Good morning, everyone. Wonderful to be here today to introduce our Founders Award recipient. I'm very excited to have the honor of introducing Dr. Shelly Greenfield to all of you today. She is a professor of psychiatry at Harvard Medical School and chair of psychiatry at McLean Hospital, where she also serves as the chief academic officer. Dr. Greenfield has also served as principal investigator and co-I on federally funded research focused on treatment for substance use disorders, gender differences in substance use disorders, and health services. This morning, she will be presenting her talk titled Gender Differences in Substance Use Disorders from Science to Treatment. She is the past president of our organization and current member and past chair of the American Psychiatric Association's Council on Addiction Psychiatry. She was a member of the Advisory Committee on Services for Women for the U.S. Substance Abuse and Mental Health Services Administration from 2011 to 2017, and is a member of the NIH NIDA National Advisory Council on Drug Abuse since 2021. There's more to her bio. This is an edited version. She has many, many accomplishments and awards. On a more personal note, Shelly is an incredible colleague, mentor, and role model to me. She has inspired and supported my own career in various ways over the years. I really can't say enough about that. It's truly an honor to be up here presenting this award to her. She's also done so much for our organization in terms of her leadership over the years, and still to this day, devoting her time and sharing her wisdom when we have to navigate any difficult decisions or challenges, and just really radiates positivity, and that's always contagious. We appreciate it. So, Dr. Greenfield, if you'd like to join me on stage to accept our Founder's Award in recognition of your support of education, treatment, and policies supporting those with substance use disorders and co-occurring psychiatric disorders, your knowledge, relentless work on behalf of the Academy, and advocacy for the field of addiction psychiatry has had far-reaching benefit for medical students, fellows, those in their early careers, and the patients they treat. Thank you so much. Congratulations. It's so sweet of you. Thank you so much. We appreciate it. Now we have to take a picture. Oh, we do? All right. There you go. This way. Thank you so much. Thanks. That's great. I have to arrange myself here. I am very touched by that introduction, very, very, very touched, and thank you so much, Larissa. So, first of all, it's incredibly wonderful to be here in person with all of you back at our annual meeting. I really want to thank Dr. Mooney and Dr. Desai and the Scientific Program Committee and the Board and Catherine Cates Wessel and others, and in selecting me for the 2022 Founders Award. I'm really honored and humbled by being this year's recipient of this award, and to be here in person to receive it is just great. You know, AAAP has really been my professional home for 30 years, essentially my entire career, and I feel greatly honored to receive this award today. My AAAP mentors and friends and colleagues are intertwined with my professional development as an addiction psychiatrist through more than three decades. Addiction psychiatry is a field in which I feel incredibly privileged to be able to treat patients longitudinally and see their progress from illness to health. It's also a field where collectively we all work together to expand the evidence base for effective treatments and to try to decrease the gap between medicine's ideals and how patients should be treated and the policy and practice gaps that exist for our patients with substance use and other co-occurring psychiatric disorders. The field of addiction psychiatry is compelling to me for all those reasons, but really for many others as well. And in addition, it's just been and is and has been incredibly enjoyable to be in this field because of the amazing and fabulous colleagues I feel so fortunate to know and work with both at home and around the country and through my many years at AAAP. It's really fabulous to be here with all of you this morning in person at our first annual meeting since the pandemic began. It's good to have this opportunity to see all of you, and I'll reflect more on this in a few moments when I present my talk, which I've titled Gender Differences and Substance Use Disorders from Science to Practice. But first, I just want to present my disclosures to you. I have no conflicts of interest related to an ACCME-defined commercial interest, but I am the author of Treating Women with Substance Use Disorders, the Women's Recovery Group Manual. I will be talking about that treatment today. And I also want to acknowledge the generous support of the National Institute on Drug Abuse that supported some of the work I will be talking about. These are the learning objectives. I'm not going to read through them. They are in your materials. But before we begin, I just want to take a minute to reflect on this moment when I'm grateful that we can gather once again here at AAAP. And I want to acknowledge what a difficult time it's actually been for everyone, for all of us, for our friends and our family, our communities, and our patients and their families. These past two, now almost three years, have really been quite a stressful time. And it's been a significant time of stress and loss for many. And I want to share with you this image that's brought me a lot of peace and tranquility through the last several years. It's a photo of a sunset on a very small beach called Cold Storage Beach in North Truro, Massachusetts, which is a tiny, tiny town almost at the very tip of Cape Cod. Walking this beach, when I've had opportunity to do so, and occasionally taking in a beautiful sunset, has brought me a lot of peace and tranquility. And I just wanted to take a moment to share it with all of you. I also want to talk about, I want to reflect for a few minutes on the importance of colleagues and mentors. For those of you who are in training or early in your careers, we often talk about developing a network of mentors. AAAP has been a great place to develop mentoring relationships. I have had so many mentors who have ultimately become my colleagues and my friends through the years. They've helped me in my career. And some of them have contributed to the research I'm going to present to you today. And many are also founders and past presidents of this organization. I just want to take a couple of moments to acknowledge them. This is a partial list of a network of mentors. And I hope you see the theme. People who are mentors here become colleagues. They become friends. And it's really something that makes, I think, a professional life really sing. So first, I really want to acknowledge Dr. Roger Weiss. I started working with Roger when I was an intern. And we have continued to work together since that time. And it's been a real privilege to have Roger as my mentor, colleague, and friend. We have had offices two doors away from each other for these many years. And that has been a pleasure and a privilege. Dr. Kathleen Brady has also been a role model and mentor for many years. She's actually contributed to some of the research I am going to show you today. And then the late Dr. Ed Kansian, past president and founder of this organization, was encouraging me as a medical student in my interest in psychiatry and in addiction psychiatry. Dr. Stephen Murin and the late Dr. Jack Mendelson offered me my first position after I finished my training. The late Dr. Kathy Carroll was an early mentor of mine. I was very privileged to have her as a mentor. And she, too, contributed to some of the research I'm going to show you. This is a picture of Dr. Joanne Fertig. She and her colleague, Dr. Cherry Lohman, were program officers at NIAAA. I first started talking to them in the early 1990s about my interest in researching gender differences, in alcohol dependence. And at the time, that was 1993-94. I'm going to show you in a slide. That was kind of novel. The Office of Research on Women's Health had just been founded. They were incredibly encouraging to me to follow this line of research. I'm very grateful to them and ultimately led to my first federal grant. And then the many colleagues and friends here at AAAP through years. This is just a partial list, but I want to acknowledge Dr. John Renner, Dr. Rich Francis, Dr. Mark Gallanter, Dr. Rick Rosenthal, Dr. Michael Gendell, Dr. Tom Costin, and then all the other amazing AAAP mentors and colleagues and friends, former trainees who are now colleagues and teach me so much, and all of you. So thanks so much. And now let's begin. So research on gender and sex differences with a focus on women is a relatively recent field, actually starting really in 1990. So that's 30 years. And it started really with the founding of the Office of Research on Women's Health in 1990. And then in 1993-1994, the NIH and the FDA put out their guidelines and mandates that women and minorities need to be included in federally funded clinical trials. So that's like 1993-1994. I know for some of you that seems like ancient history, but frankly, it's really not really ancient history. It's really just 30 years, and it's only since 2016 that the NIH has mandated that sex as a biological variable be included in all human and vertebrate animal research. It's a relatively new field. So that said, what we do know is that the problems of women in addiction have long been known for many centuries. But we actually, way through the 20th century, right up until the end of the 20th century, we thought of this as problems mainly of men. This is a painting by Henri Toulouse-Lautrec of Susan Valadon, an artist, also in her own right painted around the turn of the 20th century. And in Paris, when they noticed an uptick in drinking problems amongst women. But still, generally, that was considered problems of men. And then in the last decade of the 20th century, and now well into the 21st century, what we've seen is a really precipitous narrowing of the gender gap and prevalence for substance use disorders in the U.S. and internationally. So what I'm going to do with you today is review recent epidemiologic trends, the narrowing of the gender gap. I'm going to focus on alcohol, opioids, and cannabis. We're going to talk very briefly about risks for substance use disorders and treatment barriers for women. And I'm going to show you that there has been a clinical treatment gap and a need for gender-specific interventions for women with substance use disorders that can be implemented into routine clinical practice. And then we're going to spend the balance of the time, and I'm going to present the research that we've done on the development of the Women's Recovery Group, a group therapy for women with substance use disorders. And we'll talk about the Stage 1 and Stage 2 psychotherapy development trials, the qualitative studies of the group process and the participant experiences. I'm going to tell you about a potential mechanism of action that we've studied. And then I want to show you some new research on the digital adaptations that we are currently doing of the educational content. And so before the COVID-19 pandemic, we knew that the prevalence of substance use disorders was greater in men than women, but that the gender gap had been narrowing precipitously in both the United States and internationally. In 2019, 34 million adult women had a mental illness and or a co-occurring substance use disorder with about 4.6 million women above the age of 18 and older who had both. Before the COVID-19 pandemic, this is the data from the 2013 and 2019 National Survey on Drug Use and Health. And I hope you can see, and I think this pointer will work, yes. So I think you can see that 2013 to 2019 for 12 and older, 18 and older, you see there's a narrowing gap. But I really want to show you this because look at that, age 12 to 17. In 2013, that gap had closed between boys and girls. And by 2019, girls were exceeding boys in this vulnerable age group. With alcohol use disorders in 1990, the epidemiologic catchment study showed us that the male to female prevalence was 5 to 1. But by 2000, it had narrowed to 2.3 to 1. And then by 2012, it had narrowed again to 1.9 to 1. And through multiple epidemiologic studies, we know that women born in cohorts after World War II had lower levels of abstaining from alcohol and higher levels of alcohol use disorders compared with earlier birth cohorts born prior to World War II. In the decade between 2001 and 2012, there was a 16% increase in the proportion of women who drink alcohol, 58% increase in women's high-risk drinking compared to 16% in men, and an 84% increase in women's one-year prevalence of having an alcohol use disorder versus 35% in men. And then in this study, what you're going to see is this is past-month alcohol use, past-year DSM-IV alcohol use disorder between 2000 and 2018. You can see that's females, males. You can see this gap is narrowing. You can see here by 2018, it's practically closed. And then here are 12th graders. This starts in 1975 and goes all the way to 2018. And what you see here is a good trend, which is that, you know, it's going down. This is past-month drinking and past-month alcohol intoxication. But these are boys and girls. And what you see is by 2018, the gap has completely closed in this young age group. Right there. So why do we worry? Well, there are a lot of alcohol-related risks for both men and women through the lifespan. Liver disease, brain health and memory, cancer, including breast cancer. We know drinking actually elevates your risk for breast cancer. Cardiovascular disease. We know alcohol intake over the lifetime increases your risk for cardiovascular disease. There are mental health consequences. And for women in particular, binge drinking and heavy drinking basically increases the risk for violence and assault, unintended pregnancies, and sexually transmitted infections. I want to focus for one minute on liver disease. So I don't know if you're aware of this, but these data were published in 2017. And this is alcohol. This is a young group, 15 to 39 years old. This is the increase in alcohol-related liver disease from 1988 to 2012. And what you do see here is that this went up. That's the general population. Here you see a 90% increase in males. And if you look, there's a 240% increase in alcohol-related liver disease amongst women 15 to 39 years old. It's very concerning, and that trend continues. So that's all before COVID-19, and then we have COVID-19. And so what's happened about that? Well, already in April and June of 2020, when a study compared the same period in 2019 in the United States, the frequency of alcohol use, as you all know, increased 14% overall. But there was a 17% increase in women. Women had a 41% increase in heavy drinking days and a 39% increase in the short inventory problem scale. And then there's also been studies that show there are gender differences in alcohol consumption during the pandemic with self-reported COVID and pandemic-related stress and distress. This study by Rodriguez and colleagues shows that as pandemic-related distress increased, women's rate of drinking and heavy drinking increased with pandemic-related stress, whereas for men, the levels remain the same. So why do we worry? Well, one phenomenon I think you are all aware of is this phenomenon we call telescoping, which has been documented and seen for alcohol use disorders, that women who drink progress more rapidly to serious alcohol-related physical and social consequences than their male counterparts with shorter times between landmarks, you know, first drink, first problem, and first treatment of illness progression. It happens at lower doses, consumed less frequently, and we have some evidence with other substances such as stimulants, opioids, and nicotine, but those mechanisms are not quite as well worked out. With alcohol, we have one mechanism we know quite well, which is that compared with men, women have less alcohol dehydrogenase, or ADH, in their gastric mucosa. That decreases first-pass metabolism. It means there's greater absorption of ethanol into the circulatory system. Women have more adipose tissue, lower total body water, so for each ounce consumed, there's a higher blood alcohol concentration with a heightened vulnerability to adverse physical consequences, some of which I've listed here. We also know that there are some similar findings with substances such as opioids, nicotine, and stimulants, but as I said, some of the mechanisms are not as well worked out. So I'm going to move on from alcohol to show you some recent trends in opioids. I know this is a figure, unfortunately, you're all well too familiar with, but it shows the national drug overdose deaths involving anti-opioids, and the orange and yellow lines that are here are males and females. This goes up to 2019, pre-pandemic. As you know, it's continued to rise. And as you know, males still are more likely to die of an opioid overdose death than are females. On the other hand, between 1999 and 2019, there was a 640% increase for women and a 478% increase in men. We have other studies that have shown that women are still prescribed, or have been traditionally and still prescribed more opioids than are men. They report greater cravings. And women often report using opioids to cope with pain and negative affect more than do men. This is a study of analyses from the National Survey on Drug Use and Health between 2015 and 2019. And what this looked at is past-year opioid analgesic use disorder. And again, what I want to show you is that the gender gap is pretty narrow across these age groups. But look at that 12- to 17-year-old group, just like I showed you for alcohol. Girls exceed boys. And here's another couple of graphs to look at. So here, opioid analgesic initiation in the past year. Females exceed males. And again, past-year opioid analgesic misuse. Again, in the 12- to 17-year-old age group, you see girls exceed boys. And you see also here, I think you could see, these gaps are not very large anymore. I want to spend a couple of minutes showing you some trends in pregnant and postpartum women with opioid use disorder and also overdose mortality. This is a study by Howard and colleagues published in JAMA in 2021. And what it did was it looked at all-cause mortality and drug and alcohol poisonings in recently pregnant women compared to the total female population in the childbearing age. And what it shows you is that the mortality rates for recently pregnant women increased 4.4% annually each year between 2015 and 2019, mostly attributable to causes other than pregnancy-specific complications, including drug and alcohol poisonings. And these rates were greater for recently pregnant women than for the total female population of childbearing years. And there are just two other studies I want to show you for this population that are important for you to see. This is a study by Campbell et al. It shows that in 22 states where they adopted a pregnancy checkbox on the death certificates, between 2007 and 2016, there was pregnancy-associated mortality involving opioids more than doubled in both the rate and the percent of all pregnancy-associated deaths, 4% to 10% between 2007 and 2016. And then a study by my colleague, Dr. Devita Shiff, who's at Mass General Hospital, that was published in 2018 looked at more than 177,000 deliveries in Massachusetts. 4,000 were to women with opioid use disorders. Amongst them, there were 242 opioid-related overdose events. 231 were nonfatal. 11 were fatal. But look at this. The overdose rates were lowest in the third trimester, and they increased during the postpartum period with the highest rates 7 to 12 months post-delivery, which for me actually indicates how much support and need women who are postpartum need in the year following their delivery. And that includes things like food security, housing security, other types of support, mental health support, child care support, et cetera. And look six months later, between six and 12 months later, you're seeing this kind of a death rate. With that, I do want to remind you, I know this audience really knows, that we have medications to treat opioid use disorder in pregnancy. It is the standard of care. In case you don't know the SAMHSA clinical guide recommendations, you can download this right off the web. It's a great clinical guidance, and it will give you fact sheets that you can share with patients for prenatal care, infant care, postnatal care. I also want to point out the shared decision-making tool that Connie Gill and Andre Jones created a shared decision-making tool. You can find that, too, online. And that helps with discussions with women who are pregnant, who have opioid use disorder, making decisions about medications for opioid use disorder. I have a few slides on cannabis I just want to show you. We had a great symposium yesterday. I hope you were all there for the symposium on cannabis. I just want to point out to you that if you look at the 2019 National Survey on Drug Use at Health, you're going to see that there was an increase between 2018 and 2019 to 14.8% of women who were 12 and older who had a cannabis use disorder. We also know that during the pandemic, cannabis use actually increased in adults. One online survey by Asif and all showed that the use of cannabis, there was greater odds of increased. You'll see it here. Here we go. Let me see if I can do this. You'll see there's an increased odds of use amongst anybody who was using during the pandemic. Pre-pandemic, monthly or less than weekly, their use increased. And then in a study of Kaiser Permanente in Northern California data, it suggested that there was elevated cannabis use by pregnant women after the onset of the pandemic. You can see this is pre-pandemic and this is during the pandemic. And why are we concerned about that? Well, before the pandemic, the standardized rate of prenatal cannabis use was 6.75% of pregnancies and that rate increased to 8.14% of pregnancies in that study. And we worry about it because there's evidence to show that cannabis exposure in utero actually has neurodevelopmental effects. And this is a study that just came out from the ABCD study. I think you know this is the Adolescent Brain and Cognitive Development Study. That's a collaboration across NIMH and NIDA and NIAAA. And this showed that for prenatal exposure after about six weeks of gestation, it was correlated even after controlling for lots of covariates, it was correlated in middle childhood with, here you see, in particular psychotic-like experiences, internalizing and externalizing attention, thought and social problems. And so this is certainly of concern and it's a trend that we are seeing. So finally, I want to just talk about the intersection of gender and race and ethnicity. It's sometimes actually in the past been incredibly difficult to get data, especially in big trials that would look at gender by race and ethnicity. And so I really encourage you to go online and download this report from SAMHSA. They published a lot of data that actually looks at trends in substance use, substance use disorders, treatment utilization by gender, race and ethnicity between 2015 and 2019. It takes a while to look at the tables. They're very full and the figures are very full and there's a ton of information. So what I'm going to do is I'm going to share one figure and I put more in the appendix, but you should go to this and you should take a look at it. So this is what I want to show you. So this is substance use disorder in the past year among people age 12 or older by race and ethnicity and gender between 2015 and 2019. And here's one thing I want to point out to you. So here you'll see that the highest rates were in American Indian or Alaskan Native. And you can see that for males and females, those are the highest rates. The next highest rates are people who identify as two or more races. And, again, you can see a pretty close correlation. You can look across. If you look across, like the blue lines, you're looking across different races and ethnicities at males. And if you look at the red lines, you're seeing the variation for females. So I wanted to calculate this gender difference, the gender gap that I've been telling you about, which we think in the general population is about two to one. So I went through these data, and I calculated that we think general population, it's two to one, but the male to female ratio of this past year's substance use disorders, 2015 to 2019, in Hispanic or Latino population in the United States is two to one, black or African Americans, 1.94 to one, Asian Americans, 1.76 to one, white Americans, 1.7 to one, American Indian or Alaska Native, 1.46 to one, two or more races, 1.39 to one, and Native Hawaiian or other Pacific Islanders, 1.38 to one. So it varies a lot by race and ethnicity. It's really important, and that's why this is really an important document, and you should download it. It's the kind of information we've wanted for a long time but haven't been able to get. And so reporting data by race, gender, and ethnicity is very important. There's variation, as I just showed you, in substance use and substance use disorders by intersectionality of gender, race, and ethnicity. The data needs to be reported with these demographic characteristics. Why? Because that can assist us in identifying specific barriers for populations and solutions for overcoming those barriers, both in terms of access, in terms of stigma, and it can guide consideration of specific clinical and public health interventions that are culturally and gender-appropriate tailored interventions. So to just summarize where we are in the talk right now, among the most reproducible research findings that we have is this increased prevalence in women in the past three to four decades of alcohol and drug use, the heightened vulnerability of women to adverse medical and social consequences, the telescoping course, which I described to you, and then a treatment entry with fewer years of use. Women in general, on average, have more medical, psychiatric, and adverse social consequences than males. There are specific barriers to treatment entry for women. They're less likely to be screened in primary mental health care. There's a lack of treatment services for pregnant and parenting women. Women have many economic barriers, which include lack of insurance and other resources. Trauma histories, which are more frequent in women, actually pose a barrier to getting into care for substance use disorders because often the programs are very male-based. And social stigma and discrimination, which unfortunately all of our patients seem to feel, is really highly and significantly felt by women in our society who have a substance use disorder. And women are also at higher risk and have higher prevalences of co-occurring psychiatric disorders, which include mood, eating anxiety, and PTSD, and we know that those need to be co-treated with their substance use disorders, and yet often they're not, and that poses also a barrier to care. So in terms of risks for women, for women and men, genetic factors, as you all know, biological factors, family history are important. Also the earlier age of onset and initiation of use poses a risk for later onset of substance use disorders, true for males and for females. But particularly significant for women, heavy drinking and drug use by a significant other or partner, a history of sexual or physical abuse or family violence, and again these co-occurring psychiatric disorders. Violence and trauma, as I mentioned, are highly prevalent among individuals with substance use disorders. Women are more likely to experience childhood and sexual physical abuse, and there's a strong relationship between abuse history and the onset of substance use disorders in women. So given these trends that I've just been talking to you about, are there gender differences and barriers to substance use disorder, gender differences in substance use disorder treatment outcomes, and what about gender-specific treatments? So we know in fact that gender itself is not a specific predictor of substance use disorder treatment outcomes, but the known predictors of treatment can vary in prevalence, severity, or significance by gender, such as co-occurring disorders, trauma histories, employment, educational attainment, social support, these predictors may have different levels of significance for men's and women's treatment outcomes and recovery, and it's especially true for co-occurring disorders and histories of trauma as predictors of outcomes. And yet, and yet, this is from 2019 data. Accessing gender-specific treatment is very difficult for women in the United States. In our substance use treatment facilities in one study, only 49% treated adult women, 52% treated co-occurring disorders, 42% treated trauma, 23% sexual abuse, 28% intimate partner violence, 24% for parenting and pregnant women. So quite a long time ago now, 20 years ago, we recognized that most women were going to receive treatment in mixed gender substance use treatment programs, and we recognized the need for treatment that would be gender responsive for women with substance use disorders, and so we set about a program of research to develop an evidence-based group treatment designed for women with substance use disorders who are heterogeneous to these factors and clinical characteristics that we just talked about, co-occurring psychiatric disorders, trauma histories, partner and parenting status, and life stage. And that was the impetus for the Women's Recovery Group study. The WRG was developed and tested, and NIDA funded stage one and stage two trials using mixed methods, meaning we did quantitative and qualitative analyses. It's a 90-minute, 12-session relapse prevention skills-based group. It's designed for women, heterogeneous with respect to their substance use, alcohol or drugs, co-occurring psychiatric disorders, trauma histories, all the things I just discussed with you. Women-focused content in an all-women's group composition, structured sessions with a check-in, a topic presentation, an open discussion, take-home messages, a skilled practice, and a check-out. There are 14 topics that can be flexibly chosen for 12 sessions, and we've published qualitative and quantitative data and analyses for the stage one trial, for the stage two trial, and in 2016, we published the dissemination manual for the Women's Recovery Group, and there have been three recent pilot adaptations of the Women's Recovery Group. One, an implementation study for women with substance use and eating disorders, and then Dr. Justine Welsh actually led a pilot study adapting this to transitional-aged young women, the WRGYA and Emory, and more recently, Rebecca Barton and Tracy Simpson in the Puget Sound VA did a pilot study adapting this to women military vets and that population. And now we are also working on digital adaptations of the psychoeducational content, which I'll talk to you about in a moment. What is it? What is the Women's Recovery Group? In a nutshell, it's a professionally-led, evidence-based, manualized treatment. It can accommodate women typical in addiction treatment programs, heterogeneous clinically and demographically. The content is gender-responsive based on the evidence on gender differences, exactly what I was just talking to you about. It has an all-women's group composition to enhance affiliation amongst the group. I'm going to show you how we measured that. It minimizes differences and maximizes similarities amongst members to increase that type of group cohesiveness and affiliation. It's a skills-based relapse prevention group. It's structured, and I'll show you that in a moment. It has skill practices in between the two sessions. It balances content and open discussion. There are four levels of participation we encourage. There's a group theme, which is recovery means self-care or taking care of yourself. A central recovery rule, which is recovery equals relapse prevention plus repair work and 14 session topics. What was the hypothesis? The hypothesis at the time when we started this research was that the all-women's group composition would increase group cohesiveness and what we called affiliation and increase open discussion of triggers and relapse and comfort and support. It would give us the opportunity to have women-focused group content about the education, about the antecedents, and the consequences of substance use that differentially affect women. Really, pretty much what I just summarized for you already, the differences, the gender differences, and that these would synergize and enhance outcomes for women. So it's a 90-minute structured relapse prevention group. It starts with a brief check-in, a review of a skill practice on the previous week's topic. There's a presentation of a session topic and open discussion by participants. They review the take-home messages and the upcoming week's skill practice and there's a structured check-out. So what are the 14 session topics? Well, these in blue font are what we call gender-specific topics. Effects of drugs and alcohol on women's health, what I've talked to you about today. Managing mood, anxiety, and eating problems without using substances. Violence and abuse getting help. Women and their partners. Women as caretakers. Women's use of substances through the life cycle. Reproductive health. The issue of disclosure, to tell or not to tell, which takes on the area of stigma and discrimination. And then in the black font, these are what I call the bread and butter relapse prevention types of topics and they're infused with gender-responsive content. So I wanted to summarize really quickly the main outcomes for the Stage 1 and Stage 2 trial. The Stage 1 main outcome paper was published in 2007. And what we were able to show in a small Stage 1 pilot study using a semi-open format, meaning that the groups kind of started and ended and didn't roll forward as we do in clinical practice, so a small trial, that the Women's Recovery Group produced reductions in substance use during the treatment phase that were equivalent to the effective mixed gender control condition called group drug counseling, which I will now refer to as GDC. However, there were sustained improvements in substance use in the six months post-treatment follow-up phase that were greater in the Women's Recovery Group than with the mixed gender group treatment. And because of that signal of efficacy, we were able to move forward to a Stage 2 trial. The main outcome for the Stage 2 trial was published in 2014, and I'm going to summarize that for you right now. We had 156 participants, 100 women, two sites in Massachusetts. Women were randomized to the Women's Recovery Group or to the mixed gender GDC. There was a continuous open enrollment, and why is that important? Well, we sort of felt like we would get one shot at this, and we wanted to make it, if it worked, you could just take it off the shelf and just do it in regular community practice. So we put it into regular community practice. It rolled. The group rolled for 24 months. It never stopped, just like being in any clinic anywhere. And people were just coming in and out just like people do into the group over 24 months in two outpatient programs. And what we wanted to know was if we put it into community practice, would the outcomes of the WRG be at least as equivalent to a mixed gender treatment that is effective, and that was GDC. We tried to make it as externally valid as possible, so it really resembled clinic populations. There were high levels of co-occurring disorders, major depression, GAD, PTSD. 75% had another Axis I disorder. 17% had an Axis II disorder. People had alcohol, opioid, cocaine, cannabis use, and other substance use disorders. And what we found here is that, in fact, in the first three months, actually people did have clinically significant decreases in days of use, and this is the three months. And then they actually maintained their gains in both the Women's Recovery Group and in the GDC. There were no statistically significant differences at the end of the six-month treatment phase. And we concluded that this is an effective group therapy for women heterogeneous with respect to their substance use disorders, that it actually can be delivered in treatment in a rolling group format as a gender responsive component of mixed gender treatment. So the Stage I trial, the Women's Recovery Group demonstrated a pattern of continued reductions in substance use, while the women in the mixed gender group did not. The Stage II trial demonstrated comparable effectiveness to standard mixed gender treatment and could be put into community practice as an effective gender responsive component of care. So now we asked, at the very beginning, we had this hypothesis that there would be greater affiliation, greater group cohesion, and that that would be a potential mechanism of action. So how would we operationalize cohesion? Well, the way we did it was to look at verbal affiliation. I want to show you the two studies that we did to look at that. We basically recorded everything and coded all of the group therapy tapes, and we asked, would there be greater affiliation among group members as measured by verbal affiliative statements of empathy and support? We double coded group therapy tapes for eight categories of statements of empathy and support between the two groups, the Women's Recovery Group, the mixed gender group, and we found that the number of affiliative statements made in the Women's Recovery Group was 66% higher than in the mixed gender group. But we didn't know, would that be any type of predictor of outcome as we had hypothesized? So we did another study, and we measured the relationship between the frequency of affiliative statements and the trajectory of days of any substance use through time during three months treatment and six months post. And at the end of the treatment phase of three months, women who had experienced the highest level of verbal affiliation, 65 or more affiliative statements on average, were found to reduce their substance use by about 1.75 days more than women who experienced the lowest level of affiliation. And the effects of the affiliation persisted six months post-treatment and were moderated by group therapy. Women who were enrolled in the single gender Women's Recovery Group benefited the most from exposure to the highest level of affiliation in the six months post-treatment in terms of maintaining their gains. We also wanted to understand people's experiences in the group therapies, in Women's Recovery Group and also the mixed gender one. And so we did qualitative analyses of these experiences. Basically, we examined women's experiences in both the Women's Recovery Group and the mixed gender group drug counseling. There were semi-structured interviews in the stage one trial. They were all transcribed and coded and analyzed for themes. And we found that the women in the Women's Recovery Group focused on gender-relevant topics supporting their recovery, and compared to GDC, the women in the Women's Recovery Group said they more frequently endorsed feeling safe, embracing all aspects of themselves, having their needs met, feeling intimacy, empathy, and honesty. We had a larger stage two trial, and we actually repeated this and exit-interviewed again everybody and did the same type of qualitative analysis. We did thematic analyses of qualitative interviews from the stage two trial, 77 women and 38 men. The women in the GDC rated group gender composition as significantly less helpful than the women in the WRG. The qualitative interviews, we compared women in the Women's Recovery Group again endorsed more feelings of safety, support, being themselves, opening up about important issues such as trauma, abuse, and important relationships. Here's something interesting. Both men and women endorsed feelings of guilt and shame, but only the women discussed societal stigma and judgment as being harsher toward women, especially in their roles as women and mothers. So I'm going to show you in their own words what people said in the stage one trial. A lot of the information was presented to me I was very unaware of, in particular women's health, what alcohol does to a woman's body. The education end of it was huge for me, really huge to the point I was sharing it with family and friends. Another said, I think the fact that it's all female and the fact that it's run by a female are essential because nobody ever talks about the issues being related to being female, being a caretaker, being a single mother, being a career person in a man's world. In the stage two trial, a person said, I didn't think it would matter or make a difference to me, but it really did. I just feel a little more open with women. Another one said, surprisingly, I like the fact that it was all women talking with different struggles that are gender specific. I think would not have happened in a mixed gender group. It would have been more about the alcohol itself and less about the reasons why. Another said, I think it's easier to be frank and more open than I would be in a mixed group. The past, physical abuse, I wouldn't talk about those things in a mixed group. And another said, I think there is a difference in the male-female experience with addiction. There are different reasons, different circumstances, and psychologically different needs that men and women have. I think women support each other and we listen. It's a safer place to be to just have all women. And finally, in terms of stigma, I think it's a societal perception that women who drink are just bad sloppy people and men who drink are out to have a good time. I think it's easier for women to get sucked down by their illness because it's more of a negative for women in society, the way we're looked at. So I just presented some of the data from the Stage 1 and Stage 2 trials. And I mentioned very briefly that there are these new pilot adaptations for women veterans and also for young adult women. But I want to show you some new research we're doing for digital adaptations of the content for adult women with substance use disorders. This research is led by Dr. Dawn Sugarman. She's a research psychologist that I work with at McLean Hospital. And she's been very focused on how we can actually advance more women having access to gender-specific treatments through digital adaptations. And what she's done is utilized, you've seen this figure before, the women focus group content about the education about antecedents and consequences of substance use disorders and has begun to adapt it digitally into a web-based format that can be delivered on a mobile device like an iPad or a phone. So the first study, we adapted five topics of the women's recovery group to a web-based format. First, we started with three of these modules, same as what I showed you in the topics. And in the pre-pilot phase, these were given to 30 women in an inpatient mixed-gender setting. And they responded, and then we modified it a bit and then added two more modules based on some of the things that they told us. And you can see what those are there. And then we did a pilot phase with 60 women in mixed-gender inpatient, outpatient, and partial hospitalization. And the results were published in the Journal of Women's Health in 2020. These women also had many co-occurring psychiatric disorders. This is just a figure showing you the past year mental health problems that they endorsed. And I just wanted you to see, this is early phase, so it's not exactly how it looks now, but you have an iPad, it's on your iPad, and it says things like this. For this topic, you're going to learn about X, Y, and Z. And you kind of go through it on an iPad. Have you or someone you know ever struggled with mood anxiety or eating problems? And it kind of runs through all of this. And it visually looks a lot better now. This is early phase, but I just wanted you to see a little bit of what it looked like. And here are some of the results from the pre-pilot and the pilot phase. I think you can see, so this took 41 minutes to do all five of those modules, delivered on an iPad. It takes no staff time. And you can sort of see, very high, easy to use, visually appealing, gender-specific information was helpful, 100% endorsed that. And the pilot study, the satisfaction scores did not differ by levels of care, inpatient, partial hospital, outpatient. The elements that the women rated as most relevant to recovery, the effects of substance use on self-care, the link between substance use problems and other mental health problems, especially depression and anxiety. And here's the qualitative participant feedback. I think you'll see it mirrors what you just saw from the group therapy itself. Just learning all this information is crucial for all women. I was unaware of it. I feel like the survey was right on and explained my problem as a woman with addiction to the T. It's really helpful to see the information in this way. In groups, it's great to be able to discuss these things with other people, but it's easy to miss something. Having a notepad like this is really helpful to remember everything and also see it visually. The second study that Dawn has led is to adapt this to transitional-age women with co-occurring disorders. Actually, they're coming to the hospital with a primary other psychiatric disorder. They're hospitalized, either in a residential program or in an inpatient service. And a lot of them actually don't endorse that they have any issue with substances. They're identified by their clinicians. In the pilot phase, Dawn interviewed 15 women ages 18 to 25 who were admitted to inpatient residential treatments for primary diagnosis of, and you can see the list there. And then these women said that they thought that the modules should increase interactivity with more coping skills practice to add information on navigating peer relationships and information on menstrual cycle and its relationship to substance use and craving. So the program was modified and then it was 44 women engaged with this digital program. Overall, more than 80% said that they were satisfied with the program. But the most interesting finding we had was a lot of these women did not consider themselves as having any problem with any substances. It took, again, about 40 minutes. It was delivered on an iPad. It didn't take any staff time or residential psychiatric units. But from pre- to post-intervention, participants' ratings significantly increased in their interest in making changes to their substance use and their willingness to make changes in substance use. We were actually surprised by that finding. All right, so I'm going to wrap up. So, treating women with substance use disorders. So the guiding principles, these are things I think you all know, but always ask, as you know, about alcohol, drug, and tobacco use, and yesterday we heard in the symposium, we need to really include use of cannabis as well because that is highly prevalent. Complete or refer for a full medical evaluation, including a reproductive health assessment, and assess for the full range of co-occurring psychiatric disorders and consider how that treatment's going to be integrated in treatment for substance use disorders. Evaluate the potential motivators and rewards for treatment, but also really the potential obstacles for recovery that include for women, partner, alcohol, and drug use, co-occurring psychiatric disorders, the shame and stigma that we just talked about, family, legal, and employment obstacles, and then a safety risk, including intimate partner violence and domestic violence, as well as a past history of trauma, which is highly prevalent, and risk behaviors for HIV and other sexually transmitted infections. And then as you can, use women-focused and gender-responsive approaches, which means integrating the conceptual and the empirical evidence that I just presented to you about gender differences and antecedents and consequences of addiction and the treatment process. It includes treatment for co-occurring other psychiatric disorders, trauma exposure, and all of the associated physical and mental health needs. It's also really critical to address the central role that relationships with children, intimate partners, and others play in women's addiction and recovery, and to provide, as you can, the appropriate and necessary adjunctive services. And so I'm going to conclude there is a narrowing gender gap in the prevalence of substance use disorders. Women born in the last five decades have lower rates of abstinence and higher rates of substance use. Women have a telescoping course of addiction, an accelerated course, and there are important considerations by gender and race and ethnicity. We know that treatment outcomes can be enhanced by programs that provide services and other programming specific to women's needs. It's still very hard to get that in our treatment services. I also just presented some data to you about the Women's Recovery Group. It's a manual-based, single-gender women's recovery group. It has women-focused content. We know it may enhance treatment outcomes and can be integrated feasibly and with satisfaction into community-based substance use disorder treatment programs. And digital adaptations that we are now exploring we think are promising to be able to extend gender-specific treatment to women with substance use disorders. With that, I have a lot of acknowledgments. I really need to thank a just tremendous number of people who have been co-investigators and consultants and group therapists and research study staff. Here's a picture of some of them. Some of you are here, and you actually recognize yourself in some of these photos. But this is a fantastic group of people who have helped with this research over several decades. And then I just really want to thank my family. Alan Brandt, Jacob Brandt, Daniel Brandt, without whom nothing could ever be possible, and I thank them very much. And then I thank all of you for being here and for listening today. So thanks so much. And with that, I think I'm supposed to tell you that there's just under four minutes to answer questions, and as we have been doing, people can come up to the mics. Thanks, Dr. Greenfield. That was one of the best presentations I've heard at AAAP. But the question is about prevention. Do we have any data on gender-specific treatment? Do we have any data on gender-specific prevention messages that might work? Because I know with social media now, we can target prevention messages a lot better. So that's fantastic. So now you asked a great question, and now somebody here, maybe you, is going to think about how you're going to research that, because I don't think we really have great answers to that. One thing I can tell you, there's a lot more information I could have presented. It's limited in time. But one thing you really do need to know, and I just didn't include it in this presentation for want of time, and you're not going to be surprised when I tell you this, there's been a lot of direct marketing to young girls and young women of alcohol-related beverages, and I could just show you the unbelievable numbers of targeted alcohol. There's wines for mommies, there's vodka for women, there's beers for women, they have cute names, they're pink, they've got all sorts of things. I have a lot of photos of those things. So there's been a lot of direct marketing by the beverage industry directly to women, and young women. And these things are not coincidental, the rise in use, especially in young populations, and it actually mirrors what did happen with tobacco, until we regulated how advertising for tobacco could go. It's the same thing. I mean, I just have to say, and we had an amazing presentation about cannabis yesterday. I'm just saying, we do this all the time, this unregulated advertising of all of these substances. It's a legal substance, right? Anyway, I think one thing of prevention would be to, on the ads that are directly marketed in these ways and target young people, and another is trying to figure out what types of gender-specific messaging on social media for young girls and young women would be most helpful. I can tell you most people are not aware of a lot of this information. Doctors don't discuss any of this with women and girls. They just don't. Okay, next. Hi, I'm from SUNY Downstate. Thank you for the great work you are doing. In the women's group treatment, what about outcomes of co-occurring psychiatric disorders? Was there any difference? Yes. Outcome, yeah. That's a great question. We have one paper that we wrote that shows a trans-diagnostic effect of the women's recovery group on depression and anxiety symptoms and all psychiatric. There's certain measures where you're looking at all psychiatric symptoms, depression, anxiety, they all actually decreased. We also have done other studies which really show that if you don't treat, for example, women, their co-occurring depression, they just don't really get better. The fact is before 1990, almost all of those studies, for example, alcohol use, were done in all male-based populations, especially in the VA. Basically, they said, well, that's fine because most of the depression just goes away. Women, the prevalence is two times that of men. When you don't treat that, actually, it's much harder for people to get better from whatever their co-occurring substance use disorder is. There are trans-diagnostic effects of almost all of these behavioral treatments. We do see that depression and anxiety symptoms go down. Thank you. Rich? First, I'd like to thank you and Kathleen Brady for being the modern pioneers in this area. I have two points and questions for you. The first is that my experience has long been that women in AA women's groups do better than women who go to mixed groups in AA. That confirms your stuff. I wonder whether you include an AA facilitation for long-term follow-up as part of the educational program. That's the first question. The second question is, in my long experience treating patients in groups, I've also found that men do better in groups that are with women. If we segregate the groups entirely, the women will do better and the men will do worse. Maybe that's only fair. Let me know what you think about all that. We could talk about this endlessly. Dawn Sugarman, my colleague, she actually designed a men's group therapy based on some of this and actually had piloted it. Some of the things are the same. Men actually report that they will only talk about certain things, especially anger and other kinds of family-related relationships in a male-based group. They won't bring those things up in a mixed-gender group. In addition, you're exactly right. Men generally say that they prefer the mixed-gender groups because the women actually facilitate emotive and emotion. Without that, they feel like it's harder. It's not true that they can't get there either. That's the first thing. I think there's a time and place for all of this, but what I would just say to you is it doesn't really work that well for women when the care is really not gender-responsive to their needs. It just doesn't really work. The idea of this is it's a component of care that you can put into mixed-gender programs because women are going to be treated mostly in mixed-gender treatment programs. It's a gender-responsive component of care. You can put it into community practice. SAMHSA has a lot to say about this, about how to do gender-responsive care for women in substance use treatment programs. I forgot your other question, but I'm also... One thing we do in the Women's Recovery Group is we have how to use self-help to help yourself. We present the ways in which women can use self-help and how to use it. The group doesn't insist that people do that because some people don't want to do it, but it does explain how you can use it and the way you can use it and how to find all women's self-help or mutual-help groups. We haven't done follow-up in this particular study about how many are actually using that. Do I have time for one more or no? I've got to shut it down. I'm available. I'm here all day. Please find me. I'm happy to talk to you. Thanks again. applause

gender differences

substance use disorders

gender-specific interventions

Women's Recovery Group

relapse prevention

group therapy

women-focused content

digital adaptations

gender-specific treatment