CARRARA TREATMENT / ADDICTION EXPERTS
Addiction in women is not the same condition as addiction in men — not in its causes, its neurobiology, its social consequences, or the barriers it creates to seeking and receiving effective treatment. Women progress from first use to physical dependence faster than men, are more likely to use substances as a coping mechanism for trauma, face higher levels of stigma when seeking help, and are dramatically underrepresented in addiction research. For pregnant women, the stakes compound further: the fear of legal consequences, loss of custody, and social judgment creates barriers to treatment so severe that many women avoid prenatal care entirely.
In this episode of We’re Out of Time, host Richard Taite sits down with Dr. Ken Spielvogel, Senior Medical Officer at Carrara Treatment, and Dr. Blair Steel, PsyD, a licensed clinical psychologist, for a direct clinical conversation about addiction in women — what the epidemic looks like from inside a treatment setting, what medication-assisted treatment means and does not mean, and what psychological recovery actually requires in the early stages.
For women, their families, and clinicians, this episode addresses questions that the addiction field has historically underemphasized: What are the specific vulnerabilities that make women more susceptible to substance use disorders? How does stigma prevent women from accessing the help they need? And what does evidence-based addiction treatment for pregnant patients actually look like?
Dr. Spielvogel opens with the clinical reality he has observed across years of addiction medicine practice: the epidemic is not an abstraction, and it is not stable. The population presenting for treatment has changed substantially over the past decade, driven by the contamination of the drug supply with fentanyl and synthetic opioids that have no established tolerance ceiling. He describes seeing patients who arrived believing they were managing a controlled habit who are now presenting in acute crisis because the substance they were using is not the substance they thought it was. The gender dimension is present at every level. Women progress from first use to physical dependence faster than men — a phenomenon researchers call telescoping. They are more likely to use substances as a direct coping mechanism for trauma rather than for recreation or social reasons. And they are underrepresented in treatment despite prevalence rates that in many substance categories now approach parity with men.
Dr. Steel describes the stigma barrier with clinical precision: women with substance use disorders face a qualitatively different social response than men do. The cultural script for male addiction is one of a person who lost control. The cultural script for female addiction is one of a mother who failed, a wife who betrayed, or a woman who is dangerous to the children in her life. The legal and custody consequences are not merely feared; they are real. Women who disclose substance use during pregnancy risk child protective services involvement, criminal charges, and loss of parental rights — which means that the very system designed to help them most often becomes the primary reason they do not seek help. Dr. Spielvogel adds a medical dimension: clinical research on addiction has historically been conducted on male subjects, producing diagnostic criteria and treatment protocols that were calibrated to male presentations and may systematically underperform in female patients.
Medication-assisted treatment — the use of FDA-approved medications including buprenorphine, methadone, and naltrexone to manage opioid use disorder — is one of the most misunderstood and stigmatized clinical interventions in addiction medicine. Dr. Spielvogel explains that MAT is not substituting one addiction for another. It is treating a neurological condition with evidence-based pharmacology, the same way Type 2 diabetes is treated with insulin or hypertension is treated with antihypertensives. The evidence base is unambiguous: MAT reduces overdose mortality, improves treatment retention, decreases criminal activity, and produces better long-term outcomes than abstinence-only approaches across virtually every measurable variable. For pregnant patients, the clinical case is even clearer. Abrupt withdrawal from opioids during pregnancy carries serious risks including preterm labor and fetal distress. Buprenorphine and methadone allow stabilization and supervised tapering in a medically controlled setting, protecting both mother and fetus.
Dr. Steel describes the psychological profile she consistently encounters among women entering addiction treatment: a history of unprocessed trauma — frequently childhood sexual abuse, domestic violence, or relational abandonment — that the substance has been managing. Unlike the male presentation, where substances often function to amplify positive states or facilitate social bonding, female substance use more typically functions as emotional anesthesia. The addiction becomes the primary coping mechanism for affect that has never been safely processed. Recovery, in her framework, is not simply a matter of removing the substance — it is a matter of building the psychological infrastructure to feel and process emotions that have been chemically suppressed, often for years. Without this foundation, early sobriety is characterized by an emotional rawness that is clinically significant: the pain the substance was masking returns in full, and without adequate psychological support, relapse becomes structurally likely.
Dr. Steel and Dr. Spielvogel converge on the clinical demands of early recovery for women, and agree that the first 90 days are characterized by a specific set of risks that generic addiction programming does not always address. The neurological recovery from substance dependence takes months, not weeks. During this period, women are managing post-acute withdrawal symptoms — sleep disruption, emotional dysregulation, cognitive fog, and anxiety — while also facing the practical consequences of addiction: damaged relationships, financial instability, possible legal involvement, and the shame that accumulates during active use. Dr. Steel emphasizes that the psychological work of early recovery for women requires a gender-informed therapeutic approach: shame reduction, trauma processing, attachment repair, and the development of an identity that is not organized around using. This is not decorative clinical care. It is the specific work that determines whether the physiological stabilization of detox becomes the foundation of sustained recovery.
Addiction medicine has historically been a field shaped by research on male subjects. The clinical trials, diagnostic criteria, and treatment protocols that define standard care were predominantly developed on male populations, producing a body of evidence with significant generalizability problems for women. This is not a peripheral concern. Women progress from first substance use to physical dependence faster than men — a phenomenon researchers have termed telescoping — and the mechanisms driving this acceleration differ meaningfully from the male pathway. Female estrogen levels influence dopamine sensitivity in the mesolimbic reward pathway, creating a neurobiological basis for faster progression that is distinct from behavioral or psychological factors. Treatment programs calibrated to male presentations may systematically underperform with female patients not because the programs are poorly designed, but because the underlying clinical model was not built for the population being treated.
The comorbidity profile in women with substance use disorders further distinguishes the population. Research consistently finds that women in addiction treatment have higher rates of co-occurring PTSD, depression, and anxiety disorders than male patients. A 2017 SAMHSA report found that women with substance use disorders were approximately twice as likely as men to have a co-occurring mood disorder. The directional relationship between trauma and substance use in women runs more frequently from trauma to substance use than the reverse — women are more likely than men to report that substance use began as a coping mechanism for an identified traumatic experience. This has direct clinical implications: treating the addiction without addressing the underlying trauma leaves the primary driver of use intact.
For pregnant women with opioid use disorder, the evidence on medication-assisted treatment is unambiguous. The American College of Obstetricians and Gynecologists, SAMHSA, and the Centers for Disease Control all recommend buprenorphine or methadone as first-line treatments. Abrupt opioid withdrawal during pregnancy carries documented risks including preterm labor, fetal distress, and intrauterine fetal demise — risks that far exceed those associated with appropriately managed MAT. Neonatal opioid withdrawal syndrome, while requiring clinical management, is a treatable and expected outcome of prenatal MAT that does not constitute grounds for withholding treatment from the mother.
The barriers preventing pregnant women from accessing these evidenced-based treatments are primarily social and legal rather than clinical. Fear of child protective services involvement, criminal prosecution, and loss of parental rights causes many women to conceal substance use from prenatal care providers and avoid addiction treatment entirely. This fear is clinically rational: in many jurisdictions, disclosing substance use during pregnancy exposes women to legal consequences that are disproportionately applied relative to male counterparts with equivalent substance use histories. The result is a population whose treatment-seeking is most inhibited precisely when the clinical stakes are highest.
MD - Senior Medical Officer, Addiction Medicine Specialist
Carrara Treatment, Wellness & Spa
Dr. Ken Spielvogel is the Senior Medical Officer at Carrara Treatment, Wellness & Spa, specializing in addiction medicine, detoxification, and the medical management of substance use disorders. As the physician leading Carrara's clinical team, Dr. Spielvogel supervises medically assisted withdrawal, medication-assisted treatment protocols, and the integration of emerging interventions — including GLP-1 medications — into comprehensive addiction care. He is a recurring guest on the We're Out of Time podcast and brings extensive firsthand clinical experience to discussions of the opioid epidemic, designer drugs, and the medical realities of addiction treatment.
PsyD - Licensed Clinical Psychologist
Dr. Blair Steel
Dr. Blair Steel, PsyD is a licensed clinical psychologist specializing in addiction recovery, women's mental health, and the psychological factors that drive and sustain substance use disorders. Her clinical focus centers on the early stages of recovery — the psychological patterns, relational wounds, and distorted beliefs that must be addressed for sobriety to become durable — and on the specific barriers that prevent women from seeking and completing addiction treatment. She brings both clinical depth and gender-informed perspective to the intersection of addiction, trauma, and recovery.
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Dr. Ken Spielvogel
MD
Dr. Blair Steel
PsyD
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Carrara Treatment, Wellness & Spa offers personalized care. Consult a clinician to explore your options.
