TREATMENT OPTIONS FOR PREGNANT SUBSTANCE ABUSING WOMEN
AN INTERVENTION TO TREAT PREGNANT
This paper will describe models of treatment that are available to pregnant, substance abusing women in the United States. It places these models in the context of our at times contradictory societal attitudes toward pregnant addicts. The impact of legal, medical, and community based institutions on women's treatment options is discussed, and a proposal made to extend a successful alternative to conventional treatment to all women in need: comprehensive, gender specific, residential programs.
There are over 4 million live births annually in the United States (NCHS 17). It is estimated that approximately 375,000 infants who were exposed to illegal drugs in the womb are born each year (Roberts 58). Less conservative estimates place the number of infants exposed in utero to narcotics (heroin and methadone) at 9000 per year, or 2 to 3 per 1000 live births, with an additional 375,000 babies born annually who were exposed to cocaine and crack cocaine (Brown 555). A great deal of geographic variation has been noted, but roughly 11% of women giving birth in hospitals had used some type of illegal drug during pregnancy, according to one survey (Robins 11). Because this investigation was based on urine screening or self-report and the population was not necessarily representative, the data is not reliable.
The National Association of Perinatal Addiction Research and Education (NAPARE) estimates that on average, II-% of pregnant women are using illicit substances (Peak 246). A survey by the National Institute on Drug Abuse (NIDA) found that 11% of all women ages 18 to 24 and 8.6% of all women ages 26 to 34 had used illegal drugs in the past 30 days (Smith 347). If illicit substance use is 9% to 11% in the general childbearing population, common sense dictates,1411U that the incidence could not be higher in the pregnant population. It appears possible that the estimates of drug use in pregnant women are inflated. Much more information needs to be obtained about drug use in pregnant women, but gathering the information is complicated by legal factors, which will be discussed. The number of babies who suffer ill-effects from this exposure is also unknown (Nolan 14).
The primary adverse birth outcomes associated with maternal drug addiction for the infant are low birthweight, small head circumference and prematurity (Feldman 726), and increased incidence of placenta previa in the mother (Lindo 85). However, whereas alcohol is now understood to be at the root of Fetal Alcohol Syndrome (FAS) , no such clear, causal relationship exists between nonlegally sanctioned drugs and birth defects (Lindo 85). Approximately 200,000 low birthweight babies are born annually in the U.S., 23% to teens (NCHS 28), and 30,000 infants are born with congenital anomalies (Nolan 15). In the overall U.S. population, there has been a general downward trend in illicit drug use throughout the 1980's and into the 90's, with the notable exception of crack cocaine, which was not introduced until 1985 (Robins 11).
A large number of infants are prenatally exposed to alcohol and do not develop adverse effects. Again, the data varies widely: one survey found 50% to 75% of women interviewed reported drinking "at least occasionally" while pregnant (Nolan 15) ; the Public Health Service estimates that 86% of pregnant women drink at least once and 20% to 35% drink regularly during pregnancy (Mariner 33). If these percentages are accurate, they translate to 1.5 million fetuses exposed to alcohol each year. A survey from the late 1980's found that 25% of pregnant and 55% of non-pregnant women aged 18 to 45 reported using alcohol in the last month. This research demonstrated that there has been a general downward trend in the number of pregnant women who drink alcohol, but among those who do drink during pregnancy, there has been no decrease in amount. No decrease in alcohol use in pregnancy was noted in the groups of less educated women or those less than 25 years of age (Serdula 876).
Between 6000 to 8000 babies born annually, or roughly 1 to 2 per 1000 live births will be diagnosed with FAS (Clarren 1063), a condition resulting from heavy drinking during pregnancy which can cause severe developmental delays, hyperactivity and a characteristic facies (Nolan 15). Fetal Alcohol Effects (FAE) is a more mild form of the disorder and more difficult to diagnose; generally, the effects become more apparent as children grow and demonstrate behavioral, cognitive and emotional problems.
It is necessary to mention nicotine use, because it is a prominent factor in the lives of many addicted, pregnant women, and has serious adverse consequences for their infants. Approximately 750,000 infants born annually were exposed to nicotine in-utero (Nolan 14). Nicotine is known to cause prematurity (Feldman 728), low birthweight and smaller head circumference, and is associated, disturbingly, with a two-fold increase in risk for Sudden Infant Death Syndrome (SIDS) (Nolan 14). Early research linking cocaine with increased incidence of SIDS has been subsequently disproved (Brown 562). 70% of substance abusers smoke cigarettes (Feldman 728), and illegal drug use in pregnancy is highly correlated with nicotine and alcohol use (Robins 12).
The division between pregnant women who regularly use alcohol and those who regularly use illegal drugs (and/or nicotine) is more artifactual than real. Many addicts are poly-drug users and among this group, alcohol is generally one of the drugs. In one study of cocaine and heroin addicted women, 46% reported concurrent drug and alcohol use, and 83% reported significant alcohol intake in the last month (Smith 347). Therefore, birth outcomes are usually confounded by numerous substances and other factors.
Substance abuse in pregnancy appears to be fairly common, and the scope of the problem is vast, affecting the lives of thousands of women and babies every year. The financial costs are great; hospitalization for a drug-affected newborn costs ten times the amount of a normal-newborn hospitalization, and for a baby that requires intensive care, the cost can be one hundred times that of the care of a healthy, drug-free infant. It is estimated that total medical expenses incurred by the care of drug-addicted mothers and their newborns is 500 million dollars each year (Peak 246).
There is a complex of factors which act together in a woman's life to produce a healthy baby: her pre-pregnant medical and psychiatric condition and weight, degree of familial and community support, presence of a significant other, her socioeconomic status and the availability of adequate and appropriate prenatal care (Raskin 158). These life-style factors are so significant, in fact, that supporting a woman in one of these aspects of her life can help her have a healthy baby, even in the situation of continued substance use. For example, providing appropriate prenatal care is associated with a three-fold decrease in the risk of prematurity among drug-addicted women (Feldman 728). The need for substance abuse treatment in this population is equal to the need for other types of services, for providing other services shows a dramatic effect on birth outcomes, even in the absence of chemical dependency therapy.
One study that analyzed the data controlling for variables like maternal socioeconomic status (SES), educational level and race, found that SES has a greater bearing on low birthweight, length, head circumference and cognitive outcome, than illicit drug use (Brown 561). When compared with control babies born unexposed to drugs but matched for SES, the mean birthweight, length and head circumferences of heroin and methadone exposed newborns were not significantly lower (Brown 557). It should be noted that the means of both groups were below the fiftieth percentile on the growth charts.
A great deal of research indicates that low SES, inadequate or inappropriate prenatal care, cigarette use and delivering children spaced closely together are significant determinants in low birthweight, independent of drug use (Mariner 33) (Peak 256). The conclusion which logically arises from this knowledge is that, in order to improve birth outcomes in the U.S., it is necessary to elevate the socioeconomic status of pregnant women and provide prenatal care in addition to decreasing or eliminating maternal drug use. Yet, the few in-patient addiction treatment beds available to pregnant, substance abusing women are in programs based upon a strict medical model, which treat the use of the substance as the problem, and fail to address the attending social and emotional issues that women bring to treatment with them (Peele 371). Treating the problem of pregnant, substance abusing women calls for a comprehensive approach.
REVIEW OF LITERATURE
There are 2 currently popular responses to this public health problem: one is to make treatment more accessible and appropriate for pregnant women; another is to criminalize and incarcerate substance-abusing women who are pregnant. Conventional chemical dependency treatment is based on the 12-step program of the Alcoholics Anonymous (AA) movement. The AA program was created by a physician for his near-terminal, male alcoholic patient, Bill W. The central idea of this belief system is that addiction is a disease (for which no scientific evidence exists) against which the addict has no internal defenses (Peele 26). The only possibility for sobriety exists in denying one's ability to control one's life, asking a "higher power" to provide the control, and by going to AA or other 12-step meetings frequently. Using a health-belief model (i.e. inform people that drugs are bad for them and their fetuses and they will stop), these programs attempt to change behavior without addressing the underlying causes of that behavior (Wallen 246).
A couple of new approaches have been attempted recently in treating addicted, pregnant women. One has been to incorporate services which pregnant women need into in-patient and out-patient treatment programs, specifically prenatal care, child care, and relapse prevention (Chang 327), as well as appropriate therapeutic groups with women in similar circumstances, parenting skills classes, and education and employment training (Haskett 457). Having a therapeutic group for women in treatment who are incest survivors is an intervention that is at least 20 years old in one program (Winick 311).
An intervention study from 1992 examined the effects of "enhanced" versus conventional treatment upon the drug use and birth outcomes of opiate-addicted, pregnant women (Chang 327). The women were drawn from an out-patient methadone program that provided daily methadone, counseling and random urine drug screenings (which were not reported to state authorities) . The control group received this conventional treatment, while the intervention group received, in addition to the standard services, prenatal care, "therapeutic child care" (child care plus parenting education), relapse prevention counseling, and drug screenings three times a week with cash rewards for clean urines.
The recognition of "gender specific difficulties" (Chang 328) is the model for this approach: that is the awareness that women in treatment are generally poorer, more depressed, and have more child care needs than men, and pregnant women in particular have unique medical and emotional needs. A theory integrated into this study, which is supported by research, is that drug addiction for women is a more social experience than for men, and often occurs in the context of relationships with male partners (Chang 328). For women, social experience is paramount: the self is experienced through its relation with others (Miller 14). To demand that pregnant women sever their primary social ties without helping them construct healthy support systems is unreasonable.
The unique social needs of drug addicted women are addressed in the enhanced treatment model, both by providing educative child care, and by teaching life and social skills in the relapse prevention groups that will enable the women to improve their social environment, which is essential to their recovery. This study found that the enhanced treatment participants had longer gestations, heavier babies, more prenatal care, and fewer positive illicit drug screens than the women receiving only conventional treatment (Chang 329).
There is research that demonstrates that incest survivor groups enhance treatment effectiveness for substance abusing women. one paper reported on the results of an incest survivor group that has been in existence in a treatment program in New York for 20 years (Winick 311). The theory behind this non-standard treatment modality is that significant numbers of female addicts (which includes alcoholics) have been victims of childhood incest (Winick 312). Women who attended the survivor group had improved retention and graduation rates from the program relative to women receiving standard treatment (Winick 317). A strength of this study is the extensive description of the design and dynamics of the survivors group, which was instrumental in many women's healing. The value of bonding and social connectedness for women's recovery should not be underestimated.
Although both articles reviewed above involved interventions, they should be considered descriptive rather than analytical, as raising hypotheses rather than testing them, as neither study attempted to control for confounding or chance in any way. Unfortunately, there is scanty research on women and addiction, and serious ethical issues do arise when randomizing people to different treatment modalities.
A second innovation to increase the access and appropriateness of drug treatment has been the establishment of therapeutic communities for pregnant women, which are non-medical, community based, residential treatment facilities (Peele 316). These programs tend to be quite comprehensive, stressing women's concerns, often providing child care, and are in some places staffed by recovering women, as is New Day, Inc. in Somerville, Mass. There are very few of these programs in existence nationally, and they are considered expensive and labor intensive (Mariner 36). For example, in 1990, Massachusetts had only 30 such beds in the state, 15 of which were in a prison (Mariner 36). These comprehensive programs have demonstrated some success for pregnant women relative to conventional treatment (Chang 327) (Mariner 36). These TCs incorporate into treatment an appreciation of the unique problems pregnant, substance abusing women face, as mothers, as incest survivors, and sometimes as partners and daughters of substance abusers (Brigandi).
A small number of pregnant, substance abusing women are confined to involuntary "treatment" each year as a result of civil commitment (Beane 359), but a separate paper would be required to address that topic. The increasing prosecution of pregnant women for their behavior while pregnant has significantly affected treatment options for women, and must be discussed.
Currently some states are doing drug screening of newborns and pregnant women, and sometimes providers decide that this test needs to be done; if a pregnant woman or her newborn tests positive for an illegal drug, she may be reported to a state agency, the Department of Social Services (DSS), and/or the courts (requirements vary state to state). In some states, a mother's children and the new baby can be removed from her custody immediately upon evidence of an illegal drug in her or the newborn's system, without proof of harm to any child or proof of her addiction (Logli 27), and even without the possibility of her getting treatment, which is most often the case (Chavkin 1558). As of early 1992, there had been 100 arrests of pregnant women for "fetal abuse" and 2 convictions, for newly coined crimes like "distribution of drugs through the umbilical cord" (Shoop 11).
Providing punishment rather than care, actually giving punishment in the, absence of care, seems antithetical to the alleged goal of nurturing a fetus, and is the opposite of how other industrialized nations tend to their future generations. For example, in England, if a mother's care of the fetus is found to be "neglectful" after the baby is born, she may lose custody of the child, but will not herself be arrested (Peak 253). This practice leaves the autonomy of pregnant women intact and decreases the chance that a substance-abusing mother will avoid prenatal care or drug treatment for fear of prosecution.
The theoretical framework upon which the American legal practice is based is that the rights of the fetus supercede that of its mother (Mariner 38). Prosecution for behavior never before treated as criminal raises the question if a fetus now has the legal status of a person. Finally, when pregnant, substance-abusing women avoid prenatal care and drug treatment because of the real fear of prosecution and loss of child custody, then the law could be construed as a barrier, rather than an entry, to needed treatment.
Incarceration and mandatory treatment are punishment, and are not considered to be secondary therapy for pregnant addicts by this author. Most importantly, arrest is not an effective way to protect a fetus. Mandatory treatment has demonstrated no benefits over voluntary treatment, and in a study of female addicts, compulsory clients expressed a greater desire to leave than self-referred participants (Chavkin 1557). Criminalizing drug use in pregnancy can in fact worsen birth outcomes, as substance abusing women will avoid prenatal care or drug treatment for fear of prosecution and loss of child custody (Paltrow 45). In addition, post delivery incarceration destroys maternal-infant bonding, thus adding another obstacle to family integrity and the mother's growth (Nolan 19).
The increasing criminalization of pregnant women has occurred in an environment that continues to deny them access to therapeutic interventions. In fact, one of the women convicted in 1991 had tried unsuccessfully to get into treatment while pregnant; the entire prosecution was based on evidence of her attempts to get help (Roberts 61). The obviously punitive intent of the legal establishment becomes plain in the racist and classist application of this practice. Criminalizing the activities of pregnant women who are addicted disproportionately afflicts women who are poor and of color. Research in different states has found that while rates of drug use among black and white pregnant women are almost identical, black women are ten times more likely to be reported to state authorities than whites (Paltrow 45), and poor women also are more likely to be reported (Harrison 265). The courts do not deal at all with the causes of women's addictions.
There is evidence that conventional treatment has a slightly beneficial effect on birth outcomes among this population (Harrison 263). Improved nutrition and prenatal care (in those programs that provide it) could be as significant or more a factor in these improvements as absence of drug use. Evaluating the effectiveness of conventional treatment is complicated by the significant problems that exist for women: appropriateness and access.
When other sociodemographic factors are controlled for, women in substance abuse treatment differ from men significantly in 2 ways: they are more emotionally distressed and they more frequently report a history of sexual abuse (Wallen 243). As has been noted, conventional treatment does not encourage dealing with prior life issues; yet, in investigating characteristics of pregnant, substance abusing women, the question arises if some women's drug use and level of despair are not indicative of an inability to grow beyond traumatic experiences of the past.
There is a high degree of correlation between a woman's history of sexual abuse and her current alcohol/drug use. In a publicly funded treatment setting, 44% of female heroin addicts were incest survivors (Winick 312); in a privately insured group, 33% of the women reported having been sexually abused as children (Wallen 245). other literature estimates that 65% to 75% of female drug addicts were victims of childhood incest (Wingerson 239). These women often grow up to a lifetime of abuse and sexual assault, compounded by the self-medication of drugs to relieve the depression: 80% to 90% of female alcoholics/addicts have been victims of incest and/or rape (Paltrow 45).
This group of women were likely to have had an alcoholic or substance using parent or two (Wallen 244), and the incest perpetrator himself was often a substance user who was under the influence at the time of the offense (Winick 312). This population is also at high risk of being with a chemically dependent partner. Research has shown that women who drink daily have twice the risk, and those with a drug using partner have three times the risk of being beaten while pregnant (Amaro 577). For women, victimization and addiction seem to go hand in hand: their depression and their histories are distinct from male addicts.
Substance abuse professionals and health care providers have been concerned that the disproportionate number of men in treatment programs (75% of clients are male) (Wallen 243), reflects the inaccessibility of treatment to women, as well as the greater number of male addicts in society. women overall are less likely to have private health insurance (Horton 96), limiting their options for treatment, and many programs place additional criteria for admission on women with Medicaid, further restricting their admissibility to treatment (Shoop 12).
The biggest obstacle preventing women from getting help is the way the system has dealt with issues of pregnancy and child-care. The majority of treatment programs simply do not treat pregnant women, nor do they allow women with children to keep their kids and come into the program (Chavkin 1557). Many women are also mothers, and the lack of appropriate facilities and properly designed programs illustrates a denial of and lack of commitment to the problems which women uniquely face.
In addition to these obvious systemic inadequacies, conventional treatment may make women unwelcome in other ways. Most programs do not include prenatal care (Chavkin 1557), nor do they create groups for women to explore the unique social needs that they have. For example, women's addiction usually occurs within a social context, most often with a partner; conventional treatment tries to break a woman's habit and ignore the social connections, which she must also give up (Chang 328). Women's degree of connectedness to their social contacts is consistently underestimated or ignored in conventional treatment, with the cost of being non-therapeutic to women or, worse, alienating them entirely.
Yet treatment programs reflect little awareness of these differences. Counseling sessions mix male and female clients. Incest survivors have difficulty sharing their experiences in groups of sympathetic survivors; sharing with non-empathetic strangers is rare and may be non-therapeutic (Wallen 247). The AA philosophy preaches "helplessness" in the face of the addiction. There is an element of ego degradation that occurs as part of traditional treatment, which is inappropriate and perhaps harmful to this population. AA reflects the belief that life is a power struggle, which is quite different from women's experience of life as a cooperative venture. Particularly among a population, which has a high prevalence of histories of sexual exploitation and physical assault, instructing "powerlessness" and "surrender" to a "higher power" is extremely questionable. Quite to the contrary, this group of women should be taught to take charge of their lives, to resist subjugation of all kinds, and to develop and rely upon inner strengths.
Finally, the health-belief model may not useful with this population, as women are taught from early childhood to seek approval by pleasing others, even at the expense of their own self or well-being. Social-learning theory would be more useful, because women may need to be educated to place a value on their existence, and to learn to see themselves as important, despite the norms, which devalue them.
Conventional, AA based treatment is not very relevant or accessible to pregnant women. At least by accessing conventional treatment, pregnant women may get better food and medical care and thus have healthier babies, but only 11% of addicted pregnant women ever get into treatment (Peak 258). Programs that address pregnant women's needs by providing prenatal and childcare, and gender specific groups, demonstrate improved outcomes over conventional treatment (Chang 327). There appears to be consensus in the literature about which services in addiction treatment benefit pregnant women, and the residential model provides the most appropriate services in the most sensitive environment. The agency reviewed by this author in a previous paper, New Day, Inc., is an excellent example of an "alternative"? residential treatment program for pregnant, substance abusing women.
MCH SERVICE DELIVERY/ HEALTH SYSTEM CONTEXT
Although illicit drug use in the general population and alcohol consumption by pregnant women generally have been declining since the late 1970's (Gerstein 36) (Serdula 876), those populations with the most chronic, intractable substance abuse problems were not included in these surveys. It is not clear that declining rates of substance use apply to addicts (Gerstein 24). The use of cocaine peaked in the mid 80's and has been declining ever since, but remains high (Gerstein 23). It appears that large numbers of women continue to use crack-cocaine, resulting in high proportions of births of so called "crack babies", but it is not known if these percentages are increasing or decreasing (Gerstein 29). Because of the media blitz known as the drug war, there has been increased attention to the problem by the government and public agencies, resulting in rising numbers of drug related arrests in the 80's, most of which are among black Americans, although whites report slightly higher rates of drug use (Gerstein 33). Demand for treatment increased in the mid to late 80's, possibly related to the devastating effects of crack (Gerstein 28). The median income of black families declined and black unemployment increased during the 1970 1 s and 80 1 s (Kovel lxvi) , and all of these factors have produced a huge increase in the need for on-demand treatment, but as explained in the previous section, there are not enough treatment beds to go around.
The options for pregnant, substance abusing women, excluding legal options, are treatment in a private setting, treatment in a public program, or residential treatment. The for-profit drug treatment industry is not integrated into the general health care delivery system. Public treatment programs may be connected to public or private hospitals, but due to the personal, social, legal, financial, and systemic barriers already discussed, few pregnant women get into either of these types of programs. Private treatment is reimbursed by private insurance which has no apparent connection to maternal-child health (MCH) ; although public reimbursement comes from Medicaid, which was started as a program for women and children I s health, it has historically not demonstrated beneficial effects on MCH statistics (Haas 87), and it has become largely a program for disabled adult men and women. Medicaid is funded by the states and the feds, and there is no state or national overseer f or Medicaid reimbursed drug treatment for pregnant women.
In contrast, the evolution of residential treatment for pregnant women represents an approach more centered in MCH issues. The federal government, recognizing a need for more treatment options for this population, in the late 80's put out a Request for Proposal f or programs, to be funded by block grants out of Title V (Brigandi). Title V was established in 1935 as the program to organize and administer MCH services nationally and at the state level (Guyer 297). Thus, it has a long history of being centrally involved with MCH services delivery, not as a welfare program for the poor, but as a public agency with the goal of improving the health of children and mothers. In some states, Title V may be part of the Public Health Department, thus making it well integrated into public health services, if not the medical system. As described in the introduction, pregnant addicts are benefited by social and behavioral interventions at least as much as by medical ones.
Community based activist groups, like Women for Social Justice in Boston, or CASPAR in Cambridge, were the organizations that won block grant funds from Title V to start residential facilities for pregnant, addicted women. Thus, this trend in care comes out of a direct working relationship between federal Title V and concerned community groups. This represents perhaps the best relationship between the governmental bureaucracy and grass roots citizen activism. It also places this model of care outside the control of the traditional medical system, yet it appears to best provide or integrate the MCH services this population needs (Chang 327).
The residential treatment model designed for pregnant women is well plugged into MCH services. The appropriate counseling and education takes place, prenatal care, well-child check-ups, and early intervention are arranged for, and some programs even teach women to be labor support partners to each other. I strongly believe this treatment modality makes sense, and is more relevant to pregnant women than conventional treatment, based on evidence from the literature, and upon what I have seen at New Day, Inc. and at inhospital treatment programs. There was an actual feeling of warmth and community at a residential home for recovering mothers, whereas visits to hospital treatment facilities (through locked doors) have been like nightmarish excursions into Caravaggio paintings.
This type of MCH service delivery is more wholistic than the traditional treatment model, which tends to ignore many aspects of a woman's life. The individual programs in different states can choose which services should be provided or arranged for (within the constraints of a tight budget) , and they then contract with clinics, hospitals, Visiting Nurse Associations, and social workers, etc. for the services they need. These programs are not fully funded by Title V, and are also dependent on Medicaid, fundraising, and philanthropy.
Residential treatment programs integrate relevant services for women and, on the basis of individual assessment, appear quite well organized. Improving these programs means substantially increasing funding to them, so that they can integrate the rest of the ser- vices recovering women really need, namely transitional housing, after-care counseling and support groups, and GED and employment training classes. In addition, most needed now are more facilities, with more beds for women, and more room and child-care workers for other children, to keep healing families intact. Once these programs have been adequately expanded, out-reach will be needed to bring clients in.
HEALTH SYSTEM REFORM
With the creation of universal coverage which may occur under future health care reforms, the situation for pregnant, substance abusing women could get better or worse. it is unlikely that addiction treatment will be included in the basic benefits package, as the country cannot afford it. However, the majority of private paying as well as Medicaid dependent, pregnant women have already been barred from most treatment programs, so the exclusion of this benefit alone will not have a significantly detrimental effect. But, if big cuts are made to Title V, that could remove the only accessible and appropriate treatment option available to pregnant, substance abusing women.
On the other hand, if relevant MCH services are made free, equally available to all women, and appropriate to different populations, this could significantly mitigate any negative effects observed from the lack of treatment. In fact, if prenatal care were made truly universal and, more importantly, good, we may see improved birth outcomes like in the Feldman study, even in untreated populations.
We now know what works best for pregnant addicts, and the MCH services delivery by the traditional medical system is not currently providing it. It would be a mistake to entrust the MCH care needs of a certain population to an institution that has been unable or unwilling to help. In order to meet the goals of cutting costs and improving health, a universal coverage package must include relevant services provided in an integrated and wholistic way. In this case, that means expanding women's access to treatment which addresses their social, psychological, and health needs, while ceasing to support private and public programs which treat only a medical problem, a substance addiction, and are inappropriate for women, for whom the origins of addiction lie primarily in social and personal experience.
May 9, 1994
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