't want me
to work. He forced me to have sex with him. He forced anal sex on me too. I had no
friends. He had a nine-year-old son that would visit in the summertime.

This one day I had like a premonition that something bad would happen. I had been
diagnosed with panic attacks, agoraphobia and depression. We were living in this
efficiency apartment. We lived near, about a half a block, from muscle beach. There were
some swings I loved to swing on there. I was there swinging. It was early evening. Then
this Black guy came up behind me and he raped me. He drug me down the beach with a
metal pick to my throat and then he raped me. I got in the shower for four hours. My
husband didn't believe me. He didn't believe that I was raped.

I had a nervous breakdown and called my sister. Some people helped me, the owners of a
deli. They and my sister helped me to get to a social worker. I did call the police but I was
afraid to go. It was in an area of all Black people. My husband was very mean and
abusive. I left him and went to a battered women's shelter. He found me and I went back
to him.

I got a job at a toy store. It was small but lots of famous people came in. I was only
married three years at the time. There was a woman who worked there. Her husband was
a dealer and a heroin addict. I watched them, disgusted, but later I wanted to try it, but not
by needle. I was going to smoke or snort it, but then I had a vivid dream. I was in the
forest, where I was high on heroin and then the deal for more heroin fell through.

My husband got real bad. He was getting blowjobs in the park and was having real erratic
abusive behavior. My parents visited and found out I was married and they freaked out. I
had met him in 1978, married him in 1979. In 1980, we decided to go back to Oregon. I
went ahead of him. I met this woman in Oregon and had a sexual experience with her. We
couldn't get heroin there but we were doing cocaine.

I got a job as a CNA in a nursing home. In 1981, I met my friend Ruth. We are still
friends today. I liked my job then and felt like I was maintaining. I would see my husband
occasionally and he got violent. Ruth helped me, she told me she wouldn't be friends with
me unless I left him. I became a physical therapy assistant.

Ruth was bisexual and was seeing a guy. She was dating this guy and later got an
apartment with him. I moved eight times in a two-year period. I rode my bike to and from
work and took art classes in a community college. I became very promiscuous. My friend,
Bud, gave me opium and I loved it. I also did MDA.

I had had an affair when I was with my husband with his best friend. My husband had had
a vasectomy, but I got pregnant and then had an abortion. I had three abortions when I
lived on the West Coast. I never told anyone.









I did volunteer work as a counselor. I connected with a Y and taught children how to
swim. I had lots of problems with my allergies and my eczema was very bad. I didn't
trust doctors because of my past experiences.

I had a job at a nursing home where the patients were all Medicare or Medicaid. But when
Reagan became president there were budget cuts and I was unemployed. I went wild with
my friend Sara. We had a small fling but were good friends. Sara was abducted at two by
her dad. So we went on an adventure to find her mom. After three months, I had to make
a decision. I had a friend Patty who was in Atlanta in 1983.

Positive memories? When I won the declamation contest in the 6th grade, the best actress
contest in the 8th grade, having the lead role in the high school play when I was a junior. I
always loved music and I went to a concert in Philadelphia in 1974. The other positive
experience was my cross-country trip.

I had some good memories and some good friends. My teen years were a confusing time
and hard because of my health issues. When I went to the Children's Seashore House it
was a very difficult time. I felt abandoned and scared and lonely and depressed. My
parents would come on the weekends. Nine months is a long time to be away from home
when you are 13 years old. I felt out of place and scared at school. I was on Thorazine and
Valium. I was numbed out. I wasn't feeling.

My dad died on Labor Day in 2001 and they found out mother has Alzheimer's around that
time. My sisters couldn't find me, so I found out after the fact. I felt like I lost them both
at the same time. In 2003, mom had to get her foot and part of her leg amputated. Mom
was alcoholic. At some point she may not recognize me anymore. She is 79 now. My
mother was my best friend when I was growing up. We did a lot together. Mom always
took me with her. We would go clothes shopping at nice stores in Philadelphia.

I remember going to see an endocrinologist at 12. I had this horrible fear of needles, but I
had to have my blood drawn.

Bestco was my favorite store. Mom loved to dress me up and to shop. I had a lot of fun
with my sisters. We would make up plays and play board games. Kate taught me how to
take the bus to the library. I was an avid reader. We played croquet a lot. I think all of our
parents were alcoholics.

I was brought up in a white suburb. My first exposure to other races was when my sister
worked at the boys club. This one Black boy came in our neighborhood and the neighbors
flipped out. My dad was very prejudiced, but he didn't raise us that way. I became fearful
and changed after I was raped by a Black man. There were over 800 people at dad's
funeral. He had lots of friends.

My sisters and my brother are not alcoholics, but I am sure it will pass to some of their
children. There is a long line of alcoholics in our family. I have a cross from Ireland that
my dad gave to me. I will show it to you. It was a magical time when he gave that to me.
One Christmas Eve, he came home very late. He came home so drunk he couldn't stand. I
was devastated. We had a total love-hate relationship. He knew me so well he could make









me cry in seconds. I regret not being at the house when he died. Everyone was there,
except me.

When I was little I spent lots of time at the company pool. I learned to swim when I was
six. I still love to swim. There were lots of parties and barbeques when I was growing up.

My grandpa, my mom's dad, was VP of a football team. We would go to their house a lot.
They had seven kids and each of their kids had five or more kids. My grandma was an
alcoholic. She had diabetes and ended up with colon cancer before the cirrhosis got her. I
wasn't allowed to go to her funeral. She died when I was 9 or 10.

Grandma had three sisters that were old maids. Grandpa, he took care of her sisters. They
were a lot of fun, like paper dolls. I have great memories of my Aunt Gwen. We would go
to the football training camps. We would go up there. I loved the smell of chocolate. I
loved football and baseball.

Grandma had colon cancer. A lot of people have had colon cancer in my family. I need to
get screened again. It has been three years.

The first time I hears about Alcoholics Anonymous was after dad's drinking started
interfering with his work. I went to get change from his pocket and found an AA schedule.
Our family was full of secrets. I just found out recently that one of my sisters got pregnant
in high school and gave the baby up for adoption.

I remember when I was a child I loved the fireworks. I stood on a picnic table and sang
"America the Beautiful." I was happy. It was a good feeling, a really good feeling. This
is the cross I told you about. It's a St. Patrick's cross from Ireland. I lost a lot of stuff, but
I managed to hold onto that for all these years.

My grandparents on my dad's side met in Philadelphia. Both of them were from Ireland.
He was a trolley car diver.

In 1974, I went to England, Scotland and Wales on a school trip. When I was 30, I went to
Jamaica. It was so beautiful I almost didn't leave. My dad had a lot of frequent flier
miles. The attitude was peaceful and calm. Everything was peaceful. You lived in the
moment, for the now. Our meditation today was about that...being where you are.

I moved to Atlanta from Oregon in 1983. I owned a house in Atlanta in 1993. That was
when I was sober the first time. I went to AA and NA and had a good support system. I
got computer training at Goodwill Industries and then got a job there in human resources.
I had lots of good experiences and was happy and prosperous.

I got sober in February of 1992. I met this guy in 1993. I made a vow not to get in a
relationship for a year. Now they say that you need one month of recovery for every year
of active addiction. I met him in AA. He moved in with me in 1994. He smoked pot and I
overlooked it. I thought he needed it for medicinal purposes. I had never seen marijuana
addiction. But he would go into a rage when he ran out.









In my third year of sobriety, as part of an after-care program, I went to see a psychiatrist in
1995. He gave me meds for depression and anxiety and agoraphobia. I was diagnosed
with panic disorder, PTSD (post-traumatic stress disorder), and depression. I was having
panic attacks around large groups, like in the grocery store. Wal-Mart is a bad place for
me.

The put me on tricyclics first and eventually put me on Effexor and Xanax. Now I am on
Seroquel too. I have a roommate with four personalities. I feel like I am walking on
eggshells. It is hard to be in recovery and not get down to the nitty-gritty and be honest.

I got a new job here. AA is a wonderful program, but should be more drug focus, not just
alcohol. I am reading this book about a 16-step program for women. She wrote about
women, sex and addiction too. A lot of us with addictions have other issues.

So back to Ralph. He was addicted to pot. He had ADHD (Attention Deficit
Hyperactivity Disorder). I gave him some of my meds. We were good friends. He was a
sex addict. He had a sex addiction. He masturbated a lot. It was weird. He also had
problems with rage and anger. He took his anger out on me. He broke down doors. He
grabbed me by the neck. He tried to bang my head on the washer. I feel sick thinking
about what he used to do to me.

Ralph and I lived together for six years. In 1998, he had bought a gun. It scared the shit
out of me. He pulled it out on me a couple of times. He would shoot it in the back yard.
He shot one of my ducks. I was a workaholic. I brought work home.

I tried to call police and to get away. In 1998, I decided to put the house up for sale. I was
preparing it to be sold in May of 1999. I came to Florida. The plan was to put the house
for sale. My sister's sister-in-law was a realtor. I came to Florida for a job interview. The
house sold in just one day. I had 30 days to get everything out. I wanted to get out of
Atlanta and get away from everything.

Jacksonville reminded me of Atlanta. I looked around in St. Augustine and found a condo.
But it was a bad real estate deal. I gave him $9,000 but it was just buying out his interest.

In December of 1998, I was occasionally drinking again. In May 1999, the house sold and
in June, I started drinking more. I was probably smoking pot again too. I was scared of
Ralph in the end. A friend of mine helped with a U-Haul. Ralph didn't know the address
or where I went.

Two friends came to visit me in Florida on the July 4th weekend. We went for a walk on
the beach. I guess it was some lint from the towels that caught on fire. The fire trucks
were there when we came back from our walk. I did have insurance, but I was so
depressed. I took a handful, about 23, Xanax. I spit most out. I was going to kill myself.
I said, "No, I can't do this!" So I went to a local bar and bought a drink. I met this guy.
He felt sorry for me. There was a lot of smoke damage. He said I could sleep in his
condo. We had sex of course. I was drunk.









I ended up marrying him. He was an alcoholic, a real bad alcoholic. I felt like I needed
someone to take care of me. Within a year, I lost almost everything. I couldn't get a job. I
was living off of credit cards. My truck got repossessed on Christmas.

On New Year's Eve of 1999, going into 2000, he stole two 12-packs of beer. I was in this
U-Haul he had been working on when he stole the beer. A cop was waiting when we got
back to the condo. The cop hit me and gave me a black eye. Another girl I met later, the
same cop had given her two black eyes. The cop died about 6 months later. I was charged
with petty theft, even though I didn't do anything. Someone bailed him out and then he
bailed me out. That's why they say you have to change your people places and things.

This was the first time in jail for me and I got six months of probation. I ended up
violating probation. I'm not sure how. I had to pay $40/week and I didn't have it. They
came to my door and I had been drinking, so they brought me to jail. I had just gotten my
income tax refund, three or four hundred dollars, when they got me for violation of
probation. I can't get out and then he went drinking and he got violation of probation too.

I was stuck in jail for 40 days. I was embarrassed, ashamed, didn't want anyone to know.
Even today they didn't know.

We had this meeting with a lady from a church. I got called out and it was my sister. This
was in March or April. The probation officer had called me parents. My dad had cancer
but it was in remission. I was so mad. How could they contact my family! They brought
me shackled in front of the judge. The judge gave me time served and withheld
adjudication. He had gotten 90 days, adjudication and maybe another year of probation.
He had taken my money.

When I got out of jail, I had no money and nowhere to go. I took a taxi to Bill's and then I
went to my condo. There was no electric or hot water. I stayed there that summer. I'm
not sure how I survived. Betty helped. Eventually I got a job in a souvenir shop.

His sentence. He had to go to a treatment center. There was a Christian one south of
Orlando. I never saw his record. There was a lot I didn't know about him. It was October
or November of 2005 when I left him. There are lots of lies he had told me. The whole
marriage was a lie.

Right now I am reading Everyday Grace: Having Hope, Finding Forgiveness, and Making
Miracles by Marianne Williamson. In relapse, you can't concentrate on reading. I'm
taking a spirituality class now. It's at a soup kitchen downtown. I go there to do service
work. The disease affects the physical, mind, emotions and the spiritual. I am going to
work on the spiritual part of the program now.

Relapse was definitely a learning experience. I was very involved in recovery when I was
sober before. It doesn't go away. The pain and suffering. It progresses rapidly. I guess I
needed to test that, but it really is the truth. Addiction leads to jail, institutions and death.
He (God) brought me back to life to give my story to others, so that it can give strength
and hope to others.









It was October 17, 2005 and I was in St. Augustine. I had a broken foot. My husband was
on a binge and I was trying to help him. He was a binge drinker and couldn't work. I
couldn't work with my broken foot. I was trying to get him into detox.

The cops kept coming to the apartment. I have resentment against cops. They saw what
he was doing to me, but the just asked me, "Do you have a safe place to go?" and told me
that I should leave. I got a restraining order against him, but I left sometimes. I was
arguing one of these times and I fell down the stairs right in front of the police.

I waited for 2 weeks before I got help for my foot. I kept drinking. I was in excruciating
pain. I left to go to the food stamp office and then I was going to go to the emergency
room. He disabled cars so that I was unable to drive. I was waiting for the bus for about
1.5 hours and then the bus went right by me without even stopping. There was this man in
a suit driving an SUV and he asked if I needed a ride. I normally don't take rides, but I did
and I went to the emergency room first instead of the food stamp office.

I was drinking instead of eating and I went from about 105 pounds down to 77 pounds.
Plus I was very stressed. They gave me a Loratab and crutches. It was hard to learn how
to walk on the crutches. I waited for a taxi. I started to feel dizzy and nausea and I said
out loud that something is wrong with me. The guy at the desk said the cab was coming
and that I had to leave and go outside. The cab driver carried me back to the triage nurse.
It was 10 minutes before 2:00pm.

My heart stopped. They said cardiac arrest. I flat lined three times. They broke my ribs
doing CPR. They cut off my clothes. If I had not been at the hospital, I would have been
dead. They told me, "You died. You turned blue. Two more minutes and you would have
been on life support." They were surprised that I could even talk. The cardiologist could
not find anything wrong with my heart. So this was a wake-up call for me. Everyone was
saying it was a miracle.

I was able to contact my sisters. Kate is a nurse. It didn't stop me from drinking. I was
confused and depressed. I didn't want to live. Basically, I was homeless, with no food, on
crutches. I was mad.

He had isolated me from friends. I got out and started drinking again. I didn't care. I had
been involved with this man in jail. He gave me $5,000 to get him a lawyer. I didn't trust
him. I knew he had violent tendencies because he broke my collarbone. I was so
desperate; I got sucked back into being with him.

I got back with him. There were the promises, "I've changed... I'll never do it again." etc.
We moved to New Jersey about a week before Thanksgiving. After 24 hours on a bus, I
got a voucher from the battered women's shelter to get some clothes. It was cold. I never
went back to the hospital to get my cast. I was supposed to go back.

He was a commercial fisherman. He had ajob lined up and stayed with his sister for five
days. Around New York, he started to change. He was going out on some trips. Of
course, I was still drinking. He started saying weird shit. He became very controlling.
Then he became violent.









About a week after New Years he came at me with a knife. The violence escalated. I
knew I had to get away. He broke my crutches. It was winter. It was cold. He would
give me money and then take it back. He would give me money for cigarettes. I was
driving across the bridge and out of nowhere John punched me and gave me a contusion.
Another time he punched me in my eye. It escalated. I saw stars when he hit me. I
escaped and ran to the landlord. They helped me and gave me the courage to get out. He
ran and got in the car before the police came. The landlord gave me part of the rent back.
With that $175, I took the Greyhound bus to Atlantic City and then back to FL.

Two older men in St. Augustine asked if they could pick me up and they let me sleep on
their couch. I stayed with them from the end of January to February 15t. I went to detox
on my birthday on February 15th. They sent me back home, detox only lasted a couple
days. Then I stayed at a domestic violence shelter. I stayed there for about three weeks.

You couldn't bring alcohol in the shelter, but there was a store up the street. I would sneak
beer into the shelter. I had to go through the county for payment of my medical. I went
into detox three times in March. I couldn't stay sober for even 24 hours.

I was here for two weeks and I realized that 28 days would not be enough for me. So I
asked the counselor since I was homeless and now they have extended it for as long as it
takes.

I want to go where God leads me. I would love to work and go to school. I need to get
prepared. In the mean time, I am safe here. I've been praying. Yesterday, I prayed,
"Please send me a sponsor today." And, yesterday, I found a sponsor! I wanted her to be
my sponsor. It was at the house where I go to meetings. I came to the meetings for a
while. She is in her sixties and has a lot of sobriety. She said yes!

Slow is good. I need the support before I go out there. I don't need men. I have been
collecting the phone numbers of women. With my sponsor, I will call everyday. It is
about reaching out. She will be my mentor and help me with the structure and discipline
of the program. You know that saying, "When the student is ready, the teacher will
appear." Well that has happened for me.

Mary is a survivor. She has to deal with childhood illnesses and growth problems and

alcoholism was prominent in her family. She was raped and beaten by men in most of her

relationships. Most of her partners also had addictions. She began alcohol use early and used

multiple drugs in her young adult years. She was arrested a number of times. She experienced

three pregnancies which were terminated by abortion, although carrying a pregnancy to a healthy

delivery may not have been possible due to her circumstances (pre-existing health problems,









repeated beatings from partners and heavy alcohol use). Considering all that she has been

through, she seems to be active in her recovery and is excited to have found a sponsor.

Jackie

Jackie is a 31-year-old mother of six. She is from Jacksonville, Florida and has been

married for 12 years. She begins by telling me about her children:

My boys are ages 11, 10 and 9. My girls are 7, 4 and 2 years old. My cousin has three of
them and my cousin's mom has three.

I went to school for dental assisting. I worked in fast food and was almost a manager. I've
also been interested in a career in childcare or cosmetology, or modeling. I had to grow up
fast.

My mom was a single mom. She was a good mom. She took us places. When I was 13,
she met my step-dad. He molested me from the time I was 13, until I was 17. He
threatened to hurt my mom if I told anyone. The hardest thing was watching him do stuff
to my best friend.

My step-dad would do stuff to get me in trouble so that I would have to stay home. He
worked for the law. It was horrible growing up in that house. My oldest brother got put
out when he found out what was going on. He did his own daughter like that too. I used to
have nightmares about what he did and I turned to drugs and alcohol.

God placed me here. Wednesday will be 14 days. I always took care of people, but it was
this place and God that helped me.

In high school I had one friend. I didn't talk much at school and then my step-dad took me
out of school. I wend to a community college and then I graduated with a dental assisting
degree.

I never got to go to the prom. I used to be nervous around a lot of people.

For what he did to me, he only stayed in jail one week. Then he had to live away for a
year. When I was 16 but they got back together. But, he was on me (sexually) when my
mom was in labor with my baby brother. I have two older brothers and my baby brother.
He is 17.

I recently found out I have 4 more brothers and two sisters from my dad, but we don't talk
much. It was just about two years ago when my dad first met his grandkids. My mom is
now 55 with Alzheimer's.

It was my half sister who called social services on me. She said there was no food and that
the plumbing was messed up.









I grew up in church, but I was drinking every day. Now my liver is swelled.

There was this girl Melissa I started raising when she was 12. Her mom was on drugs and
she was trying to sell her daughter's body. She lived with me once and then again. Now
she is 23. Melissa and my husband ended up being together and having sex. That would
drive me to get high and drink.

My husband is disrespectful. He was trying to get me out of the picture but now he is
trying to get back with me.

I had my neck broken in October. There was this party. I was drinking, partying and
doing lines of cocaine. These men at the party jumped on me and my head hit the bricks. I
broke my neck when I fell. My head was in a brace until April.

I needed his (my husband's) help, but I would hear stories of him cheating at work. He
slept with my stepsister. My husband gave me gonorrhea when I was seven months
pregnant. One time I jumped on him after finding a letter about him with my sister. He
was sleeping with my friends too.

He beat me and broke my jawbone and was in prison for 14 months. That was 5 years ago.
The last time, I was home washing dishes when he hit me. He left me stranded several
times. Once when I was stranded, a guy tried to rape me and I cut him up.

One of my brothers got 30 to 40 years in jail, but now with DNA he should be getting out.
He came once and shot up the house, but he didn't get arrested for that. I'll take care of
my mom when I get out of here. My Aunt will help.

I did stop drinking for a while. At one point I said "I will never try that white stuff."
When I started using cocaine, I went from using 2 days of the months to using every day.
The first time I used my friend offered it four times and I said no. The second time it was
offered, I tried it again. I started using crack three years ago.

I always paid for mine. I didn't have to prostitute to get it. I had one affair related to
crack. Crack isn't good for you when you trying to work. I was selling it in 1999 and I
thought let me try it. No, I started smoking in 1998. At first I could handle it. A lot of
girls would prostitute to help get me high. Crack will make you lie. Crack will kill you!

Wednesday will be thirty days that I have been here. Before I got here I was living on mint
gum and beer. I didn't eat. I used to take pain meds with coffee. Crack was making my
blood pressure high. I smoked $1500 at income tax time. I was smoking it in a cold tub.

Once when I was selling drugs from a hotel I got robbed. These men came in and put guns
to our heads. They made us take off our clothes and tied us up and put us in the tub. It
was horrible. I still remember that. I think it was my friend's boyfriend that set us up.

I couldn't handle cocaine. This one time Ijumped in 12 feet of water at a pool party;
knowing I can't swim!









My kids know about me. I want them to grow up drug and alcohol free.


I had a 10-year affair. One of the babies was his, but I had a miscarriage. Now I look back
and can see that I was off the chain. I was disrespectful. I had a lot of anger.

My husband always complained. I cooked and cleaned and put the kids to bed. I'm not a
bad person; just on drugs.

I used to clean a dope girl's house to get high. You know you never expect to be gone for
three days when you are on crack. I went to AA in jail but I didn't feel like I belonged. If
I had known about this place I would have been here a long time ago. I started drinking
and marijuana at 18 and cigarettes at 19.

I did have some good experiences. I was on the A-B honor roll in the 6th grade. I was
proud to walk down the aisle at the career institute. Other good things that I think of are
having potential and needing to put my mind to it, going to church, and when my kids tell
me what they would like.., for me to do right.

My visits from my kids keep me positive and moving forward.

I have three siblings, two brothers, one older and one younger. I didn't grow up with or
know my dad. School was fun from the 1st to the 5th grade. I used to get in trouble for
biting people at school. For middle school I went to a 6th grade center and then the 7th and
8th grade.

Mom never drank or anything. It was my step-dad who drank. On holidays we would go
to visit family and have big dinners. We would cook or go out of town. I remember I
always had birthday parties. We would go to NY to visit family in the summers. I hated to
go home. We went to the mall, Chinatown, on the subways and to see the Statue of
Liberty.

We would hang out at night. We would sneak out at night. When I was 17, I remember
the zodiac killings. The city isn't as safe as it used to be.

When we were little we used to stay with my Aunt and two cousins. She would dress me
and one of them (my cousin) up as twins cause we favor each other. I was a tomboy
growing up. I liked parks and to ride my bicycle and roller-skating. We couldn't go out
until mom got home when she was a single parent.

I remember my granddad in Georgia (mom's dad). I saw some of my family for the first
time at their funerals. My dad's mom, I met her once and then I went to her funeral when I
was 23.

I got along good with people. I had lots of white friends at school. My best friend was
Kim. I was 17 when I started menstruating. I was at school at lunch and didn't know what
it was. I got up and went to the office. I didn't want to go home, but I was kind of scared.









I got involved in an accident at my grandmother's funeral. My brother threw a flower with
a metal stick in it and it stuck in my eye. I had to get stitches in my eye. I wore metal over
it for about a year. I was two years behind in school. I got a broken nose too when I got in
a fight with this dude.

I would get in a lot of fights at school. I was always taking up for people. Kids used to try
to make fun of me, but I let it go. But I did beat a girl up in the 11' grade after taking a lot
of teasing from her about my eye. The girl ended up needing stitches, I beat her so bad.

I had my first boyfriend at 17, but not for long. My step-dad always found something
wrong with them. I got serious with one at 18. My step-dad would tap the phones. He
said "No one is gonna get or kiss what I'm getting." He got caught up when his
conversations was taped. He was with one Aunt. He tried to sleep with all of them. Mom
found out when she came home from the hospital.

My step-dad would get me out of jail. I've been about seven times in jail. I've been
arrested for public intoxication and worthless checks. In jail, I would just pray about stuff.
But I faced a lot of discrimination and name-calling. I was arrested for disturbing the
peace and they said maybe I needed to do 45 days in jail. I also got arrested in North
Carolina for public intoxication. Up there I was locked up with murderers and women
who killed their kids. I lived in NC about a year.

One time my mother-in-law called the police. She said I slapped her and beat her son. I
was in jail overnight for that. My husband always went to talk to his mom. A friend
befriended me, a man's mom. I used to drink and gamble and ride with my brothers. I
used to have anxiety around people.

I don't want to have to do time to see my kids.

I had a visit with my mom and kids yesterday. I have drug court today. They do tests
sometimes and if later you pop up dirty you go to jail or they put you back here. I brought
my AA book and my journal with my assignments. I'm going to start making a scrapbook.

In my adulthood, I have had a number of jobs. I started working at Crystals when I was 16
and I worked there for 5 years. Then I went to school for dental assisting. I did security
from 1999-2001 and then I went back to fast food. If I go back to that, they will move me
up to management. They would give me a lot of raises because I was hardworking. I was
so fast, so some people didn't like me.

I was close to my family as an adult until my husband turned them against me. We would
go to church, drink and go to the club. My cousin didn't drink like me. She has three of
my kids. Her mom has three. My husband lied on me a lot. When he started turning them
against me I felt like I had no one except the kids and my mom.

The plan was that after I finished school I would move in with my cousin. It broke her
heart, but I met my husband when I was 19 and I moved in with him in 1994 and got
married later in 1994.









Now is my first time in treatment, but if I had known I would have been here a long time
ago. I have plans to take advantage of aftercare.

I started using alcohol and weed when I was 18, but I was always with someone. I never
bought back then. Then, I always had drugs or had a dope friend. When you start smoking
your own drugs they say, "You are your best customer." I sold them first. I showed my
brother how to cut it up to sell. My roommate knows my brother. He is two years younger
than me, but he swears he is my daddy. He sells drugs, but he is worried about me.

One time my brother went to my cousin's house. I forgot I had cocaine in the door. He
and his friends took my cocaine and my money once, but I went to get more. They called
my mom. It was me and my husband that started showing my brother. And then I started
getting it to sell. I was just selling it first. I was just drinking and smoking weed.

I first tried powder about six years ago. At first I always said no. I really got sprung off
cocaine. I started dancing and doing private parties. My whole body would get sore. I did
that for about four years. I would dance and strip at super bowl parties to make some extra
money. My husband didn't know. I would leave my clothes and shoes at a friend's house.
When I left him, no one was there for me. I always went and got mine. He wasn't one for
working.

I always had financial struggles. My step-dad had rich friends that I used to go dance for.
I was so nervous I had to drink. I was about 23. I did what I had to do for money.

As my addiction progressed, I got worse. I used to prostitute with girls and dudes to get my
money. I would go with my step-dad's girlfriend. She would buy my cocaine and pay me.
She would always have my crack rocks. If the drugs ran out I looked sick, so I did what I
had to.

Sometimes I think in the back of my head, "Living like this ain't me. It's a sin." My
husband didn't know what I was doing.

My cousin knew. Once we were going to the club and she snatched my cocaine and I had
to beg her to give it back to me. I used to call her goodie two-shoes. I didn't want her to
try it though. I told her that after that first hit, you can't sit down. It goes on and on and
on.

My kids know. They ain't stupid. I never did it in their face. It was in the bathroom or the
shed or a hotel.

Some of the stuff you smoke, you think will whip you. You wouldn't believe what I've
seen. I've seen grown people boo-boo on theyself. I saw someone get killed over a
lighter. I've seen where drugs can take you. There this lady that lives in an Explorer
truck. She don't eat, just uses drugs. She do slimy stuff so I don't feel bad for her.

I seen people have sex with a guy with no protection. A few people in here have got full
blown HIV. I've seen females trick for fifty cents. I used to give them two or three
dollars. Crack will take you there. I don't treat them no different, the people with HIV.









There is men in here with it trying to step to females and have sex. There was this one
couple in here. They left and the dude ended up killing her.

I didn't know I could have died. I don't want my kids growing up without me. I was
embarrassed at my daughter's hair yesterday. I'm thankful that they are there and not in
foster care, but nobody will do it (take care of them) like mama. I was happy to see big
mama too, in her half a mink coat in the summer time.

The doctor told me about two years ago that my liver is swollen. I used to drink about 20
beers a day. I was at the Salvation Army for a little while, but one of the workers came in
on me in my underwear. I went off on him and got kicked out. I met someone there and
moved in with him for a while. When my husband was working, the kids were in daycare,
so Ijust had my baby with me. But my friend kept using and running out. The police kept
coming bringing him back.

Sometime it's not just what you do that causes a problem. Some people talk too much and
then you get the wrong picture. I'm not going to risk getting in trouble if people talk about
me. I don't want to hear it anymore.

I'm really admitting to it now. I was stealing from my mom, saying "Lord, please forgive
me." I would take money to get high. She has Alzheimer's. I was lying to my mom, but
she knew.

My Aunt is a preacher. At one point we were only smoking weed. Now my brother
smokes blunts back to back. We would smoke weed to take the edginess off. It helps.

Smoking stuff was the worse thing in my life. I lost cars, houses, family and friends.
Friends be hating on you when the money runs out. Never say never.

I'm going to change my people, places and things. I'm going to be involved in church,
school and in my group. Drinking can get you started. I asked when I came here why I
had to stop drinking.

There was one friend, I let him start staying with me. I used to bring him customers. He
helped clean and to put the kids to bed. I sold his phone and he never got mad at me. He
never told me no. That's what gets you started. Eventually, I had to put him out. Some
people do care, even dealers.

Jackie did not make it to her last interview. She had drug court that day and did not return.

While I cannot be sure, I have a feeling that she may have relapsed. Jackie was one of the

younger women interviewed and had been in treatment for a very short time. She did not seem

to have a strong support system, although relatives were caring for her six children. During the

interviews, Jackie's behavior reminded me of addicts I saw as a teenager in Philadelphia during









the late 1980s. It seemed that her thoughts would jump around frequently and she would move

erratically. She was well aware of the dangers of her addictions, but the drive to use drugs again

may have been stronger than she could handle. Hopefully, she will recover and be reunited with

her children.

Tracy

Tracy is a Caucasian woman who is from Long Island, New York. She is 43 years old and

the mother of 4 boys, ages 9, 12, 15 and 1 year. She remembers lots of positive experiences in

her life. When asked about her top 5 she replies:

The top 4 are my kids. Other great experiences and memories are coming into treatment,
going to see "Cats" on Broadway when I was about 20, going to see the ball drop in Time
Square, when my son received close to ten awards two years ago and had to travel to the
state capital and my first marriage, the day of my wedding.

In my family, I have just one brother, six years younger than me. My dad is awesome! He
has a Masters in Psychology. We have a great relationship. In fact, I lived with him from
the time I was 12 until I was 18. My mom is also great and was a lot of fun. All the kids
used to come to our house to go roller-skating. She now fusses a lot about the grandkids.
My 15 year old lives with my mom right now while I am in here. I will go live with her
after treatment. My 9 and 12 year old are with my ex-husband, my second ex-husband. I
have pictures of my babies to show you.

My parents got divorced when I was 4 years old. At that time, Dad was an alcoholic. He
went into AA (Alcoholics Anonymous). He never drank after the divorce and I used to go
visit him every weekend until I was 12 years old. He died on Christmas Eve of congestive
heart failure, a heart attack at 63. I don't really remember his alcoholism, but I remember
going to an anniversary meeting celebrating his sobriety.

As far as grandparents go, my mom's mom is 89 and still independent. Grandpa died in
1989. We used to visit on weekends when I lived in NY. They retired to Jacksonville. I
moved to Jax (Jacksonville) in 1989, after my first divorce. I needed a change in scenery
and my mom and grandparents were down here.

After my first son was about 18 months, my dad moved to Florida to be close. He got to
see the first two grandsons.

I can't blame my addiction on my parents. I just smoked pot for 16 years; from the time I
was 17 until I was 35. I quit for 7 years, was doing fine and then tried crack when I was
41. You see I had gotten divorced from my second husband. I was doing okay, living in
my own apartment and then my niece and nephew moved in. My ex-husband had cheated









on me four times and I was very depressed. I tried smoking (crack) with them. They
wanted to make me feel better. From the very first time I tried crack I was addicted. I
wrote a poem. I'd like to share that with you. I was in rehab for 9 months and doing well,
but then I had 12 days of relapse and used crack on 8 of those 12 days. I've been here just
a little more than 4 months now.

I wrote a poem, a letter to my addiction. We have these presentations here, Voices of
Hope we call it. We have people sing and sometimes I share my poem. I wrote a poem
about crack after praying to God for help and then ended up here in treatment. The poem
is about what you go through when you are on crack.

The World of Crack
Welcome to the world of crack
Whatever it takes it won't give back.
This nasty drug has an evil high!
Kiss all that you love and that you care for good-bye

How quickly you'll change without even knowing;
How little you'll care about those changes showing.
I look in the mirror and hate what I see;
I wonder what happed to the real me.

You'll smoke and smoke as the days pass you by.
Some mornings you'll wake up and wish you could die.
Crack will consume you day after day
But still you will chase it and smoke anyway.

You'll start smoking more as time will pass;
You won't even realize it's kicking your ass.
You'll think you're in heaven, but welcome to hell!
You're walking on fire and can't even tell.

The devil himself must have brewed this drug up
He cooked it in his evilest cup
Man could not make such an evil mistake
A drug that will cause only pain and heartache
You'll do things you never thought you could,
And, at the time, you'll think its all good.
Forget about sleep, forget about eating;
Your body is on for one hell of a beating.

Your so called "friends" are nothing but crutches
They'll help you get closer to this drug's clutches
Any true friend would steer you away
From a drug that will take every cent of your pay.

I'm completely fed up, can't take anymore









I won't let myself be crack's mistress or whore
I want to get back to the life that I had
I'm tire of feeling nothing but bad.

It's time for a "wake-up of a different kind
I'm going to take back what's left of my mind.
I'm changing direction, I'm going to straighten up,
Flee from me Satan, I'm smashing your cup.

Jesus is sitting right here by my side.
He'll help me get through this bumpy ride.
So look out world, I'm coming back!
I say "KISS MY ASS" to the world of crack.

I started running away when I was young. I ran twice from dad to mom and then from
mom to dad. After about a month I would go back to Dad's house. I didn't want to move
to Florida, but then I missed mom and decided to go to Florida. I did have an addictive
personality. I never really drank alcohol though. I tried it once when I was about 17 and
got really sick and from that point I never really drank. As I got older, I kept running from
admitting to addiction and kept running from help. I kept running until I was ready.

I was used to running from things instead of dealing with things. Rather than argue, when
there was a problem I would walk away. Like with my ex-husband, we never argued in
front of the kids.

So back to my own childhood, like I said, I grew up in Long Island, New York. It was a
great neighborhood. Everyone knew everyone. You could leave the door unlocked. I
wish things were more like back then today. At least in the three-block area I lived in, it
was safe. I had a really good childhood. I did great in school. I loved school and the
teachers. But then I quit school in the 11th grade. I started smoking pot. I was bored in
school, very smart, but was bored. I eventually did get my GED and had very high scores.
I went to college after getting my GED. I went to the community college for two years
part-time and almost completed an AA in psychology. I always admired my dad. He was
smart and always had answer.

My mom, she has always been there to help me. Now, it's my time to help her. I will
move there with her after treatment. I could even go back to school. My mom never
smoked, drank or did anything.

I started smoking when I was 17 and still smoke 3 or 4 cigarettes a day. Cigarettes have
been the hardest thing to give up as far as trying to quit. I have talked to heroin addicts
who say the same.

Holidays and birthdays were great when I was young because there were always two sets
of everything. When I got older going out to dinner in NY and to a Broadway play was the
greatest experience. I went to see 4 or 5 of them.









I enjoyed lots of activities. On weekends with Dad I would go roller-skating and play
tennis. I wasn't prissy growing up. I played in dirt but was not really a tomboy. I
remember climbing trees, but I liked to play with dolls too. I remember visiting grandma.
I would visit her for a month in the summer. We would go for walks on the beach
collecting seashells. I remember going to my Aunt's house too and swimming for hours in
her pool. We played in the neighborhood on our bikes and with hoses. One of my friends
had a pool that everyone went to. We went to the beach a lot but I didn't like the ocean
water very much. When I was 15, I was in a band and loved to sing. Those were really
good times.

You know, my baby is in foster care. I'd like to tell you about him. I had my tubes tied
after my third son was born, but somehow got pregnant. When I was pregnant I had
planned to give him up, but then he started to move inside me. I was addicted to crack
when I had him and one day I left him with a neighbor and didn't come back for days
while I was high. You don't think you will be gone for days when you are on crack. So
then DCF (social services) took him from me. I have been visiting, but the time I spend on
DCF stuff does not allow me to work and spend time with my other children. I have been
giving a lot of thought to allowing him to be adopted. It's real important for me to be able
to have continued contact. I want to tell you more about this. I really want a permanent
home for my baby. It will be an open adoption.

I had lots of friends in junior high school. I started smoking pot at about 16 or 17. I was
living with my dad then. I started singing in a band at 16. I met my first husband and we
got married when I was 18, after I got my GED.

Band and school and pot were most of what I did. I had a great relationship with my
family and some really good friends. I started my period when I was about 12 and was
developing physically then. I had my first boyfriend at 14 and married him at 18 and
stayed married until I was 29. My first sexual experience was at 16 or 17. We did it two
or three times but I got on the pill right away. I started cigarettes and marijuana when I
was 16 or 17 too.

In school I did a lot of extra work in English. I loved language. I always did extra credit.
My AA degree is in English. I wasn't much of a risk taker. I was the more cautious type.
I tried to avoid bad situations. I had three or four close friends, but they were not into
trouble either.

From age 11 to 16, I had singing lessons. I used to swim a lot at the pool. I would hang
out with friends, listen to music, hang out at a pizza parlor. I remember me and dad used
to go to museums and for nature walks. We would look at the river on weekends with dad.

Dad and I were close. I am still not over his passing in 1995. I have one brother who is
younger than me. We are very close. He lives with mother. We have different dads, so I
was the only child with dad as a teen. I spent weekends at grandma's until I was 16.

We practiced and then played three nights per week. I went to a lot of concerts, from
around age 12 until I was in my 30s. I was very into music. The whole band would go to









the concerts. Every time we played we would go to this diner and pig out. I started
working when I was 17 at a jewelry store because I quit school and wanted something to
do. Dad's girlfriend gave me a car when I was 17, but I had to wait until I was 18 to drive
in NY. Sometimes you would have to sit in traffic for 45 minutes for an 8-minute trip.

I always stayed in touch with my mother and brother. After they moved to FL, I used to
paint, draw and write poems, from age 12 until now. Even now, I need some art supplies.

The beach was a big thing as a teen. I never had a hard time with my mother until she
became Grandma. Now she is always asking me did you do this or that? I only dated my
first husband before marriage. We didn't have any kids. We grew apart and parted as
friends.

So, I was 26 when I got divorced. I met a man and decided to leave everything and drive
to Jacksonville. My grandpa was dying here. I moved down a week later. We got an
apartment with another guy. We were just smoking pot.

We were together, me and this guy, about three or four months and then I found out he was
sleeping with a 16 year old girl. So I moved in with my mother and I was pregnant at the
time. I moved in with my mom. When I had Andrew it was in 1990. When he was about
13 months old. I met my second husband. He was great. He loved Andrew. He (Sean)
was the only dad he (Andrew) knew. The other guy (Andrew's biological dad) was an
alcoholic. He never had any contact with us.

Sean was great to Andrew. His whole family loved the baby. We lived together for a
while and in 1993, we had Chris. In May of 1994, we got married and then in November
of 1996, I had James.

Sean had cheated on me and I found out. Sean and I were separated for about a year before
James was born. When we were separated for about 5 months, I was seeing this man and
still seeing Sean sometimes. I think James is Ted's baby. Sean loved James, regardless.
He knew there was a chance that it wasn't his. Ted was using crack. I thought it was best
for the baby to let Sean raise him. Now, Ted is in jail for 10 years. I know where he is. I
believe it is not Sean's baby.

We got divorced in 2002. The kids were 12, 9 and 5. Sean was staying out all night. He
was going out. I would stay home. He came home one time and said he was in love. The
house was bought in his and his mom's name. I didn't have any money for a lawyer when
we separated.

I took James and Andrew with me and let him take Chris, because we knew Chris was his
baby. His new girlfriend doesn't like kids though. I lived with a friend down the street for
a while and then got my own apartment about a year later. About a year after I got my
place, I let my niece and nephew move in. It was after my niece and nephew moved in that
I started smoking crack.

I lost everything. It got really, really, bad. There was prostitution. There was probably at
least a few months that I was doing that. I got arrested with a crack pipe, but I was









released the next day. Then I got arrested for prostitution. I was dating a man named
Daniel that was a dealer. When I got arrested for prostitution, I solicited vice. I knew
proof positive that it was him (a detective) because I had stopped prostituting for about a
month and became a confidential informant. They had had pictures of me for months
going in and out of crack houses, so they knew. I got them undercover and introduced
them to get them in. They gave me a lot of money. When they needed me, they came and
got me.

When I looked at the man in the truck I said, "I know you. I've worked with you and
Detective Smith." I told him I am ready to go to jail. I'm tired of doing this. And then
here comes this Mercury SUV and the man in the pick-up. Twelve men arrested me. They
were so nice. They didn't hand-cuff me. They let me smoke and drink my drink soda.

I spent the end of January to March 16th, 48 days in jail. I didn't want to use, but I knew I
was pregnant. I had used depo shots, so at first I didn't know I was pregnant. After jail I
spent time in my first halfway house. It was a homeless program for pregnant women.
People could stay there.

Brook Place had a program but they told me I couldn't get in without a positive drug test,
so I smoked crack twice that weekend. I got in and then went into the hospital in labor
about 5 days later. They were able to stop it, but about 2.5 weeks later he came. He was a
breach birth (butt first) and my mom was there with me.

He was premature and had to be tube fed. He had to stay in the hospital for three weeks. I
went back to River Region. I started coughing so hard it ripped my staples out. I had a
bad respiratory infection. I was supposed to see my baby every day, but one time it took
them six hours to let him see me. And then, they told me they wouldn't take me to see him
for a week.

Then I was at a homeless shelter. An employee was busted for selling crack right there. I
was crying all the time. It was hard to deal with leaving my baby at the hospital. I ran into
an old friend and we went to a motel and got high on crack.

Then came my turn to get random drug testing. The caseworker called DCF. They saw
that I was trying to get help and the released me to here. That was some time between May
and July of 2005. My baby came here too. I did everything I was supposed to do,
including parenting classes and I got a good job. In December, one of my other sons came
to live with us here. About a week later we moved to transitional housing.

It had huge bedrooms. It was a beautiful house. I was 10 months clean. I bought a car. I
was going to work. I stopped to get cigarettes and one of my old drug dealers came out
and called me over to the car. The dealer didn't know I was in recovery, but he must of
known because I was driving and looking healthy. He gave me $60 worth of free crack. I
got back home at 12:00 pm. I thought I was only going to be gone a couple hours, but a
couple hours turned into seven days.

My mom couldn't keep the baby because she worked. She asked her best friends across
the street. It is their son and daughter-in-law that have him now. They went ahead and got









licensed as foster care and he has been there since March 1st. I think I am deciding to let
them adopt.

In aftercare, I plan to live with my mom, talk to my sponsor and attend three meetings a
week. There is also an aftercare group that meets once a week.

The first time I was seven months here, and they taught me about recovery and getting
clean. Now it is ALL relapse prevention. Just recently, I was waiting for a bus after a visit
at Children's Home Society (CHS) with my son. I saw an old dealer drive by. He came by
two more times. I went back into CHS and called here. Now, I don't take that chance that I
used to.

I had four pregnancies. None were planned, and with three I had not been using any birth
control. But after I found out I was very excited. I was shocked the fourth time because
my tubes were tied. I've used birth control pills, depo shots, and had my tubes tied. Now
they are tied clipped and burned. I always used condoms too.

I didn't like the depo because it stopped my period. It didn't seem healthy. They said I
was "too old" for the pill so they went back in and re-did the tubal. I liked the benefits of
using contraception. The pill was great when I was younger. I had no problem
remembering to take them. It was in 1996 when they tied my tubes the first time.

Mathew will always be the miracle baby. But he can be a miracle baby for them. The life
I was living would have killed me. So giving me another baby prevented that. I am so
glad He chose childbirth. God didn't make him to live in government housing and
daycare. My sponsor and I drove by one of the places I could move to and there were
gunshots and drug dealers. It is not a place for my baby.

The children have been an awesome impact on my life. Its been God first, then recovery
and then my children. I always had help. My ex-husband and my mom were there. Time
is so important. They are so busy here. What I am doing now will put me in a position to
do what He needs.

My nine-year-old needs help with his homework. Chris is an A-Honor roll student. I will
be available for them. Andrew has been through the most. I will be living with him. I'll
be able to hang out with him. There will be a lot of time that the three of us can be
together. My mom pays the mortgage. I'll be putting money aside. She is retired now,
and is ready to have someone there with her. This time I will move to my moms where my
oldest son is and the other three are nearby.

That's one thing; adoption will give me the opportunity to give each of the others the time
they need. I can work part time until I find the right job. I am not going to do it again. I
can't put everything before recovery. When I put the job first, I lost it. I put the kids first,
and I lost them. Those were the first two things that I lost.

I want to use my treatment experience to help other people. There are so many people that
need help. Some just don't know how to get it.









SafeFree and Brook Place are the top two places for women with kids. If they can find a
safe place for your child to stay while you are in treatment, it is better. Here they spend all
day in daycare. I did it both ways. Now I can focus more on recovery. I'd like to get back
into an office setting.

I found out that my sister is willing to adopt my baby. For tomorrow, I hope to accomplish
a successful meeting with the adoptive parents. In the next week I will be job searching
and hope to find one. In the next month, I hope to be back at mom's house, working,
living life outside of here, being with the kids. In the next year.......(long pause), next
year, I hope to be working in my choice of career, have money to do stuff with the kids, I'd
like to be driving something nice, and I want to be still clean.

Based on her early life history, it does not seem likely that Tracy will be a crack-addicted

prostitute. She recalls a pretty happy childhood and a relatively normal life until her second

divorce. She used marijuana and tobacco as a teen and continued to use just these substances

even when she was involved with men who used other drugs. As a mother of three, she first

tried crack when she was 41 and then her life quickly spirals out of control. She spends time in

jail, gets pregnant while prostituting and becomes a police informant. Even though several of

these women had crack addictions, Tracy's story helped me to better understand how powerful

and dangerous crack use, even one use, can be. Tracy had almost a year where she was drug free

before her most recent relapse. Since she is now focused on relapse prevention, I think she has a

great chance for long-term recovery.

Pamela

Pamela is a 37 year-old African-American woman who was born in Washington, DC but

grew up in New York City. She has had a total of seven children. She tells me:

I was born in DC, with my mom and dad, but was raised from age 2 to 18 in New York. I
went to live with my grandmother and grandfather and my aunt and uncles.

I have been put through a lot. But the positive things I remember are the births of my
children, getting my drivers license at 27, the relationship I have had for the last 3.5 years
because he has dealt with everything and turning my life over to God. Another good thing
is Friday nights with my sponsor.









I was abused in DC. My children are 16, 14,12, 9, 4, 3, 2. Seven total. Four have been
adopted, I think. I have 13 total brothers and sisters, but I did not grow up with them. I
was in contact but not close. I've had lots of pain and was put through a lot.

My mom died in 1997, she had depression and a stroke. She had high blood pressure. My
dad was stabbed and shot eleven times. He was an addict. But he is alive and confined to
a wheelchair.

At two is when my trauma started. I remember sitting in my high chair and my father he
came over and shaved my head. He wanted me to be a boy. My mother stuck me
underwater in a bathtub with 4 younger siblings. I don't remember the beatings, but I was
beat a lot, my mother told me. I remember going to NY with this little suitcase. I went to
the Bronx, it was like the fifth floor of this building. My mother banged on this door and
then my mom took off running. I remember crying and running after her. I don't
remember when I was three.

My grandmother said I was underfed, bald and looked like one of the starving Ethiopian
kids. At four I started getting beatings. My grandma would beat me for soiling my pants.
I remember I would go to my Aunts house. I was afraid of it. My aunt was always good to
me but her house was scary. And then there was my Uncle. I was the thorn in his side.

Age five to seven are blank for me. My grandmother had seven children. She had four
boys and three girls. Three of the boys were drug users, all except baby uncle Kenneth.
Two of my aunts were angels. They didn't smoke and were church-going. My grandpa
was an alcoholic and he fought with my grandma all the time. I don't remember them ever
giving me anything. I used to watch everything. My grandma was mean, selfish,
stubborn, conniving and talked behind backs.

My grandma finally kicked them out. My grandfather and uncles were gone. I felt like it
was my dad and brothers that were leaving. Then it was just me, grandma and uncle
Kenneth. My grandmother made a display of me, with a pretty room, clothes and with my
hair.

My uncle played with me. First I was his punching bag and then I was his sex toy. He was
13 when he started molesting me and it went on for about 4 years. My aunts had married
and moved out. My grandma had three jobs and church so my uncle had to get me
dressed, and all.

When I was in 3rd grade I was 8 years old. I pushed the teacher. Mrs. Small was nine
months pregnant. I pushed her and she went into labor. I was in lots of fights in summer
school. There were always a lot of fights and a lot of beatings. I got into boys early.
Their parents were on drugs. I always got into trouble. I was beat by three people when I
was on my way home at 9 years old. When I got home I remember I flipped my bed over I
was so mad. My uncle had to grab me and hold me down. I got beatings for everything.

I remember being held down and my cousin Mike was there and his sister and they would
take turns doing stuff, sexual stuff, to me, touching me and hurting me. I remember all
three of them above me.









We moved again. I acted out a lot. I got in lots of fights and had a lot of suspension in
school. No one would go to school on my behalf. My grandmother went to school once
and beat me in front of the whole class. The teacher told me I couldn't go on a class trip
and I got mad and then my grandma came and beat me at school. I didn't learn in school.
I couldn't sit still and I had a lot of behavior problems. When I was 11 we moved to a
duplex. My uncle stopped molesting me but my cousin continued. I started fighting with
him and he beat me bad and gave me a black eye.

My grandma was so mean and evil, I knew if I told her she would send me back to live
with my mom. I had a lot of anger and acting out. I still don't know all my brothers and
sisters. I hated my mother for a long time. My mother would just give her babies to
someone. She would have a new man and new babies.

After eleven, it got worse in school but the molestation by my uncle stopped. At age
twelve, I don't remember much. I was going to church. I was mad at God. I was into
boys but I wasn't having sex though. I was close to my grandfather and my uncles grew
closer too. One of my uncles would beat me. He knew I was going through something but
didn't know what. There was aunt Desiree and uncle Ron and they loved me. I could feel
it.

Grandmother, they called her the old witch. Everyone was scared of her. She was a holier
than thou Christian. My mother was not liked by grandma, so I didn't like her either. At
eleven, I had thoughts of committing suicide. I thought about getting rid of my
grandmother too. I was spoiled some by aunt Desiree and uncle Ron. They made my
grandma stop beating me. I still call aunt Desiree. I never had a Christmas with my
grandma. Sometimes my aunts and uncles bought me something.

I had to sweep, mop and scrubbed the walls of a four-bedroom house. I didn't have games
or toys or outside time. I didn't have friends over or go to the movies. If my uncle went
on a date I had to go with him. I had to be proper and say yes, not yeah.

My grandmother would punish me by putting my head under the water in the tub. She
used to beat me with extension cords. She used a hammer on my hand one time for
stealing. I couldn't turn on the lights in the house. If she wasn't home I had to sit in the
dark. I remember one time she beat me with a curtain rod for a light being on, but I did not
turn on that light!

When I was thirteen, I used to have to walk by myself at 1:00am to meet her at the bus
stop. She would send me at night to the store when she needed something. I was like a
maid.

Then there were beatings where I didn't even move while she beat me. I remember asking
God, "Am I Jesus' sister?"

There was a reverend at the church, and I remember he made me sit on his lap and he
would kiss me on my lips. I tried to hide my development. I thought, maybe I am not
really here.









I would try to talk to my grandmother, to tell her something was not right with my head but
Grandma said, "It's just the devil in you." I remember once I went skating and dislocated
my hip. My grandmother made me crawl. She would not bring me to the hospital. I was
always on my knees; doing work on my knees.

When I turned 14, I was sent to DC to live with my mom. I was sent there when the
beatings from my grandmother didn't affect me anymore. I wondered sometimes if my
grandmother was getting back at my mother through me. She was good with my aunt.
Grandma needed her maid back. My grandmother adopted me. She never got welfare or
Medicaid. She worked.

My first day back in DC, I slept in an abandoned building with my mother and her new
boyfriend Danny. Danny was a good guy. He didn't touch me or beat me in three days.
My brothers lived with a gay guy and they were molested there. No one knows what my
mother was doing. Three days later my mother had a new man, Vic. Vic molested me for
two years. Mom was drinking and may have been using drugs but we didn't see that.

Vic told me I must be pretty or something if two men plus your step-dad like you. There
were 7 kids then in one bedroom. We shared the same room and three beds. Mother
didn't feed us. She got about $1,000 in food stamps and $800 or $900 in a check. We
would eat stiff oatmeal, mayo or sugar sandwiches and would sometimes have bologna or
noodles. Mom didn't use drugs at home. She was never home. I remember one time we
ate beans with grease and I got sick. My mother beat me saying I was pregnant. I had a
boyfriend that was 21. I protected my sister. When my step-dad tried to have sex with my
sister I became very violent. I would hit my brothers and sisters. I watched my mother get
beat.

My boyfriend that I have now, he taught me everything. I knew how to provide for my
kids but I was scared to touch my kids I was afraid to clean them.

I started using alcohol for killing problems on the inside. I had my first drink at 16. I
would drink to kill the pain. My step-dad, he would put me in the tub and masturbate all
over me. My mother would beat me and say I was trying to steal her man. I was 16 and
my sister was 12. He would lay us on the couch and do stuff. I ran after him with a knife
for going after my sister. I black out some information, but I remember something about
them bringing me to my step-dad's friend's house. I think something may have happened
to me (those men may have done something to me) there.

In the fridge we had water and bologna and in the cabinet there was beans, lard and
oatmeal. I remember one Thanksgiving and Christmas, my step-dad got pork-chops and
all the stuff on the side. She did too, but not us.

I started stealing, food, candy, chips and other stuff. I started stealing from people. Men
and welfare took care of me. We never went anywhere or did anything. We all shared
clothes. My mother would throw clothes away instead of washing them but only when
they couldn't be worn anymore. We would get our clothes from the thrift store. I was
embarrassed walking down the street carrying garbage bags with thrift store clothes.









I got jumped once when I lived with my mother. My mother told me to beat her, or I will
beat you. The men my mother brought around hurt us, but my mother didn't fight men
back. We would watch Oprah about men who abused women and kids and Vic was
saying, "Oh, I would never do that." But he did.

I remember a shooting at the house. Danny had come back into the picture. Vic pulled a
shotgun from under the fridge. This was after he came back in the picture. My mother
told me to bring the baby to another room. I remember my step-dad with the shotgun, but I
couldn't get out the door. All my brothers and sisters went in a room. Vic shot Danny and
killed him. My mother left with all the kids. She turned herself in the next day. We were
all split up. Five grandkids went to live with her father's mother.

My mother went to jail. She programmed all the kids to lie. We had to say Danny was
abusing and molesting us. The sent us all back to mother. Vic never got arrested. Mother
said she did it for self-defense. But Danny never did anything to us. I was sad for Danny's
family who never knew the truth.

After the killing we went home. My mother met another man. He was ok. She was with
him about a year. I started drinking and started hanging out and I had a boyfriend.

I had sex with an older man for $20. I had sex with another man in an abandoned
apartment building. I can't remember everything cause I was always drinking. I
remember mom putting my head in cold water. We moved to my mom's ex-husband's
cousin's house. She was a lesbian and we would watch them do their thing.

My grandma talked with my mom and found out what she was doing. Mother got worse
with her attitude. She would call me a bitch and try to fight me. She didn't like the
relationship I had with my grandma.

My mother was never around. She started getting sick. She had a stroke after the car
accident. She didn't do drugs around us. She was always with different men. She was
beautiful. I started staying out all night, having sex for money and stealing.

At the end she acknowledged that she knew her ex-husband was messing with us. With
mom, her men came first. My brothers and sisters were everywhere- foster care, other
places. My one brother was selling drugs and got arrested for armed robbery, but he
schemed his way out. My sisters were running the streets. I never went back after 16.

I went back to New York. I was drinking and smoking weed every day. I only smoked
cigarettes when the weed ran out. I would sniff stuff but no heavy drugs.

I was having more sex, with different boys. My grandma got worse with the beatings at
16. She wanted me to work and bring money in the house. I remember sneaking out and
having sex. I ran away at 17 when my grandma said she didn't love me. It was a long
walk to my Aunt's house. I couldn't tell them what was going on. My cousin (she's dead
now-they killed her) she was so sweet and innocent. Her mother treated her real bad. My
granddad used to molest us. She told, but nothing happened.









When we were 18, I ran away. One day, my cousin was sitting on the stoop with her little
sister. A guy came up and shot her in the head. She kept her secrets and mine. I went to
stay with my aunt at 18. The fighting caused problems and the sex with boys and the
drinking.

When the doctor told my Grandma that I was not a virgin I got in lots of trouble. At 18 she
had my Uncle tie me to a chair to beat me. When I turned 18 there was nothing, not even a
"happy birthday." They sent me away to Georgia. My Aunt said to my Grandma that I
was too big to hit anymore. In my mind I was thinking "if you touch me I will kill you." I
said, "I hate you" and then I left.

Do you know Job 3:11-26 in the Bible? It seems to be about me. I wonder why I was
born. In the Bible, Job questions God. In the end the questions are answered. I still ask
why, why, why? I wrote something based on that I'd like to share. It is titled: These are
Question I would have ask as a Child, to God!!

Cursed be the day of my birth, and cursed be the night when I was conceived, cursed it for
its failure to shut my mothers womb, for letting me be born to all this trouble.

Why, then, did you bring me out of my mothers womb? Why didn't you let me die at
birth? Then I would have been spared this miserable existence. I would have gone
directly from the womb to the grave. Why didn't I just die at birth as I came from the
womb? Why did my mother let me live? Why did she nurse me at her breasts? For if I
had died at birth, I would be at peace now, asleep and at rest. Why was I not buried like a
stillborn child, like a baby who never lives to see the light? What I always feared has
happened to me, what I dreaded has come to be. I have no peace, no quietness, I have no
rest; instead only trouble comes my way.

All I want is a reasonable answer-then I will keep quiet. Tell me. What have I done
wrong?

One special thing that I have is this karate teddy bear. It makes a noise when you squeeze
it. I have had it for four years now. My boyfriend gave it to me. He gave it to me to
protect me.

When I was 18, I moved to Georgia. I went to live with my cousin that was in the Navy. I
went in the beginning of the summer. I also lived with her one-year-old son. I should
have been going to the 12th grade, but they said I had to repeat the 11th. I decided to try for
my GED, but I didn't finish. I was drinking and smoking weed. My cousin really wanted
me to go to school, so I tried it, but I dropped out. I would drop off her son at the daycare,
go to work and then pick him up. I also watched him on the weekends when she was in the
reserves. I was drinking, smoking and partying around her son. My cousin found out and
put me out on the street.

I had a boyfriend for about six months. My boyfriend was 28 when he got me pregnant. I
moved in with him and his sister. I was drinking heavy. I didn't want a baby and was
trying to get rid of it. He wasn't growing like he should and I was bleeding a lot. I still
had a lot of anger. Weed helped me to forget.









One day I got angry and I tried to jump a fence. Ijumped on a big AC unit and my water
broke. I went to the hospital and after two weeks I started hemorrhaging. He was born at
7 months and only weighed about four pounds. I was bleeding heavy and from my rectum
too. They kept him in the ICU. I still partied and they called me to come get him.

I moved to Texas with the father and lived with his family. There were lots of drugs
around us. I remember my first experience with cocaine. I went to a crack house to get
high, but it was marijuana laced with crack. I laid my baby in a bed while I got high. My
son's family, his uncle, beat me up and then beat up the girl for giving me crack.

We lived with his family in a house with no running water. There was drugs and lots of
rats. I went to live in a hotel and then got low-income housing. I reported them.

I got pregnant again, but I am not sure if my 1st son's father was the dad or not. He was an
alcoholic. He was older than me. I went to clubs a lot and brought home different men. I
was experimenting with crack. In 1991-1992, I would go to the clubs and leave the kids
home alone. I had public assistance and free rent. I would keep the kids fed. I was
arrested for public intoxication during that time.

I had to go to the hospital to have my gall bladder out (they had to give me 19 staples). I
had really high blood pressure and I had gotten gonorrhea. I spent two weeks in the
hospital that time. It started with 104-degree fever. I laid in bed. I thought it was from the
drugs I was using. I let this guy come stay with me to help me. I was so sick they carried
me out of the house. My blood pressure was so high. I was so scared that if they tested me
for drugs that they would take my kids. I could have died that day. I would have died if
they waited for a couple more hours. I was in a lot of pain. They (at the hospital) were
thinking of calling social services, but their (the kid's) dad took the kids.

I didn't work during that time. There were three traumatic events that happened while I
was in drug treatment. That is what made me leave. The first was when a guy came over
and shot a girl in her face and the bullet went through her face and then into her boyfriend.
She went through the window and fell into my arms all bloody. The guy was dead.

Another thing that happened was when my son's grandfather shot their uncle in the head
and the cousin that was selling drugs. He shot them right in front of my 3 year-old son and
my two year old and the baby. The cousin was selling drugs and using drugs and pulled a
gun on their grandfather and then their grandfather pulled out a shotgun and killed the
kids' cousin who was high. They were right there when that happened.

The third thing was when I was 22 years old and there was something not normal that
happened at a wake. A little boy stopped breathing and his eyes rolled back in his head
and he looked like he was dying, but after a while he turned out to be okay.

The police kept raiding the house. There were lots of guns and drugs. I wondered how I
got caught up with this family? In the same project that I lived in, I got involved with a
Columbian. He beat me. I traveled with him, with drugs, to New Orleans. We got pulled
over once. I had cocaine stuffed in my privates.









He would beat me. He was a drunk. Once he hit me so hard in my temple that he gave me
a seizure. He threatened to kill me if I left. I used to leave my kids to do stuff with him. I
used to get beat and get high every day.

In 1992, my cousin in Georgia sent me a Greyhound ticket for me and my kids. I had three
months that I was clean and sober. I was looking really rough. I met someone else. I met
someone else and got pregnant. On New Year's Eve, I had a glass of champagne, and then
I was back to my old ways again.

This new guy, he threw me down the steps, beat me in front of my family. He would
always find me. I went to battered women's shelters. He found me in four of them and
then I would have to leave because of the problems he caused. He moved us to
Tennessee. My family disowned me.

My head was like a punching bag. My eardrum was busted. I had cuts, black eyes, busted
lips. I wouldn't fight back. I was small back then. I didn't eat a lot with the alcohol and
the drugs. His mom put me on a greyhound. He was beating on my first two boys and I
would get in the middle. I sent them to their father. He had a girlfriend then.

They sent me back to treatment. The third son's father came after me. It was his sister that
brought me to the store and bought diapers and sent me on the greyhound. I stayed with
my ex and his girlfriend for a week and he set me up with an apartment and paid the rent
for me and the three kids. But he was still selling drugs and drinking and the house got
raided.

The Columbian showed up at our house, saying "I want you to come back." He stayed a
couple of days and then he took the baby back with him. I left the older two with their
dad. When I got back there he had a new punching bag. He beat her up. We became
friends. She died. I don't know the real story of what happened to her.

I got with another guy, a real crack head. I had stopped smoking crack for a year. I got
pregnant with my fourth child, my daughter. I didn't talk to my mom from the time I was
16 until I was 26. Then, I realized I was my mother. Even though we had no contact for
10 years.

I supported my drinking and drugs and children until 1997. DCF (Department of Children
and Families) got involved because I would bring the kids into Burger King at 4:00am and
then bring them to the daycare at 6:00am. That was when the case was first opened. The
second time was when I was living in the hotel lodge with 4 kids. They helped me find a
place and to pay bills for six months. I had a case plan. They gave me checks at
Thanksgiving and Christmas. Then they closed out those cases.

I've had a lot of blackouts. I was going to a psychiatrist for that. In my life, once or twice
I used birth control pills or rubbers. I have a problem taking pills. I never had a problem
with heroin or pills because I didn't like them. I took Valium a couple times with
Thunderbird, but I don't like the heart racing feeling. Cocaine, it used to give me
headaches and make my heart rush. It kills the pain, but keeps the headache.









My anger is now under control. My last kids' dad, he helped me talk about it and taught
me to write it down. He never abused me. He is good. I used to treat him bad. My
daughter was one and my new baby just 5 weeks and he accepted them as his own from the
very beginning.

He drank. I always had the liquor and the beer. I got him into that. He still worked
though, not me. I would beg him to get me stuff. From 1998-2006, I didn't do cocaine.
Every now and then I wouldn't drink for a year. I went to South Carolina.

In 2002, DCF took four kids from me. From 1993-1998, I was only using alcohol and
weed. Alcohol was my biggest problem. I only did drugs when I was drinking.
Remember I told you I had my 4th child in Georgia? It was in 1997 that I had my daughter.
Her dad was a crack addict. In 1998, I started smoking crack with him a couple of time a
week.

I was drinking on the job, smoking weed in the back. I set up robberies in our own store. I
was stealing out of the stores-for fun, even though I was making $1200 a week. I was
steeling everything out of stores for about a year. Every day I was stealing bags of stuff

I went into battered women's shelter in 1998. I had a nervous breakdown and attempted
suicide. My cousin took the kids temporarily, but there was some abuse going on so DCF
took them. I was not compliant. I did classes, etc. I was in and out of psychiatric wards. I
was on psychotropic meds. Now my sons are being like me, like I was.

It was a choice between the new baby and them. They said my kids were not manageable.
Here they say they took them because of the alcohol and drugs. They loved me and I
would visit them. They said they would find me when they got older. In 2002, they were
like seven and eight. My oldest boy is messed up. They were sick and so was I. All I
knew was how to work and how to take care of them.

The case was opened with my daughter. I was drunk and relapsed once. They gave me
custody back for 2 years. The lawyer said I should leave Georgia and somebody put me on
Greyhound to South Carolina. I was pregnant again.

My youngest three were premature. The last one, I almost lost. I had my tubes tied the
last time. I was very depressed after I left Georgia. I went back in 2005. I thought I could
get my kids back, but it was the alcohol talking.

I got married to an abusive man in Georgia to try to get my kids back. I thought it would
help if I was married, but he had a record. He had been convicted of attempted murder and
spent seven years in jail. Then there was a domestic incident. I stabbed him and spent 2
days in jail, but it was self-defense.

My kids in that were in Georgia but they might be in Florida. One is almost 17 now. My
boyfriend was married for 25 years. My youngest daughter, the one that is two years old is
his baby. We met in South Carolina.









I have felt like those kids are dead; the ones they took from me. I had to pack up all their
things to send away when they were taken from me.

It has been very hard.

I tell lies sometimes or say that I don't remember. I usually don't tell people or talk about
the ones they took from me.

My other kids are in foster care right now. SafeFree is talking about bringing the kids
here. They are trying to help get me visitation. There are a lot of people involved, the
aftercare, residential, family ties, the drug dependency court and the DCF workers. The
drug dependency judge, he will talk to the other judge. I don't want them to close the case
and take my children for good. I've been here three weeks. My youngest children are
four, three and two; two girls and a boy. In three weeks, they have just given me one visit.
I didn't get to do a visit on the holiday cause no one was available to bring the kids.

I will need to get a job. SafeFree is going to be there for my support and God is with me. I
want to stay sober and clean. This and the kids is why I am here.

I had seven pregnancies, seven kids. Two were planned, but the other five, I thought, I
want this. I didn't like rubbers. No one really talked to me about contraception. They
didn't really care.

The impact of having seven kids was that there was a lot of struggling, hard times,
emotional and stressful times, dealing with attitudes and different personalities.
Sometimes I wished I didn't have kids. I need a break, but not this kind. I had them back
to back, except for the 5-6 years between the first four and then three more. I wasn't really
sexually active then. I was with a guy I married and then wasn't with anyone sometimes.

I used rubbers after my daughter. I still got pregnant though and then again with my
youngest one. I thought I couldn't have children and look what happened, seven!

My oldest son is intelligent and a bookworm.

My next son is like me, a fast talker.

My next son is quiet and laid back.

My first daughter is 10 now. She was 2 when I last saw her. I don't have many memories
of her, but she loved singing and performing.

My 4-year-old loves to sing, dance, gymnastics and all that. She is a drama queen.

My youngest son is very laid back.

My baby girl, her smile kills you.









Right now I am taking things one day at a time. Primary treatment is usually 28-45 days
and then the aftercare program can be from six months to a year. I came here in April of
2006. I was getting high when I got here. I had gotten into the homeless shelter and tested
positive for drugs. They called DCF. For 60 days I was in outpatient therapy and doing
okay, but then I relapsed. Then they came out to take my children. I went berserk...and
did some damage.

SafeFree was there for me. I did two days of detox and then I came here. That was in
June. When I was in outpatient and the kids were involved, I was very active in the
program. The two leaders helped.

This was God's plan. I am okay being here today. I've helped out with a lot of stuff. We
do service work. Now I am going to church and bible study. If I walk out on this I lose
custody of my children. This time will be different. I have committed myself. I go to AA
every day, and I learn about parenting, life skills and I do meditation between 6 am and 6
pm. In the groups and with the clients here, there is love here. I have people.

I do random urine drops every week. I go to family counseling. I see a psychiatrist. I
have a treatment plan. It's a disease, even with meds and counseling it is incurable. It
might be 2 to 5 years and then something reminds you of the pain. There are triggers.
Seeing kids reminds me of mine.

The world and me are not okay. I have like 20 different diagnoses. Only God knows
what's in my head.

You can tell by actions. These counselors know who is really hurting and who is playing.
There are things I told you that I didn't remember. There are things that all of us here have
in common, no matter what we look like. There was the prostitution, the money for sex.
And then there are the times that you blacked out and you can't even remember what you
did.

Part of the 12-steps is to make amends. We hurt our families. We have to think about
deep down, what we did and who we hurt. This is free for us. Some people complain,
they worry about things now, but they didn't think of it when they were high. We would
spend our money on drugs instead of kids' shoes. We didn't realize how much we hurt our
children. Mommy was sick.

I always wanted to be in Florida. I had a history of running away. I knew I was going to
make it. I always knew God, even as a child. This time I can feel a difference. This hit
me hard. This is the second time I am in the same situation. I am sick and tired of being
sick and tired. I have high blood pressure and constant headaches.

My boyfriend is the man I kept asking God for. He don't beat me or take advantage of me.
I am the one always yelling and fighting. He said, "I am more in love than you are." He
was right. I know what I wanted was always a house on the beach. I was always with
abusive men from state to state (DC, NY, SC, GA, TN, TX and then FL) and home to
home. I am proud to have this man in my life. This is my last home before the beach
house.









I love my higher power. I learned to depend on God in AA. Instead of telling God my
problem and what my problems are about, I trust in Him. The devil is not my higher
power. You won't get my kids!

Now I have a roommate and she is more spiritual now. I love her. I didn't really be
around white people much before now, but my great grandfather was white and my
grandma was Indian.

My mom, she looked like you.

The trauma that Pamela experienced is unimaginable. She was beaten and sexually abused

by family members and severely beaten in most of her adult relationships. Four of her seven

children were taken from her permanently and the other three were in foster care at the time of

the interviews. She saw people killed in front of her. Like several of the other women, she had

spent time in jail and in shelters. For most of her life, she had no real support system. Despite

all that she has been through, she seems to be on a path to recovery. Her new partner is

supportive and she is doing well in treatment. Her treatment includes medications for her

multiple psychiatric diagnoses and she is beginning to address the trauma and loss she has

suffered.

Conclusions

The life history interviews provided a depth of information that could not have been

gathered by a survey. It allows us to hear the life history in these women's voices. The women

who participated in the interviews also were included in the survey. However, while the survey

collapse the range of responses to means, the interviews provided a richer and more telling

understanding of addiction, violence and pregnancy among these women. For example,

reporting a history of abuse and violent relationship does not detail the extreme abuse and trauma

that these women have been through. In addition, while means are a useful way to describe a

population, reporting a mean number of three children per women does not have the same impact









that having four, six or seven children has on an individual woman's life. The life history

interviews should be kept in mind as the results of the survey are described.

Life history interviews also allowed for identification of life history themes. These

themes, which included family history of addiction, availability of drugs and alcohol, domestic

violence, sexual abuse and rape, child abuse and neglect, early substance abuse, addicted

partners, loss, family care of children, north-south transitions, secrets, prostitution, arrests,

denial, relapse, co-occurring disorders, near death experiences, isolation, sharing, spirituality,

treatment and recovery are explored in the final chapter. The emotional weight and length of

time that women spent on these issues led me to consider these as themes. Before further

exploring the life history themes identified in this chapter, the next two chapters include the

survey results. The next chapter includes descriptive statistics followed by Chapter 5, which

includes the results of the ordinary and logistic regression and comparisons to national data.









CHAPTER 4
SURVEY RESULTS: DESCRIPTIVE STATISTICS

Survey Data Collection and Data Entry

The Family Planning and Contraception Survey (See Appendix) was administered to 100

women in treatment for substance abuse between June and December of 2006. Missing

responses on individual survey responses were considered as missing and are not included in the

analysis. Responses were coded and then manually entered into an Excel spread sheet. The

Excel file was then checked for accuracy. Accuracy checks included random re-checks of a

respondent's completed questionnaire item per item, a visual inspection of each column of data

to ensure that only the appropriate coded responses were included and examination of the range

for each response to ensure no responses were outside of the range of possible responses (i.e. if

responses were coded as "0" for No and "1" for Yes, the range of possible responses would only

be 0 to 1).

Frequencies were generated for categorical variables (i.e., N or % with each response and

N missing) and then descriptive statistics (i.e., N and N missing, mean, median, standard

deviation, minimum and maximum for all continuous variables). The descriptive statistics

described above were generated in Microsoft Excel and SigmaPlot version 10 (Systat Software,

Inc. 2007). Frequency tables examine the relationship between type of substances) abused (past

year and before entering treatment) and effective contraceptive use/failure to use in past year and

past three months. Additional statistical analysis, such as regression, and comparisons to

National data are reported in Chapter 5. In the following sections, descriptive statistics are used

to describe the sample in terms of demographics, reproductive and abuse history, contraceptive

use history and intentions and substance use characteristics.









Results


Age

The mean age of respondents was 35.4 (Standard Deviation [SD] 10.6). Age of

respondents ranged from 20 to 65 years old. The median age of respondents was 32 years old.

Race and Ethnicity

Respondents were asked an open-ended question about the race she considers herself and if

she is of Hispanic decent. Sixty-two percent reported that they are white or Caucasian, 33% of

respondents reported that they are Black or African-American, and four percent reported mixed

race. One participant did not complete the question regarding race. Six percent of the women

surveyed reported Hispanic ethnicity.

Marital Status and Living Arrangements

The survey included questions about current marital status, past marriages, current living

area and about whom they lived with in the month prior to entering treatment. In terms of

current marital status, 37% reported that they are single and not in a relationship, 13% reported

single but currently in a relationship, 10% are married, 10% are separated, 28% are divorced and

two percent reported that they are widowed. The percentage of ever-married is about 50% based

on the percentages above, but 51% reported having ever been married when asked separately.

When asked where the respondent lives most of the time, 37% reported that they live in an

apartment, 37% reported that they live in a house, four percent reported that they live in a motel

or hotel, four percent reported living in a condo and 18% reported that they live most of the time

somewhere else, such as at a shelter or that they are homeless. When respondents were asked

with whom they lived with in the month prior to treatment, they could select multiple responses,

so these percentages sum to more than 100%. Twenty percent reported living alone, 18% with

mother, nine percent with their father, 30% with children, 10% with a brother or sister, 22% with









unmarried partner, 10% with housemate or roommate, one percent with In-Laws, six percent

with a boarder or roomer, eight percent with an other relative and nine percent with an other non-

relative. Husband was inadvertently not included in the list of people, however it was captured in

the space provided under "other relative". No respondents reported living with a grandparent or

grandchildren. The number of people who lived with these women in the month before

treatment was a median of three and the range was zero to 12 other people. The mean number of

people was 2.92 (SD 2.28).

Employment and Income

Only twenty-eight percent of respondents reported that they were currently employed and

only 48% reported that they were employed last year. When respondents were asked about their

best guess of income (from all sources) from last year, 3% did not respond. The percentage of

respondents in each of the income categories is presented in the Table 4-1

Education

The median highest grade or year of school completed was 12 years. The mean was 11.7

(SD 2.57). Thirteen percent of respondents had less than a 9th grade education and 34% had less

than a 12th grade education. Thirty-eight percent completed at least high school. While 28%

reported some schooling beyond the 12th grade, 43% reported going to some college, which

could have included a course, adult education or job training. Eleven percent reported receiving

an associate's degree, 4% reported earning a bachelor's degree, and 4% reported some graduate

school education. Of those who specified the type of degree earned, 7% reported degrees in the

health professions (5% in nursing, 1% in dental and 1% in medicine).

Current Health and History of Abuse and Violence

When asked to describe health in general, six participants did not provide a response.

Excellent health was reported by 18%, very good health by 19%, good health by 33%, fair health









by 23% and poor health was reported by one percent of these women. More than two-fifths

(43%) of these women reported being abused as a child and more than half (61%) reported

having been in a violent relationship.

Pregnancy, Pregnancy Outcomes, Planning and Intentions

Four percent of respondents reported that they were currently pregnant. Past history of

pregnancy was common among 89% of the women. The range of number of pregnancies was

zero to 11 pregnancies. The median number of pregnancies was three and the overall mean was

3.23 (SD 2.11) pregnancies. Four or more pregnancies was reported by 37% of respondents and

23% reported five or more. There was a total of 320 pregnancies reported, an average of close to

four pregnancies per woman among those who had ever been pregnant. Of these pregnancies,

the outcomes included 59 miscarriages, three stillborns, 56 abortions, one ectopic or tubal

pregnancy, 40 live births by cesarean section, and 180 births by vaginal delivery. The pregnancy

birth outcomes outnumber the total number of pregnancies due in part to pregnancies that

resulted in multiple births (twins). Overall, approximately 69% of pregnancies resulted in live

births.

In terms of planning and wanting each pregnancy, information was collected on 301

pregnancies. Of these pregnancies, only 52 (17.3%) were planned. Another 71 (23.6%) of these

pregnancies were situations in which the pregnancy was wanted but they did not plan to get

pregnant. The remaining 178 (59%) of these pregnancies were reported as not planned or

wanted.

Respondents were asked about the ages of these children and the number of children who

currently live with them. Only 71 children of the more than 220 reported live births, were

currently living with their mother. While the question did not specify if the children were living

with their mother at SafeFree, it is likely since SafeFree's program allows children to stay with









their mother while she is in residential treatment. Children who did not live with their mother

included 49 who were living with a relative (excluding other parent) caregiver, 46 were living on

their own, 35 with their other parent, 16 in foster care, 9 who were adopted, 1 with a non-

relative/friend, 1 in jail or detention center and 5 in another location.

Future Pregnancy Intentions

Only four percent of the women surveyed reported that they are currently trying to become

pregnant and 8% reported that they would like to become pregnant in the next year. Eight

percent reported that their partner wants them to become pregnant now and 8% in the next year.

For 5% of women, there was overlap between now and next year for reported pregnancy

wantedness for partners, in other words, 5% said their partner wanted them to become pregnant

now or in the next year.

Age of First Intercourse and Pregnancy Prevention

The mean reported age of first having sex was 15 years old with a range from 10 years old

to 22 years old. Forty-seven percent reported having sex before age 15 and 61% reported having

sex before age 16. Only 35% reported using a method to prevent pregnancy the first time she

had sex. The median reported age when a method to prevent pregnancy was first used was 17

years of age. The mean age was about 16.5 years old when a method to prevent pregnancy was

first used.

Pregnancy and Offspring

The number of pregnancies that did not result in live births (miscarriages and abortions)

was unanticipated and in hindsight age of first pregnancy should have been included in the

questionnaire. However the data collected did permit calculation of the number of years between

age of first intercourse and birth of first child. The number of years between first intercourse and

first birth ranged from one to 22 years. The median number was five years and the mean was 5.6









years. Among the 81% of women who reported having one or more live births, the mean

number of births was 2.7 (SD 1.17) and the median number of children was three. The mean

number of births is lower than the mean number of pregnancies, because not all pregnancies

resulted in childbirth. The mean age of first birth was 20.5 (SD 4.32) years and ranged from 12

to 34 years old. Twenty-four percent of these women had two or more kids before reaching 21

years of age. Ages were reported for 226 offspring. The mean age of all offspring was 12.4

years of age. Seventy-two children of these women were under the age of six, 98 were school

age (6-18 years old) and 56 were adult children over 18 years of age. The mean number of years

between the oldest and the youngest child was about seven years (SD 4.9) and the median was

six years, with a range of one to 28 years old.

Surgical Sterilization

The percentage of women who reported having had their tubes tied, cut or removed (tubal

ligation or sterilization) was 42%. This percentage was surprisingly high. There were three

women in the survey who reported having a child whose age was younger than the number of

years since surgical sterilization, two within one year of surgery and one four years after her

surgery. Two women reported surgical sterilization before having any children. Twenty-five

women reported surgical sterilization at the time their last child was born, four in the year after

their last child was born, three within two years of last child. For the remaining five women, the

number of years between the age of their last child and when they were surgically sterilized was

4, 8, 10, 17 and 19 years. When asked how many years ago the surgery was done, the mean

number of years was 10.5, the median was nine years ago and the range was from one to 27

years ago.









Past Pregnancy Prevention Strategies

Women were asked about their most recent (past 30 days) use of methods to prevent

pregnancy, where they obtained those methods and questions specific to condom use. They were

also asked about methods that they used to prevent pregnancy in the past three months, in the

past year and ever in their lifetime. The percentage of women reporting use of each method in

the past 30 days is reported in Table 4-2. While the percentage reporting using a method in the

last month is low, it should be noted that only 21% of the sample reported having sexual

intercourse with a man in the last four weeks. Use of condoms and other methods among those

who reported sexual intercourse is detailed later, however it is important to keep in mind that

using a condom once in the last month does not protect a woman from disease and pregnancy for

an entire month. Inconsistent or improper use can result in failure of the method. Intermittent

use of a contraceptive method in the past year is addressed later in this chapter. Sexual activity is

not always planned, however Table 4-2 provides a good estimation of the number of women who

may be protected by longer acting contraceptive methods.

Contraceptive methods to prevent pregnancy were obtained from a variety of sources

including seven percent from a private doctor's office, five percent from a family planning or

Planned Parenthood clinic, five percent from their partner or spouse, three percent from a

community health clinic, community clinic, or public health clinic, one percent from a hospital

outpatient clinic, one percent from a hospital regular room, one percent from a drug store and

percent from some other place.

As mentioned previously, only 21% of women reported having sexual intercourse with a

male in the last four weeks. The range of responses regarding how many times she had sexual

intercourse ranged from zero to 20. The median was zero. The mean was 1.33 among all

women and 4.3 times among those who reported having sex with a male in the last four weeks.









Nine women reported using a condom and these women reported using a condom a total of 32

times. This translates to condoms being used about 25% of the time among women who had

sexual intercourse with a male in the last four weeks. An additional approximately 25% of

sexually active women reported using some other method to prevent pregnancy in the last four

weeks. As mentioned previously inconsistent use can result in failure of the method.

The percentage of women reporting frequency of condom use and other methods used to

prevent pregnancy during sexual intercourse over the past 12 months are included in Table 4-3.

These questions were asked specifically in regards to sexual intercourse in the last year. The

percentages do not sum to 100, as these questions did not apply to those who had not had sexual

intercourse. Condoms are often used along with another method that does not protect from

disease, so some women reported both condoms and another method. However, out of 91

women who answered the question about condom use, only about 13% reported using a condom

every time they had sex in the past year.

In relation to condom use, respondents were asked about the chance that they would feel

less physical pleasure if their current partner used a condom. They were also asked about the

chance that it would be embarrassing to discuss using a condom with a new partner and the

chance that they would appreciate it if a new partner used a condom. The percentage of women

who circled each response is presented in the Figures 4-1, 4-2 and 4-3. Forty-two percent of

women reported no or little chance of feeling less physical pleasure. Sixty-seven percent

responded that there was no or little chance of being embarrassed to discuss condom use with a

new partner. Overall, 74% reported that there was a pretty good to certain chance they would

appreciate if a new partner used a condom. When only those who responded to this question









were included, 92.5% said there was a pretty good to certain chance they would appreciate if a

new partner used a condom.

To extend the timeframe further into the past and obtain data on the specific methods used,

women were asked to record use of methods to prevent pregnancy in the past 3 months, in the

last 12 months and usage ever in their lifetime. Among all women surveyed, the percentage of

women reporting methods used in the past to prevent pregnancy is presented in Table 4-4. The

three most common methods ever used were condom (69%), birth control pills (63%) and

withdrawal (54%). This population also had a high percentage of women who were surgically

sterilized (42%). In the past year and in the last three months, condoms (30% and 18%,

respectively) and withdrawal (19% and 15%, respectively) were the most frequently reported

methods used. As expected, the percentage of women who had ever used methods to prevent

pregnancy in their entire life was higher than the percentage that had reported using a method in

the past year or past three months. This is also true for substance use, described later in this

chapter, where the percentage of women who ever used a substance is higher than the percentage

who reported more recent use. Women reported that they stop using a method for a number of

reason, including side effects, wanting to get pregnant, during pregnancy and a number of other

reasons which are detailed in the next section of this chapter.

Respondents were also asked about their future intentions of using any of the listed

methods to prevent pregnancy. Table 4-5 includes the percentage of women reporting intentions

to use methods to prevent pregnancy in the next month and in the next year. The most frequently

reported intended method was condoms, followed by birth control pills. Nineteen percent

reported intentions to use condoms next month and 28% reported intentions to use next year.

Depo-Provera was the third highest intended method to be used in the next month at nine percent









but was replaced by withdrawal (10%) as the third highest for intention to use in the next year.

Excluding those who reported female sterilization as "any other method" and the top four

methods, intentions to use any of the other specified methods in the next month or next year were

reported by 3% or less of these women.

Potential Barriers to using Methods to Prevent Pregnancy

More than half of the respondents (54%) reported that they had stopped using one or more

methods because they were not satisfied with it in some way. Among women in treatment for

SUDs, the most common method women stopped using was the birth control pill (41%),

followed by condoms (16%), withdrawal (14%) and DepoProvera (12%) (See Figure 4-4). The

percentage of women reporting discontinuation of other methods was 7% IUD, 3% partner's

vasectomy, 3% foam, 2% Today Sponge, 2% contraceptive patch, 1% Norplant Implants, 1%

natural family planning, 1% emergency contraception and 1% stopped using suppository/insert

as a method to prevent pregnancy.

The percentage of women reporting each reason for discontinuing any method is presented

in Figure 4-5. By far, side effects was the most commonly reported reason for stopping use of a

contraceptive method, reported by 25% of women. Close to 10% of women reported stopping

methods due to decreased sexual pleasure, because the method was too messy, and because the

method failed. Cost and access to methods did not appear to be a common reason to stop using a

method in this population as each of these reasons were reported by less than 5 % of women.

Birth control pills are one of the most widely used methods of contraception, however they

are also commonly discontinued for a number of reasons including changes to menstrual cycle,

cost, and concerns about or actual side-effects (See Table 4-6). The methods of contraception

that were discontinued and number of women reporting stopping the method, by each reason for

discontinuation are listed in Table 4-6.









Substance Use

Women were asked about their use of drugs of abuse. They were asked to indicate if they

had ever used the substance, if they used it in the last 12 months, if they had used in the last 30

days and if they used it on the day before they entered treatment. These women were also asked

how old they were the first time that they used each substance. As an exploratory question, they

were also asked about use of high sugar and high fat foods to see if the prevalence reporting use

increased after entering treatment. Descriptive statistics for these substances is detailed below.

Tobacco

Tobacco was the second most common substance reported as ever used and used in the

past year, but was the most commonly reported substance used in the last 30 days and on the day

before entering treatment. Eighty-two percent of these women reported using tobacco in their

lifetime and 74 % reported using it in the past year. Sixty-one percent reported tobacco use in

the last 30 days and 60% used it the day before treatment. The median age of first use was 14

and the mean age of tobacco initiation was 14.1 (SD 2.7) with a range from nine to 24 years old.

Alcohol

Alcohol had the highest percentage of women reporting lifetime use at 92%. Seventy-nine

percent reported use in the past year. Only 25% reported use in the past 30 days, while 42%

reported using alcohol the day before they entered treatment. This apparent discrepancy could

be explained by the fact that some woman had been in treatment for longer than 30 days at the

time they completed the survey. The mean age, 14.6 (SD 3.53) and median (14 years old) of first

alcohol use was close to that of tobacco initiation. The bottom end of the age range was the

same at nine years old, but it ranged to 35 years of age for reported first use of alcohol.









Marijuana

Marijuana and cocaine had similarly high prevalence of 74% reporting lifetime use among

these women. Forty-six percent reported using marijuana in the last year, but only 13% reported

using in the past 30 days, and 16% reported use in the day prior to entering treatment. The

median age of first marijuana use was 15 and the mean of 15.9 (SD 4.06) years old, was greater

than alcohol and tobacco and ranged from 11 to 30 years of age.

Cocaine

As mentioned previously, cocaine and marijuana had similarly high prevalence of lifetime

use at 74% each. Only alcohol and tobacco were more common among substances ever used.

More than half (54%) of women reported cocaine use in the past year which was a higher

prevalence than past year marijuana use. Twenty-one percent of women reported cocaine use in

the past 30 days and 26% used it the day before entering treatment. The mean age of first

cocaine use was 20.5 (SD 8.06) and the median was 18 years of age. The age of first use for

cocaine ranged from 11 to 52 years old.

Crack

Fifty-six percent of these women had used crack in their lifetime and 42% had used it in

the past year. Fifteen percent reported using it in the past 30 days and 13% on the day prior to

treatment. The mean age of first crack use was 27.2 (SD 9.07) and the range was 13 to 52 years

of age.

Pain relievers

Fifty percent of the respondents reported use of pain relievers in their lifetime and 39%

reported use in the past year. Ten percent reported use in the last 30 days and 12% used the day

prior to entering treatment. The mean age of first use of pain relievers was about 21 (SD 5.93)

and ranged from 12 to 33 years old.









Other drugs of abuse

The percentage of women reporting lifetime use, use in the last 12 months, the last 30 days

and on the day before entering treatment for all other drugs of abuse which were included in the

survey are presented in Table 4-7. The mean age (SD) of first use and the range for age of

initiation is also included in Table 4-7.

High sugar and high fat foods

The results for the percentage of women reporting consumption high sugar and high fat

foods were similar in term of prevalence but with a difference in mean age of first use. Thirty-

five percent of women reported consumption of high sugar foods, while 34% reported use of

high fat foods. For high sugar and high fat foods, 28% of women reported consuming these

types of foods in the last 12 months, 18% in the last 30 days and 12% on the day prior to entering

treatment. Six percent more women reported consuming these foods in the last 30 days than

before entering treatment. The mean age for high sugar foods was 9.62(10.7) and for high fat

foods was 7.7(6.13). While these results may not seem to be relevant, there is an inverse

relationship between BMI and substance use because some drugs of abuse, like alcohol and

cocaine, replace the desire for food (Kleiner et al. 2004, Warren et al. 2005). Other studies have

shown weight gain associated with addiction treatment (Hodgkins et al. 2004).

Most Prevalent Drugs of Abuse

Top four ever used substances, in order, were alcohol, tobacco, marijuana and cocaine.

The top four drugs used in the past year were alcohol, tobacco, cocaine and marijuana. The top

four drugs used in the last 30 days were tobacco, alcohol, cocaine and crack but the most

commonly used drugs on the day before entering treatment, in order from highest reported

prevalence were tobacco, alcohol, cocaine and marijuana.









Age of First Use

When we look at the minimum age of first use, alcohol and tobacco use were reported as

early as nine years of age, followed by inhalants (age 10) and then marijuana and cocaine as

early as age 11. Heroin was the only substance for which 18 years or above was reported for age

of first use. Hallucinogens, inhalants and tobacco were the only substances for which no one

reported first use at above the age of 24.

Summary and Next Steps

The previous sections described the sample in terms of demographics, contraceptive use

history and intentions, reproductive and abuse history and substance use characteristics. In the

following chapter, additional frequencies and the results of regression analysis are reported as

well as comparisons to national data. The next chapter examines the relationship between the

use of contraceptive methods, substance use and demographic characteristics. Comparisons to

the National Survey of Family Growth reports and other national estimates related to substance

use and addiction treatment admissions are also included in Chapter 5.

4-1. Past Year Income
Income Percent
Less than $10, 000 69%
$10,001 $15,000 9%
$15,001 $20,000 8%
$20,001 -$25,000 4%
$25,001 $30,000 4%
More than $30,000 3%









4-2. Past 30 Day Use of Methods to Prevent Pregnancy
Method Used to Prevent Pregnancy % Using in Past 30 Days
Birth Control Pills 5%
Condoms 10%
Partner's vasectomy 1%
Withdrawal/pulling out 10%
Depo-Provera, Injectables 2%
Norplant Implants 0%
Rhythm/safe period by calendar 4%
Natural Family Planning 4%
Emergency contraception (How many times?) 0%
Diaphragm 0%
Female condom, vaginal pouch 0%
Foam 0%
Jelly/Cream without diaphragm 0%
Cervical cap 0%
Suppository/insert 0%
Today Sponge 0%
IUD 3%
Lunelle, (once-a-month injectable) 0%
Contraceptive patch 0%
Other method 9%
What other method? abstinence (7%)

4-3. Percent Reporting Frequency of Condom or Other Method in Last 12 Months
Used Condom Other Method
Every time 12% 13%
Most of the time 5% 5%
About half the time 11% 3%
Some of the time 19% 9%
None of the time 34% 44%

4-4. Reported Use of Methods to Prevent Pregnancy in Last Three Months, Last 12 Months and
Ever in Lifetime
Method Used to Prevent Pregnancy Past 3 Months Past Year Ever
Birth Control Pills 6% 11% 63%
Condoms 18% 30% 69%
Partner's vasectomy 1% 1% 7%
Withdrawal/pulling out 15% 19% 54%
Depo-Provera, Injectables 2% 4% 27%
Norplant Implants 0% 0% 3%
Rhythm/safe period by calendar 3% 3% 10%
Natural Family Planning 4% 2% 7%
Emergency contraception 1% 2% 6%
(How many times?) (1) (2) (8)
Diaphragm 0% 0% 2%









Table 4-4 Continued
Method Used to Prevent Pregnancy Past 3 Months Past Year Ever
Female condom, vaginal pouch 0% 0% 3%
Foam 0% 0% 13%
Jelly/Cream without diaphragm 0% 0% 0%
Cervical cap 0% 0% 1%
Suppository/insert 0% 0% 3%
Today Sponge 0% 0% 4%
IUD 3% 4% 10%
Lunelle, (once-a-month injectable) 0% 0% 0%
Contraceptive patch 0% 2% 6%
Other method 13% 8% 4%

4-5. Reported Future Intentions to Use Methods to Prevent Pregnancy
Method to Prevent Pregnancy Next Three Months Next Year
Birth Control Pills 10% 20%
Condoms 19% 28%
Partner's vasectomy 3% 1%
Withdrawal/pulling out 6% 10%
Depo-Provera, Injectables 9% 8%
Norplant Implants 0% 0%
Rhythm/safe period by calendar 3% 3%
Natural Family Planning 2% 3%
Emergency contraception 1% 1%
(How many times?) (0) (0)
Diaphragm 0% 1%
Female condom, vaginal pouch 0% 1%
Foam 0% 0%
Jelly/Cream without diaphragm 0% 0%
Cervical cap 0% 0%
Suppository/insert 0% 0%
Today Sponge 0% 0%
IUD 3% 3%
Lunelle, (once-a-month injectable) 0% 0%
Contraceptive patch 2% 3%
Other method 8% 8%
What other methods? 3% abstinence 3% abstinence
6% tubal 5% tubal









4-6. Reasons for Discontinuation, Methods and Number of Women Reporting


Reason for Discontinuation
Too expensive
Too difficult to use

Too messy

Your partner did not like it

You had side effects


You were worried about side effects
You worried the method would not work

The method failed, you got pregnant

Method did not protect against disease
Doctor told you that you should not use
the method again
Method decreased sexual pleasure
Too difficult to obtain the method
Did not like changes to menstrual cycle

Other Reasons


Methods (N)
birth control pills (4)
birth control pills (1), condoms (1),Today
Sponge (2)
withdrawal/pulling out (4), foam (3),
condoms(l), suppository/insert (1)
condoms (5), birth control pills (1)
withdrawal/pulling out (1)
birth control pills (11),Depo-Provera,
Injectables (9), IUD (3), contraceptive patch (1)
Norplant Implants (1)
birth control pills (4), contraceptive patch (1)
withdrawal/pulling out (2), natural family
planning (1)
condoms (2), withdrawal/pulling out (6)
Depo-Provera, Injectables (1)
IUD (2)
birth control pills (2), IUD (2)

condoms (8), withdrawal/pulling out (1)
birth control pills (2)
birth control pills (4), IUD (1),
Depo-Provera, Injectables (1)
condoms (3), IUD (2), emergency contraception
(1), withdrawal/pulling out (1), Depo-Provera,
Injectables (1)


4-7. Percentage Reporting Past Substance Use and Age of Initiation
Ever Last Last Before Mean Age
Used 12 Months 30 Days Treatment Age (SD) Range
Heroin 19% 11% 0% 2% 23.79(4.14) 18-30
Hallucinogens 34% 9% 0% 0% 15.89(2.16) 12-20
Inhalants 18% 6% 0% 0% 16.3(4.16) 10-24
Tranquilizers 24% 10% 0% 0% 18.5(4.35) 13-27
Sedatives 27% 18% 2% 6% 19.7(5.23) 13-30
Stimulants 22% 8% 0% 0% 18.2(2.92) 14-26












50%

45%

40%

35%

30%

25%

20%

15%


-I


15% 14%


11%


10%

5%

0% I I I
No chance A little chance A 50-50 A pretty good An almost
chance chance certain chance

4-1. Percentage of Women Who Reported Chance of Feeling Less Physical Pleasure with
Condom Use.


70%

60% -

50% -

40% -

30% -

20% -

10% -

j-Ln/


63" .


14%


4% 4%
S 0%


U /o -I I I -----I
No chance A little A 50-50 A pretty good An almost
chance chance chance certain
chance

4-2. Percentage of Women Who Reported Chance of Feeling Embarrassed to Discuss Condom
Use with New Partner.










70

60

50

40

30

20

10

0



4-3.


12%
14%




No chance A little chance A 50-50 chance A pretty good An almost
chance certain chance

Percentage Who Reported Chance of Appreciating Use of Condom by New Partner.




50 ..-


40Vc,- Birth Control Pill

3 Condoms
O Withdrawal
205 ,-Y O DepoProvera

STIUD

Other Methods

Methods Discontinued


4-4. Types and Percentages of Methods Discontinued










* Side-effects
* Too messy
O Decreased sexual pleasure
O Method failed
* Other reasons
* Partner did not like method
O Changes to menstrual cycle
* Worried about side-effects
* MD advised to discontinue
* Difficult to Use
O Cost
O Worried method would not work
* Did not protect from disease
* Difficult to obtain


w


0 5 10 15 20 25
4-5. Percentage of Women Reporting Specified Reasons for Discontinuation of Method









CHAPTER 5
STATISTICAL ANALYSIS AND COMPARISONS TO NATIONAL DATA

Introduction

This chapter includes frequencies of selected variables, regression analysis results and

comparisons to national data. Frequency tables were used to examine the relationship between

type and frequency of substances) used (past year and before entering treatment) and effective

contraceptive use/failure to use in past year and past three months. Since this was an

observational study and not an experimental design, regression analysis was chosen for further

analysis of the data. This method does not examine cause-effect relationships, but does allow for

examination of relationship between two variables. Regression analysis is a commonly used

method to test the relationship between variables, such that a model can be made to make

predictions about one variable based on another variable (Darlington 1990). While often used to

analyze the relationship between two quantitative variables, such as weight and blood pressure, it

can also be used when there is a dichotomous variable such as yes/no or use/not use. In other

words, it can be used to describe the relationship between age (x, the independent

variable/explanatory or predictor variable) and contraceptive use (y, the dependent or

criterion/response variable).

There are a number of types of regression analysis. In the results presented in this chapter,

ordinary and logistic regressions were used. Ordinary regression was used to find the

relationship between continuous data, such as the number of years since surgical sterilization

method or age of substance use initiation (dependent variables) and demographic characteristics

such as age and years of education (independent variable). When the value of a response

variable was "use" or "not use", logistic regression was used. Using contraceptive methods as the

dependent variable and demographic characteristics as independent variables, logistic regression









method was used to find the relation between the past and planned use of contraceptive methods

and demographic characteristics. Some of the independent variables included in the analysis

were age, race, ever married, past year employment, education, history of abuse and history of

domestic violence.

In this chapter, survey data are also compared to summarized data in the 2002 National

Survey of Family Growth (NSFG), previous NSFG surveys and other national survey reports.

When available comparisons were made in terms of age, race/ethnicity, past and current

contraceptive use and types of methods used, rates of surgical sterilization, age at admission and

primary substance of abuse, education, employment, ages of specific substance initiation, and

prevalence of substance use in past month, past year and ever.

Frequencies

Use of one or more contraceptive methods

When surgical sterilization is included as a method, 77% of women used one or more

method of contraception in the past year and 67% used one or more method in the past three

months. This means 33% of women used no method in the last three months and 23% did not

use any contraceptive method in the past year. Among those that used a contraceptive, the mean

number of methods used was 1.6 methods for the past year and 1.4 methods in the last 3 months.

Contraceptive use by past substance use

Table 5-1 examines the relationship between type of substances) abused (past year and

before treatment) and effective contraceptive use/failure to use in past year and past three

months. Excluding tobacco, alcohol, cocaine, marijuana, crack and pain relievers were the most

commonly used substances in the past year. Among women who used these substances, use of a

contraceptive method in the past year was reported more frequently by those who used crack

(90%) than those who reported alcohol (80%), cocaine use (83%) and pain reliever use (82%) in









the past year. Table 5-1 also examines drug used in the day prior to treatment and contraceptive

use in the past three months. For example, 35% of recent cocaine users, 25% of recent marijuana

users and 24% of recent alcohol users reported no contraceptive use in the last three months.

Since some women reported using more than one substance either on the day before treatment or

in the past year, the numbers/percentages reported in Table 5-1 sum to more than 100 or 100%.

Contraceptive use by age

Among women age 35 or younger, 75% used one or more method to prevent pregnancy

(including past surgical sterilization) in the past year, but only 63% used one or more method in

the past three months. Among women over 35 years old, about 80% reported using any method

in the past year and 73% reported using a method to prevent pregnancy in the past three months.

It should be noted however, that most of the women who were not using a method were over the

age of 45. For women between the ages of 36 and 45, almost 90% used one or more methods in

the past year and 79% reported using a method to prevent pregnancy (including surgical

sterilization in the past three months.

Contraceptive status by marital status

There were differences in contraceptive use when examined by marital status. Among

single women who were not currently in a relationship (N=37), 73% reported using a

contraceptive method in the past year and 59% reported using a method in the last three months.

Ninety-two percent of single women who were in a relationship (N=13) reported contraceptive

use in the past year, and 77% reported using a method in the last three months. Seventy percent

of married women (N=10) reported using a method to prevent pregnancy in the last three months

and in the past year. Seventy-eight percent of separated women (N=9) reported using a method

in the past year, however only 56% reported using a method in the past three months. Among









divorced women (N=28), 78% used a method in the past year and 71% used a method to prevent

pregnancy in the past three months.

Comparisons by Race

Demographic characteristics

As mentioned in Chapter 4, 62 of the women in treatment reported white/Caucasian race,

33 reported Black/African American and four women reported mixed race. One individual did

not complete the question regarding race and is excluded from the comparisons of this section.

In terms of age, Black women in treatment had a higher mean age (39 years) than white (34

years) or mixed women (29 years). White women were more likely to report ever being married

at 55%, compare to mixed women (50%) and Black women (45%). A higher percentage of

Black women reported being employed last year (61%) compared to only 42% of white women,

however, 31% of white women reported current employment compared to only 18% of Black

women. The mean number of years of school completed was similar among Black and white

women, at close to 12 years, while the mean was 10 years of schooling for the four mixed race

women who completed the survey. About sixty percent of Black and white women reported

having ever been in a violent relationship, but history of abuse as a child was reported slightly

more often among white women (48%) than among Black women (42%). Mean age of first

sexual intercourse was about the same for Black women (15.4 years) and white women (14.9

years)

Pregnancy, childbirth and pregnancy intentions

Average number of pregnancies was 3.5 for Black women and 3.2 for white women. More

pregnancies were terminated by abortion by white women (39 abortions) as compared to Black

women (17 abortions). Among Black women, about 10% of pregnancies were planned, 18%

were not planned but were wanted and about 69% were reportedly not planned and not wanted.









Among white women, about 20% were planned, 25% were wanted but not planned and 47%

were not planned or wanted. Black and white women had a similar mean age at first childbirth

(mean of about 20 years of age). However mean age at last childbirth was 28 years old for Black

women and 26 years old for white women, which may be explained by the fact that the average

age at the time of the interview was older for Black woman than white women.

Contraceptive history

White women (39%) were more likely to report using a contraceptive method at first

intercourse than Black women (27%). On average, Black women reported starting to use

contraceptives two years later than white women, at 17.8 years and 15.8 years, respectively.

However, they had a similar mean number of years between sex and first childbirth. There was

no difference between Black and white women in terms of percentage who reported surgical

sterilization, however the mean number of years since surgical sterilization was 14.6 years for

Black women and 9.4 years for white women. In terms of contraceptive use in the past year,

white women reported birth control pills more frequently than Black women (16% vs. 0%,

respectively). White women also reported withdrawal more frequently as a method used in the

last year as compared to Black women (about 24% vs. 9%). However, condoms were reported as

a contraceptive method used in the past year by almost 40% of Black women and only 24% of

white women. Black women reported planning to use Depo-Provera (9% vs.7%, respectively)

and condoms (36% vs. 25%, respectively) in the next year more frequently than white women.

Discontinuation of contraceptive method

White women (59%) were more likely than Black women (45%) to report ever having

stopped using any contraceptive method. A higher percentage of white women reported

discontinuing use of condoms and Depo-Provera as compared to Black women. A slightly

higher percentage of white women reported discontinuation of IUD than Black women, but a









higher percentage of Black women reported discontinuation of withdrawal as a contraceptive

method. The most striking difference was for birth control pills, which were reportedly

discontinued by 61% of Black women and 32% of white women.

Substance use history

Figure 5-3 presents mean age of substance initiation by race. With the exception heroin

and pain reliever initiation, white women had an earlier mean age of substance use initiation for

all other substances than Black women in treatment (See Figure 5-3). The difference in mean

age of initiation was most pronounced for hallucinogens, cocaine and crack. On average, the

mean age of hallucinogen initiation was 15 years for white women and almost 18 years for Black

women. The mean age of cocaine initiation was 19 years for white women and about 22.5 for

Black women. Mean age of first use of crack was 25 years for white women and about 30.5

years of age for Black women.

White women had higher rates of reported tobacco use in their lifetime (86%), past year

(80%) and on the day before treatment (62%) compared to Black women (73%, 61% and 55%,

respectively). The percentages of women reporting alcohol use in lifetime, past year and day

before treatment were similar for white and Black women. Black women (21%) reported

marijuana use on the day before treatment more often than white women (12%), but there was

not much difference by race fore past year and ever use of marijuana. Cocaine was reported by a

higher percentage of Black women than white women for lifetime, past year and more recent

use. Crack was reported by slightly more white women (14%) than Black women (12%) on the

day before treatment, but lifetime and past year use was reported by a higher percentage of Black

women. The percentage of women reporting heroin use in lifetime and past year was higher

among white women. Lifetime use of hallucinogens was about the same for white and Black

women, but past year use of hallucinogens was reported by a higher percentage of white women.









Lifetime, past year and past month reported use of pain relievers was about the same for Black

and white women, but a higher percentage of Black women reported use of pain relievers on the

day before treatment.

Regression Analysis

The results of the regression analysis are presented below. Ordinary regression was used

to find the relationship between continuous data, such as the number of years since surgical

sterilization or age of substance use initiation (dependent variables) and demographic

characteristics such as age and years of education (independent variable). When the value of a

response variable was "use" or "not use", logistic regression was used. Using contraceptive

methods the dependent variable and demographic characteristics as independent variables,

logistic regression method was used to find the relation between the past and planned use of

contraceptive methods and demographic characteristics. Some of the independent variables

included in the logistic regression analysis are age, race, ever married, past year employment,

education and history of abuse or domestic violence. Examples of some of the dependent

variables include surgical sterilization, use/non use of individual contraceptive methods in the

past 30 days, past 3 months, last year, ever in lifetime, and future plans to use contraceptive

methods in the next year.

For the ordinary regression, the size of the regression coefficient in the results for the

independent variable indicates the size of the effect that variable has on the dependent variable.

A negative coefficient indicates a negative relationship and a positive coefficient indicates a

positive effect. For example when examining the effect of age on number of years since

sterilization, a positive coefficient indicates that the number of years since sterilization is

expected to increase when age increases by one. For the results reported in this chapter, a

correlation coefficient of less than .30 is considered weak, .30 to .59 as moderate and .60 or









greater as a strong relationship. The square of the correlation coefficient between the dependent

and independent variable is presented as the R2. The p-value was considered statistically

significant at p <.05. The significant results of the logistic regression are summarized with the

odds ratio included in the text and additional details in the corresponding tables. For these

results, if the 95% confidence interval for the odds ratio includes "1" or the p-value is .05 or

greater, the results are not considered statistically significant.

Ordinary regression results

For the ordinary regression, the equation f=yo+a*x was used. In reporting the ordinary

regression analysis results, the coefficient, standard error (SE), t-statistic, p-value (Prob.), R-

squared (coefficient of determination), adjusted R-squared, F-statistic, Durbin-Watson Statistic

and number of observations are included in the results tables which are referred to in each

section for significant findings. The correlation coefficient is reported in the tables as a number

between -1 and 1. If the number is positive, it indicates that higher values of x (such as age)

generally go with higher values of y (such as years of education). This is referred to as a "direct"

relationship. When the coefficient is negative (when more x goes with less y), an "inverse"

relationship is used to describe the results. A coefficient value near zero mean there is no

particular relationship between the variables.

Only the adjusted R-squared values, reported as percentages, for significant results are

included in the text. The R2 is the fraction of the variation in y that is explained by its

relationship with x. In other words, the R2 value represents the percent of the variation in the

dependent variable that is explained by the independent variable in the model. For example, an

adjusted R2 = 0.15 means that just 15% of the variation in the dependent variable can be

explained by the independent variable in the regression equation.









Logistic regression results

To assess whether the specific types of contraceptive methods used were related to selected

characteristics of women in treatment, a series of logistic regressions were performed. Each

regression examined whether a sociodemographic factor (age, race, ever married, past year

employment, history of abuse, history of domestic violence, number of pregnancies, number of

surgical sterilization and number of live births) [predictor variables] were associated with

whether or not these women reported use of contraceptives dichotomouss response/outcome

variables, 0=No, 1=Yes]. Since the frequency of reporting some contraceptive methods was low,

there were insufficient numbers to conduct a regression for some contraceptive methods (such as

Lunelle, contraceptive patch, diaphram, female condom, contraceptive foam, contraceptive

jelly/creams, suppository/insert, sponge and norplant). The results of the logistic regression

analysis are summarized in tables for each independent/predictor variable.

For the logistic regression results, an odds ratio greater than one implies a positive

association, less than one implies a negative association and an odds ratio equal to no implies no

association. Significant results (p-value <.05 and 95% CI for OR does not include 1) are

summarized in the sections below with references to the appropriate tables for additional

information. Results for which the 95% confidence interval includes the value of "" were not

considered statistically significant and are not included in these results. Each logistic regression

table for the significant results includes the logistic regression coefficient (0), the accompanying

standard error, Wald Chi-square test result, p-value and when available the odds ratio (OR) and

95% confidence interval ( CI) for the OR. The text includes the 95% CI around the measured

OR.

Effect = Age. Table 5-28 includes a summary of the logistic regression results for the

effect of age. As expected, the probability of surgical sterilization increases with age. The









probability of lifetime use of certain contraceptive methods (contraceptive foam, IUD, the

sponge) also increases with age. The probability of using contraceptive methods in the last

month (birth control pills, withdrawal and "other" method), last three months (birth control pills,

withdrawal and condoms), last year (birth control pills and withdrawal) and lifetime (Depo-

Provera and withdrawal) decreases with age. The probability of women reporting intentions to

use contraceptive methods in the next year (birth control pills, withdrawal and Depo-Provera)

increases with age.

The results of the logistic regressions for age (Table 5-28) indicate that odds of birth

control pill use in the last month decreased by an estimated factor of .54 (95% confidence

interval = .32, .91) for each 1-year increase in age. For each 1-year increase in age, odds of

withdrawal and "other" method reported in the last month decreased by an estimated factor of

.77 (95% confidence interval = .63, .94) and .87 (95% confidence interval = .79, .996),

respectively. Odds of methods used in the last three months decreased by an estimated factor of

.71 (95% confidence interval = .53, .96) for birth control pills, .94 (95% confidence interval =

.88, .999) for condoms and .85 (95% confidence interval = .76, .95) for withdrawal for each 1-

year increase in age. Odds of methods used in the last year decreased by an estimated factor of

.82 (95% confidence interval = .70, .95) for birth control pills and .84 (95% confidence interval

.76, .94) for withdrawal for each 1-year increase in age. Odds of methods used ever in lifetime

decreased by an estimated factor of .93 (95% confidence interval = .88, .98) for Depo-Provera

and .95 (95% confidence interval = .91, .99) for withdrawal for each 1-year increase in age. For

each 1-year increase in age, odds of methods used ever in lifetime increased by an estimated

factor of 1.06 (95% confidence interval = 1.002, 1.11) for contraceptive foam, 1.12 (95%

confidence interval = 1.02, 1.23) for the sponge and 1.07 (95% confidence interval = 1.01, 1.11)









for IUD. Odds of intentions to use methods in the next year decreased by an estimated factor of

.92 (95% confidence interval = .87, .98) for the birth control pill, .80 (95% confidence interval =

.66, .97) for Depo-Provera and .73 (95% confidence interval = .59, .92) for withdrawal with each

1-year increase in age.

Effect = Ever-married. No significant differences were found for contraceptive method

use by ever-married status and therefore no table is included in the results

Effect = Race. The regression results for the effect of race on contraceptive method use

are presented in Table 5-29. Women who reported Black or mixed race had a significantly and

substantially decreased likelihood of reporting withdrawal as a contraceptive method used in the

last 3 months (odds ratios ranging from 0.01 to 0.73, p< .05) and a significantly and substantially

decreased likelihood of reporting withdrawal as a contraceptive method used in the last year

(odds ratios ranging from 0.07 to 0.91, p< .05) compared to women who reported "white" race.

Women who reported Black or mixed race also had a significantly and substantially decreased

likelihood of reporting withdrawal as a contraceptive method used in their lifetime (odds ratios

ranging from 0.05 to 0.30, p< .0001) and a significantly and substantially decreased likelihood of

reporting birth control pills as a contraceptive method ever used (odds ratios ranging from 0.08

to 0.46, p= .0002) compared to women who reported "white" race. Those who reported Black or

mixed race had a significantly and substantially increased likelihood of reporting intentions to

use condoms as a contraceptive method in the next year (odds ratios ranging from 1.23 to 7.46,

p< .05) compared to women who reported "white" race.

Effect = Employed Last Year. The regression results for the effect of employment on

contraceptive methods used are presented in Table 5-30. Those who were not employed last year

had a significantly and substantially decreased likelihood of reporting "other" contraceptive









method used in the last 3 months (odds ratios ranging from 0.03 to 0.78, p< .05) and they had an

increased likelihood of reporting rhythm as a contraceptive method in their lifetime (odds ratios

ranging from 1.01 to 24.87, p< .05) compared to women who were employed last year.

Effect = History of Abuse. The regression results for the effect of history of abuse on

contraceptive methods used are presented in Table 5-31. Those who did not report a history of

abuse had a significantly and substantially increased likelihood of reporting contraceptive foam

as a method used in their lifetime (odds ratios ranging from 1.31 to 19.88, p< .05) than women

who had a history of abuse.

Effect = History of Domestic Violence. The regression results for the effect of history of

domestic violence on contraceptive methods used are presented in Table 5-32. Those who did

not report a history of domestic violence had a significantly and substantially decreased

likelihood of reporting condoms as a contraceptive method used in the last three months (odds

ratios ranging from 0.11 to 0.91, p< .05) than women who had a history of domestic violence.

Women without a history of domestic violence had a significantly and substantially increased

likelihood of using birth control pills in their lifetime (odds ratios ranging from 1.11 to 6.04, p<

.05) and Depo-Provera in their lifetime (odds ratios ranging from 1.27 to 10.92, p< .05) than

women with a history of domestic violence. The results for withdrawal as a method used in their

lifetime was higher for women without a history of domestic violence, but the results were not

quite statistically significant. There was a significantly and substantially increased likelihood of

intentions to use condoms as a method to prevent pregnancy in the next year (odds ratios ranging

from 1.09 to 8.32, p< .05) for those without as compare to those with domestic violence history.

Effect = Surgical Sterilization. The regression results for the effect of surgical

sterilization on contraceptive methods used are presented in Table 5-33. Women who were not









surgically sterilized had a significantly and substantially decreased likelihood of reporting

condoms as a method used in the last year (odds ratios ranging from 0.12 to 0.80, p< .05) and

withdrawal as a method used last year (odds ratios ranging from 0.12 to 0.80, p< .05) than

women who were surgically sterilized. Non-sterilized women had a significantly and

substantially increased likelihood of reporting "other" methods to prevent pregnancy in the last

year (odds ratios ranging from 1.35 to 96.58, p< .05) than surgically sterilized women.

Unexpectedly, non-surgically sterile women had a significantly and substantially decreased

likelihood of reporting intentions to use birth control pills in the next year (odds ratios ranging

from 0.02 to 0.51, p< .01).

Effect = Number of Pregnancies. Table 5-34 includes a summary of the logistic

regression results for the effect of number of pregnancies. The probability of condom use in the

past year, and the probability of ever using an IUD to prevent pregnancy decrease with

increasing number of pregnancies. Odds of condom use in the past year decreased by an

estimated factor of .68 (95% confidence interval = .52, .89) for each additional reported

pregnancy. Odds ever using an IUD in lifetime decreased by an estimated factor of .63 (95%

confidence interval = .42, .97) for each additional pregnancy.

Effect = Number of Births. The logistic regression results, which includes the effect of

number of births is summarized in Table 5-35. The probability of withdrawal in the last 3

months and the last year, and the probability of ever using vasectomy to prevent pregnancy

decrease with increasing number of births. The probability of ever using Depo-Provera in

lifetime and the probability of surgical sterilization increases with increasing number of births.

For each additional reported childbirth, odds of withdrawal as a method used decreased by an

estimated factor of .63 (95% confidence interval = .41, .97) for the last three months and by an









estimated factor of .65 (95% confidence interval = .44, .95) for the last year. Odds of vasectomy

as a method ever used decreased by an estimated factor of .36 (95% confidence interval = .17,

.79) for each additional birth. Odds of Depo-Provera as a method ever used increased by an

estimated factor of 1.39 (95% confidence interval = 1.02, 1.90) for each additional birth. Odds of

surgical sterilization increased by an estimated factor of 2.02 (95% confidence interval = 1.40,

2.91) for each additional birth.

National Substance Abuse Data

Data on admissions to substance abuse treatment is available from the Treatment Episodes

Data Set (2006). Nationally, in the period between 1995 and 2005, the five most common

substances at admission were alcohol, opiates (including heroin), cocaine, marijuana and

stimulants. In the 2005 TEDS data, males made up 68% of treatment admissions, while only

women in treatment were included in the current survey.

Although data was not collected on the primary drug or drugs of abuse in the present

survey, we can estimate the primary substances of abuse by examining which drugs were used on

the day prior to entering treatment. Table 5-36 compares the percentage of women in the present

survey who reported using each substance of the day before treatment compare to primary

substance reported in the TEDS data (Substance Abuse and Mental Health Administration,

Office of Applied Statistics 2006). National longitudinal data on primary substance at admission

is presented in Figure 5-4.

In 2005 TEDS, approximately 39% of all admissions reported concurrent problems with

drugs and alcohol (Substance Abuse and Mental Health Administration, Office of Applied

Statistics 2006). In the current survey, 24% reported using one or more drugs and alcohol and

more than half of the women who reported alcohol use on the day prior to entering treatment also

reported drug use.









Comparisons of Current Survey and National Survey Demographic Characteristics

Gender

Nationwide, males outnumber females in admission to treatment for substance use

disorders (Substance Abuse and Mental Health Services Administration 2007). In 2005, females

represented 32% of admission. Compared to males, females in the Treatment Episodes Data Set

(TEDS) were less likely to be in treatment for alcohol or marijuana and more likely to be in

treatment for opiates or cocaine (Substance Abuse and Mental Health Services Administration

2007).

Age

Based on 2002 TEDS data, the average age at substance abuse treatment admission for

females was 33.3 years, while the average age in the current survey was 35.4 years. In 2005,

approximately 88% of TEDS admissions were between the ages of 18 and 54, while in the

current survey data, women's ages ranged from 20 to 65 years of age. In the 2005 TEDS data,

the proportion of admissions less than 25 years of age was 26%, aged 25 to 34 years was 25%,

aged 35 to 44 was 28% and over 45 years of age was 21% (Substance Abuse and Mental Health

Services Administration 2007). Among women in treatment at Gareway, the proportion

surveyed that were less than 25 years of age was 14%, aged 25 to 34 years was 40%, aged 35 to

44 was 22% and over 45 years of age was 24%.

Race/Ethnicity

The racial/ethnic composition of TEDS admission in 2005 was Black 22%, White 59%,

Hispanic 14% and other 5%. The racial/ethnic composition in the current survey was Black 33%,

White 62%, mixed 4% and Hispanic 6% (asked separately from race). While the percentage of

clients in SafeFree who reported Black/African American as their race is much higher than the

national average, the race/ethnicity characteristics is reflective of the community served; which









according to the 2000 U.S. Census data was 65% percent Caucasian, 29% African American and

4% Hispanic or Other for this city in Florida.

Socioeconomic status

Persons represented among TEDS admissions were less likely to be employed than the

U.S. population (Substance Abuse and Mental Health Services Administration 2007). Seventy-

one percent of 2005 TEDS admissions (aged 16 and over) were not in labor force or

unemployed, compared to 37 % of the U.S. population. Among TEDS admission 21% were

employed fulltime, compared to 52% nationally. In the current survey, 28% reported that they

were currently employed and 48% reported that they were employed last year. No data was

collected on whether employment was full or part-time but since 69% reported making less than

$10,000 last year it is most likely that many of these women did not have fulltime employment.

For those aged 18 and older in TEDS 2005, 34% did not complete HS (nationally the

percentage is 16%) (Substance Abuse and Mental Health Services Administration 2007).

Education beyond HS was 22% among TEDS admission (52% nationally). The TEDS

percentages were similar to what was found in the present study, with 34% having less than a HS

education and 28% reporting some schooling beyond the 12th grade.

National Survey Drug Use Characteristics Compared to Women in Treatment for SUDS

The following sections compare substance use data in the present survey to prevalence of

past month, past year and lifetime use of substances in the National Survey on Drug Use and

Health and other national surveys.

Age of initiation

National surveys, such as the NSDUH (2006) have reported earlier ages of initiation for

some substances (inhalants, marijuana) than for other drugs of abuse like cocaine, pain relievers

and tranquilizers (See Figure 5-5) (Substance Abuse and Mental Health Services Administration









(SAMHSA) Office of Applied Statistics 2007). This pattern was also true in the current survey

of women in treatment for SUDs (See Figure 5-6). The average age of first use of alcohol was

16.4 years according to national survey data, while it was younger, at 14.6 years in the current

survey of women in treatment for SUDs. Tobacco initiation was also earlier in the current

survey at 14.1 years than the national average of 17.3 years of age.

Prevalence of substance use

As might be expected, women in treatment for SUDs had higher lifetime and past year use

of marijuana, cocaine, crack, heroin, hallucinogens, inhalants, pain relievers, tranquilizers and

stimulants as compared to women surveyed in the 2005 National Survey on Drug Use and Health

(See Table 5-37) (SAMHSA Office of Applied Statistics 2007). Women in treatment also had

higher rates of past month use of marijuana, cocaine, crack and pain relievers as compared to

women in the 2005 NSDUH. Compared to young adults in NSDUH and MTF surveys

(SAMHSA Office of Applied Statistics 2007; Johnston, O'Malley & Bachman 2002), the

percentage of women reporting lifetime use of marijuana was about 20% higher among women

with SUDs (See Table 5-38). However, past month marijuana use was more common among

young adults in the national surveys than among women with SUDs. Only 13% of women in

treatment reported marijuana use in the past month, while 17% of young adults surveyed by the

NSDUH and MTF reported marijuana in the past month. Slightly higher percentages of women

in treatment reported lifetime history of alcohol use, however use in the past year was the same

as the NSDUH and use in the past month was only reported by 25% of women in treatment, but

was reported by over 60% of young adults surveyed by MTF and NHSDUH. A higher

percentage of women in treatment for SUDS reported lifetime, past year and past month use of

tobacco as compared to young adults in the NSDUH and the MTF studies (See Table 5-38).









Women in treatment also had percentages of lifetime and past year use of inhalants, but higher

percentages of young adults reported past month use of these substances (See Table 5-38).

National Survey of Family Growth (NSFG) Comparisons

Summarized data in the 2002 National Survey of Family Growth (NSFG) report was used

to compare the survey results to a nationally representative sample of women in surveyed in the

2002 NSFG (Centers for Disease Control 2007). The NSFG included 7643 civilian non-

institutionalized women between the ages of 15 and 44. The present survey included

institutionalized women who ranged in age from 20 to 65. Ninety percent of the women in

treatment for SUDs were under the age of 50 and 86% were between the ages of 20-44.

Data from the 2002 NSFG indicate that more than 98% of women who have ever had

sexual intercourse have used at least one contraceptive method (Centers for Disease Control

2007). Only 82% percent of women in treatment for SUDs reported ever using any method.

The percentage of women reporting a method to prevent pregnancy at first intercourse is much

lower among women with SUDs than current national estimates and is lower than national

percentages reported more than two decades ago. Among women with SUDs, only 35% reported

using a method to prevent pregnancy the first time she had sex. While nationally, 43% of

women in 1982 and 79% in 2002 used a method of birth control at their first intercourse (Centers

for Disease Control 2007).

Since the 1980s, the leading methods of current contraception used in the United States

have been the oral contraceptive pill followed by female sterilization (Centers for Disease

Control 2007). Female sterilization is by far the most common currently used contraceptive

method among women with SUDs, followed by condoms and withdrawal.

The leading method "ever used" in the NSFG and in the present survey was condom,

followed by oral contraceptives and then withdrawal (See Figure 5-5). Women in the NSFG









reported ever use of condom and oral contraceptives more commonly than women with SUDs.

Ninety percent of women in the 2002 NSFG reported ever using a condom, while 69% of women

with SUDs reported ever using a condom. In 2002, 82% of women in the NSFG reported ever

using oral contraceptives, while 63% of women with SUDs reported ever using the birth control

pill. The percentage of women reporting ever using withdrawal was about the same in both

groups. Withdrawal was reported by 56% of women in the 2002 NSFG compared to 54% of

women with SUDs. The percentage of women reporting ever use of withdrawal more than

doubled between the 1982 NSFG and the 2002 survey (See Figure 5-5) (Centers for Disease

Control 2007).

Some methods of pregnancy prevention were more commonly reported among women

with SUDs. For example, 27% of women with SUDs reported ever using Depo-Provera 3-month

injectables, while only 17% of women in the 2002 NSFG reported ever using this method.

Female sterilization among women with SUDs was double the national rate with about 42% of

women with SUDs and 21% of women in the NSFG reporting surgical sterilization (Centers for

Disease Control 2007). The percentage of women who had ever used the sponge, IUD,

diaphragm, rhythm, and spermicidal foam decreased nationally between 1995 and 2002. (Centers

for Disease Control 2007). These methods were also infrequently reported among women with

SUDs.

By race/Ethnicity, the 2002 NSFG found that 69% of Hispanic women, 79% of Black

women and 87% of white women have used the pill, however 24% of Black and Hispanic

women, but only 14% of white women, had ever used the Depo-Provera (Centers for Disease

Control 2007). In the present survey, about 41% of Black or mixed women reported ever using

the pill while 77% of white women reported ever using oral contraceptives. Among women with









SUDs, ever use of Depo-Provera was also more common among white women (31%) than

among Black and mixed women (22%). While the number of Hispanic women was small in the

present study, sterilization was reported less frequently by Hispanic women than for white and

Black women. Surgical sterilization was reported by 33% of Hispanic women, 40% of white

women and 42% of Black women in treatment for SUDs. However these percentages were much

higher than the percentages reported in the national survey, which found 23-24% of Black and

Hispanic women were using surgical sterilization as a method of contraception (Centers for

Disease Control 2007).

Nationally, among women under 30 years of age, the leading method of contraception is

the pill and by age 35, the leading method is female sterilization (Centers for Disease Control

2007). In the present survey, surgical sterilization was as common as birth control pill use in the

last three months, used by 13% of those under 30 years of age, while condoms and withdrawal

were used by 28% of women under 30 in the last 3 months. Sixty-five percent of women in

treatment for SUDs who were age 35 and older were surgically sterilized. When surgical

sterilization is included as a contraceptive method, women with SUDs are more likely to report

use of one or more contraceptive methods in the last three months than found in the national

survey. (See Figures 5-6 and 5-7). Only 5% of women in treatment compared to 38% nationally

reported not using any method to prevent pregnancy in the last three months.

Summary

The results presented in this chapter indicate that there are differences in contraceptive use

by substance use. Interestingly, women who reported crack use in the past year and before

treatment were more likely to report past year and recent contraceptive use. This chapter also

compared substance initiation and substances used by race. With the exception of pain relievers

and heroin which was reported at an earlier mean age by Black women, the mean age of









initiation for substance use was earlier for white women than Black women. A higher

percentage of white women reported heroin use in their lifetime and past year than Black

women, while a higher percentage of Black women reported lifetime and past year use of

cocaine, crack and sedatives. A higher percentage of Black women reported marijuana use on

the day before treatment.

The ordinary regression analysis included a number of independent variables such as age,

education, age of sexual intercourse, age of contraceptive use, age at childbirth and age of

substance use initiation. Dependent variables included years since surgical sterilization,

pregnancy related variables and substance use. The results of the ordinary regression found that

some of the variation in years since surgical sterilization, age of first contraceptive use, years

between oldest and youngest child, age of cocaine initiation and age of crack use initiation was

due to age. Some of the variation in age at first intercourse, number of pregnancies, and age at

last childbirth was due to education. Relationships between age at first intercourse and age at

first childbirth, age at first contraceptive use and age at first childbirth, number of not

planned/not wanted pregnancies and number of abortions, age at first birth and total number of

births, age at first birth and years between the oldest and youngest child, age at last birth and

total number of births. Substance use relationships were also found, such as age at inhalant use

initiation and age at tobacco initiation, between age at alcohol use initiation and age at tobacco

initiation, alcohol use initiation and age at marijuana and stimulant initiation, age at marijuana

use initiation and age at tobacco initiation, age at crack initiation and age at cocaine initiation,

age at cocaine initiation and age at tranquilizer initiation, and age at cocaine initiation and age at

stimulant initiation.









Logistic regression was used to assess whether the use/non use of specific types of

contraceptive methods were related to selected characteristics of women in treatment, such as

age, race, employment, history of abuse and domestic violence, sterilization, and number of

pregnancies and births. The probability of surgical sterilization increased with age. The

probability of lifetime use of certain contraceptive methods (contraceptive foam, IUD, the

sponge) also increased with age. The probability of using contraceptive methods in the last

month (birth control pills, withdrawal and "other" method), last three months (birth control pills,

withdrawal and condoms), last year (birth control pills and withdrawal) and lifetime (Depo

Povera and withdrawal) decreased with age. The probability of women reporting intentions to

use contraceptive methods in the next year (birth control pills, withdrawal and Depo Provera)

increased with age. Women who reported Black or mixed race had a decreased likelihood of

reporting withdrawal as a contraceptive method used in the last three months and in the last year

compared to white women. Non-white women also had a decreased likelihood of reporting

withdrawal and birth control pills as contraceptive methods used in their lifetime. Black and

mixed race women had a increased likelihood of reporting intentions to use condoms the next

year. Women who were not employed last year had a decreased likelihood of reporting "other"

contraceptive method used in the last three months and an increased likelihood of reporting

rhythm as a contraceptive method in their lifetime compared to women who were employed last

year.

When the effects of abuse and domestic violence were examined, those who did not report

a history of abuse had an increased likelihood of reporting contraceptive foam as a method used

in their lifetime than women who had a history of abuse. Women without a history of domestic

violence had an increased likelihood of using birth control pills and Depo-Provera in their









lifetime than women with a history of domestic violence. They also had an increased likelihood

of intentions to use condoms as a method to prevent pregnancy in the next year than women who

with a history of domestic violence. Those who did not report a history of domestic violence had

a decreased likelihood of reporting condoms as a contraceptive method used in the last three

months than women with a history of domestic violence.

Women who were not surgically sterilized had a decreased likelihood of reporting

condoms and withdrawal as methods used last year than women who were surgically sterilized.

Non-sterilized women had an increased likelihood of reporting "other" methods to prevent

pregnancy in the last year and a decreased likelihood of reporting intentions to use birth control

pills in the next year.

The probability of condom use in the past year, and the probability of ever using an IUD to

prevent pregnancy decreased with increasing number of pregnancies. The probability of

withdrawal in the last three months and the last year, and the probability of ever using vasectomy

to prevent pregnancy decreased with increasing number of births. The probability of ever using

Depo-Provera in lifetime and the probability of surgical sterilization increased with increasing

number of births.

In terms of comparisons to national data, despite the inherent differences in the

populations, the percentages of women who used specific substances before treatment was

surprisingly similar to the national TEDS data, with the exception of cocaine use which was

higher in this population of women in treatment. As would be expected, women in treatment for

SUDs have higher lifetime, past year and past month reported use of most illicit drags than non-

institutionalized women surveyed by the NSDUH. However women with SUDS have lower

rates of past month use of marijuana and alcohol than young adult women in the NSDUH and









MTF surveys. Women in treatment for SUDs reported earlier initiation of marijuana, sedatives,

stimulants and tranquilizers but reported first use of cocaine and heroin at a later age than the

most recent national estimates.

In terms of pregnancy prevention methods, women in treatment were twice as likely report

surgically sterilization than a national sample of women. The top three method of ever used

methods were the pill, condom and withdrawal for women in this survey and nationally, however

the percentage of women reporting lifetime use of the pill and condom was lower for women

with SUDs than women in the NSFG. Women with SUDs were more likely to report use of any

method to prevent pregnancy (including abstinence) in the last three months. A higher

percentage of women with SUDs reported recent use of sterilization and condoms, while

nationally a higher percentage reported recent birth control pill use as a contraceptive method.

In the next chapter, the themes from the life history interviews are examined followed by a

discussion of how the life history themes and the survey findings relate to the literature reviewed

in the introductory chapter. The final chapter will conclude with some limitations and

recommendations.









5-1. Frequency Reporting Past Year and Recent Substance Use and Number and Percent
Reporting No Contraceptive Method
Substance No Method Used Day No Method
Use Past Past Year Before Past 3
Year (N) N (%) Treatment (N) Months N (%)
Alcohol 79 16(20%) 42 10(24%)
Marijuana 46 8(17%) 16 4(25%)
Cocaine 54 9 (17%) 26 9 (35%)
Crack 42 4 (10%) 13 1 (8%)
Pain Reliever 39 7 (18%) 12 3 (25%)
Heroin 11 2(18%) 2 0
Hallucinogens 9 2 (22%) 0 N/A
Tranquilizers 10 2 (20%) 0 N/A
Sedatives 18 3 (17%) 6 1 (17%)
Stimulants 8 2 (25%) 0 N/A

5-2. Percentage of Women Reporting Illicit Drug Use in Lifetime, Past Year, Past Month and
Day before Treatment by Race
Lifetime Past Year Past Month Before Treatment
Drug White Black White Black White Black White Black
Marijuana 75 73 44 48 12 12 12 21
Cocaine 71 79 52 58 19 21 23 33
Crack 53 61 39 45 15 15 14 12
Heroin 24 9 13 6 2 3
Hallucinogens 35 33 12 3
Inhalants 20 18 7 3 -
Pain Relievers 50 52 39 39 10 9 9 18
Sedatives 24 36 17 21 2 3 5 9

5-3. Regression for Age in Years and Year of Education
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Years of Education)
Age in Years .0899 .0227 3.9631 .0001
(Independent Variable)
Number of Observations 100
R-Squared .1381 F-Statistic 15.7063
Adjusted R-Squared .1293 Durbin-Watson Statistic 2.0590

5-4. Regression for Age in Years and Number of Years Since Surgical Sterilization
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Years Since Surgical Sterilization)
Age in Years .5931 .0504 11.7589 <.0001
(Independent Variable)
Number of Observations 41
R-Squared .5747 F-Statistic 52.7015
Adjusted R-Squared .5638 Durbin-Watson Statistic 1.6773









5-5. Regression for Age in Years and Age of First Contraceptive Use
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age of First Contraceptive Use)
Age in Years .0746 .0215 17.6970 .0008
(Independent Variable)
Number of Observations 85
R-Squared .1148 F-Statistic 10.7685
Adjusted R-Squared .1042 Durbin-Watson Statistic 1.6310

5-6. Regression for Age in Years and Years Between Oldest and Youngest Child
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Years Between Oldest and Youngest Child)
Age in Years .1478 .0444 3.3258 .0014
(Independent Variable)
Number of Observations 71
R-Squared .1034 F-Statistic 7.9579
Adjusted R-Squared .0904 Durbin-Watson Statistic 1.6524

5-7. Regression for Age in Years and Age of Cocaine Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age of Cocaine Initiation)
Age in Years .2855 .0716 3.9851 .0002
(Independent Variable)
Number of Observations 67
R-Squared .1318 F-Statistic 9.8668
Adjusted R-Squared .1184 Durbin-Watson Statistic 2.2257

5-8. Regression for Age in Years and Age of Crack Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age of Crack Initiation)
Age in Years .4557 .0751 6.0706 <.0001
(Independent Variable)
Number of Observations 49
R-Squared .2511 F-Statistic 15.7554
Adjusted R-Squared .2351 Durbin-Watson Statistic 2.1847

5-9. Regression for Education in Years and Age at First Intercourse
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at First Intercourse)
Education in Years .2437 .0820 2.9725 .0037
(Independent Variable)
Number of Observations 99
R-Squared .0835 F-Statistic 8.8347
Adjusted R-Squared .0740 Durbin-Watson Statistic 2.2788









5-10. Regression for Education in Years and Number of Pregnancies
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Number of PregnanciesO
Education in Years -.1168 .0812 -2.0551 .0426
(Independent Variable)
Number of Observations 99
R-Squared .0417 F-Statistic 4.2232
Adjusted R-Squared .0318 Durbin-Watson Statistic 1.5163

5-11. Regression for Education in Years and Age at Last Childbirth
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Last Childbirth)
Education in Years .6706 .1772 3.7843 .0003
(Independent Variable)
Number of Observations 79
R-Squared .1119 F-Statistic 9.6991
Adjusted R-Squared .1003 Durbin-Watson Statistic 1.9264

5-12. Regression for Education in Years and Years Since Surgical Sterilization
Explanatory Variable Coefficient SE t-Statistic Prob.
Dependent Variable Years Since Surgical Sterilization
Education in Years .7841 .3124 2.5103 .0163
(Independent Variable)
Number of Observations 41
R-Squared .0500 F-Statistic 2.0533
Adjusted R-Squared .0257 Durbin-Watson Statistic 1.5345

5-13. Regression for Age at First Intercourse and Age at First Childbirth
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at First Childbirth)
Age at First Intercourse .5879 .1936 3.0364 .0033
(Independent Variable)
Number of Observations 80
R-Squared .0921 F-Statistic 7.9128
Adjusted R-Squared .0805 Durbin-Watson Statistic 2.0143

5-14. Regression for Age at Contraceptive Use and Age at First Childbirth
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at First Childbirth)
Age at Contraceptive Use .5214 .1877 2.7775 .0071
(Independent Variable)
Number of Observations 68
R-Squared .0741 F-Statistic 5.2831
Adjusted R-Squared .0601 Durbin-Watson Statistic 2.0752









5-15. Regression for Number of Not Planned/Not Wanted Pregnancies and Number of Abortions
Explanatory Variable Coefficient SE t-Statistic Prob.
Dependent Variable Number of Abortions
Number NPNW Pregnancies .1628 .0442 3.6940 .0004
(Independent Variable)
Number of Observations 99
R-Squared .1233 F-Statistic 13.6460
Adjusted R-Squared .1143 Durbin-Watson Statistic 2.0303

5-16. Regression for Number of Pregnancies and Number of Births
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Number of Births)
Number of Pregnancies .3275 .0473 6.9213 <.0001
(Independent Variable)
Number of Observations 82
R-Squared .2995 F-Statistic 34.199
Adjusted R-Squared .2907 Durbin-Watson Statistic 1.9050

5-17. Regression for Age at First Birth and Number of Births
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Number of Births)
Age at First Birth -.1217 .0264 -4.6086 <.0001
(Independent Variable)
Number of Observations 80
R-Squared .2140 F-Statistic 21.2393
Adjusted R-Squared .2039 Durbin-Watson Statistic 1.7069

5-18. Regression for Age at First Birth and Years Between Youngest and Oldest Child
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Years Between Youngest and Oldest Child)
Age at First Birth -.5277 .1175 -4.4897 <.0001
(Independent Variable)
Number of Observations 69
R-Squared .1563 F-Statistic 12.4097
Adjusted R-Squared .1437 Durbin-Watson Statistic 1.8504

5-19. Regression for Age at Last Birth and Number of Births
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Number of Births)
Age at Last Birth .0795 .0255 3.1134 .0026
(Independent Variable)
Number of Observations 79
R-Squared .1118 F-Statistic 9.6935
Adjusted R-Squared .1003 Durbin-Watson Statistic 2.0065









5-20. Regression for Age at Inhalant Initiation and Age at Tobacco Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Tobacco Initiation)
Age at Inhalant Initiation .2079 .0774 2.6862 .0169
(Independent Variable)
Number of Observations 17
R-Squared .3248 F-Statistic 7.2157
Adjusted R-Squared .2798 Durbin-Watson Statistic 2.2779

5-21. Regression for Age at Alcohol Initiation and Age at Tobacco Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Tobacco Initiation)
Age at Alcohol Initiation .2532 .0684 3.7005 .0004
(Independent Variable)
Number of Observations 71
R-Squared .1542 F-Statistic 12.5755
Adjusted R-Squared .1419 Durbin-Watson Statistic 1.9674

5-22. Regression for Age at Alcohol Initiation and Age at Marijuana Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Marijuana Initiation)
Age at Alcohol Initiation .6227 .0884 7.0427 <.0001
(Independent Variable)
Number of Observations 63
R-Squared .2362 F-Statistic 18.8595
Adjusted R-Squared .2236 Durbin-Watson Statistic 2.3370

5-23. Regression for Age at Alcohol Initiation and Age at Stimulant Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Stimulant Initiation)
Age at Alcohol Initiation .5710 .0879 6.4968 <.0001
(Independent Variable)
Number of Observations 17
R-Squared .1267 F-Statistic 2.1771
Adjusted R-Squared .0685 Durbin-Watson Statistic 2.0885

5-24. Regression for Age at Marijuana Initiation and Age at Tobacco Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Tobacco Initiation)
Age at Marijuana Initiation .3586 .0514 6.9800 <.0001
(Independent Variable)
Number of Observations 59
R-Squared .3958 F-Statistic 37.3394
Adjusted R-Squared .3852 Durbin-Watson Statistic 1.8906









5-25. Regression for Age at Marijuana Initiation and Age at Cocaine Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Cocaine Initiation)
Age at Marijuana Initiation 1.003 .2334 4.2850 <.0001
(Independent Variable)
Number of Observations 60
R-Squared .1611 F-Statistic 37.3394
Adjusted R-Squared .1469 Durbin-Watson Statistic 1.8906

5-26. Regression for Age at Crack Initiation and Age at Cocaine Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Cocaine Initiation)
Age at Crack Initiation .7732 .0970 7.9748 <.0001
(Independent Variable)
Number of Observations 46
R-Squared .5740 F-Statistic 59.2892
Adjusted R-Squared .5643 Durbin-Watson Statistic 1.8192

5-27. Regression for Age at Cocaine Initiation and Age at Tranquilizer Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Tranquilizer Initiation)
Age at Cocaine Initiation .6150 .0554 11.2955 <.0001
(Independent Variable)
Number of Observations 19
R-Squared .3673 F-Statistic 9.8705
Adjusted R-Squared .3301 Durbin-Watson Statistic 2.0889

5-28. Regression for Age at Cocaine Initiation and Age at Stimulant Initiation
Explanatory Variable Coefficient SE t-Statistic Prob.
(Dependent Variable Age at Stimulant Initiation)
Age at Cocaine Initiation .5356 .0326 16.4229 <.0001
(Independent Variable)
Number of Observations 17
R-Squared .4998 F-Statistic 14.9904
Adjusted R-Squared .4665 Durbin-Watson Statistic 2.4699


5-29. Logistic Regression for Age
B


SE Wald


p Odds
ratio


95% CI for
odds ratio
Lower Upper


Surgical Sterilization
BC Pill Last Month
Withdrawal Last Month
Other Last Month
BC Pill Last 3 Months


0.1067
-.6093
-.2643
-.1210
-.3424


0.0249
0.2636
0.1003
0.0595
0.1536


18.3073
5.3440
6.9414
4.1432
4.9662


<.001
0.0208
0.0084
0.0418
0.0258


0.544
0.768
0.886
0.710


0.324
0.631
0.789
0.525


0.911
0.935
0.996
0.960









Table 5-29 Continued


Condom Last 3 Months
Withdrawal Last 3 Mo.
BC Pill Last Year
Withdrawal Last Year
Withdrawal Lifetime
Depo-Provera Lifetime
Foam Lifetime
Sponge Lifetime
IUD Lifetime
BC Next Year
Withdrawal Next Year
Depo-Provera Next Year


SE Wald


-.0624
-.1647
-.2042
-.1705
-.0508
-.0695
0.0549
0.1115
0.0671
-.0803
-.3099
-.2239


0.0315
0.0574
0.0784
0.0527
0.0205
0.0273
0.0268
0.0491
0.0300
0.0328
0.1138
0.0977


3.9186
8.2463
6.7890
10.4818
6.1652
6.4927
4.2129
5.16
4.9910
5.9780
7.4116
5.2530


p Odds
ratio
0.0478 0.939
0.0041 0.848
0.0092 0.815
0.0012 0.843
0.0130 0.950
0.1008 0.933
0.0401 1.056
0.0231 1.118
0.0255 1.069
0.0145 0.9230
0.0065 0.7330
0.0219 0.7990


95% CI for
odds ratio
0.883 0.999
0.758 0.949
0.699 0.951
0.761 0.935
0.913 0.989
0.884 0.984
1.002 1.113
1.015 1.231
1.008 1.134
0.8650 0.9840
0.5870 0.9170
0.6600 0.9680


5-30. Logistic Regression for Race
P SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Withdrawal Last 3 Mo. -1.1891 0.5288 5.0556 0.0245 0.093 0.012 0.737
Withdrawal Last Year -0.7001 0.3339 4.3962 0.0360 0.247 0.067 0.913
BC Lifetime -0.8298 0.2249 13.6074 0.0002 0.190 0.079 0.459
Withdrawal Lifetime -1.0718 0.2380 20.2730 <.0001 0.117 0.046 0.298
Condom Next Year 0.5543 0.2298 5.8173 0.0159 3.030 1.231 7.460

5-31. Logistic Regression for Last Year Employment
P SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Other Method Last 3 Mo. -0.9099 0.3991 5.1986 0.0226 0.162 0.034 0.775
Rhythm Ever 0.8047 0.4093 3.8661 0.0493 5.000 1.005 24.872

5-32. Logistic Regression for History of Abuse
P SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Foam Lifetime 0.8144 0.3471 5.5048 0.0190 5.098 1.308 19.877









5-33. Logistic Regression for History of Domestic Violence
0 SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Condom Last 3 Months -0.5726 0.2689 4.5324 0.0333 0.318 0.111 0.913
BC Pill Lifetime 0.4754 0.2161 4.8397 0.0278 2.588 1.109 6.037
Withdrawal Lifetime 0.4103 0.2108 3.7879 0.0516 2.272 0.994 5.191
Depo-Provera Lifetime 0.6572 0.2745 5.7331 0.0166 3.723 1.269 10.919
Condom Next Year 0.5507 0.2593 4.5098 0.0337 3.009 1.089 8.315

5-34. Logistic Regression for Surgical Sterilization
0 SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Condom Last Year -0.5948 0.2467 5.8120 0.0159 0.304 0.116 0.801
Withdrawal Last Year -1.4575 0.5256 7.6905 0.0056 0.054 0.007 0.425
Other Last Year 1.2167 0.5452 4.9812 0.0256 11.398 1.345 96.582
BC Pill Next Year -1.0986 0.3891 7.9725 0.0047 0.111 0.024 0.511

5-35. Logistic Regression for Number of Pregnancies
0 SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Condom Last Year -0.3852 0.1375 7.8505 0.0051 0.680 0.520 0.891
IUD Lifetime -0.4562 0.2153 4.4894 0.0341 0.634 0.416 0.966

5-36. Logistic Regression for Total Number of Births
0 SE Wald p Odds 95% CI for
Ratio Odds Ratio
Lower Upper
Surgical Sterilization 0.7039 0.1862 14.2857 0.0002 2.022 1.403 2.912
Withdrawal Last 3 Mo. -0.4556 0.2171 4.4029 0.0359 0.634 0.414 0.970
Withdrawal Last Year -0.4379 0.1967 4.9537 0.0260 0.645 0.439 0.949
Vasectomy Lifetime -1.0104 0.3967 6.4877 0.0109 0.364 0.167 0.792
Depo-Provera Lifetime 0.3274 0.1590 4.2394 0.0395 1.387 1.016 1.895


5-37. Drugs Used Prior to Admission
Drug Current Survey of TEDS
Women 2005*
Alcohol 42% 39%
Heroin 10% 15%
Cocaine 26% 14%
Crack 13% 10%
Marijuana 16% 16%
Source: Office of Applied Statistics (2006)









5-38. Percentages of Females Using Illicit Drug Use in Lifetime, Past Year, and Past Month:
Women with SUDS (WSUD) and Women NSDUH, 2005 (NSDU)


Drug
Marijuana
Cocaine
Crack
Heroin
Hallucinogens
Inhalants
Pain Relievers
Tranquilizers
Stimulants


Lifetime
WSUD
74
74
56
19
34
18
50
24


NSDU
35.5
10.6
2.3
0.9
10.7
6.4
11.6
7.9


22 6.9


Past Year
WSUD NSDU
46 7.9
54 1.6
42 0.4
11 0.1
9 1.1
6 0.7
39 4.4
10 2.1


Past Month
WSUD NSDU
13 4.0
21 0.7
13 0.2
0 0
0 0.3
0 0.2
10 1.8
0 0.7


8 1.1 0 0.4


5-39. Comparison of NSDUH and MTF Prevalence Estimates (Young Adults, 2005) and
Lifetime, Past Year, and Past Month Prevalence in Women with SUDs
Substance Time Period NSDUH MTF Women w/SUDs
Marijuana


Lifetime
Past Year
Past Month

Lifetime
Past Year
Past Month

Lifetime
Past Year
Past Month

Lifetime
Past Year
Past Month


52%
28%
17%

13%
2%
0.5%

86%
78%
61%

67%
47%
39%


54%
31%
17%

9%
2%
0.3%

87%
83%
67%

N/A
49%
40%


74%
46%
13%

18%
6%
0

92%
79%
25%

82%
74%
61%


Inhalants


Alcohol


Tobacco














25
White
women 20

SBlack 15
women


10
5t









5-1. Age of Illicit Drug Use Initiation among Women with SUDS by Race

50 -
040








30 -
5-1. Age of Illicit Drug Use Initiation among Women with SUDS by Race







40


- 30




10 -
S20
II-



0 I I I I I I I 1 I
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

-0- Alcohol -- Opiates Cocaine
-- Marijuana A Stimulants -- Otherinot reported

5-2. Primary Substance of Abuse at Admission: TEDS 1995-2005. (Office of Applied Statistics
2006)























5



PCP LSD Stimulants Pain Sedatives
Relievers
Inhalants Marijuana Cocaine Ecstasy Heroin Tranquilizers
5-3. Mean Age at First Use for Specific Illicit Drugs among Past Year Initiates Aged 12 to 49:
2005


* Age in
Years


5-4. Age of Illicit Drug Use Initiation among Women with SUDS










100-

8 1982 NSFG

6 1995 NSFG
O 2002 NSFG
20
SE O 2006 Women w/SUDs

Pill Condom Withdrawal

5-5. Most Commonly Reported Methods of Contraception Ever Used in the NSFG (1982, 1995
and 2002) and Among Women with SUDs

Non-users

SFemale Sterilization
11%
O Pill

1900 o L Condoms

Other methods

5-6. Percentage of US Women by Contraceptive Status (Last Three Months) (NSFG 2002)


Non-users

Female Sterilization

[ Pill

"18 0 Condoms

Other methods

5-7. Percentage of Women in Treatment for SUDs by Contraceptive Status (Last Three Months)









CHAPTER 6
DISCUSSION AND CONCLUSIONS

Introduction

In the preceding chapters, a literature review was presented which included several

theories related to addiction, violence and fertility. Then the materials methods of the qualitative

and quantitative research were described. In the third chapter, life histories of five women were

included as examples of women's experience of addiction, including the characteristics of

addiction and the women who experienced it. This was followed by a presentation of the results

of the survey, results of the ordinary and logistic regression and comparisons to national

summarized data. In this chapter, themes from the life history interviews are examined followed

by a discussion of how the life history themes and the survey findings relate to the literature

reviewed in the introductory chapter. At the conclusion of this chapter, several limitations are

discussed and recommendations are made for current programs and future research.

Life History Themes

Family history of addiction

As described in the introductory chapter, risk of addiction is often passed down through

families. Risk increases as the number of addicted family members increases. All of these

women had one or more parents that were alcoholics or addicts. In Tracy's life, it was her dad

that was a recovering alcoholic. Alcoholism was and issue for Sara's mother and for both of

Mary's parents and her grandmother. Sara also mentioned that her father had a gambling

addiction and two of her siblings became addicted to drugs. Pamela's mother drank a lot of

alcohol. They knew she was involved with drugs, but she did not use drugs in front of the kids.

Pamela's father was also an addict, but he was not around during her childhood when she was









sent to live with her grandmother. Jackie said her mom did not use alcohol, but her step-dad

drank and her brothers were involved with drugs.

Availability of drugs and alcohol

Whether it was alcohol available in the home or a culture of drug use in college or on the

streets, availability of drugs and alcohol was a factor in initiation of use and then of maintaining

a supply for these women's addictions. There were stories of stealing alcohol from the house to

go drink with friends and of going to Jamaica to smuggle marijuana when there was a shortage in

New York. Sometimes, an alternative drug was used when the drug of choice was no longer

available. Alcohol was always available in the home when Mary was a child and she and her

friends would steal alcohol and drink it. Tracy's smoking and marijuana use started when she

joined a band in high school. Drug experimentation and use was common in college for both

Mary and Sara, and was initially viewed as recreational and a way to party. However, for Jackie

and Pamela, exposure was closer to home and drugs and alcohol were available and used as a

way to forget and dull the pain in their lives. For Tracy, her first exposure to harder drugs was

through an addicted partner and then she started using crack after her niece and nephew brought

it into her home.

Domestic violence

Domestic violence can take many forms. Its victims are not just the individual who is

receiving the punches, kicks, threats and verbal attacks. Children who witness these events are

more at risk of being in abusive relationships as adults. Three of the five women were abused by

spouses/partners to the point where they had to get help to get away from the abuse and some

sought refuge in domestic violence shelters on numerous occasions. Most of the women

interviewed described a history of violence in their families. While verbal and emotional abuse

was also common, examples of physical violence are described below.









Sara mentions how her mother was a violent drunk and also remembered when her father

was went to jail for beating her brother with a razor strap while he was tied to a chair. Mary

often witnessed her father beating her mother and then he beat her as a teenager. As an adult,

Mary was repeatedly and brutally victimized in her relationships with men. Before turning to

drugs, Jackie had nightmares about the abuse by her stepfather and was involved in lots of fights

with peers at school. Her stepfather threatened to hurt her mother if she did not do what he

wanted sexually. Jackie had her nose broken in one fight and in another fight, the girl she fought

with required stitches. She was also involved in numerous violent incidents while selling and

using drugs. Once she saw someone killed over a lighter. Jackie's husband spent time in jail for

breaking her jaw. Jackie was not afraid to fight and was able to defend herself in some but not

all situations. At the time of the first interview, she was recovering from a broken neck from

when she was attached by men at a party.

Pamela dealt with so much violence in her life, from her mother, father, grandmother,

grandfather, uncles, cousins, mother's boyfriends and husbands, fights at school and then later in

her relationships with men. Pamela was repeatedly physically and sexually abused from early

childhood and she witnessed her mother and her siblings being abused by men. As a teen,

Pamela both protected and beat on her siblings. As an adult, she experienced threats and

beatings in most of her relationships with men. She had a busted eardrum and cuts and bruises

from daily beatings. She stabbed one husband in self-defense. Tracy does not mention violence

in her life, but when she lived as a crack addict and prostitute and became a police informant, she

certainly must have been witness to violent events.

Sexual abuse and rape

Sara remembered being fondled on a stairwell and also mentions a friend's uncle who threatened

to rape her. She recalls men would expose themselves to her. Sara had a close relationship with









her father, and it is possible that her father did more than what was shared in the interview. She

describes that she had to help him with the urinal when she was a child and mentions accusations

that her mother made. As an adult she has trust issues with men, but she does not say why.

Mary's first sexual experience was described as when she was raped by a fraternity student in

college. In another instance, she agreed to date a guy and was forced to perform oral sex on him,

and then was stalked by him. She got married and was raped and sodomized by her husband.

Mary was dragged down the beach at knifepoint and raped by a stranger. Jackie's sexual abuse

began earlier. Her mother met her step-dad when she was 13 and she reports that he molested

her from the time she was 13 until she was 17. She also witnessed him molest her friend and his

own daughter. As an adult, a man tried to rape her after her husband left her stranded

somewhere, but she said that she "cut him up". Pamela also described sexual abuse in her

family. She and a cousin were both molested by her grandfather. She also described how her

uncle and two cousins would hold her down and sexually abuse her. At fourteen, her step-dad

started molesting her and did so for two years. Pamela's step-dad allowed other men to molest

her and then did the same to her sister.

Child abuse and neglect

From the accounts of physical, emotional and sexual trauma described above it is clear that

four out of five of these women were victims of abuse. While all of these women experienced

one or more pregnancies, only three decided to bear children. Among the three who have given

birth to children, none of the children were living with their mothers. That Pamela, Tracy and

Jackie love their children was clear to me. Their addiction and life circumstances prevented

them from providing for their children at the time of the interview. As both Tracy and Jackie

described, when you are on crack, you think you will just be gone for a couple hours, but you

end up gone for days. When you are addicted, you put drugs/alcohol first and your children's









needs later. Being involved with drugs exposed their children to violent behavior. For example,

three of Pamela's children (when they were ages 3, 2 and an infant) were present when their

grandfather shot and killed their uncle and cousin. Since Pamela and Jackie were in abusive

relationships, their children witnessed the abuse. And while Pamela did leave her children alone

while she went to party, she also tried to protect them from abusive partners. The loss of their

children is another theme that is addressed in a later section.

Early responsibilities

Both Sara and Pamela mentioned having care-taking responsibility for other siblings. In

Mary's experience, it was her sisters who cared for her and taught her how to read. Sara thought

that the early responsibility that she had might have been one of the reasons that she did not have

children of her own. After her father died, she took care of her sisters. She provided for her

sister's baby and then took her niece in after her sister (who was also an addict) was murdered.

Pamela remembers stealing food for her siblings. Both Pamela and Sara recall holding a knife in

order to protect their sisters from their stepfathers or mother's boyfriends.

Early substance use and progression to addiction

For these women, alcohol, tobacco and marijuana seemed to be the primary substances that

were used first. For Tracy, tobacco and marijuana remained her primary substances until close to

age forty. For Sara, marijuana was also her drug of choice for a long time, until it was laced with

crack and she became addicted to that as well. For Pamela and Mary, alcohol use started early.

Pamela started getting high as a teen, but Mary's poly-substance abuse really grew in college.

Jackie started using alcohol and marijuana at 18 and at 31 already has developed alcohol related

liver disease. All of these women progressed from smoking marijuana to use of "hard" drugs

like cocaine, crack and opiates. They lived with their addiction for years before seeking

treatment and they all reported periods of abstinence and relapse.









Substance use by partners

Many of these women had relationships with partners who also had drug and alcohol

problems. Tracy mentions an affair with a man who is a crack addict who may be the father of

one of her children. She also mentions another relationship with a crack dealer. Jackie described

extramarital affairs with men who were drug dealers. And most of the husbands and partners

that Mary discussed were men who were heavy users of alcohol and drugs. Mary also mentions

a relationship with a partner with marijuana and sexual addiction. Pamela's relationships also

brought her closer to drugs, with boyfriends who were dealers and users.

Loss through disease, accidents, death and estrangement

Loss of loved ones was a common theme in the histories of these women. Sara's twin died

when her middle sister was born. Her brother was killed in a car crash on the way to their

grandmother's funeral. Her father died when she was 13, her mother's mother died when she

was 14. When she was 21, her mother died and some years later, her middle sister was

murdered. She is estranged from both of her two living siblings, one of whom was also involved

in drugs when she last knew his whereabouts. Tracy's losses include her father passing and

losing her husband through divorce. At the start of her life history, she talks about her father in

the present tense and it is not until later that she mentions that he died years ago. The depression

after her divorce is one of the reasons that Tracy decides to try crack with her niece.

Jackie and Mary are both saddened by the fact that their mothers have Alzheimer's disease.

Jackie remembers that for some of her family members, the first time she saw them was at their

funerals. Mary lost her grandmother when she was about 10 years old. She also mentions a

friend from the children's rehabilitation hospital who died. She found out about her mother

Alzheimer's disease and her father's death at the same time and felt like she had lost both

parents. Pamela never really knew her biological father, but she said he was an addict and had









been shot and stabbed eleven times before being confined to a wheelchair. Her mother died from

a stroke when Pamela was about 27 years old. Pamela witnessed one of her mother's male

friends, one that had never abused her or her siblings, get shot and killed. In drug treatment she

saw a man shoot a woman in the head with the bullet killing the man next to her and the woman

fell through the window into Pamela's arms. Pamela also mentions a woman who she becomes

friends with who she describes as one of her ex's "new punching bag" who ends up dead.

Pamela says she feels like four of her children, the ones they took from her permanently, are

dead.

Loss of children

These women lost children through miscarriage, abortions, social services, parental

kidnapping and through their addiction. Sara became pregnant once and had planned to abort the

pregnancy before she miscarried. Mary had three abortions. The other three of these women

gave birth to 17 children. Eight of these children were in foster care or adopted and relatives

were caring for the other nine children. One of Tracy's children was living with her mother, one

was in foster care and two were living with their dad. Of Jackie's six children, three were

staying with her cousin and three with her aunt. Pamela's rights to four of her children were

permanently terminated. She was not sure if they were adopted or not since the boys had

emotional/behavioral problems. Her other three children were currently in foster care, but she

was trying to get them back.

Family care of children

Having a family support system protected some children from being placed in foster care

or taken from their mother permanently. Even though Jackie was grateful to have family, she

was disappointed in how they were being cared for and thought that no one could care for them

like her. For Tracy, her mother cared for her oldest son and the second two were taken by their









dad. Her fourth child was in foster care because her mother could not care for a baby and she

was not certain who the father was.

North-South transitions

It was interesting that all of these women reported some movements between the northeast

and the southeastern United States. For example, Tracy moved back and forth between New

York City and Florida before settling in Florida. Pamela also spent most of her childhood in

New York and Washington, DC and then moved to Georgia and Florida. Mary, who traveled

extensively throughout the U.S. grew up in Delaware and traveled often to Philadelphia where

she began college. She also spent time in Georgia before moving to Florida. Sara was born in

Florida then moved to Georgia and then lived New Jersey for 26 years before returning to

Florida. Jackie grew up in Florida, but spent summers with family in New York when she was

growing up.

Secrets

All of these women had secrets, some of which they shared. Some even mentioned that

they had never told anyone what they told me in these interviews. This may be why there seems

to be some inconsistencies in their life stories. As they told me their stories, they may have

discerned that I was listening not judging. As part of their recovery these women were all

involved in working on their 12-Steps, so they may have also been using the life history

interviews as an opportunity to work towards Step 5, which is to "Admit to God, to ourselves

and to another human being the exact nature of our wrongs." (Alcoholics Anonymous 1955, pp.

59-60). Not all of the memories that were shared or remembered were things that they did.

Some were wrongs were things that were done to them. I heard stories about being molested and

raped, about infidelity and contracting sexually transmitted diseases. They told me of suicide

attempts, abortions, prostituting, sex without condoms and arrests. Four women were arrested









numerous times before entering treatment. The four who had been married admitted to

pregnancies by someone other than their husbands. Some initially said they would never use

cocaine/crack or heroin, but then described using later in their history. Another mentioned that

she never had to prostitute to get her drugs, but then talks about stripping and sex with men and

women to get money for drugs and alcohol. Another said she always used condoms when she

was prostituting, but then reported that she got pregnant while prostituting after having her tubes

tied and while using Depo-Provera shots!

Promiscuity, prostitution and arrests

Four of the five women admitted to exchanging sex for money or drugs and to multiple

arrests. Sara was the only one who was never arrested (although there were a couple of times

that she would have been if the police had searched her). Sara also appeared to have had less

sexual partners in her lifetime even though she was the only one to have never married. Pamela

started prostituting as a teenager and recalled the first time that she had sex with an older man for

$20. Pamela remembers that her mother had numerous sexual partners and that she would have

babies by all these different men and then would give her children away. After a long history of

sexual abuse, Pamela reports sex with numerous partners and was not certain who the father was

of a number of her children. After her mom passes, she realizes that she is a lot like her mother

even though she had not seen her in ten years. Pamela reported being arrested five times.

Jackie did not report sexual activity with boys as a teen and she married early. Her abusive

stepfather did not want boys to interfere with his continued molestation of her. While she was

married, Jackie would get money by stripping and then later turned to prostitution to get crack.

Jackie talked a lot about what other women would do for crack, such as sex without condoms.

And while she reportedly felt bad for them and gave them money, she also describes having sex

with men and women for drugs or money. Jackie was arrested seven times. Mary did not have









any sexual relationships until she was an adult. After she was raped and became heavily

involved with drugs and alcohol, she reports becoming very promiscuous. While we did not

discuss prostitution, she did report having sex with men under the influence and sex in exchange

for a place to stay. She was also arrested numerous times and spent time in jail for violating

parole by drinking. Tracy married early and only mentioned three or four sexual relationships

before using crack. While on crack, she was a prostitute and police informant. Her most recent

arrest was for soliciting a police officer prior to entering treatment.

Denial

Denial is common among addicts. They may deny outright that they have a problem and

may deny the impact their disease has on themselves and those around them. Sara felt like she

needed the prescription medications that she stole and told lies to obtain drugs. Denial is not just

about lying, as it can be an unconscious way to submerge painful memories, thoughts and

feelings. Examples of denial in these histories include examples such as feeling like she could

stop using drugs/alcohol whenever she wanted, that the beatings would stop if she stayed in an

abusive relationship, that she was over the grief she had experienced as a child, that with

economic security she will no longer have a problem, that she can do it all on her own, and as a

couple of women mentioned, she will only be gone from her kids for a couple hours while she

goes to get high on crack.

Relapse

Periods of abstinence and relapse were common themes in the life history interviews. This

was Tracy's second time at SafeFree. The first time she had close to a year of drug-free living.

She had her kids with her in transitional housing, and had a job and a car before she relapsed

after seeing an old dealer who gave her $60 worth of free crack. Sara's desire to use drugs was

gone at one point in her life, which she attributes to God answering her prayer. But then she









thought if she could stop once, she could stop again, but it took years to reach this point. Mary

thought after a period of abstinence that she could start drinking alcohol in moderation, but soon

became dependent again. The craving to use again can be so strong that reasonable decisions

about use cannot be made. The drugs may make you feel like you are invisible as was mentioned

by Sara and others or you may believe that you can keep it a secret, but while you can lie to the

counselor, physician and your family, routine and random drug testing may prove you have been

using.

Illness, injuries and near-death experiences

I was surprised to hear how closely these women had come to death and survived. Sara

mentioned a severe pelvic infection from a sexually transmitted disease for which she was

hospitalized for weeks. Another time, she thought she would die from an overdose. They

described pre-term deliveries, and post-partum bleeding and infections. Tracy believes she

would be dead today if she had not gotten pregnant (while prostituting and using crack) after her

tubes were tied. Pamela mentions a hospitalization where doctors said she would have died if

the people who carried her out of her apartment had waited another hour. There were mentions

of suicide attempts and blacking out due to drug and alcohol use.

Mary and Pamela were severely beaten for years. There were physical injuries and scars

related to attacks, such as Jackie's broken neck, and the internal scars from abuse and rapes. All

of these women had co-occurring psychiatric issues. Depression was frequently mentioned.

Pamela says she has 20 different diagnoses and takes numerous psychotropic medications. And

then there is Mary, who suffers from anxiety, PTSD and agoraphobia. Shortly before entering

treatment, Mary weighed 77 pounds and went to the emergency room with a broken foot. After

they gave her crutches and pain medicine, she was told she must wait outside. Outside the









hospital, she went into cardiac arrest and would not have survived if she had not received

emergency medical intervention.

Drugs and alcohol instead of food

In addiction, drugs and alcohol take over the desire for natural rewards such as food. As

mentioned above, Mary only weighed 77 pounds prior to entering treatment. She admits that

alcohol replaced food. Jackie was also underweight at the time of the interviews. She mentions

that at one point she was living on alcohol, crack and chewing gum. Pamela reported that she

use to be much slimmer when she was using. Sara and Tracy had been in treatment longer and

were not underweight. Tracy mentioned how when she relapsed, the dealer who gave her free

crack must have known that she had not been using because she looked healthy and had gained

weight.

Isolation

Before entering treatment, most of these women were socially isolated. Tracy had her

mom and kids. Jackie mentions that her husband tried to turn her family against her and felt like

she only had her kids and her mom (who has Alzheimer's). All of Pamela's children were taken

from her and she is trying to get three of them back with her current boyfriend. Sara had only

her niece and grandnephew to call. Mary felt like her family disowned her. Their addictions and

abusive relationships cut them off from family and friends, so when they needed help there was

often no one there.

Sharing and connecting to others

Sharing was a more recent theme identified through the life history interviews. These

women shared intimate details of their life stories with me and also shared stories in their 12-step

recovery groups at SafeFree. Most expressed that they wanted to be able to help other women,

even just one other woman with addiction, by sharing their stories. In group, they share not just









their stories, but strategies and advice about what is working for them and what to watch out for

when they leave treatment. Many mentioned the importance of changing their "people, places

and things" to avoid relapse. They learn to reach out to sponsors and others who can help them

in recovery. Several women mentioned that they would like to help others with addictions once

they have had a year or more of sobriety. In treatment, they also share responsibilities with

others in terms of daily tasks such as phone monitor, monitoring the gate and cleaning.

Spirituality

Spirituality is an important part of the 12-step model of recovery. Many of the 12-steps

refer to a higher power; such as admitting powerlessness and turning things over to God (as you

know Him), confessing to Him and doing His will (Alcoholics Anonymous 1955). These

women all had history of church involvement at some point in their lives. Mary grew up in the

Catholic Church and went to Catholic schools. Pamela went to church often when she lived with

her grandmother and remembers praying a lot as a child. Sara went from church to church

looking for relief from her pain. She believes God has answered her prayers. Jackie had close

ties to the church and as mentioned previously her Aunt is a preacher. All of these women

repeatedly mentioned God and faith and prayer. Their backgrounds may have been a useful

foundation for the 12-steps.

Treatment and recovery

All of these women were in residential treatment for substance abuse at SafeFree.

Residential treatment is an alternative to hospitalization and provides a structured environment

where patients live 24-hours-a-day, 7-days-a-week. Drug treatment and rehabilitation services

are provided, as well as meals and a place to sleep. Some residential programs, like the one at

SafeFree, provide specialized services for women. These services include allowing children to









stay with their mother in treatment, child care, specialized counseling, transitional housing and

advocating for women and their children in child welfare/criminal justice cases.

Certain criteria have to be met to qualify for admission to residential treatment. Tracy,

during her last pregnancy reported trying to get help with her addiction, but without a positive

drug test could not be admitted. So she returned after getting high on crack and then shortly later

had a pre-term delivery. Usually, less restrictive treatment options are utilized before admission

to residential treatment. Addicts with co-occurring psychiatric disorders, those in abusive

relationships, and those who are homeless and without family or a social network are more likely

to need residential services. Being away from the people and places associated with their drug

use can help in maintaining abstinence. Residential treatment may have been recommended in a

social services case plan or may have been mandated by a judge in family or criminal cases.

This was not the first treatment episode for most of these women. For example, Sara had

been in treatment for substance dependence in New Jersey on numerous occasions, where she

lied about her cocaine use and where treatment, to her, seemed to be a revolving door. She

mentions that one young woman went there for treatment more than 30 times. In the past, Mary

had been actively involved with Alcoholics Anonymous and other 12-step groups that helped her

to remain drug and alcohol free for years. Prior to this admission, she went through

detoxification and was in intensive outpatient treatment, but continuously relapsed.

Detoxification is an important step in treating some drug dependencies, such as alcohol and

opiate addiction. During detoxification, toxicity and withdrawal symptoms are managed and

stabilized through medical procedures and psychological support. Sara explained that "detox" is

not the same everywhere you go and that she know of no one who what want to go through the

"detox" she went through before entering SafeFree's residential program.









Homelessness and positive drug screens appeared to be a common path to SafeFree. Three

of the women mentioned staying at a homeless shelter which required random drug testing and

referrals. Four women had been arrested on numerous occasions and all three of the mothers had

one or more children under the supervision of child protective services. Mandatory drug court

and drug testing was required for at least three of these women and they knew that a positive

result could send them to jail instead of returning to treatment. When children were involved,

there was also the potential to lose parental rights to the child/children.

Summary of Life History Themes

As documented in the proceeding sections there were numerous themes which emerged

from the life history interviews. These themes included family history of addiction, family

violence and child abuse, sexual abuse and rape, access to drugs and alcohol, early substance use

initiation, violent relationships, substance abusing partners, and loss through disease, accidents,

death, estrangement and child protective services interventions. For these women, drug and

alcohol addiction were often associated with promiscuity, prostitution and arrests. Keeping

secrets, denial and isolation were common, as were co-occurring medical and psychiatric

disorders. Many of them women had relapsed in the past, but they appeared to be actively

participating in sharing and connecting with others and spirituality appeared to be an important

factor in their treatment and journey to recovery. The next section provides additional details

about the treatment environment and process.

Treatment Environment and Treatment Process

SafeFree's residential treatment facility is located in an economically depressed area of

Florida. The women served by SafeFree's residential program are usually not covered by private

insurance and are unlikely to be able to self-pay for treatment. Addiction often results in "hitting

bottom" before entering treatment, which may mean job loss, alienation from family and friends,









arrests, poverty and homelessness. SafeFree's residential treatment includes a number of

services to meet a wide range of their clients needs. Their staff includes physicians, nurses,

counselors, mental health technicians, administrators and volunteers who are in treatment or

recovery. SafeFree encourages continued involvement after residential treatment and many

successful clients with long-term abstinence from substance use sponsor other clients in

treatment.

SafeFree's treatment of addiction is based on 12-step recovery model (Alcoholics

Anonymous 1955). Women attend and participate in 12-step groups and work individually on

each of their 12 steps. They also received individual and group therapy. Family counseling was

another service available to those who had family members willing to participate. It was

interesting to see how engaged some of these women were in their groups and to hear about

which of the 12-Steps they were working on and what they were learning in treatment. Several

of the women interviewed were receiving medication for depression, anxiety and other

psychiatric conditions in addition to the treatment they received for substance use disorders. Not

all treatment providers are able to offer prescription medications and medication/medical

monitoring of other illnesses. As documented in both the interview and survey results, many of

these women had a history of trauma (child abuse, sexual abuse, violent relationships). SafeFree

offers special counseling for victims of trauma.

SafeFree offers women with children the option of keeping their children with them while

they are in treatment. From the interviews, it appears that social services and family courts

intervened before many of these women entered treatment, although Tracy did have her children

with her at one point and Pamela was trying to get her youngest three out of foster care and into

SafeFree with her. SafeFree has an onsite child development center, offers parenting classes and









permits scheduled visits from children and other family. The women I spoke to and the

observations I made of children playing and interacting with parents (4th of July cookout) gave

me the impression that SafeFree supports and encourages the mother-child bond and family

relationships. On the other hand, women expressed disappointment with social services (child

protective services) including missed visits with kids because the social worker would not or

could not bring them. One woman also mentioned that child protective services requirements

interfered with the possibility of working and that case plan requirements limited the time she

had available to spend with her other children.

The proceeding sections have focused on life history themes and treatment characteristics.

The next sections discuss these life history themes and selected survey results in relation to some

of the addiction theories and literature described in Chapter 1.

Life History Themes and Survey Results in Relation to Selected Addiction Theories and
Previous Research

Stages of change

In terms of stages of changes (Prochaska, DiClemente & Norcross 1992), four of these

women appeared to be in the maintenance/recovery stage. While all of them had recently taken

action to make a change, one woman, Jackie, appeared to still be contemplating a change. Those

who did not prepare for the change may have more difficulty maintaining abstinence. Sara,

Tracy and Mary had all been able to maintain months or years of abstinence in the past but

eventually relapsed. For Tracy the relapse was short, only two weeks, while for Mary and Sara,

it took several years to return to abstinence. As Tracy mentioned it was one thing to learn how to

live in recovery, but additional skills were needed to avoid relapse. Just as the brain is involved

in drug reward and withdrawal, there are neurobiological influences on relapse. Some of these









factors are addressed in the next section on biological influences. As described in Chapter 1,

addiction is complex with biological, cultural, environmental and psychological influences.

Biological

As discussed in Chapter 1, genetic factors account for a substantial portion of the risk of

substance dependence (Kendler et al 1997; Schuckit 2002. While this study did not test any

biological hypothesis or genetic markers, family history of addiction was common for all of

these women. Four of the women had at least one parent with a substance abuse problem and this

may have resulted in increased susceptibility for addiction once they began using drugs. Genetic

factors may have influenced their drug metabolism, brain reward and their response to drugs of

abuse, however these biological responses could not be systematically evaluated by thy study

design used in this research. Researchers have evaluated the neurological foundation of craving

for drugs (Robinson & Berridge 1993) and recent brain imaging studies have shown that

addictive behavior may be related to decreases in natural rewards, reduced ability to cognitively

control behavior and increased activity in areas that respond to drug related stimuli (Kalivas &

Volkow 2005). Drug-related stimuli, such as the people, places and things that were associated

with drug use, seemed to be important in the life history interviews. Even in periods of

abstinence, seeing a former drug dealer, partnering with someone who uses drugs or alcohol, or

seeing the crack could make craving for the drug more intense and relapse more likely.

In addition to individual susceptibility and metabolic differences, the strength, amount and

route of administration may have also played a role in these women's addiction. As drug use

progressed, tolerance developed and resulted in intakes of huge amounts of alcohol for Mary,

Jackie and Pamela. While several of these women smoked marijuana for years, once they started

smoking cocaine, in the form of crack, their lives began to spiral out of control. This is in line

with finding by Dr. Cottler and her colleagues who found that use of opiates and cocaine had the









shortest length of time between onset of abuse and dependence (LOTAD) regardless of the

characteristics of the group of analysis (Ridenour et al. 2005).

Cultural

Parents, siblings and peer groups have a strong influence on the decisions teenagers make

about whether or not to use drugs and continued use (Kandel 1978; CASA, 2002). Growing up

in homes where drugs and alcohol are abused by other family members, can lead to acceptance

of this behavior. Four of the five women were raised in homes where substances were abused.

Jackie, Pamela and Sara also mention substance abuse and addiction among their siblings. While

these women did report some positive peer relationships as children, Jackie and Pamela did

report conduct problems at school. As noted in Chapter 1, researchers have suggested conduct

problems may be linked to seeking out peers where risky behavior and drug use are accepted

(Cadoret et al. 1995). Tracy's school problems seemed to begin after she started smoking

marijuana, whereas, Mary and Sara grades and attendance in college were affected by their drug

abuse.

As mentioned in Chapter 1, the "Gateway" theory is popular theory of drug abuse, which

suggests that early use of licit drugs like tobacco and alcohol or "softer" drugs like marijuana

may lead to exposure to and use of "harder" drugs like cocaine and opiates (Kandel, Yamaguchi

& Chen 1992). In both the survey results and the life history interviews it was apparent that use

of alcohol, tobacco and marijuana preceded the use of other drugs like cocaine and opiates.

Learning one route of administration could lead to other drugs being used by the same route, like

Tracy who inhaled marijuana before inhaling crack or alternately women may have

experimented with different routes of administering the same drug, like Sara who would take

opiates orally, transdermally or by injection.









As a historical analysis of drug abuse in the United States (Drug Enforcement Agency

2007; Aurin 2002; Agar & Reisinger 2002) would suggest, culture also plays a role in what

drugs are available (indigenous, imported, processing and supply chain, laws), where drugs are

used (crack houses, bars, homes), who uses drugs and with whom (age of user, use with other

users, peers, partners and family) and how drugs are used (i.e. route of administration, quantity,

what drugs are used together). The women interviewed used drugs that were available in their

surroundings. When the supply of drugs changed, they often switched drugs or transported drugs

with them. While early drug use was often a social experience that they shared with significant

others and friends, heavy use often led to changes in where use was acceptable. Most of these

women described not using drugs in front of their children, they would report using drugs in

another room of the house or leaving their children alone to get high. Poly-substance use was

common among women surveyed and those who were interviewed.

Environmental

Environmental exposure to drugs of abuse comes in many forms including second-hand

exposure in the home and some neighborhoods. The women interviewed did mention use by

parents and their partners, and it was apparent that drugs were readily available in the

community. Exposure may also happen inadvertently, for example some of the women had their

first experience with crack through smoking marijuana that they did not know was laced with

crack. Even without direct exposure, second hand exposure to smoked drugs can sensitize the

brain and make continued use more likely once experimentation begins.

Psychological

Theories of co-occurring disorders/dual diagnoses have been used to describe high rates of

addiction and mental illness, which often occur together (Bachmann & Moggi 1993). While it is

often unclear whether the addiction led to the development of the mental illness such as









psychotic symptoms after long-term marijuana use (Ferdinand et al. 2005) and alcohol related

depression (Gold & Aronson 2003) or if those with psychiatric disorders such as anxiety and

depression are using drugs of abuse to self-medicate, these conditions are strongly correlated.

Psychiatric disorders were not addressed in the contraceptive survey, however the survey

showed that many of these women were victims of child abuse or had been in violent

relationships, which may lead to PTSD. As Schuck and Widom (2001) have reported child

abuse increases the risk of substance abuse. Anxiety, depression, panic attacks, post-traumatic

stress disorder and substance dependence are common psychological consequences of

traumatic/violent events (Smith et al. 1990; Galea et al. 2002; Schuster et al. 2002). Not only

were these women likely to be victims of childhood sexual abuse and domestic violence, but

their substance use may have put them at increased risk of further victimization as suggested by

Miller (1996). Dual disorders were common among the women interviewed and at least three

mentioned symptoms that are common in those diagnosed with PTSD. This is an important issue

for addiction treatment, because relapse is more common if the co-occurring condition is not

treated.

Addiction and Pregnancy

The Institute of Medicine (1995) suggested that overall, about 57% of all pregnancies are

unintended at the time of conception and the proportion of unintended pregnancies is much

higher among women who abuse illegal drugs and alcohol (Institute of Medicine 1995). In the

present survey more than 82% of the pregnancies were unplanned. There were 178 unwanted

pregnancies (almost 60% of all pregnancies) and 56 abortions reported by these 100 women.

Pregnancies that are not planned and not wanted are more likely to be terminated by abortion and

children that result from unwanted pregnancies have poorer health outcomes (Institute of

Medicine 1995).









Four of the women surveyed reported that they were currently pregnant and eight percent

reported that they would like to become pregnant in the next year. Many of the women surveyed

had pregnancies that occurred during periods of drug and alcohol use. Among those that were

interviewed the three who had children had used drugs during pregnancy. Drugs use was

associated with a number of adverse pregnancy outcomes among the women interviewed,

including miscarriages, severe prematurity, neonatal intensive care, maternal complications after

delivery, and loss of children through child protective services interventions. Among the

women who were surveyed there were 59 miscarriages reported and three stillborns, which may

have had some relationship to drug and alcohol use.

Documenting long-term effects of maternal substance abuse on children is a challenge for

a number of reasons including frequent moves, homelessness, arrests, lack of telephone,

controlling/abusive partners, kids removed from home and confidentiality and legal issues. State

mandatory reporting laws may make women hesitant to admit to substance use even in live

threatening situation. Women who were interviewed sometimes denied substance use when they

were hospitalized or would not admit to all of the substances they were using. Pregnant women

and mothers with SUDs may fear losing their children if they seek treatment. (Ayyagari et al.

1999). This fear is not unwarranted since many of the women in treatment had children that

were living with another relative and 25 children were either living in foster care or had been

adopted. As Eyler and Behnke (1999) noted, the effects of drugs may be exacerbated in children

who are poor or have less than optimal caregiving environments. Even among those who were

employed last year, most of the women surveyed were living below the poverty line. Not only

are these children four times more likely to be abused or neglected (Jaudes & Voohis 1995), they

are also more likely to be separated from their families and have parental rights terminated.









As described by the Kaiser Family Foundation (2002), substance use can place women at

higher risk for contracting a sexually transmitted disease (STD) because they are more likely to

have sex with multiple partners and impaired judgment can interfere with decisions about

condoms and contraception. Three of the five women interview mentioned contracting an STD.

Multiple partners were also commonly mentioned during the interviews. Some thought that they

couldn't become pregnant or that their drug addiction would prevent pregnancy. Even though

they were at risk for STDs condoms were used inconsistently.

Wenzel and colleagues reported that availability and cost were the most common barriers

to contraceptive use among homeless women (Wenzel et al. 2001). In another study of homeless

women, perceived deterrents to contraceptive use were cost, side effects, partner's dislike, fear of

health risks, and not knowing how or which method to use. Some of the women interviewed

mentioned that no one had ever discussed things like menstruation, risk of pregnancies and

contraception with them. The survey of women in treatment found that side effects were the

most common reported reason for stopping a method of contraception. Other potential barriers

to continued use reported by close to 10% of the women surveyed included that the method

failed, it was too messy or that it decreased sexual pleasure. Less than five percent mentioned

cost as an issue and only a couple women indicated that availability was a factor.

Women often take the primary responsibility for children, which can make it difficult to

receive addiction treatment and parent simultaneously. Responsibility for children, along with

inability to obtain child care services, is reportedly one of the most significant treatment barriers

among women (van Olphen & Freudenberg 2004). Since women in this residential treatment

center have childcare services available, this is not a barrier to remaining in treatment for these

women. Instead, it appears that availability of treatment beds is a more significant barrier.









Another barrier may be the requirement for a positive urine drug test (some drugs have rapid

excretion and may not be detected) because women, especially pregnant women, who present for

drug addiction treatment should not be turned away. Sometimes, when an addict is turned away

from treatment because there is no space available, the addict dies before seeking treatment

again. Several of these women witnessed drug-related homicides, such as Jackie, who saw

someone killed over a lighter.

Life History Themes and Survey Results in Relation to Selected Fertility Theories and
Previous Research

Fertility theories

Understanding natural fertility is important in studies that look at ways that fertility is

controlled, such as through cultural norms and practices related to sexual intercourse and

contraception (Coale, Ansley & Trussell 1974). One of the limitations of the survey is it did not

include some important questions related to natural fertility, such as age of menarche and length

of breastfeeding or postpartum amenorrhea. One aspects of fertility that is controlled by

biological mechanisms is maternal age and its impact on possibility of conception (Dunson,

Columbo & Baird 2002; Markus et al. 1998). Among the women surveyed, age at first childbirth

ranges from 12 to 34 years of age while the average age at first childbirth was 20 years old.

Demand Theory and Diffusion of Norms Theory focus on how changes in reproductive

behavior and fertility rates are due to changes in the demand for children related to the costs and

benefits of having children and due to the cultural diffusion of lower or higher fertility norms

(Davis 1963; Caldwell 1980; Becker 1981; Pollack &Watkins 1993). The results of the surveys

and the interviews would suggest that the supply of children is greater than the demand for

children. Many of these women lack the resources that economist argue would influence the

choice to have children. Considering the lack of resources and that close to sixty percent of









pregnancies were reported as "unwanted" and yet only some of these unwanted pregnancies were

terminated, there appears to be a huge gap. Although having children could increase welfare

benefits and provide opportunities for subsidized housing and childcare, it is unlikely that the

benefits outweigh the costs for many of these women.

In the past few decades, it does appear that lower fertility norms have diffused in the

United States and most other countries. Total Fertility Rate (TFR) is a way to summarize

fertility levels at a point in time. Political policies, economic forces and changing cultural norms

have led to a significant decrease in the median total fertility rate which was 5.4 children per

woman in the 1950's, whereas in 2000 the median was estimated as close to two children per

woman and 40% of people lived in countries where rates were below replacement levels (United

Nations 1999). The mean TFR in the United States was 2.1 in 2000, but there differences among

racial/ethnic groups (See Figure 6-1). Even though the population surveyed has not reached their

reproductive potential (as many women are young enough to have more children) the mean of

2.2 children overall and 2.7 per woman who had children in this population is higher than

average rates for the United States. Since most women in the survey had their first child before

age 35, if we look at the population who are 35 or less, approximately 78% may have the

potential to produce more children (i.e. they have not been surgically sterilized). In the present

study, the average age of sterilization was 28 years old and among these women the mean

number of pregnancy was about four and on average they had three children before sterilization.

Decisions to reproduce may be influenced by the woman's partner. Eight percent of the

women in the survey reported that their partner wanted them to get pregnant in the next year. In

the interviews, it was noted that being in a married relationship led to acceptance of children that

may not have been fathered by their spouse. As Feldman-Savelsberg (1995) also describe,









motherhood did appear to help these women connect to their partners families and this

connection sometimes led to assistance in escaping from violent relationships.

As described in Chapter 1, not all women who desire children are able to have them and

not all women who want to control their fertility are able to do so (Quesnel-Vallee & Morgan

2004; Bongaarts 1991). Because of poverty and lack of insurance, these women are unlikely to

have access to treatment for infertility. In terms of contraceptive use cost did not seem to be a

major barrier, however most of these women were poor women and they may have had access to

free or low cost contraception through programs such as Medicaid or health department clinics,

as is suggested by research by King and Meyer (1997). Although ideally, women should be able

to prevent unwanted pregnancy, abortion was used by many of the women surveyed to prevent

unwanted childbirth. The increasing legal restrictions being placed on abortion in the last

decade may lead to increasing number of unwanted births.

Behavioral ecology/Life history theory

Evolutionary anthropologists sometimes use life history theory to explain many behaviors

and physiological traits in terms of maturational and reproductive features that are key in the life

course. While the survey did ask some questions that are important in life history theory, such as

age of first sexual intercourse and age of first childbirth could be calculated, there was a missed

opportunity to collect some of the other details that would have been relevant to a life history

analysis, such as age of menarche, age at first pregnancy (since may were aborted or miscarried).

Despite these limitations, some of the findings of the surveys and interviews are reviewed here in

light of selected research on life history in the literature.

In terms of reproduction, as articulated by MacDonald (1997), a "life history strategy of

parenting" evolves "as a coordinated response to the environment" and is influenced by

"mortality rates, longevity, pair bonding, age of first reproduction, period of pre-adult









dependency and levels of maternal and paternal investment" (p. 327). While a small number of

women interview cannot be used to generalize, if we look back to the interviews, we see women

experiencing lives where mortality rates are high. Most have lost one or both parents to death or

disease (specifically, Alzheimer's Disease). Many experienced unstable or no pair bonding

between their parents and all reported unstable bonding in their adult lives. Age of first

reproduction was young for two of the three women who had children. A couple of these women

had to steal and take on adult responsibilities for siblings during their early teen years. Most had

limited contact with parents in their early adult lives as they left for college, moved or got

married. Tracy appeared to have the most parental investment and she became an addict much

later than the other four women. Pamela seemed to have the least parental investment and she

got involved with illicit substances at an earlier age. It did appear that these women wanted to be

more invested in their children's lives, but in some cases they were no longer able to do so. The

limited resources available to these women and their children may result in future unstable

environments.

Although the survey was more limited in the types of data collected, the small number of

women who are currently married and the high number that have been abused or in violent

relationships suggest that these women have also experienced unstable bonds. Questions about

income, employment and education also indicate that they may lack educational and financial

resources. MacDonald states, "the motive to maximize the number of surviving offspring may

conflict with the evolved motive to increase or maintain social status" (1997, p.359). Maybe the

lack of potential increases in socioeconomic status made it more likely for some of these women

to adopt an early pairing, high fertility and low investment reproductive strategy.









In regards to substance use, Hill and Chow analyze risky alcohol use from a life history

perspective (2002). They generated predictions based on what they describe as an "evolutionary

analysis of risk taking" (2002, p. 401). They found that risky drinking increases among those

with unstable environments, and is more prevalent among those without children, younger

adults, single individuals and men (Hill & Chow 2002). In the present survey, there was no

difference in mean age among those with and without a history of alcohol use prior to treatment

and no difference in terms of the percentage with and without a history of child abuse, however

there was a difference in average number of children between the two groups. The mean number

of children among women who did not report alcohol use on the day before treatment was 1.7,

while for those with recent alcohol use, the mean number of children was 2.9. Interesting, as

Hill and Chow point out, is that when the future environment is unstable, early reproduction and

other risk-taking behaviors may be a more likely. In comparing mortality and homicide rates,

Hill and Chow write:

Compare to the areas with longest life expectancies, the community areas with the shortest
average life expectancy also showed higher birth rates for young groups of women, which
we interpret as taking a risk strategy that may yet be the best one for leaving any
descendents in this environmental context. (2002, p. 405)

While having children in an unstable environment adds additional stress to the family, if we

think about it in terms of the potential for your genes to pass down to future generations, it

makes sense to have more children, because many do not survive.

A life-history perspective is not the same as biological determinism, instead it allows for

behavioral theories to be used to help explain the effects of environmental instability (Hill &

Chow 2002). A number of studies would suggest that there is an inverse relationship between

substance abuse and socioeconomic status. It may be the case that people who live in unstable

environments are more likely to engage in substance use and other risk-taking behaviors.









However, it is also important to point out that substance abuse can cause environmental

instability and is associated with violence in the home, family disruption and job loss. As

mentioned previously many addicts "hit bottom" before seeking treatment, so it is not surprising

that many addicts are living in poverty.

Life history theory has also been used in the analysis of early childhood sexual abuse in

women (Vigil, Geary & Byrd-Craven 2005). Vigil and colleagues predicted that among women

who experienced child sexual abuse, that sexual behavior and age of first childbirth would occur

at an earlier age (2005). In their study, they found that women with a history of childhood sexual

abuse began having sex and had their first child, on average, 1.5 years earlier than those without

abuse history. Although the survey did not include a question about child sexual abuse, it did

include a question regarding abuse in childhood. One notable difference when comparing

women who were abused as a child compared to those who did not report a history of child abuse

was the percentage who reported being in a violent relationship as an adult. While 51% of

women with no reported history of child abuse reported having been in a violent relationship,

75% of those who were abused as a child also reported being in a violent relationship. There

was not much difference between groups for age of first intercourse and age at first childbirth

among those with and without a history of child abuse, but again, the survey did not specifically

ask about child sexual abuse.

There is substantial evidence that addiction impairs parenting, however some researchers

have used a life history method to examine the importance of motherhood in the lives of addicts.

From interviews with crack and heroin addicts, Hardesty and Black describe that,

Their lives as mothers took place in a context of poverty, marginalization, and abuse.
Motherhood provided an identity and a line of work that grounded them amidst this
dislocation. As their life options became more restricted over time, motherhood provided a









lifeline through addiction and into recovery... In recovery, children became the markers of
success in a treatment program (Hardesty & Black 1999 p. 602)

Motherhood may have played a similar role in the lives of the mothers who were interviewed and

surveyed. The role of life history events, such as the ones described in this section, is one way of

examining contextual and environmental influences of substance use and reproductive behavior.

Another way of exploring the context and influences in these women's lives is through life

history narratives, which is discussed in the next section.

Life history narratives

There is a "fundamental human tendency to tell stories" (Bayoumi & Kopplin 2004,

p.570). A life history narrative, rather than a factual account of events, is a social construction of

reality. It is how someone experiences reality from her/his perspective. Some would argue that

all "case studies, narratives, descriptions and factual reportage are all social constructions that

produce their own realities" (Carson 2001, p. 198). Carson states "descriptions of what we do

are never simply reports on how things really are, but are essentially influenced by who we are;

any description is a self description" (Carson 2001, p. 199). The life history is one way to tell a

story, but there are a number of other ways to tell a story and from many different perspectives.

For some people, the mothers who were interviewed for this research may be perceived as "bad

mothers" because of the things they did while addicted to drugs. We may have read these stories

from a different perspective, influenced by our own experiences of childhood and lived

experience of abuse, neglect, dysfunction, poverty or from a perspective that lacks these

experiences. However, it is hoped that through a reading of their life history narratives, that

readers may have a better understanding of these women's lives. In the following paragraphs,

the value of these life history stories in the context of diagnosis, treatment and recovery are

explored.









One of the first things medical students learn before interacting with patients is how to take

a medical history. The medical history is essential in making a diagnosis. The medical history is

a collection of information, such as age, sex, employment, marital status, household information,

weight, height, history of diseases, illness and injuries, appearance and current symptoms.

Physicians use the information they collect in a history and match it to what they have learned

about the signs and symptoms they have learned about in order diagnose a problem and to

provide the best treatment options. Some have described medicine itself as "a narrative art, and

physicians are inveterate storytellers" (Pollack 2000, p.108) and as described by Good and Good,

Physicians talk in stories, whether discussing patients anecdotally or analyzing "cases" in
formal settings... They teach through stories.. Physicians practice in stories. They carry
out their work by developing narrative accounts of patients and formulating therapeutic
activities in relation to these anecdotes. They reason and make decisions in narrative
terms. (Good & Good 2000, pp. 50-51)"

Although the utility of narrative in medicine is apparent, medical professionals are increasingly

aware of the importance of patient life history narratives, which can provide a better

understanding of patients and how they experience illnesses than simply taking a medical

history. As Greenhalgh and Hurwitz (1999) describe, narrative-based medicine, unlike modern

medicine, provides a "...metric for existential qualities such as the inner hurt, despair, hope,

grief, and moral pain which frequently accompany and often indeed constitute, the illness from

which people suffer" (Greenhalgh & Hurwitz 1999, p. 50). Greenhalgh and Hurwitz also write

that the narrative "provides meaning, context and perspective... It defines how, why and in what

way the patient is ill" (Greenhalgh & Hurwitz 1999, pp.48). Narrative methods also "remind us

that behind every practice, there is a person waiting to be heard" (Carson 2001, p. 202)

Bayoumi and Kopplin, in advocating for a storied case report/case report as narrative are

convinced that this approach "...will make the bedside encounter more scientific (yielding an

improved evidence base and structure for making diagnosis) and more artful (yielding an









enhanced understanding of the patients perspective and needs)...", 2004, p.570). The typical

medical history has a "coherent linear story structure of disease that gets applied to patients in

making a diagnosis", while personal narratives "are not linear, coherent, or even logical; they are

messy and written 'on the fly'." (Watson 2007).

The women's life stories presented in Chapter 3 are not always linear, coherent and logical.

Their stories jumped at times from one part of their life to another. What they described may not

make sense to someone who did not experience their experiences. However these narratives can

be considered as a part of healing. Narratives, as described by Garro and Mattingly, "are a part

of the process of healing, and when this cultural work is successful, narrative ameliorates

disruption: it enables the narrator to mend the disruption by weaving it into the fabric of life, to

put experience into perspective" (Garro & Mattingly, 2000, p. 29). Like the narratives of

addiction reviewed by Hurwitz, Tapping and Vickers (2007), the stories of the women interview

also appeared to take the form of a confessional narrative, as a quest for recovery, or both.

Listening to, writing and reading these women's life histories certainly gave me a better

understanding of their experiences. Being able to put their experiences into perspective may

have helped them in their recovery and may have the potential to help other women with SUDs.

While I asked them to participate in the research, all of the women interviewed asked me to help

them to share their stories in the hope that they could help another woman with addiction.

Limitations

There are a number of limitations to this research that should be pointed out. This

dissertation research began as a research project and since the research questions and data

collection instruments were designed before some of the theoretical research was reviewed there

were additional areas, which would have been interesting to explore that unfortunately were not.

Also, since this was exploratory observational research it does not allow for inferences to the









population of all women with substance use disorders. The sample size for the interviews was

small, but the detailed information collected does provide an idea of the life experiences of

women with addiction. Although the survey collected information on hundreds of variables,

there are additional questions that could have been included. In addition, while the regression

analysis provided useful information about the relationship between two individual variables, a

multiple regression model; which considers the influence of numerous variables, is an important

next step for this data. While these and other limitations exist, this dissertation has the potential

to add to the knowledge base of anthropological studies of addiction. It is hoped that this

knowledge can improve the understanding and treatment of women with addiction so that these

women can break out of the cycle of addiction and violence and provide a better future for their

children.

Recommendations

There are several caveats, however given the limitations listed above I would make the following

recommendations in three arenas:

1. Contributions to Anthropology

a. It makes sense to use a life history approach in collecting data from a high risk

population that have reasons not to trust researchers.

b. Other researchers should prepare for this type of research by establishing rapport

with the treatment staff and individual clients. During life history interviews the

researcher should listen without making judgments. Many of their memories are

painful and therefore the ability to empathize and show compassion is important.

c. In the future, there should be more ethnographic studies of sub-groups of women

in treatment.

2. Public Health Policy









a. We should remove drugs from our communities. The drug problems we see in

the United States are not common in countries where drugs are not available and

not socially accepted.

b. There needs to be advocacy for system wide changes, such as making early

intervention and treatment more widely available.

c. Since many people with substance use problems have other psychological and

medical co-occurring disorders, treatment programs that address dual disorders

should be expanded.

d. Addicts need help to recover from addiction. Once treatment is widely available

we should consider recruiting people into treatment.

e. Relapse prevention is very important. Assistance should be provided to help

those in recovery to change their surroundings while maintaining a support

system.

3. Specific to SafeFree

a. Like many other treatment centers the need for treatment is greater than the space

available. If funding permits, treatment beds should be increased.

b. SafeFree provides a wide range of services that addresses many of the needs of

their clients. They should continue to provide services tailored to the special

needs of women with addiction, especially services that address trauma and

victimization.

c. SafeFree should continue to advocate for addicted mothers and their children and

continue services that help families to stay together.









d. SafeFree should consider offering family planning and contraceptive counseling

to women in treatment.

Conclusions

While a number of studies have focused on condom use and reducing the spread of

sexually transmitted infections, few studies have evaluated family planning, the full range of

contraceptive choices and barriers to effective use, in a population of women with substance use

disorders. Some research that has been done focuses on the "what" but not the "why" questions

related to addiction and pregnancy intentions. Through a review of the literature and use of

qualitative and quantitative research methods, this dissertation provides insight into why women

become addicted, why there is a cycle of addiction and the impact on fertility and contraception.

Unfortunately, many addicts do not receive treatment for addiction until they hit bottom. By the

time they enter treatment, these women may have lost their family, friends, home, money and

employment. Initially, the research was planned to first elucidate barriers to contraceptive use

among women with SUDs and then attempt to increase knowledge, access, and acceptance of

voluntary effective contraceptives. It was expected that this could result in a reduction in

unwanted or unplanned exposure to drugs and alcohol during pregnancy. It appears that in this

population of women, there was a missed opportunity much earlier in their lives. When surgical

sterilization is considered as a contraceptive method, the percentage of women using any

contraceptive method is quite high in this population of women. Non-sterilized women are not

always using the most effective methods of pregnancy prevention and many women are at risk of

STDs and AIDS because of inconsistent condom use. In terms of preventing drug exposed

pregnancies, many of these women have already completed child-bearing.

Addressing barriers to contraception and condom use is still important in increasing

acceptance and use, but addressing barriers to treatment for women with addiction is equally









important. Pregnant women who self-report drug use should not have to have use drugs and

have it confirmed by urine testing to enter treatment. Considering the high number of mistimed

and unwanted pregnancies in this study and the number of abortion reported, most of these

women were not able to adequately delay or prevent unwanted pregnancies. It may prove useful

to increasing family planning education and effective contraceptive use among sexually active

girls and young women before drug experimentation. Young women who are using drugs in

their teenage years often begin sexual activity during those years as well. While all young

women should be informed about the risks of substance use and sexual activity, they should also

be informed about ways to minimized their risk. Ideally, there should be a contraceptive method

available that lasts for years, is easily reversible, inexpensive, with few side effects and that does

not require numerous visits to medical providers. Until such a method is available and widely

used, additional services are required for at-risk girls and women.

Although there is a great need to reduce the number of children adversely affected by

addiction, coerced abortions and sterilizations and placing children of addicted mothers in long-

term foster care are not solutions to this problem. Women with substance use problems should

be encouraged to get help and should not have to fear of losing their children and prosecution

when they seek treatment. When addiction prevention has failed, early intervention and

addiction treatment are required to reduce current harm and possibly break the cycle for future

generations. Treatment beds should be increased and the number of programs that offer services

to women and their children should be expanded. Because addiction is a chronic relapsing

disease, not all women who receive treatment are able to maintain abstinence from drugs, but the

alternative to treatment is a life with increased mortality, violence, legal implications,

homelessness, poverty, isolation or early death. The children who are exposed to these









conditions are more likely to face similar circumstances. Addiction treatment programs, such as

SafeFree's residential program for women, are helping women with SUDs to change their lives

and in the process may be creating a new chapter of hope and healing in the lives of these

women and their children.


3 -

2-* Overall TFR
Hispanic TFR
1- I Black TFR
0 1 1 DO White TFR
Overall Hispanics Blacks Whites

6-1. Total Fertility Rates Overall and by Race/Hispanic Ethnicity: The United States, 2000


214









APPENDIX
SUPPORTING DOCUMENTS

IRB Application

University Of Florida Institutional Review Board
1. Title Of Protocol: Barriers to Contraceptive Use Among Women with Substance Use
Disorders
2. Principal Investigator(s): Kimberly Frost-Pineda, MPH, Doctoral Candidate Anthropology,
Box 100183, Gainesville, FL 32610-0183, (352) 392-6698, kimfp@ufl.edu, (352) 392-8217.
3. Supervisor (If PI is Student): Allan F. Bums, Ph.D., Professor of Anthropology, College of
Liberal Arts and Sciences, P.O. Box 117300, (352) 392-2230, afburns@anthro.ufl.edu, (352)-
392-3584
4. Dates of Proposed Protocol: From IRB Approval/May 2006 To December 2006
5. Source of Funding For The Protocol: There is no direct funding for this research, however, the
PI was awarded an NIH Loan Repayment Program award which will pay a portion of her student
loans as she conducts this research.
6. Scientific Purpose of the Investigation: The purpose of this research is to explore past, current
and intended contraceptive use among women in treatment for substance abuse and dependence.
Another purpose is to explore the lived experiences of women in treatment for substance use
disorders.
7. Describe the Research Methodology in Non-Technical Language. The UFIRB needs to know
what will be done with or to the research participantss.
There are three components to this research:
1. Women at the addiction treatment center (N=100) will be asked to complete a survey
on contraception use using questions from the National Family Growth Survey.
2. Five women will be asked to participate in life history interviews. These interviews
will take approximately two hours each and will be scheduled on five separate visits.
3. The researcher will describe the treatment context and process.
8. Potential Benefits and Anticipated Risk. (If risk of physical, psychological or economic harm
may be involved, describe the steps taken to protect participant.)
There will be no direct benefit to participants who participate in the survey, however, the data
collected has the potential to improve service availability at the addiction treatment center if
there is an identified need. Telling a life history, while it does have the potential to bring up
painful memories, can also be therapeutic. There will be counselors and psychiatrists available if
anyone experiences distress as a result of these interviews.
It is anticipated that some of these women will have had interactions with the child welfare
system. They will be told they should not discuss any unreported incidents of child abuse
because of state mandatory reporting laws. However, there is no other risk of outside disclosure
as data will be collected and reported in an anonymous form.
9. Describe How Participant(s) Will Be Recruited, the Number and Age of the Participants, and
Proposed Compensation (if any):
One hundred consecutive adult women (age > 18 years) in treatment for substance use disorders
will be asked to complete the contraceptive survey.
Five adult women will be asked to participate in the life history interviews. The proposed
compensation is a $10 Wal-mart gift card per interview, with a maximum of five interviews per
person.









10. Describe the Informed Consent Process. Include a Copy of the Informed Consent Document
(if applicable).
The Principal Investigator will explain the purpose of the study including any risks and potential
benefits. Potential participants will be given a copy of the attached informed consent document
and questions will be answered. Signatures will be obtained before any interview questions are
asked. They will be told they should not discuss any unreported incidents of child abuse because
of state mandatory reporting laws. Participants will be informed that their data will be stored and
reported in an anonymous and summarized form. Those who participate in the interviews will be
able to discontinue participation at any time.

Principal Investigator's Signature

Supervisor's Signature
I approve this protocol for submission to the UFIRB:

Dept. Chair/Center Director Date









Informed Consent Form


Protocol Title: Barriers to Contraceptive Use Among Women with Substance Use Disorders
Please read this consent document carefully before you decide to participate in this study.

Purpose of the research study:
The purpose of this study is to examine past, current, and intended contraceptive use among
women in treatment for substance abuse and dependence. Another purpose is to explore the
lived experiences of women in treatment.

What you will be asked to do in the study:
There are two parts to this study.
One hundred women here at SafeFree will be asked to complete a survey about contraceptive
use. If you decide to take part in this survey, you will also be asked questions about your age,
education, number of children and the substances) which led to your treatment seeking.
Five women at SafeFree will be asked to participate in life history interviews. These interviews
will be broken into a number of interviews. Each interview will focus on a different time in your
life, such as early childhood experiences, adolescence, motherhood, adult relationships and
treatment experiences.

Time required:
30 minutes to 1 hour if you participate in the survey.
8-10 hours (five interviews of about two hours) if you choose to take part in the interviews.

Risks and Benefits:
You may be uncomfortable answering some of the survey and interview questions. You may
choose not to answer any question. Talking about life experiences is sometimes helpful, but if it
makes you feel sad you may stop and speak to a staff member at any time. You should not talk
to me about any unreported abuse of your children because the State of Florida would require me
to report it. We do not anticipate that you will benefit directly by participating in this study, but
it is possible that will use the results to improve services in the future.

Compensation:
You will not paid for taking part in the survey.
If you participate in the interviews, you will receive a $10 Wal-Mart gift card at the end of each
interview.

Confidentiality:
Your identity will be kept confidential to the extent provided by law. This means that we will
not tell anyone you participated. Your responses will be kept anonymous.

Voluntary participation:
Your participation in this study is completely voluntary. There is no penalty for not participating.

Right to withdraw from the study:
You have the right to withdraw from the study at anytime without consequence.









Whom to contact if you have questions about the study:
Kimberly Frost-Pineda, Graduate Student, Department of Anthropology, P.O. Box 100183,
Gainesville FL, 32610-0183, 352-392-6698.
Allan Burns, PhD, Professor of Anthropology, College of Liberal Arts and Sciences, P.O. Box
117300, (352) 392-2230.

Whom to contact about your rights as a research participant in the study:
UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; ph 392-0433.

Agreement:
I have read the procedure described above. I voluntarily agree to participate in the procedure and
I have received a copy of this description.
Participant: Date:
Principal Investigator: Date:









Letter of Support


April 28, 2006
Kimberly Frost-Pineda, MPH
Box 100183
Gainesville, FL 32610-0183

Dear Ms. Frost-Pineda,

The purpose of this letter is to confirm our support of your PhD dissertation proposal entitled
Barriers to Contraceptive Use Among Women with Substance Use Disorders. We are pleased
that you have chosen our treatment center as the site of your research and we will be glad to
assist you in any way possible. We look forward to working with you and expect that your
analysis and results may help to address perceived barriers to contraceptive use in this
population.

Sincerely,

The Administration of SafeFree









Family Planning and Contraception Survey


(Please DO NOT write your name on this survey)

Basic Information
1. How old are you?
2. What race do you consider yourself?
3. Are you of Hispanic decent? YES NO
4. What is your current marital status?
Single (not in a relationship)
Single (in a relationship)
Married
Separated
Divorced
Widowed
5. Have you ever been married? YES NO
6. Where do you live most of the time?
apartment
house
motel/hotel
condo
other:
7. Who did you live with in the month prior to entering treatment? Please circle all that
apply.
by myself
mother
father
children
brother or sister
unmarried partner
housemate or roommate
in-laws
grandparent
grandchildren
boarder or roomer
other relative
other non-relative
8. How many people lived with you?
9. Are you currently employed? YES NO
10. Were you employed last year? YES NO
11. What is your best guess of your income (from all sources) from last year
Less than $10,000
Between $10,001and $15,000
Between $15,001and $20,000
Between $20,001and $25,000
Between $25,001and $30,000
More than $30,000









12. What is the highest grade or year of regular school you completed?
13. Did you go to college? YES NO (skip to question 14)
14. If you went to college, what degree did you receive?
15. Would you say your health in general is
excellent
very good
good
fair
poor
16. Were you abused when you were a child? YES NO
17. Have you ever been in a violent relationship? YES NO
18. Are you currently pregnant? YES NO
19. Have you ever been pregnant? YES NO
20. How many times have you been pregnant?
21. In which of the ways shown below did the pregnancy end?
(please write how many of each below)
How many?
Miscarriage
Stillbirth
Abortion
Ectopic or tubal pregnancy
Live birth by Cesarean section (C-section)
Live birth by vaginal delivery

22. Please include the number of pregnancies that fall into each of the categories below
How many times?
Planned the pregnancy
Wanted to get pregnant, but did not plan to get pregnant
Did not plan or want to get pregnant
23. How old are the children that were born to you? Please list ages below.

24. How many of these children live with you?
25. For your children who do not live with you, where are they now?
(please write how many of each below)
Adopted
Foster care
Non-relative/friend
Other Parent
Other Relative caregiver
Died/passed away
Missing
Living on own
Jail or detention center
Hospital
Other location









26. How many children (including step children, adopted, foster and other children you care
for as your own) do you now have?
27. How many of these children live with you?
28. Are you currently trying to become pregnant? YES NO
29. Do you want to become pregnant in the next year? YES NO
30. Does your partner want you to become pregnant now? YES NO
31. Does your partner want you to become pregnant in the next year? YES NO
32. How old were you when you first had sex?
33. Did you use a method to prevent pregnancy the first time you had sex? YES NO
34. How old were you when you first began using methods to prevent pregnancy?
35. Have you ever had both of your tubes tied, cut, or removed? This procedure is often
called a tubal ligation or tubal sterilization.? YES NO
36. If yes, how many years ago?
37. In the past 30 days, have you used any of the following to prevent pregnancy? Please
check all that you have used in the past 30 days.
In the past 30 days have you used Birth Control Pills?
In the past 30 days have you used Condoms?
In the past 30 days have you used partner's vasectomy?
In the past 30 days have you used withdrawal/pulling out?
In the past 30 days have you used Depo-Provera, Injectables?
In the past 30 days have you used Norplant Implants?
In the past 30 days have you used rhythm/safe period by calendar?
In the past 30 days have you Natural Family Planning?
In the past 30 days have you used emergency contraception?
If yes, How many times?
In the past 30 days have you used diaphragm?
In the past 30 days have you used female condom, vaginal pouch?
In the past 30 days have you used foam?
In the past 30 days have you used Jelly/Cream without diaphragm?
In the past 30 days have you used cervical cap?
In the past 30 days have you used suppository/insert?
In the past 30 days have you used the Today Sponge?
In the past 30 days have you used an IUD?
In the past 30 days have you used Lunelle, (once-a-month injectable)?
In the past 30 days have you used contraceptive patch?
In the past 30 days have you used any other method?
If yes, what other method?

38. Where have you obtain methods used in the past 30 days? (Circle all that apply)
Private doctor's office
HMO facility
Community health clinic, Community clinic, Public health clinic
Family planning or Planned Parenthood Clinic
Employer or company clinic
School or school-based clinic
Hospital outpatient clinic









Hospital emergency room
Hospital regular room
Urgent care center, urgi-care or walk-in facility
Friend
Partner or spouse
Drug store
Some other place

39. Please think about the last four weeks. How many times have you had sexual intercourse
with a male in the last four weeks?
40. Did you use a condom? YES NO
41. How many of those times did you use a condom?
42. Did you use some other type of method to prevent pregnancy? YES NO
43. How many of those times some other method to prevent pregnancy?
44. Thinking back over the past 12 months, would you say you used a condom with your
partner for sexual intercourse
Every time
Most of the time
About half of the time
Some of the time
None of the time
45. Thinking back over the past 12 months, would you say you some other method to prevent
pregnancy with your partner for sexual intercourse
Every time
Most of the time
About half of the time
Some of the time
None of the time
46. What is the chance that if your current partner used a condom during sex, you would feel
less physical pleasure?
No chance
A little chance
A 50-50 chance
A pretty good chance
An almost certain chance
47. What is the chance that it would be embarrassing for you and a NEW partner to discuss
using a condom?
No chance
A little chance
A 50-50 chance
A pretty good chance
An almost certain chance
48. What is the chance that if a new partner used a condom, you would appreciate it?
No chance
A little chance
A 50-50 chance









A pretty good chance
An almost certain chance
49. In the past 3 months, have you used any of the following to prevent pregnancy? Please
check all that you have used in the past 3 months.
In the past 3 months have you used Birth Control Pills?
In the past 3 months have you used Condoms?
In the past 3 months have you used partner's vasectomy?
In the past 3 months have you used withdrawal/pulling out?
In the past 3 months have you used Depo-Provera, Injectables?
In the past 3 months have you used Norplant Implants?
In the past 3 months have you used rhythm/safe period by calendar?
In the past 3 months have you Natural Family Planning?
In the past 3 months have you used emergency contraception?
If yes, How many times?
In the past 3 months have you used diaphragm?
In the past 3 months have you used female condom, vaginal pouch?
In the past 3 months have you used foam?
In the past 3 months have you used Jelly/Cream without diaphragm?
In the past 3 months have you used cervical cap?
In the past 3 months have you used suppository/insert?
In the past 3 months have you used the Today Sponge?
In the past 3 months have you used an IUD?
In the past 3 months have you used Lunelle, (once-a-month injectable)?
In the past 3 months have you used contraceptive patch?
In the past 3 months have you used any other method?
If yes, what other method?

50. The next questions are about the past year (in the last 12 months). In the past year, have
you used any of the following to prevent pregnancy? Please check all that you have used
in the last 12 months.
In the past year have you used Birth Control Pills?
In the past year have you used Condoms?
In the past year have you used partner's vasectomy?
In the past year have you used withdrawal/pulling out?
In the past year have you used Depo-Provera, Injectables?
In the past year have you used Norplant Implants?
In the past year have you used rhythm/safe period by calendar?
In the past year have you Natural Family Planning?
In the past year have you used emergency contraception?
If yes, How many times?
In the past year have you used diaphragm?
In the past year have you used female condom, vaginal pouch?
In the past year have you used foam?
In the past year have you used Jelly/Cream without diaphragm?
In the past year have you used cervical cap?
In the past year have you used suppository/insert?









In the past year have you used the Today Sponge?
In the past year have you used an IUD?
In the past year have you used Lunelle, (once-a-month injectable)?
In the past year have you used contraceptive patch?
In the past year have you used any other method?
If yes, what other method?

51. Have you ever (in your lifetime) used any of the following to prevent pregnancy? Please
check all the methods that you have ever used.
Have you ever used Birth Control Pills?
Have you ever used Condoms?
Have you ever used partner's vasectomy?
Have you ever used withdrawal/pulling out?
Have you ever used Depo-Provera, Injectables?
Have you ever used Norplant Implants?
Have you ever used rhythm/safe period by calendar?
Have you ever used Natural Family Planning?
Have you ever used emergency contraception?
If yes, How many times?
Have you ever used diaphragm?
Have you ever used female condom, vaginal pouch?
Have you ever used foam?
Have you ever used Jelly/Cream without diaphragm?
Have you ever used cervical cap?
Have you ever used suppository/insert?
Have you ever used the Today Sponge?
Have you ever used an IUD?
Have you ever used Lunelle, (once-a-month injectable)?
Have you ever used contraceptive patch?
Have you ever used any other method?
If yes, what other method?

The next group of questions asks about your future plans to prevent pregnancy.
52. In the next month, do you plan to use any of the following to prevent pregnancy? Please
check all the methods that you plan to use in the next month.
In the next month, do you plan to use Birth Control Pills?
In the next month, do you plan to use Condoms?
In the next month, do you plan to use partner's vasectomy?
In the next month, do you plan to use withdrawal/pulling out?
In the next month, do you plan to use Depo-Provera, Injectables?
In the next month, do you plan to use Norplant Implants?
In the next month, do you plan to use rhythm/safe period by calendar?
In the next month, do you plan to use Natural Family Planning?
In the next month, do you plan to use emergency contraception?
If yes, How many times?
In the next month, do you plan to use diaphragm?









In the next month, do you plan to use female condom, vaginal pouch?
In the next month, do you plan to use foam?
In the next month, do you plan to use Jelly/Cream without diaphragm?
In the next month, do you plan to use cervical cap?
In the next month, do you plan to use suppository/insert?
In the next month, do you plan to use the Today Sponge?
In the next month, do you plan to use an IUD?
In the next month, do you plan to use Lunelle, (once-a-month injectable)?
In the next month, do you plan to use contraceptive patch?
In the next month, do you plan to use any other method?
If yes, what other method?

53. In the next year, do you plan to use any of the following to prevent pregnancy? Please
check all the methods that you plan to use in the next year.
In the next year, do you plan to use Birth Control Pills?
In the next year, do you plan to use Condoms?
In the next year, do you plan to use partner's vasectomy?
In the next year, do you plan to use withdrawal/pulling out?
In the next year, do you plan to use Depo-Provera, Injectables?
In the next year, do you plan to use Norplant Implants?
In the next year, do you plan to use rhythm/safe period by calendar?
In the next year, do you plan to use Natural Family Planning?
In the next year, do you plan to use emergency contraception?
If yes, How many times?
In the next year, do you plan to use diaphragm?
In the next year, do you plan to use female condom, vaginal pouch?
In the next year, do you plan to use foam?
In the next year, do you plan to use Jelly/Cream without diaphragm?
In the next year, do you plan to use cervical cap?
In the next year, do you plan to use suppository/insert?
In the next year, do you plan to use the Today Sponge?
In the next year, do you plan to use an IUD?
In the next year, do you plan to use Lunelle, (once-a-month injectable)?
In the next year, do you plan to use contraceptive patch?
In the next year, do you plan to use any other method?
If yes, what other method?

76. Did you ever stop using a method because you were not satisfied with it in some way?
YES NO
77. What methods did you stop using
Method Stopped Using? Please list your reason for
stopping (see numbers below)
birth control pills
condoms
Partner's vasectomy
withdrawal/pulling out









Depo-Provera, Injectables
Norplant Implants
Rhythm/safe period by calendar
Natural family planning
emergency contraception
diaphragm
Female condom, vaginal pouch
Foam
jelly/cream without diaphragm
Cervical cap
suppository/insert
Today Sponge
IUD
Lunelle, (once-a-month injectable)
contraceptive patch
any other method
For the methods checked in the last section, please list reasons)
Too expensive.............. ...... .........
Too difficult to use.................................2
T oo m essy ........................ ..... ..............3
Your partner did not like it..........................4
You had side effects................................5
You were worried you might have side effects...........6
You worried the method would not work................7
The method failed, you became pregnant ................. 8
The method did not protect against disease..........9
Because a doctor told you that you should not use the method again.... 10
The method decreased your sexual pleasure.............11
Too difficult to obtain the method....................12
Did not like the changes to your menstrual cycle......13
O their reasons ............................. ................ 14

Substance Use
The next group of questions will ask about your use of certain substances. For each one, please
check the box if you ever used (in your lifetime), if you have used the substance in the last year,
last month or the day before you entered treatment. In the last column, please write the age you
first tried each substance.
Substance Ever Used in Used in Used the How old were you
used? last 12 the last day before the first time?
months? 30 days? treatment?
Tobacco
Alcohol
Marijuana
Cocaine
Crack
Heroin









Hallucinogens
Inhalants
Pain relievers
Tranquilizers
Stimulants
Sedatives
Other drugs
High sugar
foods
High fat foods

Thank you for completing this survey. A summary of the results will be available in December
of 2006 and will be provided to SafeFree.

Best wishes for success in your treatment and beyond!











Life History Interview Guide


Introductions
Introduce myself and explain my research project to the potential participant.
Go over the informed consent and if she is willing to participate ask her to sign the consent form.
Remind her of State of Florida laws regarding mandatory reporting of child abuse.
Remind her that she can refuse to answer any question and that she may choose to end the
interview and/or her participation at any time.
Explain that we will focus on different areas of her life at different interviews.
Ask her to tell me a little about herself; where she is from, where she grew up, etc.
ask if she can remember 5-10 positive/happy experiences in her lifetime.
Tell her next time we will be talking about her childhood.
Ask her to bring pictures, news clippings, letters or journals to future interviews.
Conclude the interview, thank her and set up the time for the next interview.

Childhood
Thank her for her continued participation.
Give her a one page decorated sheet, which includes the positive/happy experiences that she
mentioned at the previous interview.
Ask her if she brought anything that she would like to show me during this interview.
Remind her that the first area of her life that I would like to learn about is her childhood years.
Give her time to reflect on those years and listen and take notes as she describes:
* number of siblings
* memories of her parents, relationship with mom and dad
* grandparents, role of her grandmothers
* memories of where she lived
* school experiences
* were drugs and alcohol used at home
* memories of holidays, birthdays
* was she a "tomboy"
* what types of activities did she enjoy
Conclude the interview, thank her and set up the time for the next interview.
Tell her next time we will be talking about her teenage years.

Adolescence
Thank her again for the last interview. Explain that her continued participation is important to
me.
Go over any questions/clarify issues from the last interview.
Remind her that we will be focusing on her teenage experiences at this interview.
Give her time to reflect on those years and listen and take notes as she describes:
* relationships with her family
* relationships with peers
* first menstrual cycle, other physical changes
* first boyfriend









* sexual experiences
* substance use
* school experiences
* was she a risk-taker, and if so, what were those risks
* did others think she was a risk taker
* did her friends take risks, and if so, what were those risks
* hobbies/activities she enjoyed
Conclude the interview, thank her and set up the time for the next interview.
Tell her next time we will be talking about her adult life.

Adulthood
Thank her for the last interview.
Go over any questions/clarify issues from the last interview.
Ask her if she brought anything that she would like to show me during this interview.
Remind her that we will be focusing on her adult experiences at this interview.
Listen and take notes as she describes:
* work experiences
* relationships with her family
* intimate relationships
* substance use/ treatment experiences
* financial/legal issues
* would she describe herself as a risk-taker, in what ways
* religious/spirituality influences
* positive/happy memories of these years
Conclude the interview, thank her and set up the time for the next interview.
Tell her next time we will be talking about her family planning and parenting experiences.

Family planning/Parenting
Thank her again for the last interview.
Go over any questions/clarify issues from the last interview.
Remind her again of State of Florida laws regarding mandatory reporting of child abuse.
Tell her again that she can refuse to answer any question and that she may choose to end the
interview and/or her participation at any time.
Remind her that we will be focusing on her family planning and parenting experiences at this
interview.
Listen and take notes as she describes:
* history of pregnancies
* planned/wantedness
* number and ages of children
* contraception, past and current
* perceived barriers to use
* perceived benefits to use
* impact of having children)
* child care issues
* ask her to tell me something special about her children)









Conclude the interview, thank her and set up the time for the next interview.
Tell her next time we will be talking about her future plans/goals.

Future plans
Thank her for her continued participation in the study.
Go over any questions/clarify issues from the last interview.
Remind her that we will be focusing on her future goals during this interview.
Listen and take notes as she describes:
* her plans for her life post-treatment
* her intentions regarding future pregnancies
* her plans to use contraception
* child care/employment plans
* how she will use her treatment experience in the future
* how she will try to avoid relapse
* what she hopes to accomplish tomorrow, in the next week, the next month and the next
year.
Conclude the interview, thank her again, let her know how much I appreciate her sharing her
story with me. Remind her that no identifying information will be included in the written report.
Give her my contact information and let her know that I can send her a copy of my dissertation if
she would like me too.









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Zelman, E. C. (1977) 'Reproduction, ritual, and power', American Ethnologist, vol. 4, no. 4, pp.
714-733.









BIOGRAPHICAL SKETCH

Kimberly Frost-Pineda was born in Philadelphia, Pennsylvania in 1970. She is the first in

her family to go to college. Kimberly started working at the age of fourteen and has been

employed continuously since then with the exception of the academic year in which she

completed more than 50 credit hours with a 4.0 GPA at the University of South Florida. She

received the Associate of Arts degree in Liberal Arts from Central Florida Community College

in 1994 and then the Bachelor of Arts degree in Women's Studies in 1995 from the University of

South Florida. Kimberly specialized in Maternal and Child Health within the Department of

Community and Family Health for her Master of Public Health Degree, which she received in

1998. Her professional positions include two years as Senior Grants Specialist in the Division of

Research Compliance at the University of South Florida, followed by Research Coordinator and

then Assistant in Psychiatry and Director of Public Health Research during her six years in the

Division of Addiction Medicine at the University of Florida. Kimberly is co-author of numerous

scientific publications and presentations. She is currently employed as a Senior Research

Scientist in Clinical Evaluation at Philip Morris USA.

Kimberly is mother to four children; Daniel (born in 1996), Joshua (born in 1999), Isaiah

(born in 2003), and Rachael (adopted at age 12 in 2004). Kimberly enjoys discussing and doing

math with Daniel and watching him put all his heart into soccer in the hopes that one day he can

play professionally. She takes pleasure in reviewing Joshua's excellent grades and beautiful

artwork and in seeing him smile. She enjoys hearing Isaiah's stories, watching him play and

being recipient to all his hugs and kisses. Kimberly is hopeful for Racheal, who has the

opportunity for a good life despite the neglect and abuse she experienced in her birth family and

in her seven years in foster care. After completing the PhD, she plans to continue to grow in her

current career and spend more time with her children and her new husband.





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ADDICTION AND PREGNANCY INTENTIONS: UNDERSTANDING THE WHY BEHIND THE WHAT By KIMBERLY FROST-PINEDA A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008 1

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2008 Kimberly Frost-Pineda 2

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To my Parents and my Children 3

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ACKNOWLEDGMENTS I thank my committee for all of their advice, support and feedback throughout my years as a student in the doctoral program. I am especi ally grateful for mentoring received from Dr. Mark S. Gold, Distinguished Professor and Chief of Addiction Medicine at the University of Florida who provided employment, encouragem ent, recommendations and opportunities and directly influenced my decision to work toward the PhD. I would also not have come this far without Dr. Allan Burns, Professor of Anthropol ogy and Chairman of my committee, who taught me and provided guidance and suggestions th rough the many different research ideas and proposals. Ultimately, the life hi story interviews, which Dr. Burns recommended, were the most valuable and memorable experience of my PhD research. I acknowledge and thank Dr. Connie Mulligan, Associate Professor of Anthropology, fo r reviewing and providing useful suggestions on early drafts and Dr. John Krigbaum, Assistant Professor of Anthropology, and Dr. Mark Lewis, Professor of Psychiatry and Neuroscience, at the University if Florida for their kind support and positive encouragement. I thank my parents, Thomas Frost, Patricia Fr ost and Rose Marie Faunt, for the influences they had on who I am today. I appreciate the encouragement I have received from friends, colleagues, and other family members, incl uding Grandma Adams w ho helped support my undergraduate studies. I am esp ecially grateful to my four ch ildren, Daniel, Joshua, Isaiah and Racheal, who through these past few years sacrificed their time and forwent activities with me so that I could get his done. I a ppreciate my new husband, Christopher, who came into my life as my sister Deanna Frost passed into the next, on May 6th 2007. I thank him for his help with my children and for his patience. I am grateful to Dr. Candice Hodgkins and her colleagues who opened doors for this research. I acknowledge the Natio nal Institutes of Health (Loan Repayment Program) for their 4

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support during this research. I am also gratef ul to all of my new colleagues in Clinical Evaluation at Philip Morris USA, especially Dr. Paul Mendes, Dr. Hans Roethig, Dr. Mohamadi Sarkar and Dr. Sunil Kapur, for giving me time and encouragement to finish this dissertation and I thank Dr. Qiwei Liang and Mr Lonnie Rimmer for their advi ce on statistical analysis and reporting. Lastly, I would lik e to acknowledge my deep a ppreciation to the women who participated in this research a nd who shared their lives with me. 5

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TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ........11 LIST OF FIGURES.......................................................................................................................14 ABSTRACT...................................................................................................................................19 CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE...............................................21 Introduction................................................................................................................... ..........21 Purpose of the Research........................................................................................................ ..21 Review of the Literature.........................................................................................................24 How Does Anthropology Contribute to Our Understanding of Addiction, Reproduction and Violence?........................................................................................24 What is Addiction?..........................................................................................................27 Drug and drug addiction history...............................................................................28 Modern disease.........................................................................................................29 Defining substance use disorders: Substance abuse and dependence......................30 What are the Theories of Addiction?...............................................................................31 Initiation, continuation, transition from use to abuse and dependence, cessation, relapse..................................................................................................31 Selected addiction theories and examples................................................................32 Biological, cultural, environmental, and psychological...........................................33 How do Women Experience Addictions?.......................................................................36 Epidemiology of substance use among women.......................................................37 Substance use during pregnancy..............................................................................38 What is the Role of Violence in Addicted Womens Lives?...........................................40 Child abuse and neglect............................................................................................40 Domestic violence....................................................................................................41 Substance abuse and violence..................................................................................41 What Special Issues Surround Addiction and Pregnancy?..............................................41 Unintended pregnancy..............................................................................................41 Effects on the fetus...................................................................................................42 Child welfare and legal implications........................................................................43 What Pregnancy Planning/Contraceptive St rategies do Women with SUDs use?..........44 How do Fertility Theories and Other Factors Explain Fertility Rates?...........................48 Fertility theories.......................................................................................................48 Other factors affecting fertility.................................................................................49 Can Human Behavior al Ecology and Life History Theory Partially Explain Reproductive and Addictive Behavior?.......................................................................50 6

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What Are the Common Themes in Life Histories/Narratives of Addiction?..................52 Can the Cycle be Changed? Is Survival Possible?..........................................................52 Prevention and intervention: Pre-co nception and early prenatal care......................52 Treatment for pregnant wome n and women with children......................................53 Integrating family planning......................................................................................53 Key components of a comprehensive treatment program........................................54 2 MATERIALS AND METHODS...........................................................................................59 Study Design Summary..........................................................................................................59 Human Subjects Protection.............................................................................................59 Research Setting..............................................................................................................6 1 Study Population and Size...............................................................................................62 Qualitative Materials and Methods.........................................................................................63 Interview Guide Development........................................................................................63 Data..................................................................................................................................64 Qualitative Data Reporting and Analysis........................................................................65 Quantitative Materials and Methods.......................................................................................65 Questionnaire Development............................................................................................65 Analysis Variables...........................................................................................................68 Survey Data Analysis......................................................................................................69 3 LIFE HISTORY INTERVIEWS............................................................................................74 Introduction................................................................................................................... ..........74 Sara.........................................................................................................................................74 Mary........................................................................................................................................86 Jackie......................................................................................................................... .............96 Tracy.....................................................................................................................................102 Pamela...................................................................................................................................109 Conclusions...........................................................................................................................120 4 SURVEY RESULTS: DESCRIPTIVE STATISTICS.........................................................122 Survey Data Collection and Data Entry................................................................................122 Results...................................................................................................................................123 Age................................................................................................................................123 Race and Ethnicity.........................................................................................................123 Marital Status and Living Arrangements......................................................................123 Employment and Income...............................................................................................124 Education.......................................................................................................................124 Current Health and History of Abuse and Violence......................................................124 Pregnancy, Pregnancy Outcomes, Planning and Intentions..........................................125 Future Pregnancy Intentions..........................................................................................126 Age of First Intercourse and Pregnancy Prevention......................................................126 Pregnancy and Offspring...............................................................................................126 Surgical Sterilization.....................................................................................................127 7

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Past Pregnancy Prevention Strategies...........................................................................128 Potential Barriers to using Methods to Prevent Pregnancy...........................................131 Substance Use................................................................................................................13 2 Tobacco..................................................................................................................132 Alcohol...................................................................................................................132 Marijuana...............................................................................................................133 Cocaine...................................................................................................................133 Crack......................................................................................................................133 Pain relievers..........................................................................................................133 Other drugs of abuse..............................................................................................134 High sugar and high fat foods................................................................................134 Most Prevalent Drugs of Abuse....................................................................................134 Age of First Use.............................................................................................................135 Summary and Next Steps..............................................................................................135 5 STATISTICAL ANALYSIS AND CO MPARISONS TO NATIONAL DATA.................142 Introduction................................................................................................................... ........142 Frequencies....................................................................................................................143 Use of one or more contraceptive methods............................................................143 Contraceptive use by past substance use................................................................143 Contraceptive use by age........................................................................................144 Contraceptive status by marital status....................................................................144 Comparisons by Race....................................................................................................145 Demographic characteristics..................................................................................145 Pregnancy, childbirth and pregnancy intentions....................................................145 Contraceptive history.............................................................................................146 Discontinuation of contraceptive method..............................................................146 Substance use history.............................................................................................147 Regression Analysis......................................................................................................148 Ordinary regression results.....................................................................................149 Logistic regression results......................................................................................150 National Substance Abuse Data....................................................................................155 Comparisons of Current Survey and Nationa l Survey Demographic Characteristics...156 Gender....................................................................................................................156 Age.........................................................................................................................156 Race/Ethnicity........................................................................................................156 Socioeconomic status.............................................................................................157 National Survey Drug Use Characteristics Compared to Women in Treatment for SUDS.........................................................................................................................15 7 Age of initiation.....................................................................................................157 Prevalence of substance use...................................................................................158 National Survey of Family Growth (NSFG) Comparisons...........................................159 Summary........................................................................................................................161 6 DISCUSSION AND CONCLUSIONS................................................................................178 8

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Introduction................................................................................................................... ........178 Life History Themes......................................................................................................178 Family history of addiction....................................................................................178 Availability of drugs and alcohol...........................................................................179 Domestic violence..................................................................................................179 Sexual abuse and rape............................................................................................180 Child abuse and neglect..........................................................................................181 Early substance use and pr ogression to addiction..................................................182 Substance use by partners......................................................................................183 Loss through disease, accident s, death and estrangement......................................183 Loss of children......................................................................................................184 Family care of children..........................................................................................184 North-South transitions..........................................................................................185 Secrets....................................................................................................................185 Promiscuity, prostitution and arrests......................................................................186 Denial.....................................................................................................................187 Relapse...................................................................................................................187 Illness, injuries and near-death experiences...........................................................188 Isolation..................................................................................................................189 Sharing and connecting to others...........................................................................189 Spirituality..............................................................................................................190 Treatment and recovery..........................................................................................190 Summary of Life History Themes.................................................................................192 Treatment Environment and Treatment Process...........................................................192 Life History Themes and Survey Results in Relation to Selected Addiction Theories and Previous Research................................................................................194 Stages of change.....................................................................................................194 Biological...............................................................................................................195 Cultural...................................................................................................................196 Environmental........................................................................................................197 Psychological.........................................................................................................197 Addiction and Pregnancy..............................................................................................198 Life History Themes and Survey Results in Relation to Selected Fertility Theories and Previous Research...............................................................................................201 Fertility theories.....................................................................................................201 Behavioral ecology/Life history theory..................................................................203 Life history narratives............................................................................................207 Limitations.................................................................................................................... .209 Recommendations.........................................................................................................210 Conclusions...........................................................................................................................212 APPENDIX SUPPORTING DOCUMENTS...................................................................................................215 IRB Application....................................................................................................................215 Informed C onsent Form........................................................................................................21 7 9

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10 Letter of Support...................................................................................................................219 Family Planning and Contraception Survey.........................................................................220 Life History Interview Guide................................................................................................229 LIST OF REFERENCES.............................................................................................................232 BIOGRAPHICAL SKETCH.......................................................................................................252

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LIST OF TABLES Table page 1-1. Theories of Addiction............................................................................................................55 1-3. Percentages of Females Aged 15 to 44 Reporting Past Mont h Use of Alcohol, by Pregnancy Status and Age (1999-2000)............................................................................56 2-1. Examples of Services Provided by SafeFree.........................................................................72 2-2. Interview Topics....................................................................................................................73 2-3. Family Planning and Contraceptive Methods.......................................................................73 4-1. Past Year Income......................................................................................................... ........135 4-2. Past 30 Day Use of Me thods to Prevent Pregnancy............................................................136 4-3. Percent Reporting Frequency of Condo m or Other Method in Last 12 Months.................136 4-4. Reported Use of Methods to Prevent Preg nancy in Last Three Months, Last 12 Months and Ever in Lifetime........................................................................................................136 4-5. Reported Future Intentions to Use Methods to Prevent Pregnancy.....................................137 4-6. Reasons for Discontinuation, Methods and Number of Women Reporting........................138 4-7. Percentage Reporting Past Substance Use and Age of Initiation........................................138 5-1. Frequency Reporting Past Year and Recent Substance Use and Number and Percent Reporting No Contraceptive Method...............................................................................166 5-2. Percentage of Women Repor ting Illicit Drug Use in Life time, Past Year, Past Month and Day before Treatment by Race.................................................................................166 5-3. Regression for Age in Years and Year of Education...........................................................166 5-4. Regression for Age in Years and Number of Years Since Surgical Sterilization...............166 5-5. Regression for Age in Years and Age of First Contraceptive Use.......................................167 5-6. Regression for Age in Years and Y ears Between Oldest and Youngest Child...................167 5-7. Regression for Age in Years and Age of Cocai ne Initiation...............................................167 5-8. Regression for Age in Year s and Age of Crack Initiation...................................................167 5-9. Regression for Education in Ye ars and Age at First Intercourse........................................167 11

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5-10. Regression for Education in Y ears and Number of Pregnancies.......................................168 5-11. Regression for Education in Y ears and Age at Last Childbirth........................................168 5-12. Regression for Education in Years a nd Years Since Surgical Sterilization......................168 5-13. Regression for Age at First Inte rcourse and Age at First Childbirth.................................168 5-14. Regression for Age at Contracep tive Use and Age at First Childbirth.............................168 5-15. Regression for Number of Not Planned/Not Wanted Pregnancies and Number of Abortions..........................................................................................................................169 5-16. Regression for Number of Pr egnancies and Number of Births.........................................169 5-17. Regression for Age at First Birth and Number of Births...................................................169 5-18. Regression for Age at First Birth a nd Years Between Youngest and Oldest Child..........169 5-19. Regression for Age at Last Birth and Number of Births...................................................169 5-20. Regression for Age at Inhalant Initiation and Age at Tobacco Initiation..........................170 5-21. Regression for Age at Alcohol Initiation and Age at Tobacco Initiation..........................170 5-22. Regression for Age at Alcohol Init iation and Age at Marijuana Initiation.......................170 5-23. Regression for Age at Alcohol Initiation and Age at Stimulant Initiation........................170 5-24. Regression for Age at Marijuana In itiation and Age at Tobacco Initiation......................170 5-25. Regression for Age at Marijuana In itiation and Age at Cocaine Initiation.......................171 5-26. Regression for Age at Crack Initi ation and Age at Cocaine Initiation..............................171 5-27. Regression for Age at Cocaine Initia tion and Age at Tra nquilizer Initiation....................171 5-28. Regression for Age at Cocaine Init iation and Age at Stimulant Initiation........................171 5-29. Logistic Regression for Age..............................................................................................171 5-30. Logistic Regression for Race.............................................................................................172 5-31. Logistic Regression for Last Year Employment...............................................................172 5-32. Logistic Regression for History of Abuse.........................................................................172 5-33. Logistic Regression for Hi story of Domestic Violence.....................................................173 5-34. Logistic Regression fo r Surgical Sterilization...................................................................173 12

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13 5-35. Logistic Regression fo r Number of Pregnancies...............................................................173 5-36. Logistic Regression fo r Total Number of Births...............................................................173 5-37. Drugs Used Prior to Admission.........................................................................................17 3 5-38. Percentages of Females Using Illicit Drug Use in Lifetime, Past Year, and Past Month: Women with SUDS (WSU D) and Women NSDUH, 2005 (NSDU)..................174 5-39. Comparison of NSDUH and MTF Prev alence Estimates (Y oung Adults, 2005) and Lifetime, Past Year, and Past Mont h Prevalence in Women with SUDs........................174

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LIST OF FIGURES Figure page 1-1. Stages of Change in Addiction. Base d on Prochaska and DiClementes Model (1992).......56 1-2. Primary Substance of Abuse among Wome n Aged 15 to 44 Admitted to Treatment, by Pregnancy Status: 1999 (SAMHSA Treatment Episode Data Set (TEDS))......................57 1-3. Florida Domestic Violence Offences and Relationship of Victim to Offender. (Florida Department of Law Enforcement Uniform Crime Reports, 2007). http://www.fdle.state.fl.us/ FSAC/UCR/2006/CIF_annual06.pdf......................................57 1-4. Baseline Alcohol Intake Among Women and Choices for Reducing Risk of an Alcohol Exposed Pregnancy (Centers for Disease Control 2003)...................................................58 4-1. Percentage of Women Who Reported Chan ce of Feeling Less Phys ical Pleasure with Condom Use.....................................................................................................................139 4-2. Percentage of Women Who Reported Chance of Feeling Embarrassed to Discuss Condom Use with New Partner.......................................................................................139 4-3. Percentage Who Reported Chance of A ppreciating Use of C ondom by New Partner........140 4-4. Types and Percentages of Methods Discontinued...............................................................140 4-5. Percentage of Women Reporting Specifi ed Reasons for Discontinuation of Method........141 5-1. Age of Illicit Drug Use Initia tion among Women with SUDS by Race..............................175 5-2. Primary Substance of Abuse at Admission: TEDS 1995-2005. (Office of Applied Statistics 2006).................................................................................................................175 5-3. Mean Age at First Use for Specific Illici t Drugs among Past Year Initiates Aged 12 to 49: 2005...........................................................................................................................176 5-4. Age of Illicit Drug Use In itiation among Women with SUDS............................................176 5-5. Most Commonly Reported Methods of Contraception Ever Used in the NSFG (1982, 1995 and 2002) and Among Women with SUDs............................................................177 5-6. Percentage of US Women by Contracepti ve Status (Last Three Months) (NSFG 2002)....177 5-7. Percentage of Women in Treatment for SUDs by Contraceptive Status (Last Three Months)............................................................................................................................177 6-1. Total Fertility Rates Overall and by Race/ Hispanic Ethnicity: The United States, 2000...214 14

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LIST OF ABBREVIATIONS AA Alcoholics Anonymous AAA American Anthropological Association AIDS Acquired Immune Deficiency Syndrome APA American Psychiatric Association ASAM American Society of Addiction Medicine Logistic regression coefficient BAL Blood Alcohol Level CASA Center on Addiction and Substance Abuse CDC Centers for Disease Control CI Confidence Interval CSAP Center for Substance Abuse Prevention DAWN Drug Abuse Warning Network DCF Department of Children and Families DEA Drug Enforcement Administration DHHS Department of Health and Human Services DSM-IV Diagnostic and Sta tistical Manual of Mental Disorders, Fourth Edition FAS Fetal alcohol syndrome FDLE Florida Department of Law Enforcement HIV Human Immunodeficiency Virus HS High School IDU Injection Drug User IOM Institute of Medicine IRB Institutional Review Board IUD Intrauterine Device 15

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LOTAD Length of time between onset of abuse and dependence MSA Master Settlement Agreement MTF Monitoring the Future N Number NA Narcotics Anonymous NAAAPI National Association of African Americans for Positive Imagery NIDA National Institute of Drug Abuse NSDUH National Survey of Drug Use and Health NSFG National Survey of Family Growth OAS Office of Applied Statistics OB/GYN Obstetrics/Gynecology ONDCP Office for National Drug Control Policy OPPAGA Office of Program Policy Anal ysis and Government Accountability OR Odds Ratio PTSD Post Traumatic Stress Disorder Prob/p p-value R Correlation Coefficient R-squared/R2 Coefficient of determination SAMHSA Substance Abuse and Mental Health Services Administration SD Standard Deviation SE Standard Error STD Sexually Transmitted Disease STI Sexually Transmitted Infection SUD Substance Use Disorder TEDS Treatment Episodes Data Set 16

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17 TFR Total Fertility Rate U.S. United States UCR Uniform Crime Reports WSUDs Women with Substance Use Disorders x Independent variable/explana tory or predictor variable y Dependent or criter ion/response variable

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18

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Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy ADDICTION AND PREGNANCY INTENTIONS: UNDERSTANDING THE WHY BEHIND THE WHAT By Kimberly Frost-Pineda May 2008 Chair: Allan Burns Major: Anthropology Addiction and fertility are complex, multifacet ed phenomena, which affect individuals, families and societies. They are biological a nd cultural and have huge economic and political influences and impacts. This dissertation explores addiction and fertility through a review of the literature and original qualit ative and quantitative research in a population of women in residential treatment for Substance Use Disorders (SUDs). The purpose of this dissertation is to describe and explain womens experiences of ad diction through life history interviews and to explore and analyze demographic, reproductive, contraceptive a nd substance use characteristics in this population. Results are th en compared to national substan ce use and reproduction surveys. Women with SUDs have often been victims of child abuse and domestic violence. Many have co-occurring psychiatric, medical and socio economic problems. Substance abuse is related to a number of reproductive health risks in cluding rape, risky sexual behavior, sexually transmitted infections and unintended pregnancies. Substance use during pregnancy can cause numerous adverse pregnancy outcomes. Drug a nd alcohol use are commonly associated with cases of child abuse and neglect. Total fertili ty rates among women with SUDs are much higher than rates in developed countries around the world. But addic tion conflicts with and interferes with reproduction and parenting. 19

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Addiction and fertility are disc ussed and examined through the le ns of several theories and frameworks including a human behavioral ecology perspective, life history theory and life history narratives. While there is a great need to reduce the number of children adversely affected by substance abuse and addiction, coerced abortions, st erilizations, termination of parental rights and incarceration are not solutions to this problem. When addiction prevention and delayed or protected sexual ac tivity have failed, early interv entions, education and treatment are required to reduce current harm and possibl y break the cycle for future generations. 20

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CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE Introduction The dissertation consists of six chapters. Th e first chapter introduces background literature on addiction and pregnancy intentions and desc ribes the theoretical underpinnings of this research. The second chapter describes the mate rials and methodology used. The third chapter includes the results of the life history interviews. The fourth chapter describe s the survey results. The next chapter includes an analysis of the survey results and makes comparisons to national data. The sixth (final) chapter synthesize the data and assesses these finding through theories and frameworks discussed in this chapter. The final chapter also includes recommendations for future research and programs. Purpose of the Research There are two hypothesis explored by this rese arch. First, that there are barriers to effective contraceptive use am ong women with substance use disorders (SUDs). The second hypothesis is that the lived experi ence of women with addictions can provide insight into the proximate and distal causes of addiction. Examin ing contraceptive needs and perceived barriers in a population of substance abusing women, coul d help to identify areas where programs and services are needed to redu ce child and prenatal drug expos ure and other forms of child maltreatment. Exploring the life histories of wo men with addiction prov ides information that may have a significant impact on treatment c onsiderations and on changing the cycle and reproduction of addiction and abuse. The research described in subsequent chapters includes a wealth of information reported by women in tr eatment for SUDs. The ethnographic component documents womens experiences of living with addict ion in a life history format, in an attempt to answer some of the why questi ons surrounding addiction and fertility. The goal of the survey 21

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was to further describe women in treatment and id entify issues related to effective contraceptive use and family planning among women with substan ce use disorders. The survey attempts to answer the what question regard ing the prevalence and types of past, current and future family planning practices in a population of women in treatment for SUDs. It also investigates perceived barriers to contraceptive use, substanc e abuse history, demographics and history of violence. References to national surv ey data are made for comparison. There are scores of theories and models of a ddiction, most of which consider addiction as a chronic, relapsing, life-long dis ease. Drug experimentation and abuse usually begin in childhood and adolescence and while not everyone who uses a drug of abuse becomes addicted, the pathway to addiction always includes substance e xposure. Some individuals may be more prone or less at risk for developing a ddiction due to biological traits and genetic factors. However behavioral, emotional, learning, and environmental factors are also important Addiction affects the individual, the family, the work environment and it has huge societal costs. The economic cost of drug abuse was close to $181 billion in 2002 (Office for National Drug Control Policy 2004). Like the cycle of violence, which is often linked to drug and alcohol use, there is a cycle of addiction, such that childre n who are genetically predisposed and those who are exposed to addictive behavior and stress in th e home environment are at greater risk for addiction. Without intervention, drug addiction can lead to nu merous severe conse quences, including poverty, arrests, family destructio n, morbidity and death. Addiction may lead to additional consequences for females, who have the ability to bear children and who traditionally be ar the primary responsibility fo r caring for children and other family members. While women are now able to regulate their fertility through the use of contraception and family planning services, the number of unintended an d unwanted pregnancies 22

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remains high in the United States. Addiction can impair a womans ability to consent to sexual relationships, can make regulating fertility more difficult and may also impact her ability to protect and care for he r children. In addition to economic and medical consequences of addiction, there are serious social consequences. Substance abuse is a comm on factor in cases of child abuse and neglect. Sometimes these child ren are permanently removed from their homes, parental rights are terminated, and these children may spend year s waiting for a new home. The wait is especially long for children with special needs, defined by the U.S. Department of Health and Human Services as a child w ho is part of a sibling group wh ich is to be adopted together, above the age of eight, minority ra ce, and those with a mental, physic al or emotional disability. Many children are never adopted and once they ag e out of the foster care system, many end up homeless. Without family ties and social support, the outlook is bleak for these children. Although there is a great need to reduce the number of children adversely affected by addiction, coerced abortions and sterilizations are not a solution to this pr oblem. When addiction prevention has failed, early interventions and addi ction treatment are requ ired to reduce current harm and possibly break the cycle for future gene rations. It may also prove useful to increase family planning education and effective contraceptive use among sexually active girls and young women before drug experimentati on. In addition, there should be efforts made to overcome barriers to effective contraceptive use among wo men with substance use disorders (SUDs). The following sections set the foundation and address some of the important questions related to the research conducted for my dissertation. Because the discipline of anthropology draws from history, philosophy and epistemology as part of its perspect ive, some of these questions are more philosophical than practical. 23

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Important Questions How does anthropology contribute to our understanding of addiction, reproduction and violence? What is addiction? What are some theories of addiction? How do women experience addictions? What is the role of violence in addicted womens lives? What special issues surround addiction and pregnancy? What are the pregnancy planning/contraceptiv e strategies used by women with substance use disorders (SUDs)? How do fertility theories and other factors explain fertility rates? Can behavioral ecology and life history theory partially explain reproductive and addictive behavior? What are the common themes in life hi stories/narratives of addiction? Is there existence beyond the dis ease? Is survival possible? Review of the Literature These questions are addressed in this chapte r through a selected revi ew and analysis of relevant literature. In Chapter 6, addiction and fertility are examin ed through the lens of some of the theories described here with a special emphasis on life history th eory and life history narratives. How Does Anthropology Contribute to Our U nderstanding of Addiction, Reproduction and Violence? Simply put, anthropology is the study of humankind. Anthro pologists study human origins, biological characteristics, cultural a nd physical development, and social mores and beliefs (Dictionary.com Unabridged 2007). An thropology contributes to our understanding of addiction, reproduction and violence in a number of ways. Archeology and forensic sciences are used to better understand and explain these experi ences. Anthropologists of ten analyze historical factors related to addiction, reproduction and vi olence and they may study these issues from a human behavioral ecology or provi de evidence of genetic influences. They may also examine these issues from an emic perspective (unde rstanding from an insiders view), compare 24

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phenomena cross-culturally or use or develop theories to explain ad diction, fertility and violence. Anthropology is about using and relating multiple methods from multiple disciplines. It is not just about theory; it is also about surveys and life histories. Anthropology may be the discipline that pulls all the research and researchers togeth er to better understand an d address human issues. Anthropological methods are often used to ga ther data, which can be used in prevention, intervention, treatment and po licy recommendations. To review all of the anthropological literature on addiction, reproduction and violence is beyond the scope of this chapter, however a number of examples are provided below. Archeologists have studied the prevalence of violence in past popul ations by identifying signs of trauma in human remains, looking at the material culture and examining population density, available resources and environmenta l conditions (Torres-Rouff & Costa Junqueira 2006). Forensic anthropologist may determine whet her injuries were inte ntional or accidental and whether self-inflicted or due to homicide (F alsetti 1999). Forensic sc iences have also been useful in determining patterns of drug use and ex posure in at risk groups (Kintz et al. 2005). Historical and political aspects of addiction have been analy zed by a number of researchers including Aurins (2000) manuscript on opium use in the United States and Agar and Reisinger (2002a; 2002b) who describe aspect s of the heroin epidemic of the 1960s. Genetic studies have contributed to the understanding of protective and risk factors for alcoholism (Mulligan et al. 2003). Anthropologists have also ex plored environmental aspects of substance use, such as the influence of the workplace on alcohol use (Ames 1990). Historical analysis of produc tion and reproduction, such as that by Lamphere on womens changing roles in an industrial se tting is also present in the anth ropological literature (Lamphere 1986). Some anthropologists have examined the role of stable food sources on fertility and child 25

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survival (Pennington 1996), while others have us ed an evolutionary perspective to examine genetic and other factors in reproduction, such as rate of concep tion and length of gestation (Gill 1997). Ethnographic descriptions of reproduction have been published, including a recent review of five examples by Taylor (2004). Numerous examples of cross-cultural studies on reproduction can also be found in the anthr opological literature (Zelman 1977; Sobo 1993; Whittemore & Beverly 1996). Anthropologists have used ethnography to descri be things such as use of substances by indigenous peoples (Hanna 1974) and drug user decision-making (Agar 1975). Other examples of anthropological research incl ude biocultural studies, such as that conducted by Lende (2005), which incorporated findings from neurobiological research into ethnographic methods to better understand the role of wanting in a sample of Columbian adolescent drug users. Researchers have used in-depth interviews with addicted se x workers to gain insight into the relationship between childhood sexual abuse and later risk of HIV (Dickson-Gmez et al. 2006). Anthropologists have also analyzed drug use (crack) trends to inform theory (Agar 2003). Studies of violence and child abuse are well represented in the literature. Two examples cross-cultural studies of violence include Snajdrs study of domestic violence among Muslim women (2005) and Van Vleets ex amination of discourses and practices of violence in a community in the Bolivan Andes (2002). Anthro pological perspectives on violence include analyses by Nancy Scheper-Hughes whose work has documented the impact of violence among the poorest and most vulnera ble populations (Scheper-H ughes 1987; Scheper-Hughes 1993; Scheper-Hughes & Sargent 1998). Studies of child abuse and neglect include Jill Korbins work, with publications on this issue spanning more than two decades (Korbin 1981; Korbin 2004; Korbin 2006). While working within the field of anthropology or as part of an interdisciplinary 26

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team, anthropologists have made numerous contribut ions to understanding a ddiction, fertility and violence. In addition to c ontributing to understanding these issues, anthropologists also recognize the importance of influencing policy decisions, as evidenced by recommendations regarding ratification of the World Health Organization Framework Convention on Tobacco Control (Society for Medical Anthropology 2007) and a recent public policy statement on the rights of children (Society for Medical Anthropology 2007). What is Addiction? Addiction, in its broadest context, can incl ude any number of beha viors including alcohol or drug dependence, pathological gambling, bing e eating, problematic internet use and sex addiction. While addiction is sometimes used to describe attachment to activities such as shopping, puzzles or a particular te levision program, addiction generally refers to a pathological attachment. Addictive behaviors impact the brain reward system. Initially, there is a high or euphoric feeling when the drug re aches the brain, when the slot s hit the jackpot, when highly palatable food is consumed and when orgasm is reached during masturbation or other sexual experiences. However, for someone who becomes addicted, there is a loss of control over the behavior and they may continue to seek that initial high despite the fact that they now need to lie and steal to obtain the drug and avoid withdrawal. The pathological gambler may spend his or her life savings and have to de clare bankruptcy, the binge eater may become obese and diabetic and the sexual addict may get sexually transmitted diseases and destroy relationships with their partners. Regardless of what the addiction is there are often physical emotional and economic personal and social consequences. In the following sections, addiction is primar ily used to describe drug addiction, although co-occurring addictions may also be explored in later chapters. No t all substances have the same abuse and addiction potential. As mentioned prev iously, some substances affect the brain and 27

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are thus considered to be psychoactive. Dr ugs of abuse produce a brai n reward and are selfadministered by animals in the laboratory and by humans. We have learned a lot about addiction and the brain in the last few decades, but addict ion is not a new concept. The next section reviews some historical ex amples of drug addiction. Drug and drug addiction history The history of psychoactive substance use goes back thousands of years. The Drug Enforcement Agency has documented this histor y in an oral transcript (Drug Enforcement Agency 2007), which is summarized in the paragraphs below. Many drugs of abuse come from natural so urces such as the poppy flower (morphine, opium and heroin), tobacco, cannabis and the coca plant. Early routes of administration included chewing, eating or drinking and then smoking and i nhalation. Many of these flowers and plants had medicinal uses. Opium, for example was desc ribed in medical text from China dating back to the 8th century. Opium was used as an anti-diarrhea agent at a time when infections diseases could lead to a quick and early death. Refined opium and pure alcohol were combined in the 16th century to form laudanum and its use later becam e widespread in the US. People began smoking opium in the early 1700s, especially in China, but by the mid 1800s, there were opium-smoking dens in all the major U.S. cities. Morphine which is much more potent than opium was discovered in the early 1800s and with the invention of the hypodermic needle in the 1860s the drug was injected directly into the blood stream. Cocaine was discovered in the second half of the 19th century and like morphine and later heroin it was advertised in pa rt as a treatment for other addictions. Addiction to opium-based drugs became a huge problem for middleclass women in the late 19th century as these drugs were used by physicians for childbirth, cramps, pre-menstrual syndrome and were even available over the counter. 28

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At the start of the industrial revolution, there were patent me dicines containing these drugs that were given to children, which sometime re sulted in death. Substance abuse and addiction became such a problem that legislation was en acted, which included the Pure Food and Drug Act of 1906, the Opium Exclusion Act and the Harrison Narcotics Act (which is the foundation of drug law enforcement at the federal level). Th e Department of Justices Drug Enforcement Agency (DEA) was created in 1973, but its root s go back to the Bureau of Prohibition in the 1920s and the Federal Bureau of Narcotics in 1930. With legislation, The Depression and World War II, drug use d eclined in the United States so that by 1960, prevalence was very low. Use increased in the late 1960s and President Nixon was the first President to declare a War on Drugs. The Controlled Substances Act was enacted and the Drug Enforcement Agency was formed in 1973. Because the United States government was focused on heroin, distribution systems and us e of cocaine increased substantially in the 1970s, including international organized crime. Co caine and crack use led to increased violence in many cities, especially during the cocaine/crack epidemics of the late eighties and nineties. While there have been some reductions in the prevalence of tobacco and illicit drugs use, substance abuse and dependence con tinues to be a significant probl em with huge societal costs. Modern disease Addiction is well established as a chronic, relapsing il lness with both physical and psychological components in the medical and beha vioral sciences. Addiction has also been described as a disease of the emoti ons, of relating to others and of the spirit (American Society of Addiction Medicine 2007). The great-great-g randson of Charles Darwin, William Pryor, who was once addicted to heroin, calls addiction a lov e substitute. He write s that, At the root of all addiction is pain, just as it is at the root of being human (Pryor 2004, p.1). Addiction is much more than simply physical dependence; ot herwise, detoxification would cure addiction. 29

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Tolerance and withdrawal, marker s of physical dependence, are just two of the seven diagnostic criteria physicians use to diagnose substance dependence (defined below). For a clinical diagnosis of substance dependence, three or more criteria must be present in a one-year period. Defining substance use disorders : Substance abuse and dependence According to the Diagnostic and Statistical Manual of Me ntal Disorders, Fourth Edition (American Psychiatric Association, 1994), substance abuse is define d as a maladaptive pattern of substance use, leading to clinically significant di stress or impairment marked by one (or more) of the following, in the same 12-months: recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home. recurrent substance use in situations in which it is physically hazardous recurrent substance-related legal problems continued substance use despit e having persistent or recurre nt social or interpersonal problems caused or exacerbated by the effects of the substance. The DSM-IV definition and criteria for substa nce dependence (Ame rican Psychiatric Association, 1994) ar e included below: Drug dependence is defined as a maladaptive patt ern of substance use, leading to clinically significant distress or impairment marked by three (or more) of the following, in the same 12months: tolerance -a need for more of the drug to achie ve intoxication or desire d effect or decreased effect with continued use of the same amount. withdrawal -in which the charac teristic withdrawal syndrome appears in the absence of the substance or the same or a similar substan ce is taken to relieve or avoid withdrawal. the drug is taken in larger quantities or over a longer period than was intended. there is a persistent desire or unsuccessf ul efforts to cut down or control use. a significant amount of time is spent in obtaining, using or re covering from use. 30

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important social, occupational, or recreational activities are reduced or stopped because of use. continued use despite adverse consequences. What are the Theories of Addiction? Initiation, continuation, transi tion from use to abuse and dependence, cessation, relapse There are scores of theories of addiction, many of which were described in a monograph published by the National Institute on Drug A buse in 1980 (U.S. Department of Health and Human Services 1980). In Table1-1 numerous theories of addicti on are listed as well as their relationship to self, others, soci ety and nature (U.S. Department of Health and Human Services 1980). Examples of these theories include C oping Theory and Bad-Habit Theory (focused on internal factors which influence addiction), Fami ly Theory and Drug Subcultures Theory (which focus on relationships to others), Learned Behavior and Role Theory (which describe and explain societal influence) and Genetic Theory and Social Neurobiological Theory (which emphasize the role of biology and nature). With the exception of the Metabolic Deficiency Perspective, all of these theories address the first component of addi ctive behavior, which is initiation of substance use. After initiation, the cycle of addiction includes continuation of substance use, the transition from use to abuse and dependence, cessation of subs tance use and relapse. It is beyond the scope of this chapter to review all th eories of addiction, however, a nu mber of theories and examples are provided in the next section. Once someone becomes addicted to a substance it is very difficult to discontinue use. Prochaska and colleagues have developed a model to describe stages of change in addiction (Prochaska & DiClemente 1982; Prochaska, DiCl emente & Norcross 1992). As illustrated in Figure 1-1, the stages are prec ontemplation, contemplation, preparation, action, maintenance and relapse. Prochaska and DiClementes model makes it easier to understand why change takes 31

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time and relapse is so common among addicts; because it is part of the change process. Someone may spend years as an addict in the pre-contem plation phase or may try to change dozens of times before long-term success. Some individuals exit the model by death. Once an individual reaches maintenance, continued abstinence is gene rally considered a recovery phase which leads some to long-term recovery (and exiting from the model), while others relapse. Selected addiction theories and examples Some theories of addiction have focused on the neurobiology of addictive behavior, such as Robinson and Berridge who have examined th e neurological foundation of craving for drugs in what they describe as the incentive-sensit ization theory of addiction (Robinson & Berridge 1993). The Gateway theory is another popular th eory, which suggests that early use of licit drugs like tobacco and alcohol or softer drugs like marijuana may lead to exposure to and use of harder drugs like cocaine and opiates (Kandel, Yamaguchi & Chen. 1992). Learning to inhale one drug may also be a gateway to inhala tion of other substances (Gold & Frost-Pineda 2006). Use of certain substances may increase th e risk of developing psychiatric symptoms and disorders, such as chronic heavy marijuana use; which increases the risk of developing psychotic symptoms and schizophrenia (F erdinand et al. 2005) and alc ohol related depression (Gold & Aronson 2003). Theories of co-occurring disorders/ dual diagnoses have been used to describe high rates of addiction and mental illness, which often occur together (Bachmann & Moggi 1993). Gold et al. recently proposed a theory of chronic low-level exposure to opiates in the operating room and brain sensitization which ma y increase the risk for opiate addiction among anesthesiologists (Gold et al. 2004 ; Gold et al. 2006). Addiction is complex, with biological, psychological, emotional and cultur al influences. Some examples from the literature under the broad categories of biological, cultural, environmental and psychological are explored below. 32

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Biological, cultural, environm ental, and psychological Biological. The effects of drugs on the brain appear to be related to complex interactions with a number of neurotransmitter systems, including dopamine, serotonin and opioid systems. All drugs of abuse have an effect on the brain reward pathway, but not all drugs are equally addictive. The strength, amount, route of admini stration (how quickly it reaches the brain) and individual metabolism all play a role, as do indi vidual susceptibility differences. Drugs that reach the brain more quickly, such as smoked cocai ne or tobacco and injected heroin, are more immediately rewarding than drugs that are absorb ed through the skin or digestive system. Some researchers have suggested that those who are at greater risk of addic tion may have a Reward Deficiency Syndrome and proposed that this may be due to a genetic defect in their reward pathway neurotransmitters (including dopamine, serotonin, GABA norepinephrine, opioid and cannabinoid) (Comings & Blum 2000). Genetic factors account for 40-60% of the risk of alcohol dependence (Kendler et al 1997; Schuckit 2002). In fact, th ere is a three to five times greater risk of developing alc ohol dependence if there are alcoholics in your genetic family and the risk is greater with increasi ng number and closeness of the ge netic relatives (Schuckit 2002). Genetic factors may be responsible for the leve l of response to a drug, enhanced brain reward, and how the drug is metabolized (Schuckit 1998 ; Hwang et al. 1999; Risinger, Doan & Vickrey 1999; Roberts et al. 2000, Thiele et al. 1998; Bowers et al. 199 9; Yagi, Yasuda & Nicki 2000; Engel & Allan 1999). Recent studies have looked at addiction liability and the transition from abuse to dependence. Dr. Cottler and her colleagues have examined the length of time between onset of abuse and dependence (LOTAD) in attempts to el ucidate liability to addiction among individuals and groups and addictive liability of drugs (Ridenour et al. 2005). Use of opiates and cocaine had the shortest LOTADs regardless of the characteri stics of the group of anal ysis (Ridenour et al. 33

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2005). Early substance use and females also had shorter LOTADs, but there were no differences between African-Americans and Caucasians in the length of time between onset of abuse and dependence (Ridenour et al. 2005). Cultural. Peer groups and peer pressure influen ce substance initiation and maintenance, especially among teens (Kandel 197 8). Parents and siblings also have a strong influence on the decisions teenagers make about whether or not to use drugs (CASA, 2002). Children of one or more addicted parents may have impulse and behavioral problems. Conduct problems can lead to rejection by peers at school and failing grades, which makes it more likely they will seek out peers where risky behavior and drug use are accepted (Cadoret et al. 1995). Substance use may be a way that individuals say something about themselves or others. For example one recent study found gender differences in how smokers are perceived, with female smokers being perceived as slutty and out of control and male smokers described as manly, relaxed, and in control (Nichter et al. 2006, p. 215). Culture also plays a role in what drugs are available (indigenous, imported, proce ssing and supply chain, laws), where drugs are used (crack houses, bars, homes), who uses drugs and with whom (age of user, use with other users, peers, partners and fam ily) and how drugs are used (i.e. route of administration, quantity, what drugs are used together). Culture also influences the perceive d effects drugs, including medications (George et al. 2006). Environmental. Environmental exposure to drugs of abuse comes in many forms. Sometimes, drug use is prevalent in the home or neighborhood and exposure cannot be avoided. On the other hand, it could be the workplace that influences alcohol (Ames 1990) or other drug use. Media also influences substance use. Before the Master Settlement Agreement (Wilson et al. 1999), billboards and other forms of outdoor advertising promoting tobacco use were 34

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widespread. Alcohol advertisi ng continues to be widespread including television, radio and print. Even with restriction, tobacco advertisi ng continues with ads such as that for Newport cigarettes, which says to FIRE IT UP, a messa ge that could also be promoting marijuana use (National Association of African Americans for Positive Imagery 2007) Exposure may also happen inadvertently, such at house painters w ho after exposure to alcohol in paint and had hi gher rates of alcohol abuse and dependence and physicians, particularly anesthesiologists, who have hi gher rates of prescription misuse, abuse, and dependence (Vaillant, Bright on & McArthur 1970; Gold, Fros t-Pineda & Pomm 2005). In addition to access to potent opiates, higher rate s of addiction among anesthesiologists may be related to occupational exposure in the operating room (Gold et al. 2004). For example, Gold and colleagues (2004) found that opiates, such as fentanyl, could be detected in the operating room air. Long-term exposure to opiates could sensitize the brain lead ing to higher rates of addition among doctors who later use these drugs (Gold et al. 2004; Gold et al. 2006). Psychological. Antisocial personality disorder, bipolar disorder, panic disorder and schizophrenia all increase the risk of a substance use disorder (Schuckit 2000). One model of a pathway to alcohol dependence suggests that some individuals drink to c ontrol internal distress (Conrod, Pihl & Ditto 1995). Some children have more anxious and depressed feelings than other children. When these indivi duals begin to drink alcohol, th ey may initially feel better, leading them to drink more ofte n in larger quantities. Drugs of abuse may be more rewarding when taken in stressful situations and stress is cons idered to be a significant factor in relapse (Liu & Weiss 2002). Substance use disorders and Post Traumatic Stress Disorder (PTSD) occur so often together that there may be a relationship between these disorders (Jacobsen et al. 2001). The risk 35

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of SUDs may be four times greater in those w ith PTSD (Chilcoat & Breslau 1998). Usually, the traumatic event(s) and symptoms of PTSD (avoidance, hypervigilance, re-experiencing the trauma, exaggerated startle response, and trouble sleeping) precede the development of substance abuse and dependence (Saxon et al 2001) which may be a way to escape or self-medicate to reduce PTSD symptoms (Khantzi an 1985; Chilcoat & Breslau 1998). How do Women Experience Addictions? There is evidence that suggests womens expe rience of addiction may be different than mens experience of addiction. There may also be special issues in recovery for women. Women are more likely to be victims of childhood sexual abuse and are more likely than men to be victims of domestic violence and this victimi zation places them at increased risk for substance dependence (Miller 1996). Substance use also pl aces these women at increased risk of further victimization (Miller 19 96). Women are disproportionately affected by certain psychiatric disorders, such as binge ea ting, anxiety and depression, whic h are often co-morbid with substance abuse and dependence (National Ins titute on Drug Abuse & American Psychiatric Association 2004). And women with substance use disorders are more likely to experience depression, eating disorders, pa nic disorders and post-trauma tic stress disorder (Becker &Walton-Moss 2001; Brienza & Stein 2002). While females often begin using substances at a later age than males, the progression to addiction and negative conseque nces happens much more rapidly among females (CASA 2003). There is also evidence that drugs may have di fferent effects during di fferent phases of the menstrual cycle (National Institute on Drug A buse & American Psychiatric Association 2004). Some gender differences may make it more diffi cult for women to stop using a substance, to remain in treatment and to avoid relapse after treatment. 36

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Epidemiology of substa nce use among women In public health and preventative medicine, epidemiology is the field that studies the incidence, prevalence and determinants of disease or health condition in populations. While many of the determinates of addiction were e xplored in the previous section of addiction theories, in the following paragraphs estimates of the incidence and prevalence of substance use, abuse and dependence among women of child bearing age is elucidated. The actual prevalence of substa nce abuse by women of child b earing potential is unknown. Drug use is clearly recognized as dangerous and many substances of abuse are illegal so there is a tendency to under report use. Among nonpregna nt women ages 15 to 44, 49.8% used alcohol and 20.5% were binge drinkers (Substance Abuse and Mental Health Services Administration 2002). Alcohol use patterns before pregnanc y often predict drinking during pregnancy (U.S. Department of Health and Human Services 2000). Data from the National Household Survey on Drug Use and Health, show that self-reported illicit drug use among all 18-to-25-year-olds climbed from 14.7 percent in 1997 to 18.8 in 1999 (S ubstance Abuse and Mental Health Services Administration 2005). Prevalence of drug use is highest among young adults (18 to 30). Most pregnant women also fall in this age group. Re sults of the 2003 National Household survey estimated that approximately 4 percent of marri ed females aged 18 to 49 were dependent on or abusing alcohol or an illicit dr ug compared with 11 percent of females who were divorced or separated and 16 percent of females who had neve r been married. Five and one-half percent of females between the ages of 18 to 49 years old who reported living with one or more children were dependent on or abusing alcohol or an illicit drug in 2003 (Substance Abuse and Mental Health Services Administration 2005). Another measure of substance use is Emergency room visits related to drugs. The Drug Abuse Warning Network reported the following close to 290,000 Drug ED visits for women in 37

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2005 (See Table 1-2). Females had a higher rate of drug-related suicide visits (55 visits per 100,000 population) than males (34 per 100,000) in 2005. (Substance Abuse and Mental Health Services Administration 2007). The national Treatment Episode Data Set (TEDS) for 2005 included 590,759 females who were admitted to treatment substance abuse and dependence (Substance Abuse and Mental Heal th Services Administration 2007). Substance use during pregnancy Prevalence data on past month alcohol use by ag e and pregnancy status is provided in the table below. As detailed in Table 1-3, younger pregnant females are more likely to report binge and heavy alcohol use than older pregnant wome n (Substance Abuse and Mental Health Services Administration, Office of Applied Studies 2002a). Binge alcohol use (defined for women as four or more alcoholic drinks on a single occasion) is less likely to be reported by Hispanic pregnant women (1.4%) than by pregnant white wome n (4.1%) or pregnant Black women (5.6%) (Substance Abuse and Mental Health Services Administration, Office of Applied Studies 2002a). In their 1999 survey, the Centers for Disease Control found similar rates of alcohol use among pregnant women (see rates above for women over 25), with 12.8% of pregnant women reporting alcohol use and 3.3% binge drinking (Centers for Disease Control 2002). The survey also reported that pregnant women over 30 years old, who were unmarried and employed were more likely to report alcohol use, binge drinking, and frequent drinking (Centers for Disease Control 2002). Women over 30 years of age may be less likel y to reduce or eliminate alcohol use when pregnant due to alcohol dependency (Ebrahim et al. 1999; Grant & Douison 1998). In other surveillance reports, women with a high school education or le ss, those with low incomes, younger (<25 years) women, white women, non-Hispanic women and American Indian women have higher rates of smoking during pregnancy, while for alcohol use during pregnancy, those 38

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who are >35 years, with higher incomes and those with more than a high school education have higher rates of drinking during pr egnancy (Phares et al. 2004). While a standard drink in the United States is defined as 12-ounces of beer, 8-ounces of malt liquor, 5-ounces of wine or 1.5-ounces or a shot of 80-proof disti lled spirits or liquor, (U.S. Department of Health and Human Servic es 1995; Centers for Disease Control 2007), one study of pregnant women found the median self-d efined drink was 22-ounces of malt liquor, 8ounces of fortified wine and 2-ounc es of spirits (Kaskutas 2000). When asked about their alcohol use in the 12 months before they became pregnant 88% of fortified wine drinkers, 75% of spirits drinkers, 53% of malt liquor dr inkers, 50% of wine drinkers and 48% of beer drinkers underestimated how much alcohol they consumed (Kaskutas 2000). Past month cigarette smoking is reported by about 20% of pregnant women. The National Pregnancy Health Survey found that an estimated 5.5 percent of pregnant women reported using an illegal drug while they were pregnant (U.S. Department of Health and Human Services & National Inst itute on Drug Abuse 1996). This equates to about 221,000 drugexposed infants. Based on 1992 data, the Na tional Institute on Drug Abuse estimated the number of infants exposed prenatally to one or more illegal drugs at between 625,000 to 729,000 per year (about 15 to 18 percent). Rates of drug-exposed pregnancies vary by hospital, from a few to more than 30 percent. In one recent study, 11% of the mothers admitted to illicit substance use, but 43% of the 3000 infants tested positive for illicit substances (Lester et al. 2001). Pregnant women are less likely to re port current substance abuse than non-pregnant women, but women report pre-pregnanc y levels of use after they gi ve birth (U.S. Department of Health and Human Services & Natio nal Institute on Drug Abuse 1996). 39

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In 2001, young pregnant women aged 15 to 17 ha d rates of illicit drug use that were similar to rates for non-pregnant females in the same age group, 15.1% and 14.1% respectively. Rates of illicit drug use in 2001 were similar amo ng white, Black and Hispanic pregnant women. In 1999, pregnant women aged 15 to 44 were more likely to enter treatment for cocaine abuse followed closely by alcohol and then opiates, whil e non pregnant females had the highest rates of treatment admissions for alcohol (Substance Abus e and Mental Health Services Administration, Office of Applied Studies 2002b) (See Figure 1-2). In 1999, about 28% of pregnant women admitted to treatment were referred through the criminal justice system, 28% were selfreferrals and 11% were referred by a health professiona l (Substance Abuse and Mental Health Services Administration, Office of Applied Studies 2002b). What is the Role of Violence in Addicted Womens Lives? There is a relationship between violence and substance abuse. Women with SUDs have often witnessed family violence and have been vi ctims of traumatic events as children and in their adult relationships. Childre n who are victims of abuse are mo re likely to abuse substances and have other risky behaviors during adolescence. Substan ce abuse, domestic violence and poverty are often present in families in which ther e are reports of child abuse and neglect. Child abuse and neglect Women who were physically abused as children are about twi ce as likely to abuse alcohol than non-abused adults. Childhood abuse is a sign ificant risk factor for later alcohol and substance abuse (Schuck & Widom 2001). In Florida, there were more than 235,800 reports to its Florida Abuse Hotline of suspected child abus e/neglect cases in fisc al year 1999-2000 (Office of Program Policy Analysis and Government A ccountability 2001). The Department of Children and Families determined investigation was required for 164,464 cases and determined that 76,494 children were victims of abuse and neglect during that year (Office of Program Policy 40

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Analysis and Government Accountability 2001). In the United States, domestic violence cooccurs with child abuse/neglect in at least half of the cases reported to child protective services. Domestic violence Many cases of domestic violence go unreported. However, data that are available indicate that domestic violence is a widespread problem. Figure 1-3 presents statistics on domestic violence offences reported to law enforcemen t in Florida during 2006 (Florida Statistical Analysis Center 2007a; 200b). As documented by the Florida Department of Law Enforcement (See Figure 1-3), there were 8,175 cases in which th e victim was the child of the offender. The majority of these cases were categorized as simple assaults, aggravated as saults and forcible sex offenses. There were close to 30,000 domestic violence crimes against spouses and over 35,000 offenses reported among cohabitants in 2006 (Flori da Statistical Analys is Center 2007a; 200b). Substance abuse and violence Anxiety, depression, panic at tacks, post-traumatic stress disorder and substance dependence are common psychological consequences of traumatic/violent events (Smith et al. 1990; Galea et al. 2002; Schuster et al. 2002). These consequen ces may develop in those who experience the violence/trauma as victims and those who witness these events. In one study, 27% of females with a history of PTSD also had a lifetime history of SUDs, while those the prevalence of lifetime SUD among those without PT SD was estimated to be about 8% (Kessler et al. 1995). What Special Issues Surround Addiction and Pregnancy? Unintended pregnancy According to the Office of Disease Prevention and Health Promotion and U.S. Department of Health and Human Services, mo st women are unaware that they are pregnant until after they are already 6 weeks pregnant (2005 ). Overall, about 57% of a ll pregnancies are unintended at 41

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the time of conception and the proportion of unintended pregnancies is much higher among women who abuse illegal drugs and alc ohol (Institute of Medicine 1995). Effects on the fetus Substance abuse during pregnancy is associat ed with increased risk of miscarriages, stillbirths, pre-term deliveries, low birth weig ht, and perinatal death. Nationally in 1997, 11.4% (436,600) births were pre-term, 7.5% were lo w birth weight (291,154), 1.4% (54,973) births were very low birth weight, a nd 27,968 infants died in their first year of life. Without intervention, women who have one child with Fe tal Alcohol Syndrome (FAS) due to alcohol use during pregnancy, have a 75% risk of having a nother child with FAS for each pregnancy (Burd et al. 2000). However only 1% of OB/GYN doctors report that they as k patients about alcohol use at every prenatal care appointment (Diekm an et al. 2000). Infant mortality and child morbidity caused by substance use disproportionately affects the poor and those who receive late or no prenatal care (Pollard 2000). Documenting long-term effects of maternal substance abuse is a challenge because following this population may be especially difficult (moving, arrests, lack of telephone, controlling/abusive partners, homelessness, treatment, shelters, kids removed from home, confidentiality issues, legal issues), as is delineating what effects are the results of prenatal exposure, and which are related to the early childhood environment. Children of parents who abuse drugs are more likely to have an a ddiction as adults (M cGinnis & Foege 1999). Additional consequences for these children may include increased risk of HIV infection and a higher risk of abuse, neglect and abandonment (Belew & Morrison-Rodrig uez 2005). More than half all pediatric AIDS cases in the United States are related to injection drug use, either by the mother or her sex partner. In one large study, almost 10% of adverse pregnancy outcomes 42

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(stillbirths, neonatal deaths, prem ature delivery, small head circum ference, small for gestational age) were linked to maternal smoking (Kallen 2001) The effects of drugs are exacerbated in childr en who are poor or have less than optimal care giving environments (Eyler & Behnke 1999). Drug use has a negative effect on childrens health when they are exposed in the home. Ch ildren whose parents abus e alcohol and drugs are three to four times more likely to be abused or neglected (Jaudes & Voohis 1995). An estimated 10 million children in this country have one or more addicted parents, with serious mistreatment affecting 675,000 of these children (B elew & Morrison-Rodriguez 2005). Children who are the result of unwanted preg nancies have poorer health outcomes (Institute of Medicine 1995). Contraceptive choices should be available and affordable for women who do not wish to become pregnant. If substance-abusing women are identified early, and receive prenatal care and drug abuse treatment, they have a reduced risk of pre-term delivery, intrauterine growth re tardation, and having a low birth weight infant (Substance Abuse and Mental Health Services Administration 1995). Outcomes for women who start drug treatment and prenatal care afte r the first trimester still have better outcomes that those who do not receive these services (Substance Abuse and Mental Health Services Administration 1995). Child welfare and legal implications Addiction does not make a person into a ba d mother (Boyd 1999) and many mothers with substance use disorders feel guilty about the effects of drug use on their children (Harding & Richie). However, addiction ca n, and often does, impair the abil ity to appropriately parent a child and may lead to child abuse and neglect. In a survey of child welfare professionals, 71.6% of 915 professionals said substance abuse was one of the top three reasons for the rise in child abuse and neglect reports (The National Center on Addiction and Substance Abuse 1999). It is 43

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estimated that substance abuse is involved in 30% to 90% of confirmed child abuse cases and 75% of child abuse related deaths (Belew & Morrison-Rodriguez 2005). Reports in the media of child abuse and negl ect related to substa nce abuse and mental illness are numerous. A particularly horrific example of child neglect was reported in the news in November of 2005 (ABC News Or iginal Report 2005) when the proposal for my research was being developed. In this case, a mother of seven was found passed out among garbage and more than 300 empty beer cans. Her blood alcohol level (BAL) was .40 (a BAL of .08 is considered intoxicated in most states). Of the three youngest children that lived with her, the youngest two (ages 6 weeks and 16 months) starved to death after not being fed for days (ABC News Original Report 2005). Even when services are available, pregna nt women and mothers with SUDs may fear losing their children if they seek treatment. (Ayyagari et al. 1999). Their concern is not unreasonable considering that substance use during pregnancy has le d to arrests and prosecutions for child abuse and other charges. In 2006, 15 states and Washington, DC statutes includes reporting requirements for suspected prenatal subs tance abuse and almost all of those states, including Florida, include language on drug use during pregnancy in their definition of child maltreatment (Child Welfare Information Gateway 2007). Many states also have other statutes related to drug use or drug paraphernalia around children. What Pregnancy Planning/Contraceptive Strategies do Women with SUDs use? Women with Substance Use Disorders (SUDs) face a number of repr oductive health risks including risky sexual behavior and unintended pr egnancy. There are a number of factors that may make access and use of contraceptiv es difficult for women with SUDs. Female cocaine smokers, for example, may have more frequent sex with multiple partners either by coercion or while impaired, which ma y prevent adequate cont raceptive use (Richard, 44

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Bell & Montoya 2000). In a study of women who have HIV or are at risk of HIV, researchers found that crack, cocaine, and injecting drug use were associated with inconsistent condom use (Wilson et al. 1999). Unintended and unwanted pre gnancy is an addition al stress that women with SUDs are ill equipped to handle. While a number of studi es have focused on condom use, especially in terms of protecti on against HIV, few studies have examined family planning and contraceptive use among women with SUDs. Substance use can place women at higher ri sk for contracting a sexually transmitted disease because impaired judgment makes them less likely to use condom s or other forms of contraceptive and more likely to have sex with multiple partners. (Kaiser Family Foundation, 2002) Women with SUDs appear to be less likel y to use contraception, despite the risk of pregnancy and sexually transmitted diseases. In a study of heroin-addicted women in the 1980s, only 25.8% used contraception compared to 48.5% of women nationa lly (Ralph & Spigner 1986). In a more recent study, researchers used cross-sectional interviews with opiatedependent women enrolled in a drug treatment program to determine contraceptive use. Morrison et al. reported that 44.2% of sexually active women at risk of becoming pregnant did not use a contraceptive method (Morrison, Rube n & Beeching 1995). Contraceptive use is more prevalent in France, but is sti ll significantly different among drug users compared to the general population. One study that compared contraceptive practices of injecti ng drug users (IDUs) to national survey data in France, found that wo men IDUs age 25 to 34 were less likely than women in the national sample to use contraceptive s, 77% and 84% respectively (Vidal-Trecan et al. 2003). However, condom use was much high er, reported by 64% of women IDUs and 10% of women in the national survey. In another study of IDUs, researchers examined sexual decision-making and contraceptive use and found that 15-27% of these women said that they did 45

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not participate in decisions about when to have sex, use condoms or contraception (Harvey et al. 2003). Those who did report decision making were 20 times more likely than others to use contraceptives. In this study, women were le ss likely to use condoms and other forms of contraceptives if they were in longe r relationships (H arvey et al. 2003). Researchers have reported that there are et hnic differences in at titudes and behaviors related to contraceptiv e use among person in substance abuse treatment (Gutierres & Barr 2003). Gutierres and Barr report that history of abuse also impacts contraceptive use. Native American and Mexican American women with histories of abuse and a concern about pregnancy were more likely to use contraceptives, but European American women with similar histories and concerns were less likely to use contr aceptives (Gutierres & Barr 2003). These authors recognize the importance of reducing unintende d pregnancies among drug users and addicts (Gutierres & Barr 2003). Other studies have promoted increasing the use of contraceptives to decrease alcohol exposure (Ingersoll et al. 2003) Ingersoll and colleagues re ported on 143 women who used alcohol and did not use contraceptives at the start of the study. The women received one contraceptive counseling session and four motivat ional counseling sessions and were followed for six months. Among these high-risk women, 56% were using contraceptiv es at the six-month follow-up (Ingersoll et al. 2003). Barriers to contraceptive use Cabral and colleagues note the importan ce of designing prevention and intervention programs that fit womens lives (Cabral et al. 2001). In their study, women from drug treatment facilities, homeless shelters, a nd public housing developments were recruited for a prospective study of condom use, however the authors found at baseline that about 25% of these women 46

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wanted to have a baby and over 40% believed their partner wanted them to have a baby and this significantly impacted consistent use of condoms during the study (Cabral et al. 2001). Harding and Richie found that among women in treatment for opiate addiction, women who had a low perceived risk of pregnancy were less likel y to use contraceptives (2003). Among 974 homeless women, availability and cost were reported to be the most common barriers to contraceptive use, but alcohol use in this population was found to impact use of contraceptive services (Wenzel et al. 2001). In a study of over 200 homeless women who were at risk of pregnancy, Gelberg and colleagues reported perceived deterrents to contr aceptive use (Gelberg et al. 2002). They found the most common deterrents to contraceptives were co st, side effects, partners dislike, fear of health risks, and not knowing how or which method to use. Sexual partners have a significant influence on womens reproductive health including use of contrace ptives, but it is often difficult to determine the conditions of use, reasons for use, and actual behavi ors relative to what partners think about contraception, especi ally cross culturally. In Gelb erg and colleagues study, not knowing which method to use, how to use it, and cost of contraceptives were the most common deterrents among women with a history of substance abuse (Gelberg et al. 2002). There is strong evidence to suggest that prev entive programs that include family planning are warranted in drug treatment settings. In a prospective study of 1,155 drug-using women whose infants were removed from them at birth and placed in foster care researchers found that among the 926 drug-using women available at follow-up, 22% had gi ven birth to another infant who was also placed in foster care (Lewis et al. 1995). Another study, which included 1,576 newborns in foster care due to maternal subs tance abuse, documented that 60% of the infants already had one or more siblings in foster care (Childrens Defense Fund 2000). Child welfare 47

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programs that do not address substance abuse, and substance abuse programs that do not address family planning, may lead to an increasing number of children who have been exposed to toxic substances, increased cases of child abuse and ne glect and removal of ch ildren because of abuse and neglect. Pregnancy and parenting may represent barrie rs to treatment seek ing, availability of services, or completing treatment. As menti oned previously, women may fear losing their children or legal prosecution if they admit to drug use or are identified by a positive drug test. The number of women in need of treatment far exceed s to number of beds available in treatment. Cost of treatment may be another barrier, sin ce most addicts hit bottom before seeking or being referred to treatment. Women often take the primary responsibility for children, which can also make it difficult to receive treatment and pa rent simultaneously. Responsibility for children, along with inability to obtain child care services, is one of the most significant treatment barriers among women (van Olphen & Freudenberg 2004). How do Fertility Theories and Oth er Factors Explain Fertility Rates? Fertility and reproduction are complex phenomena. They are both biologically based and culturally significant. Reproductive rates ha ve varied across time and places and this significantly impacts population si ze and structure. Throughout history demographers have noted transitions where initially fertility and mort ality are high, but after transition, fertility and mortality are lower. Fertility theories One theory used to explain fertility rates is the Natural Fertility Theory (Henry 1961), which focuses on physiological mechanisms which impact the ability to reproduce, such as length of time between menarche and first pr egnancy, time spent breastfeeding and length of post-partum a menorrhea. Understanding natural fe rtility is important in studies that look at 48

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ways that fertility is controlled, such as through cultural norms and practices related to sexual intercourse and contracep tion (Coale & Trussell 1974). Two predominate theories of changes in reproductive behavior and fertility rates, Demand Theory and Diffusion of Norms Theory, focus on ch anges fertility due to changes in the demand for children related to the costs a nd benefits of having children and changes in fertility due to the cultural diffusion of lower or higher fertility norms (Davis 1963; Caldwell 1980; Becker 1981; Pollack & Watkins 1993). Other th eories suggest that resources available to parents (such as childcare, time off from work) infl uence the choice to have children. Other factors affecting fertility Aspects of fertility that are controlled by biological mechanisms include the sex of offspring and maternal age and its impact on possibility of conception (Dunson, Columbo & Baird 2002; Markus et al. 1998) however these factors are important socially as well. Reproduction is also full of symbols; which can vary from culture to culture. It may be about love and other emotions and in some cultures it is tied to what it means to be female (Westfall & Benoit 2004). It is also about connectedness, kinship and relationships within communities (Feldman-Savelsberg 1995). While many theorists have focused on demand for children, not all women that desire children are able to become pre gnant and/or maintain pregnancy and not all women who want to limit the number or timing of pregnancies and ch ild-births are able to do so (Quesnel-Vallee & Morgan 2004; Bongaarts 1991). Choices regarding reproduction are not solely individual decisions. Sometimes who bears children and when is influenced by politics and sometimes it is about power relations (Basu 1997; King & Meyer 1997). In the United States, more and more legal restrictions are being placed on abortion in the last decade. Poor women may have access to free or low cost contraception through program s such as Medicaid or health department 49

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clinics, but are unlikely to have access to treat ment for infertility, while for middle class women, insurance plans may cover infer tility treatments but not cont raception (King & Meyer 1997). Internationally, forces outside the individual and family also control womens fertility. Some countries limit the number of children pe r family, like China, w ith its one-child policy (Barett & Tsui 1999). Another exam ple of the political economy of fertility is the international aid provided to developing counties in order to control fertility (R ichey 2004) and limit population growth. Political policies, economic fo rces and changing cultural norms have had a significant impact on global fertility. In the early 1950s the median total fertility rate (TFR) was 5.4 children per woman and only one country had a total fertility rate below the replacement level of about 2 children per woman (Un ited Nations 1999). However estimates for 2000 indicate that the median is now close to two and 40% of people live in countries where the rate is below two children per woman. Sixty-three perc ent of people lived where the TFR was above 4.8 in the early 1950s, compared to today where only 10% of people live in areas where TFR is above 4.8 (United Nations 1999). Can Human Behavioral Ecology and Life Histor y Theory Partially Explain Reproductive and Addictive Behavior? Human behavioral ecology uses the principles of evoluti onary theory to study human behaviors and cultures. Human beha vioral ecology can be used to explain behavioral variations and adaptations to competitions between life-history demands su ch as reproduction and parental care and mate acquisition (Borgerhoff Mulder 2003). For example, Hill and Reeve have used the principles of behavioral ecology to explain the invers e relationship between wealth and fertility (2005). A behavioral ecology perspective also provides a useful framework to analyze how inheritance, individual variati on and the functionality of certain traits may play a role in substance use (Lende & Smith 2004). Specificall y, Lende and Smith have described potentially 50

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evolved traits such as the genetic basis of drug a buse, variations in pers onality and physiological responses, and the adaptiveness of craving and withdrawal. Life history theory is anot her framework used in evolutionary anthropology and other disciplines, which proposes that many behavior s and physiological traits can be explained by maturational and reproductive features that ar e key in the life cour se, such as age of menstruation, age of first sexual in tercourse and age first childbirth. Life history theory has been used in the analysis of earl y childhood sexual abuse (Vigil, G eary & Byrd-Craven 2005), human reproductive behavior (MacDonald 1997), fertility (Bock 2002) a nd risky drinking (Hill & Chow 2002). Bock suggests that using life history theory can help explain fertility related issues that demographers have had difficulty in understanding, such as [C]onflicts of interest between parents a nd children and between men and women, the allocation of resources to competing and/or alternative forms of investment in reproduction and parenting, resource flow within the household, demographic transitions and particularly the fertility transition associated with economic development, and variation in life history characteristics such as fertil ity and mortality across populations (Bock 2002, p. 145). Vigil and colleagues describe social correlates of life history events and then reports on the impact of a history of childhood sexual abuse on age of menarche, sexua l activity and timing of first childbirth (Vigil, Geary & Byrd-Craven 2005). Hill and Chow an alyze the impact of environmental instability on risk-taking behavi ors (2002). MacDonald focuses on how stressful environments, both physical and psychological, ca n delay reproduction (1997). MacDonald also describes how the ability to m ove up in society can result in delayed reproduction, increased investment in children and lowe r overall fertility (M acDonald 1997). Some of these life history events, including contextual and environmental influences, is discusse d further in the final chapter to obtain a better understanding of the reproductive lives and addictive behaviors of women in treatment for substance use disorders. 51

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What Are the Common Themes in Life Histories/Narratives of Addiction? Hurwitz and colleagues have reviewed seve ral examples of personal accounts of drug addiction written by women including The Agony of Ecstasy (Gordon 2004), More, Now, Again: A Memoir (Wurtzel 2002), Go Ask Alice (Anon ymous 1972), I Never Saw the Sun Rise: Diary of a Recovering Chemically Dependent Teenager (Donlan 1977), The Partys Over Diary of a Recovering Cocaine Addict (He ndrick 1992), How to Stop Time: Heroin from A to Z (Marlowe 1999), Women and Cocaine: Personal Stories of Addiction and Recovery (Greenleaf 1989), Drinking: A Love Story (Knapp 1996). Hurwitz and co-authors also review accounts of womens addiction to food and sexu al addiction (2007). These life histories are in the form of biographies and memoirs that have been analyzed as narratives of addiction (Hurwitz, Tapping & Vickers 2007). In the addiction story, environmental characteri stics are often minimized, while the spiritual aspects are emphasized (Hurwitz Tapping & Vickers 2007). Accounts of addiction often take the form of a confessional narrative of illness or as a quest for recovery and health. Medical professional can use narratives to gain a better understanding of a patients experience and their illness. The lived experience of wome n in treatment for substa nce use disorders, which are presented as a collection of life histories in Chapter 3 is discussed further in the final chapter. In this discussion, themes of the drug experi ence, illness, suffering, spirituality and recovery within the life histories are explored. Can the Cycle be Changed? Is Survival Possible? Prevention and intervention: Pre-co nception and early prenatal care The best ways to decrease the prevalence of substance abuse by pregnant women are to reduce substance use by women of child beari ng potential (through prev ention, intervention and treatment) and to increase contraceptive use by women who use drugs and alcohol. Improving child health starts before c onception. Women of reproductive potential should receive pre52

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conception care prior to becoming pregnant. At r outine office visits they could be screened for substance abuse and could be given advice a bout contraception, nutri tion, the importance of early pre-natal care, and other periconceptional health issues (Morris on 2000). Methods to reduce harm among substance abusing women have included reducing or stopping drug use, prenatal care, lifestyle change s, and substituting other drugs or attempting to counteract the effects of the drug (Rosenbaum & Irwin 2005). Treatment for pregnant wome n and women with children Treatment interventions have include hospita ls, clinics, emergency rooms, drug hotlines, schools, psychiatric counseling, jail and prison, social worker couns eling, mental health clinics, drugs for drugs, AA and NA 12-step programs, re habilitation, acupuncture, removal of children and placement in foster care, proposed orphanage s for drug exposed children, and therapeutic communities (Belew & Morrison-Rodriguez 2005). Nationally it is estimated that only 20% of the women who need treatment receive it (S ubstance Abuse and Mental Health Services Administration 2002). Despite the various types of intervention and treatment, one survey found that only 11% of pregnant women receive the drug treatment services they need (Center for Substance Abuse Prevention 2005). Integrating family planning There have been reports of efforts to in tegrate family planning programs into drug treatment. In one of these, preliminary asse ssments indicated that only 38% of women in treatment who were sexually active in the pa st month had used a contraceptive (Armstrong, Kenen & Samost, 1991). In their drug treatm ent population of 599 women, 81% already had at least one child and 76% reported that their la st pregnancy had been unintended (Armstrong, Kenen & Samost 1991). Misinformation about cont raceptives and perceived negative health effects (that they caused bleedi ng, blood clots, cancer, headache mood swings, water retention 53

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and weight gain) were the main barriers reported by Armstrong and colleagues (1991). Some authors have promoted linking primary care, fami ly planning, and addictio n treatment (Wenzel et al. 2001). Brief intervention and motivational in terviewing can help reduce risk of alcoholexposure during pregnancy (Babor et al. 2000). The Centers for Disease Control has reported that motivational interviewing can reduce the risk for alc ohol-exposure during pregnancy by decreasing alcohol consumption, increasing cont raception use, or both (Centers for Disease Control 2003) (Figure 1-4). In th is study, risk was reduced in 69% of high-risk women. (Centers for Disease Control 2003) Key components of a comprehensive treatment program The Substance Abuse and Mental Health Services Administration has described numerous components for substance abuse treatment to me et the needs of women (Brady & Ashley 2005). These components are summarized below Services to improve access such as child care or transportation services Services to address needs, such as prenat al and pediatric care, psychosocial education, human immunodeficiency virus (HIV) preventi on and risk reduction, and mental health services, especially those that address post traumatic stress disorder, since many of these women have a history of trauma and abuse. Programs designed for women only, a treatmen t environment that is more focused on womens issues, and which may provide a mo re supportive, nonconfr ontational approach to treatment. In the concluding chapter, addiction and fe rtility are further explored and examined through themes that emerged from the interviews, and then through a discu ssion of the literature and several theories presented in this chapter. The final chapter concludes with recommendations for current programs and future research. 54

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1-1. Theories of Addiction Theory Theorist Relationship to Achievement-Anxiety Theory Misra Society Adaptational Theory Hendin Society Addiction-to-Pleasure Bejerot Nature Addictive Experiences Theory Peele Others Availability and Proneness Theory Smart Self Bad-Habit Theory Goodwin Self Biological Rhythm Theory Hochhauser Nature Cognitive Control Theory Gold Self Combination-of-Effects Theory McAuliffe and Gordon Others Conditioning Theory Wikler Others Coping Theory Milkman and Frosch Self Cyclical Process Theory van Dijk Others Defense Structure Theory Wurmser Self Developmental Stages Theory Kandel Others Disruptive Environment Theory Chein Others Drug Subcultures Theory Johnson Others Ego/Self Theory Khantzian Self Existential Theory Greaves Self Family Theory Stanton Others General Addiction Theory Lindesmith Self Genetic Theory Schuckit Nature Hyperactive Adolescents Theory Loney Others Incomplete Mourning Theory Coleman Others Interactive Framework Huba, Wingard and Bentler Others Learned Behavior Theory Frederick Society Life Theme Theory Spotts and Shontz Self Metabolic Deficiency Perspective Dole and Nyswander Nature Multiple Models Theory Gorsuch Self Natural History Perspective Robins Society Personality-Deficiency Th eory Ausubel Self Perceived Effects Theory Smith Self Role Theory Winick Society Self-Derogation Theory Kaplan Others Self-Esteem Theory Steffenhagen Others Social Deviance Theory Hill Others Social Neurobiological Theory Prescott Nature Source: U.S. Department Of Health And Human Services (1 980). Theories On Drug Abuse: Selected Contemporary Perspectives. NIDA Research Monograph 30. DHHS pub lication number (ADM) 80-967. Available online at http://www.nida. nih.gov/pdf/monographs/30.pdf Last accessed on August 16, 2007. 55

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1-2. Number of Female Emerge ncy Department Drug Mentions, 2005 Drug Number of Mentions (females) Cocaine 155,985 Heroin 55,503 Marijuana 80,597 Stimulants 54,419 MDMA 4,419 LSD 251 PCP 2,913 All illicit drugs 288,960 Source: SAMHSA Drug Abuse Warning Network (2007) 1-3. Percentages of Females Aged 15 to 44 Re porting Past Month Use of Alcohol, by Pregnancy Status and Age (1999-2000) 15 to 17 18 to 25 25 to 44 Use Last Month Pregnant Not pregnant Pregnant Not pregnant Pregnant Not pregnant Alcohol 8.6 26.1 10.1 53.6 14.0 50.2 Binge Alcohol 7.0 15.4 4.8 29.6 3.1 17.1 Heavy Alcohol 2.0 3.3 0.9 7.5 0.5 3.0 Source: Office of Applied Studies (2002b) Contemplation Relapse Precontemplation Preparation Action Maintenance 1-1. Stages of Change in Addiction. Base d on Prochaska and DiClementes Model (1992). 56

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1-2. Primary Substance of Abuse among Wome n Aged 15 to 44 Admitted to Treatment, by Pregnancy Status: 1999 (SAMHSA Treatment Episode Data Set (TEDS)). 1-3. Florida Domestic Violence Offences and Relationship of Victim to Offender. (Florida Department of Law Enforcement Uniform Crime Reports, 2007). http://www.fdle.state.fl.us/ FSAC/UCR/2006/CIF_annual06.pdf 57

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1-4. Baseline Alcohol Intake Among Women and Choices for Reducing Risk of an Alcohol Exposed Pregnancy (Centers for Disease Control 2003). 58

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CHAPTER 2 MATERIALS AND METHODS Study Design Summary In this chapter the research methods used ar e described. Details re garding human subjects protections, the research setti ng, study population and size, and ma terials and methods utilized are provided. The materials and methods in th is chapter are divided into two sections, a qualitative section and a quant itative section, and explain how the interview guide and questionnaire were developed and details about analysis variables and types of analysis. A two pronged research design was used in this research in attempt to qualitativ ely answer some of the why questions related to addiction and fertility behind the what quantitative data that were collected by the survey. Ethnographic data was collected through life history interviews to provide a context and background for the results of the survey on contraceptive use and barriers to using contraceptives in a population of wome n in residential treatment for Substance Use Disorders (SUDs). After approval by my Ph D committee and the University of Florida Institutional Review Board 02 (Protocol # 2006U-0439), life history interviews were conducted in the summer of 2006 and questionnaires were ad ministered between June and December of 2006. Human Subjects Protection To ensure the protection of human subjects in this resear ch, the study was reviewed and approved by the University of Florida Institutional Review Bo ard 02 (IRB application included in the Appendix, Protocol # 2006-U-0439) and the administration of the addiction treatment center. (See Appendix for le tter of approval). To further prot ect the identity of the women who participated in this research, the addiction treatm ent provider will be referred to as SafeFree. This name is fictitious and was chosen in rec ognition that these women were safe and drug free 59

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during this research. Additional information about SafeFree and the study population are included in the Research Setting and Study P opulation sections of this chapter. As is described in the IRB application, the Pr incipal Investigator ex plained the purpose of the study including any risks and potential benefi ts. One hundred consecutive adult women in treatment for substance use disorders were aske d to complete the contraceptive survey. Women were asked individually and in gr oups. Staff at SafeFree assisted with the research by locating potential participants, introduci ng the researcher to clients, scheduling time, providing meeting space and assisted with collecting completed survey s. Potential participants were given a copy of the IRB approved informed consent document to read and any questions were answered before participation (See Appendix for a copy of the IRB approved informed consent form). Informed consent was documented before any of the research questions were asked. Signed informed consent forms were stored separately from the anonymous questionnaires and life history interviews so that there would be no link to c onnect responses on the questionnaire to individual res pondents. No identifying informati on was collected on the survey. This was to ensure that responses were complete ly anonymous. Participants were informed that their questionnaire data would be stored and reported in an anonymous and summarized form. No compensation or other incentive was provi ded to those who completed the survey. Five adult women participated in the life history interviews. It was anticipated that some of these women may have had interactions with the child welfare system and they were reminded not to discuss any unreported incidents of child abuse because of state mandatory reporting laws. They were also told they could discontinue part icipation at any time. In the interviews, names and dates were modified to protect the privacy of respondents. Each woman received a $10 WalMart gift card at the end of each interview. There was a maximum of five interviews and $50 60

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per person. Since one participant was not available for her last interview, her last gift card was given to a staff member to give to her. As previously mentioned, there was no dire ct benefit to participants in the survey, however, the data collected may have the potential to improve services at SafeFree. Sharing personal life history can be therapeu tic, but it also has the potentia l to bring up painful memories. Counselors and psychiatrists were available if anyone experienced distress after sharing their story. Research Setting Participants in this research were recruited at SafeFree residential treatment facility in a large city in Florida and all data was collected at this site. SafeFree is th e one of the largest nonprofit organization offering alcohol abuse, substance abuse and relate d behavioral health services in Florida. They offer a number of services including detoxification and specialized residential addiction treatment services for women with substance use disorders and those with dual diagnosis (See Table 2-1). SafeFr ee serves one of the largest cities (in square miles) in the United States. The 2000 U.S. Census data indi cate that 65% percent of the population is Caucasian, 29% is African American and 4% is Hi spanic or Other. This research site was selected because of its proximity to the Univers ity and because of SafeFrees interest in this research. Substance abuse and child abuse and neglect are critical problems in the metropolitan area served by SafeFree. According the Florida Unif orm Crime Report this city averaged nearly 8,500 drug arrests and 3,400 DUI arrests per year in the years between 1998 and 2002, (Florida Statistical Analysis Center 2007a; 2007b). In 1999, the Florida Department of Children and Families (DCF) did a statewide survey of protect ive supervision cases to obtain baseline data on substance abuse (Office of Program Policy Analysis and Governme nt Accountability 2001). In 61

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this area, 57.65% of child abuse and neglect cases required substance abuse treatment as part of the case plan, while statewide 52% of case plans identified the need for substance abuse treatment (Office of Program Policy Analysis and Government Accountability 2001). There were more than 12,900 reports of child maltreatment in one of the areas served by SafeFree between July 1, 2002 and June 30, 2003 and in fiscal year 2004-2005, there were more than 11,000 reports of child abuse or neglect (Dep artment of Children and Families 2005). The monthly reported rate of child abuse and ne glect in the area surrounding SafeFree is 3.8 per 1,000 children, which is higher than the statew ide rate of 3.6 per thousand children. Study Population and Size SafeFree has a maximum of 30 inpatient beds for women at any given point and it is anticipated that on average each woman receives 45-60 days of residential treatment. For the qualitative component, five women were selected from the populat ion in residential treatment during the summer of 2006. Wome n learned about the research in terviews through participation in the survey and the first five volunteers were as ked to come to the first interview. Two of the first five women were not available for the fi rst interview and so two additional women were asked to participate. These five women were interviewed on 4-5 different occasions for approximately two hours per interview during the summer of 2006. The interview guide is included in the Appendix and is described furt her in the next section of this chapter. For the quantitative component of this resear ch, a N of 100 was selected. This N was selected based on a number of factors including, the exploratory nature of the research, the feasibility of collecting the data within the pe riod of IRB approval a nd it was in line with feedback received from Dr. Mark Yang, Professor of Statistic at the University of Florida. The N in this study was not a random sample of women whose responses were used to make inferences to all women in treatment for substa nce use disorder, rather the N represents the 62

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women who were in treatment at the time the da ta were collected with the goal of describing characteristics and relationships between vari ables in this group of women. Had it been a random sample of a large or unknown population si ze, the sample size ne eded in this study would have been 96 at the 95% c onfidence level with a margin of error of +/-10. This sample size is calculated as follows ((1.96)2*(.5)*(1-.5))/(.1) 2, where 1.96 represents the z value for the 95% confidence level, under normal distribution .5 represents the proporti on picking a choice and .1 represents the confidence interval of +/-10 expressed as a decimal (Creative Research Systems 2007). However, as preciously mentioned the purpose of the survey was to capture data on the characteristics of the population of women who were in treatment for substance use disorder at the time of the research, not to make inferences from a random sample. The questionnaire that was developed to conduc t this survey is in cluded in the Appendix and is described in further detail later in this chapter. Althoug h it was expected that women in residential treatment are inheren tly different to a nationally repr esentative sample of the U.S. population in terms of numerous factors such as age, gender, income, and substance use history, to have a better understanding the results of this surv ey in light of nati onal surveys, several questions from national surveys were included in the questionnaire developed for this research. Details on questionnaire development and analys is variables are described under the heading Quantitative Materials and Methods. Qualitative Materials and Methods Interview Guide Development The qualitative portion of the research was de signed to provide a context and background for the survey research and was also intended to provide a better unders tanding of some of the why questions behind the what information found in the literature and in the survey results. Although five life histories cannot pr ovide definitive answers that are generalizable to all women 63

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with substance use disorder, an examination of these life histories allows for identification of themes which can be analyzed within the contex t of this research a nd previous studies and theories that are found in the l iterature. In-depth semi-structu red interview, a commonly used method in anthropology (Bernard 1994), was the se lected method of qualitative data collection. It was expected that the narratives of these wo men would include basic information about ages and places and also give us insi ght into the their individual lif e histories and specifically how addiction has impacted their lives. In addition, it was hoped that these interviews would provide us with a better understanding of the human face and social context of fertility and addiction. Life history interviews with five women were selected as the method for collecting these womens stories. An interview guide was developed and is included the Appendix. The interview guide was developed in consultation with my committee Chairman, Dr. Burns, to ensure a successful interview experience. Informan ts were able to talk a bout their life story in the order and detail that they preferred. The in terviews were open ended in terms of what the women could talk about and the guide was used as a starting point for discussion and to provide some consistency in the type of data collecte d. These in-depth, in-p erson interviews were conducted to provide a more detailed and person al account of the relationship between trauma, substance abuse, family planning and child welfar e issues. For each life story, approximately five separate two-hour interviews were conducted. Ea ch woman received a tendollar Wal-Mart gift card for each completed interview. Information about the treatment environment and treatment process was also collected to provide another ethnographic dimension to this study. Data The interview methods and interview guide we re reviewed and appr oved by the University of Florida Institutional Review Board (Proto col # 2006-U-0439) prior to the conduct of the research. The qualitative data were collected by note taking during the interviews and are 64

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presented in Chapter 3 in an ethnographic life story format. Topical areas included in the interview guide are summarized in Table 2-2. Th e interviews were not video or audio recorded in order to protect privacy. Qualitative Data Reporting and Analysis Field notes were taken during the interviews. These detailed notes were recorded as the participant described their individual histories on five separately scheduled interviews. Sometimes abbreviations were used to capture th e full details of her descriptions. After each interview, field notes were review ed and any areas in need of furt her clarification were addressed at the next scheduled interview. After the inte rviews were completed, the notes were reviewed again and then transcribed into an electronic form at. In transcribing these notes, names and dates were changed to protect confid entiality. The life history inte rviews were sent to several reviewers and to my thesis committee members fo r review and comments. To provide a more seamless story, references to where interviews be gan and finished were deleted as well as some mentions of items that participan ts brought in to share during inte rviews. The complete set of life histories is included in Chapter 3. The historie s were reviewed and re-read numerous times to identify life history themes and areas fo r discussion in the final chapter. Quantitative Materials and Methods Questionnaire Development In order to develop a questionna ire that was relevant to this research project, numerous nationally representative surveys were reviewed and several questions and topical areas were selected from the National Family Growth Surv eys (Centers for Disease Control) and other national and treatment surveys such as The Natio nal Survey of Drug Use and Health, Treatment Episodes Data Set, the Drug Abuse Warning Netw ork and Monitoring the Future surveys which are conducted or sponsored by the Substance Abuse and Mental Health Administration 65

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(SAMHSA) or the National Inst itute on Drug Abuse (NIDA). Th is questionnaire was developed to collect a variety of inform ation regarding demographic char acteristics, health and abuse history, pregnancy related information, number of children, types of contraceptives used in the past and future intentions to use methods to prevent pregnancy, reasons for stopping use and questions related to substance use. Because one goal of the research was to co mpare selected data collected to national prevalence figures some of the family pla nning and contraceptive survey questions (See Appendix) were selected from the National Su rvey of Family Growth (NSFG)(Centers for Disease Control) and were asked according to specific timeframes that are used in the Monitoring the Future Studies (MTF) (Johnston, O'Malley & Bachman 2002; National Institute on Drug Abuse) and the National Survey on Dr ug Use and Health (NSDUH) (Substance Abuse and Mental Health Administrati on). For examples, women were asked about the same types of methods to prevent pregnancy (birth control pill s, condoms, withdrawal, etc.) and periods used (last 3 months, last year, ever) that were asked about in the NSFG and questions about substances used included the times frames of last month, last year and ev er as does the MTF and the NHSDUH. Standard demographic questions were also included (age, r ace, marital stat us, education, general health status) as well as questions that seemed pertinen t to the research based on the review of the literature (num ber and wantedness of pregnancies, number and ages of children, history of abuse and domestic violence, potential barriers to contraceptive use and about use of substances prior to entering treatment). Contrace ptive data from the National Surveys of Family Growth (1982, 1995 and 2002 [Centers for Disease Control]) were used for general comparisons. 66

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The questionnaire was designed to collect data on a number of variables in a condensed format. The survey itself was self-administered, so that after informed consent, women could read and answer the questionnaire in the time that they needed. The final questionnaire was six double-sided pages. The questionnaire included mo stly closed ended questions with multiple choices for responses. For example, two of the questions are provided below. Would you say your general health is a. excellent b. very good c. good d. fair e. poor Thinking back over the past 12 months, would y ou say you used a condom with your partner for sexual intercourse a. Every time b. Most of the time c. About half the time d. Some of the time e. None of the time Respondents were able to write in responses to questions that asked how old or how many, for example, how old are you? and how many times have you been pregnant? Questions that had an other category among the possible response choices also included space for a written response, such as, where do you live most of the time? e. other: Race was also open-ended, such that participants were asked, what race do you consider yourself? Check boxes were used for contraceptive use ques tions (See multiple examples in Appendix) and 67

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a matrix format was used to collect information about history of substance use and age at first use (See sixth/last page of the survey). With the exception of the contraception term inology that was included, the questionnaire was developed so it could be easily comprehended at the eighth grad e reading level. It was also designed to be easy to use so that respondents could answer hundreds of questions in six doublesided pages. Related questions (such as questions about past contraceptive use and questions about future intentions) were usually grouped together in sect ions and respondents could check appropriate responses or circle all that applied from lists. Pr ior to implementing the survey, feedback on the full questionnaire was sought from my supervisory committee, colleagues in the UF Division of Addiction Medici ne, UF medical students, underg raduate students and women at SafeFree. Suggestions were incorp orated before finalization of the survey. The final draft of the survey was reviewed and approved by the supe rvisory committee and the Institutional Review Board prior to conducting the research. Analysis Variables The Family Planning and Contraception Survey included demographic variables such as age, marital status, education, employment, and income. It also included questions about the subjects health, history of a buse, pregnancy status, pregnanc y history, pregnancy planning, age and number of children, age at first intercourse, a nd about their intentions to become pregnant. The survey included questions abou t the types of contraceptives (see Table 2-1) that were used in past month, where methods were obtained and a series of questions about condom use. Contraceptive use in the last three months, the last year a nd lifetime history of use of approximately twenty different methods were also explored. Data on future plans to prevent pregnancy in the next month and next year and reasons why they may have stopped using a method were collected. The last series of ques tions asked about twelve specific substances or 68

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categories of drugs of abuse (tobacco, alcohol, ma rijuana, cocaine, crack, heroin, hallucinogens, inhalants, pain relievers, tranquilizers, stimulants, sedatives) and also in cluded an other drug category, high sugar foods and high fat foods. For each of these, data regarding if they had ever used, used in the last 12 months, used in the la st 30 days or on the day before treatment was collected. They were also asked to indicate the age they were when they began using the substance Survey Data Analysis Descriptive Statistics. For the variables described above, frequencies were generated for categorical (i.e., dichotomous ye s/no responses and income categor ies) variables (N or % with each response and N missing) and descriptive st atistics (i.e., N and N missing, mean, median, standard deviation, minimu m and maximum) were calculated fo r continuous vari ables (i.e. age, number of pregnancies, number of children, years since surgical sterilization, age at first sexual intercourse, age of children and age at first use of drugs and alcohol). These results are presented in Chapter 4. Additional analysis, regre ssions and comparisons. Frequency tables were used to examine the relationship between type and frequency of substance(s) used (past year and before entering treatment) and effective contracep tive use/failure to use in past year and past three months. These tables are included in Chapter 5. Comp arisons by age and race are also included in Chapter 5. Since this was an observational study and not an experimental design, regression analysis was chosen for further analysis of the data This method does not examine cause-effect relationships, but does allow for examination of relationship between two variables. Regression analysis is a commonly used met hod to test the relationship between variables, such that a model can be made to make predictions about one va riable based on another variable (Darlington 69

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1990). While often used to analyze the relationshi p between two quantitative variables, such as weight and blood pressure, it can also be used when there is a dichotomous variable such as yes/no or use/not use. In other words, it can be used to describe the relationship between age (x, the independent variable/explanatory or predic tor variable) and cont raceptive use (y, the dependent or criterion/response va riable). In the results presen ted in Chapter 5, ordinary and logistic regressions were used. SigmaPlot (Version 9, Systat So ftware Inc, San Jose, CA) was used for the ordinary regression analysis and SA S (SAS Institute Inc, Cary, NC) was used to conduct the logistic regressions. Ordinary regression was used to find the relati onship between continuous data, such as the number of years since surgical sterilization method or age of s ubstance use initiation (dependent variables) and demographic char acteristics such as age and y ears of education (independent variable). When the response variable was "use or "not use", logistic regression was used. Using contraceptive methods as the dependent variable and demographic characteristics as independent variables, logistic regression method was used to find the relation between the past and planned use of contraceptive methods and demographic characteristics. Independent variables included in the analysis and presented in Chapter 5 are age, race, ever married, past year employment, education and history of abuse or domestic violence. Additional details about the variables of analysis are included in Chapter 5. In the ordinary regression results, the size of the regression coefficient for the independent variable indicates the size of the effect that variable has on the depende nt variable. A negative coefficient indicates a negative relationship and a positive coefficient indicates a positive effect. For example when examining the effect of age on number of years sin ce sterilization, a positive coefficient indicates that the number of years since sterilization is expected to increase when age 70

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increases by one. For the results reported in Chap ter 5, a correlation coeffi cient of less than .30 is considered weak, .30 to .59 as moderate and .60 or greater as strong. The square of the correlation coefficient between the dependent and independent variable is presented as the R2. This is the fraction of the varia tion in the dependent variable that is predicted by the independent variable. The p-values, which i ndicates confidence that the indepe ndent variable is in someway correlated with the dependent vari able, was considered statistically significant at p <.05. The significant results of the logi stic regression are summarized with the odds ratio and 95% confidence interval for the odds ratio included in the text and addi tional details in the corresponding tables. For the logistic regression results, if the 95% confidence interval for the odds ratio includes or the p-value is .05 or grea ter, the results are not considered statistically significant. In Chapter 5, the survey data was also compared to summarized data in the 2002 NSFG, previous NSFG surveys and other national survey reports. When available comparisons were made in terms of age, race/ethnicity, past and current contraceptive use and types of methods used, rates of surgical sterilization, age at admission and primary substance of abuse, education, employment, ages of specific subs tance initiation, and prevalence of substance use in past month, past year and ever. The life hi stories of women in treatment for substance use disorders may be useful in understanding some of the survey results and differences between these results and national estimates. Therefore, be fore the survey results are pres ented, the life history interview results are provided in Chapter 3 to provide a context and background for the subsequent chapters. 71

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72 2-1. Examples of Services Provided by SafeFree Type of Service Examples Prevention Children of alcoholics Community education Web-based educational intervention services Intervention Help for family members Reduce risks associated with substance abuse Prevent further abuse Assessment Psychiatric evaluation Treatment referral Detoxification Assessment, det oxification, and stabilization Secure environment Twenty-four hour medical coverage Outpatient Services Aftercare Crisis intervention Co-dependency services Dual diagnosis Family therapy Individual and group therapies Intensive outpatient services Random drug screening during treatment Relapse prevention Juvenile Justice Behavior management Case management Dual Diagnosis Halfway Housing 12-step groups Employment assistance Life skills Personal support Residential Treatment 12-step recovery model Dual diagnosis Child Development Center Individual and group therapies Infants and children can stay with mother Family counseling Links to community resources Parenting skills Medication management Trauma recovery

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2-2. Interview Topics Life Periods Areas Discussed Childhood Number of siblings, memories of her parents, relationship with mom and dad and, grandparents, role of her grandmothers, memories of where she lived, school experiences, were drugs and alcohol used at home, memories of holidays, birt hdays, was she a tomboy, what types of activities did she enjoy. Adolescence Relationships with her family, relationships with peers, first menstrual cycle, other physical changes, fi rst boyfriend, sexual experiences, substance use, school experiences, was she a risk-taker, and if so, what were those risks, did others think she was a risk taker, did her friends take risks, hobbie s/activities she enjoyed. Adult Work experiences, relations hips with her family, intimate relationships, substance use/ treatm ent experiences, financial/legal issues, would she describe herself as a risk-taker, in what ways, religious/spirituality influences, positive/happy memories of these years. Pregnancies, contraception and children History of pregnancies, planned/ wantedness, number and ages of children, contraception, past and curr ent perceived barriers to use, perceived benefits to use, impact of having child(ren), child care issues, ask her to tell me someth ing special about her child(ren). Future Intentions Her plans for her life post-treatment, her intentions regarding future pregnancies, her plans to use c ontraception, child care/employment plans, how she will use her treatme nt experience in the future, how she will try to avoid relapse, what she hopes to accomplish tomorrow, in the next week, the next month and the next year. 2-3. Family Planning and Contraceptive Methods Methods Birth Control Pill Female Condom, Vaginal Pouch Condoms Foam Vasectomy Jelly/Cream without Diaphram Withdrawal/Pulling Out Cervical Cap Depo-Provera, Injectables Suppository/Insert Norplant Implant Today Sponge Rhythm/safe period by calendar IUD (Intrauterine Device) Natural Family Planning Lune lle, (once-a-month Injectable) Emergency Contraceptives Contraceptive Patch Diaphragm Any Other Method 73

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CHAPTER 3 LIFE HISTORY INTERVIEWS Introduction This chapter includes the life histories of five women in treatment for addiction who shared their stories with me. An interview guide was used (See Appe ndix), but these women could tell their stories in the orde r and level of detail that they wished. Each interview begins with a brief introduction. Only names and some dates were change to protect the privacy of these women. Inconsistencies were not edited. The interviews are presented as follows: Sara Mary Jackie Tracy Pamela While these women had diverse backgrounds there are many commonalities in their stories. Themes and areas of concordance and dissonance are presented in Chapter 6. The text that follows is their words. Sara Sara is a 50-year-old African-American wo man. She has a strong voice, filled with wisdom. She has no children but has helped rais e her siblings and her sisters daughter and grand-nephew. She tells me: I was born in Jacksonville, but moved when I was 15 after my father died. I moved to Georgia about thirty-three years ago. In 1979, I went to Princeton, NJ after mom died and lived mostly there until December of 2005. I had a job as a nanny. Im not sure why I took that job because I never liked kids or housew ork, but I was fired so I went to stay with my niece in Pennsylvania. I was having a massive addiction to painkillers. They (my niece and her son and my sister) had an interven tion and bought me a train ticket. I never imagined I would be in this c ity again. I am estranged from my sister here. I was brought here and I brought my addiction with me. It sat right next to me on the train on the way here. I had this medicine dispenser. It was horrifying. I was passing out and sleeping all the time. 74

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When I first started as a nanny it was great. I just needed the pain meds for pain, but it became an addiction. I found a doctor that w ould write me prescriptions anytime. The doctor was a pusher, a drug pusher. I overcame street drugs. I smoked lots of marijuana over the years. One day someone gave me ma rijuana laced with crack. It was only with the grace of God that I was turn ed around. I remember I had to had to get high. I used to bargain with God for Wednesday because I needed to get high on Monday and Tuesday. I was going to my drug dealer crying. I cried and I prayed I love it and dont want to stop, but I cant take it anymore. The next da y that black switch turned off. There was no more obsession. God took that away. It was very difficult to accept such a blessing. It was a horrible way of living. God is a loving and understanding God. I thought I would try to fool G od. If God could let me do this for three more months, and then I could say the same prayer. And I hear d a voice that He coul d promise, but I would not be sure if it will be one day or three years to answer. It took me almost 6 years to stop. I have learned that one does not tease that drug (crack). I took pills for two or three years. I lost my coping skills and did not know how to live. I didnt know how to pay bills anymore. I li ved on the bare necessities, but I had an expensive dope habit. Even thought I was not using crack, I forgot how to manage money. I would be extravagant and go on expensive sho pping trips. I didnt pay bills. Well I paid the motor vehicle bills. I didnt need to get high anymore. There was no desire. I was in a lot of pain though, pain from osteoa rthritis. I also have a degenerative joint disease that required lots of surgeries. I had knee problems and knee pain. I suffered a lot. I was scared to give into th e pain. I started a routine of moving from one township to anotherso I could go to new hospi tals. At first I was very hone st about the pain. At first they gave me Dilantin. It was like wow they believed me. At first I was a sincere person in pain. The first time I went into treatment in Prin ceton, there was a therapist, a nurse who cried through the whole thing as I told my story. She was a godsend. This was my first addiction after my other addiction. This addi ction was to the pain pills that they had started prescribing after my s houlder surgery. I never told th em about the weed laced with crack. No human force or program could help with that. I was smoking it while I was in treatment. The therapist did ask me about other drug use once. Their program was a revolving door. There was a pill for everything. An anti-psychotic, a sleeping pill, an anti-anxiety me dication. We were falling asleep in detox. My therapist, she just had me for a patient. I had one roomma te that was thirty year s old and had been in treatment 27 times! It wasnt unusual to see the same people 5 or 6 times. There was no 12-Steps, no idea of sponsors. The therapist would just encourage meetings. Going to the ER (emergency room) started for pain. The doctor said for them to give me a shot of Dilantin, but I felt ab solutely nothing. The nurse ha d never given me the shot! When I went back I felt the prick and the dr ug, and it was Oh my God! I never felt it the first time they said to give me the shot. 75

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I had a ritual. On Fridays I would get off from work and then go to the ER at about 1:00am in a suburban beautiful hospital. I woul d tell them about my rheumatoid arthritis and would tell them that yes, I had had the blood test for it. I would have a panic attack and they would give me something intrav enously. I thought I had died and gone to heaven. I would leave the hospital with a pr escription. There was one 24 hour pharmacy I used to go to until I was red flagged. I did have a medical history of pain and so I went to another pharmacy. It had been about three y ears since I was doing all of this. I would go back to another hospital and get oral Percocet I could persuade them. My addiction was screaming but the pain was there. I would get morphine in one place, Dilantin in the next. I would go to one place on Friday and another on Saturday. I would juggle prescriptions. I met a woman through the ER. She gave me a morphine patch. It was 50mg and I took it because I needed something for the pain. I was taking 100 mg by the following week. Then I remember I was at a pizza place with the family I worked for and something was happening with the patch. I went to the car an d took off the patch. It was supposed to be worn for 72 hours but I extended it. I first bought one patch and then a whole box of them. They worked well for a while and I cut back on the pills I was taking. I used them for three months, but then they stopped working. The lady I got them from told me to go see the doctor. When I went to the doctors office it was filled with poor Hispanics and Blacks. I thought to myself Are all of these people here for the same reason I am? The office staff was very compassionate. There was a grea t big sign that said if you want any of the major pain pills that you were in the wrong pl ace. But the doctor prescribed them. He gave me 40 Tylenol #4 with codeine. I was feeling lightheaded now. After he got my medical history he gave me Percocet. I got a month supply, which I took in 2 weeks. Then I asked for 10s instead of 5s. When th e doctor first asked me if I wanted to try Oxycontin, the addict in me said Yes! but the other person in me said no. Then I was taking the Oxycontin, Percocet and some other drug and it almost killed me. I remember that I had to get in a cold shower and I prayed, God, pl ease not like this. I remember I would have to jump around. I was surprised when I woke up. I had taken the pills too close together. I was so afraid I was going to die. I put myself out of my job. I was paying cash for $200 prescriptions because insurance would have caught on. And, oh how dumb I w ould play with the pharmacist about the strength. I would never run out of my supply. Addicts, we see things differently. For example, I took some Percocets from the medicine cabinet of my employer. I actually went through her bedroom into her bathroom while she was sleeping to get them. Well she caught me and asked what I was doing. I told her I needed them for the pain. She was a lawyer and told me I was breaking the law and threw the remaining pills in the garbage. Well the next day I went through the garbage to find them. I just coul dnt believe that she didnt understand the pain. As an addict I felt like I am invisible even if there are fifty people around who could see what I was doing. I felt like how dare you que stion me when I know that I am in pain. When I came to Jacksonville in 1987 it was to bury my middle sister. She was murdered. That was when I was first introduced to mariju ana with crack. It numbed the pain. This place reminds me of my sister. I miss her so much. 76

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I have another sister. She is the youngest. She is not a spiritual person but uses God and the Bible to judge people. Wh at happened before returning here this time was my doctor had given me a whole stack of prescriptions to last a while. In December of 2005, my sister had an intervention for me with medical people and church people. I didnt think people were watching. My sister communicated very little with me. When my pills got low and I asked her to help me get more she said no. My sister made calls and they referred me to here. They said I could come in that very same day at 10am, but I took the pills that were packed and then took the rest of them and then went into detox on Dec. 19th. I didnt want to feel withdrawal. I had gone to treatment in Princeton three or four times for withdraw al. In this city, I didnt know anyone that would leav e and want to come back ag ain. Detoxification in here was substandard; just the basics. Detoxification here was not a place you want to keep coming back tounless you were on the streets. I was cold, crying and sad. I spent Christmas and New Years day here in detox. Thinking back, I didnt celebrate my 50th birthday either. Because my addiction was so powerful that I did not celebrate anything, excep t by maybe taking some extra pills. There were many times that I would just not show up to celebrations. I chose not to have children because I wanted to party all night. I loved it, the partying. However, I did care for my niece for my sister who was murdered and I also have a grandnephew who is nine years old. On holidays, I was still getting high and even when I wasnt high there was something missing. Now, I am getting coping skills. I am learning all over again how to pay bills, how to live on my own. I used to be able to do that back in my twenties and thirties, but then the addiction took it over. Some of the most positive experiences of my life were when my niece graduated from college and the birth of my grand-nephew. Im in the extended program here, which includes stages and phases. I am at the highe st level and can now use a cell phone so I can keep my connection with him. My niece came to live with me when she was 14. I was very cold to her initially. I didnt realize it, but part of me died with my si ster. I would freeze when my niece hugged me. But I learned. And she learned that with me there was no cursing, no name-calling, no clamor and no disrespect. Her son doesnt know any of it either and for that I am thankful. When I grew up there was a lot of verbal and p hysical abuse. My mother was an alcoholic and my middle sister was an addict. She wa s abusive to her daughter. My niece was very fearful at first and always afraid of conseque nces. But I was able to help her break the cycle of abuse and now her son rarely gets sp anked. It was unusual to hear voices raised when we lived together. Another positive thing is that my grand-ne phews dad had once had an alcohol problem and was verbally abusive, but now he has got ten his life together, got his GED and is now almost done his BS. My niece will be graduating from college too. 77

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I told the two of them that th ey cannot be selfish and dont put their son in the middle of it. They dont use him as a pawn. I helped them with this and talked to them. I told my niece not to deny the father. He had grown up in fo ster care. They are both very involved. I hope that I have helped to stop that abuse from passing down. My nephew feels safe. I couldnt, I didnt feel safe. My niece is very grounded and stable. She puts her kids first. We had many long talks where I tr ied to share some wisdom. I went to college. I got caught shoplifting when I was 19. I did it for the thrill of it. I tried to take something impossible. My mother call ed the priest, an Episcopalian priest. He was a pervert. My punishment was to go to college. I would be sleeping in the classroom with my pen in my hand and my coffee. Eventually they told me not to come back. But I did go back to college in my thirties and fortie s. Then an Awas not good enough for me. I was very active and involved when I went back on my own. Look I brought some pictures of my grandnephe w, his dad and my niece. This was on a trip to Baltimore. I dont think I told you this. I was born in J acksonville. I had a twin sister, but she died when I was just 19 months old. My mother ex aggerated, but my sister may have had some sort of leukemia. My middle sister was born on the same day that my twin died. She was called a present. And here I am, still grie ving even though I was just 19 months old when she died. Ive always felt like my twin was my guide. I had two brothers and three sisters. Now I j