A formative study of drug-using women in Georgia: Setting the Stage for an RCT

Irma Kirtadze M.D. Addiction Research Center

Tbilisi, Georgia

Acknowledgements

  Participants

•  National Institute on Drug Abuse R01 DA029880 (PI H Jones)

  US study collaborators: Hendrée Jones, Kevin O’Grady, Wendee Wechsberg, Bill Zule

  RTI SATEI Team, especially Rachel Middlesteadt Ellerson, Keryn Murphy, and Julianne Foster

  Georgian Project Team: David Otiashvili, Marina Chavchanidze, Natia Topuria

  Russian Collaborator: Evgeny Krupitsky

Outline

• Background • Study Design

• Findings

• Current and future directions

Republic of Georgia ●  One of the first countries to adopt Christianity, in the early

4th century, remains strongly Georgian Orthodox

●  From 1921 to 1991, the Georgian Soviet Socialist Republic was one of the 15 soviet republics of the USSR

●  Suffered from civil war and economic crisis during the 1990s

●  Rose Revolution of 2003, at which time the new government introduced democratic and economic reforms

●  It covers a territory of 69,700 square kilometers

●  Its current population is almost 4.5 million

•  There are no reliable data regarding drug abuse among women in Georgia •  It has been estimated that 40000 Injecting drug users are in the country, and only 1.5 - 4% of the drug treatment population comprise women •  An extrapolation based on these estimates suggests that there are approximately 2,000-3,000 women in Georgia with problem drug use •  Heroin and injectable pharmaceuticals such as Subutex (buprenorphine) are the drugs of choice but their availability has been greatly reduced in the past few years

•  Currently drugs are very scarce in the Republic of Georgia, which leads to abuse of pharmaceuticals and home-made stimulants (‘Vint” and ‘Jeff’), and crocodile (made from codeine). Use of these home-made drugs can cause severe morbidity and death •  Other drugs of choice include benzodiazepines and Lyrica (Pregabalin) and other combinations of pharmaceuticals

Drug Abuse among Women in Georgia

Drug Abuse Treatment for Women in Georgia

●  There are no drug treatment programs designed for women

●  The stigma associated with entering drug treatment is so severe that very few opioid-dependent women make such choice

●  Women drug users are shunned

by their family, highly vulnerable to police harassment and at risk for sexual, physical, and emotional abuse by male partners and drug dealers

IMEDI – Investing Methods for Enhancing Development in Individuals

IMEDI means hope in

Georgian

Study Design: Aims 1 and 2

Study Design: Qualitative Interviews

●  Experienced qualitative interviewers conduct 90-to-120 minute individual

interviews

●  Interviewers strive to maintain a balance between systematic data collection in pertinent topic areas and exploration of emergent themes

●  Interviews are conducted in a conversational style that flows from the respondent’s perspective to approximate friendly interactions between two people

●  Interview questions address key aspects related to the research questions and the domains of interest

●  Data analysis:

►  InVivo using the original audio-taped interview in Georgia ► Qualitative analysis of interviews translated into English

The IMEDI Project: Aim 1

  N=67 women approached (4 cities of Georgia)   8 did not meet eligibility criteria   4 refused participation

 N=55 injection-drug-using women recruited using venue-based outreach (e.g., low threshold services)   Eligibility for participation included:

-  conversant in Georgian -  able to provide informed consent -  age 18 or older -  actively injecting drugs (injected within the past 30 days, as evidenced by

venipuncture stigmata) -  sexually active (at least once in the past 30 days)

Aim 1: Participant Characteristics

Demographic Characteristics of Females (n=55) Mean (SD) Age, in years 35.7 (9.5) Education School 30 (55%) College 5 (9%) University (unfinished) 5 (9%) University 15 (27%) Unemployed 48 (87%) Marital Status Single 5 (9%) Cohabiting 12 (22%) Separated/Divorced/Widowed 16 (29%) Marriage 15 (27%) Remarriage 7 (13%) Mean (SD) Number of Children 1.3 (1.0)

Themes: Drug-using women are

twice stigmatized

Females are stigmatized by society and their male partners for being addicted to drugs

Women are treated differently “you are weak and cannot fight that much…so because you are a woman he puts you aside…they gave me “secondary” drugs, they took all that was good and left some left-overs for me which is the worst…I was paying for everything and they gave me that garbage…I have wished for many times to be a man to kick their asses.”

Themes: Women Initiate drug use in the

context of an intimate partner relationship

Women commonly stated that their husbands/main partners were drug users and it was their husbands / partners initiated them into drug use

“Majority of drug user women have started drug use because their husband made them to start. In my case as well, my husband made me to start drug use… It is getting easier for a man because a woman becomes absolutely dependent on her husband.” “When in a family only man injects he has to think of where to get money every day, while non-user wife distributes money according to the family needs. But if a woman becomes a drug user, then both of them spend most of the money on drugs, leaving small amount for their kids.”

Themes: Context makes women dependent on men for drugs and sustenance

Women typically rely on men to provide the drugs and economic means to live for themselves and their children

“even if the woman is the bread winner of the family…It is up to a made to decide how to spend the money.”

“Generally, women inject mostly with men. If you have money, men may buy the drug for you. Then, they come to your place… you give them a drug dose for injection because they bought it for you… then they may steal a dose on their way to your house and then ask for more money… it’s common.”

A “sexual relationship in exchange of drugs [is typical], as well as they [female drug users] cooperate with police to avoid any trouble.”

Individual Interviews

 Information about Practice  Women in Georgian Society  Perceptions about Drug Use

and Treatment of Drug Addiction in Georgian Society

 Barriers and Strengths of the Georgian Treatment System

 Recruitment of women who use drugs

Study Design: Aim 2

Themes: Physical, sexual and emotional violence are common aspects of life- leading to HIV risks

“Most often a woman might become a victim of psychological violence… he can torture a woman by not giving her drugs when he has it...Without any reason, he just wants to behave in this way and he behaves.”

“have gone through sexual and psychological violence ”

“I know the girls…who agree to anything for any drug.”

“How do women take care of themselves after violence? a time passes and they become closed in themselves, they refer to no one for help.”

Themes: Need for women-focused services and these services must be confidential and provide

anonymity

There is a need for women-focused services, and these services must be confidential and provide anonymity. “[the lack of confidentiality and anonymity] that is fatal for every woman… there are a lot of fatal cases because women have some diseases but won’t go to doctors because confidentiality is not guaranteed… I really want to stress that.”

Aim 2: Provider Characteristics

Demographic Characteristics of Providers Georgian 34 (100%) Females 24 (71%) Mean (SD) Age, in years 42.6 (9.9) Mean (SD) Years of Education 17.0 (1.4) Highest Degree PhD 4 (12%) MD 22 (65%) Nurse 2 (6%) Undergraduate 6 (18%)

The IMEDI Project: Aim 2 Findings

Drug-using women are twice stigmatized ► Stigmatized by society and by their male partners for being women and being addicted to drugs

◄ “This is quite a stigmatized group, even twice more stigmatized than group of the men users. Even the drug user men themselves do not perceive these women as… full-fledged members of society.” “Female drug users first of all encounter stigma and discrimination on behalf of the society and male drug users, as we’ve already mentioned, not to mention doctors.” “I don’t want to say it’s more superficial treatment, but drug user women become subjects to criticism… Yes, probably. If her status were revealed a woman disclosing her drug user status would be treated less adequately and in an undesirable manner.”

The IMEDI Project: Aim 2 Findings

► There is both a lack of services and a lack of diversity of services. ◄

“Well, there were cases, maybe I shouldn’t say it, but there were cases when doctors refused their patients’ medical services after patients told them about their [drug] problem.” “Well… I am not sure… probably she would still fail to go (for treatment), because public opinion is very important to her…. And staff of this program (substitution therapy) is also a part of the society, is it not? I mean we need to work a lot in this direction to change a level of consciousness of the society in the first place…”

Barriers to treatment or Receiving services

The IMEDI Project: Aim 2 Findings

Need for women-focused services

► Health care providers agreed there was a need for specialized treatment programs for women ◄ ► However, the components and systems for such treatment were not specified ◄

“I would probably do separate site for women only. Not sure why, but this would be better. Not that men and women would go together, but where women would attend separately.” “Well… it should be a house for women having difficult life conditions. This is how I would call it. I would not call it the house for drug user women. A rehabilitation center…something like a crisis center…with psychological rehabilitation, for example detox, substitution therapy... some kind of a complex approach. I think it would be better in terms of violence.”

The IMEDI Project: Interim Summary and Conclusions

Both drug-using women and health care providers agreed that:  Drug using women are twice stigmatized, and that women-centered drug treatment is

needed.

Treatment Implications Women drug users may benefit from a comprehensive intervention that includes HIV, sex,

and drug risk reduction as well as providing women with skills to achieve and maintain purposeful days and meaningful social connections.

Provider Implications Health care providers need training regarding the illness and treatment of drug addiction.

Policy Implications The need for a women-specific services and a comprehensive network of service linkages

for all patients in drug treatment are critical public health issues and should be of paramount consideration by Georgian policy makers to urgently address.

Based on the qualitative findings, we developed and are now pre-testing two interventions: Reinforcement-Based Treatment+Women’s Health CoOp

  physical, mental. and sexual health education and skills   job preparation   recreation   develop drug-free peer relationships

Case Management   physical, mental, and sexual health education and skills   relaxation/stress management   case management

The IMEDI Project: Current Directions

Research Site

Job club & recreational activities

Job club & recreational activities

Summary

► Drug addiction impacts everyone and everyone can be part of the solution.

► Women drug users around the world share common experiences of pain, shame, social isolation, stigma, gender inequality, sexual, physical and emotional abuse. These issues are often heighted when they are pregnant.

► Effective interventions to reduce drug addiction and the HIV risks associated with addiction must be built on promoting strengths and protective factors while concurrently minimizing factors that make women vulnerable.

Thank you!

irma@altgeorgia.ge