For women only: Hormones may prevent addiction relapse

Notably, a recent functional MRI study comparing 17 male and 10 female abstinent cocaine-dependent subjects indicated that the women more often used verbal coping strategies to decrease cocaine craving.²⁹ This finding supports the potential benefit of psychotherapy to prevent relapse in women with a history of substance dependence.

Hormone regulation. For many women, continuous oral contraceptives (OCPs) can improve affect variability across the menstrual cycle and diminish negative mood. Others, however, experience negative changes in mood or affect while taking OCPs. Risk factors for a negative response include:

• history of depression or other psychological distress symptoms
  
• dysmenorrhea
  
• PMS
  
• history of pregnancy-related mood symptoms
  
• family history of OCP-related mood complaints
  
• being in the postpartum
  
• age 30
  

Careful studies of relapse with continuous OCP hormone control are needed before we would recommend this treatment routinely. For individual women at risk for relapse, however, you might consider using continuous OCPs to stabilize hormone fluctuations in the late luteal phase.

Continuous OCPs can be given so that women have only two to three menstrual periods per year. Formulations with ethinyl estradiol and norethindrone—such as Necon 0.5/35 or 1.0/35—may stabilize mood more effectively than others.

Give a 2-month trial, then re-evaluate progress. Because of the increased risk of clotting, only nonsmokers and women without a history of blood clots should take OCPs.

Case report: Fighting the cravings

Eight months ago, when Ms. H was still using cocaine, her primary care physician prescribed fluoxetine, 20 mg/d, for depressive symptoms. Her mood has not improved, nor has her menstrual cycle-related depression or irritability. She asks if anything else might stop her premenstrual cravings.

Because of Ms. H’s reported PMS, we counsel her to be especially vigilant for alcohol cravings around the luteal and late luteal phases of her menstrual cycle (Table 4). We discuss with her:

• the need to watch for signs of relapse
  
• the importance of aggressive treatment, including psychotherapy, group therapy, and residential treatment, as needed.
  

We continue fluoxetine, which has decreased alcohol consumption in some studies.³¹ In collaboration with her primary care physician, we also prescribe an oral contraceptive for Ms. H to take continuously to stabilize her mood across the menstrual cycle.

She agrees to a 2-month trial, and we schedule a follow-up appointment to re-evaluate her progress.

Table 4

Interventions to prevent relapse in women with addiction disorders

Track craving and mood symptoms in relation to the patient’s menstrual cycle
Educate her about triggers for relapse
Provide psychotherapy to bolster her coping strategies for stressful life events
Screen for comorbid mood or psychiatric disorders and treat them aggressively
Treat premenstrual mood symptoms with a selective serotonin reuptake inhibitor and/or by regulating hormone levels with a continuous oral contraceptive

Related resources

• Carroll ME, Lynch WJ, Roth ME, et al. Sex and estrogen influence drug abuse. Trends Pharmacol Sci 2004;25(5):273-9.
  
• Roth ME, Cosgrove KP, Carroll ME. Sex differences in the vulnerability to drug abuse: a review of preclinical studies. Neurosci Biobehav Rev 2004;28(6):533-46.
  
• Everitt BJ, Robbins TW. Neural systems of reinforcement for drug addiction: from actions to habits to compulsion. Nat Neurosci 2005;8(11):1481-9.
  

Drug brand names

• Fluoxetine • Prozac
  
• Ethinyl estradiol and norethindrone oral contraceptive • Necon, others
  

Disclosures

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.