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Official websites use. Share sensitive information only on official, secure websites. Please Address Correspondence to: Michael W. It is also used to treat certain psychiatric disorders. One concern with the club setting is that exposure to loud sounds can cause permanent sensorineural hearing loss. Another concern is that consumption of MDMA may enhance such hearing loss. Hearing loss was assessed by the auditory brainstem response ABR and cochlear histology. MDMA was developed to treat depression and anxiety disorders and is useful in treating patients with post-traumatic stress disorder PTSD Mithoefer et al. Recent reports show that MDMA and other amphetamine abuse continue to increase, particularly in the adolescent and young adult populations Johnston et al. People attending such venues are typically exposed to loud music for a period of 4—5 h at a time Weir, ; Williams et al. This is a major concern because it is well established that exposures to loud sounds for prolonged periods of time or on repeated occasions cause permanent noise-induced hearing loss NIHL Gunderson et al. Both of these neurotransmitters are believed to play a protective role against acoustic trauma Lendvai et al. Thus far, no studies have addressed the converse possibility that MDMA enhances the toxicity of loud sound exposure. Hearing loss was assessed by the auditory brainstem response ABR. The cumulative levels of noise trauma and MDMA consumption were intended to model amounts experienced by clubbers or rave-goers. Regarding the ABR, a repeated high-dose MDMA regimen in the rhesus monkey caused shortening of P3 and P4 wave latencies and prolongation of P5 wave latency that lasted up to 13 wk post-treatment Taffe et al. These are important issues, because the United States Animal Welfare Act requires investigators to consider the use of less traumatic procedures and animal models that are lower on the phylogenetic scale i. Thus, the dosing regimen of our experiments were more relevant to the human situation while adjusting for the different metabolic rates between the rat and human Green et al. We also sought to extend previous findings by examining both ABR amplitudes and latencies, as well as the interactive effects of MDMA administration with an auditory stressor condition viz. This would provide information about the best animal models, dosing regimens, stimulus parameters and general electrophysiology procedures for future studies. Committee on Care and Use of Laboratory Animals. Rats were handled and weighed on days of treatment and ABR measurements. Normal saline 0. The injection site was varied from side to side to minimize discomfort and potential tissue damage that may result from multiple injections, and injections were done in the home cage environment. The MDMA-treated rats i. Baseline temperatures were measured 30 min before the first MDMA or saline injection. Temperatures were also taken 30 min before the last 4 th injection i. The caged animals were then placed inside a double-walled sound-attenuation booth Industrial Acoustics Co. Animals were free to move about the cage. The anesthesia method was rejected because this would not mimic the Rave party scenario and would introduce a possible confounding effect from the co-administration of the anesthetics and the MDMA. Following procedures used by others Gourevitch et al. Having the animals exposed in pairs ensured that the animals from these two groups received the exact same noise exposure. Rats that did not receive essentially the same noise trauma i. Animals were monitored visually by one or more technicians through a one-way window in the acoustic chamber. As noted by others, the animals remained calm, engaging in normal exploratory behavior without any apparent distress during the noise exposure Gourevitch et al. No animal was observed to be reducing its sound exposure by burying its head beneath the body of its cage mate and there was no preferred orientation of the animal in relation to the speaker. The sound exposure of 1 h at dB SPL resulted in a cumulative exposure level of Pa 2 h which is equivalent to 10 h of exposure at dB or 32 h of exposure at dB Williams et al. These exposure levels are well within the range experienced by patrons who repeatedly attend nightclubs and raves Gunderson et al. Four rats, one rat from each treatment group, were ABR tested on any single testing day. Three wks later Day 21 , the animals were again tested with ABRs. ABR recordings were conducted on all animals in all four treatment groups on Days 1 and 8 to monitor and verify the dissipation of such temporary threshold shifts in the two noise-exposed groups. A substantial dissipation of the temporary threshold shifts were observed from Day 1 to Day 8, but very little change in the ABR thresholds between Days 8 and ABR recordings followed standard procedures Church et al. Body temperature was carefully regulated in a narrow normothermic range of A small animal rectal probe, coated with a lubricating jelly and connected to a temperature monitor Model 43TD, Yellow Springs Instruments Co. A water-circulating heating pad was used to regulate and maintain normothermia by raising or lowering the temperature of the circulating water Model TP, Gaymar Industries, Orchard Park, NY. Ophthalmic ointment was applied to both eyes to prevent corneal drying during anesthesia. The active electrode was inserted at the vertex, the reference electrode below the left ear, and the ground electrode below the right ear. Evoked potentials were collected by a commercial instrument and amplified , times with a digital bandpass of — Hz Bio-logic Corp, Mundelein, IL. Recordings were made in an electrically shielded, double-walled sound attenuation chamber Allotech, Inc. ABR threshold shifts elevations were used to assess hearing loss Church et al. ABR thresholds were determined by the method of limits Church et al. Each ABR trace was comprised of stimulus-evoked responses. Threshold was defined as the lowest intensity to elicit a reliably scored ABR component Church et al. The amounts of ABR threshold shifts were calculated by subtracting the baseline pre-treatment ABR thresholds from the post-treatment thresholds. To provide anatomical verification that the noise trauma caused permanent inner ear damage, the right and left cochleae were harvested from one representative animal in each of the four experimental groups. Animals were euthanized 1 wk after the last ABR recording by rapid decapitation. The remaining tissue, still attached to the modiolus, was permeabilized 0. After three rinses, the organ of Corti was dissected from the modiolus in four to five segments. The segments were mounted on slides using an aqueous mounting medium Fluoromount, Diagnostic Biosystems Inc. Slides were assessed on a microscope equipped for epifluorescence, using a 50x oil immersion objective and a scale for measuring a portion of the microscope field Leitz Wetzlar, Wetzlar, Germany. The scale was calibrated to measure a slide field of 0. The first two scale lengths were not counted. The apical turn was counted first; the other turns were followed by moving down the cochlear spiral. Each successive 0. The percentage of missing hair cells was calculated for each row and plotted as a function of distance in mm from the apical end of the surface preparation. Z-stacks of 15 to 25 images were then combined to make 3-D projections. The 3-D projections were visualized using real-time interactive image-analysis software Imaris version 7. To examine hearing loss, the primary outcome variable was the ABR threshold shift i. Although ABR thresholds were tested in response to 32 kHz tone pips, four Thus, the true threshold shifts of these two groups could not be determined, because of so much missing data. Treatment group was a between-subject measure and Frequency was a within-subject measure. To assess possible treatment-induced body temperature effects at the time of drug and noise exposure, temperatures were analyzed by a 2-way ANOVA for the between-subject measure of the four treatment Groups and the within-subject measure of three time points pre-treatment, prior to the last 4 th injection but just before noise trauma, and post-noise trauma. When any 2-way ANOVA indicated a significant treatment group main effect or interaction, simple effects tests 1-way ANOVAs and Student-Newman-Keuls or paired t-tests were used to make post hoc pairwise comparisons between individual treatment groups. The data for both experiments were collected simultaneously. Binaural click stimuli generated by a 0. Presenting stimuli at fast repetition rates constitutes an auditory stressor test that can reveal neurological abnormalities e. Thus, Experiment 2 used this stressor test to see if MDMA treatment interacted with the stimulus repetition rate. In comparison, the human ABR is labeled with Roman numerals with the major neurogenerators believed to be the distal auditory nerve I , proximal auditory nerve II , cochlear nucleus III , superior olivary complex IV , and the termination of the contralateral lateral lemniscus in the inferior colliculus V Moller et al. ABR threshold determinations were the same as described for Experiment 1 with the exception that Experiment 2 was able to report the 32 kHz tone pip results. The Greenhouse-Geisser corrections for the degrees of freedom were used for all within-subject variables. For the ABR thresholds, the data were assessed as previously described in Experiment 1. Figure 1 shows the mean ABR threshold shifts for each treatment group at each tone pip frequency as well as the results of post hoc pairwise comparisons. Multiple ABR traces are taken at the lower stimulus intensities to aid wave identification and to verify reproducibility. The ABR latency scale includes a 0. Figure 3 shows representative images from the basal turn of the cochlear tissue surface preparations from one representative animal in each of the four treatment groups. The animals from the two noise trauma groups i. The assessments of hair cell loss are presented as cytocochleograms in Figure 4. These gaps were most likely due to mechanical shearing from the noise trauma itself, rather than fixation or dissection artifact personal communication on 12 January with Dr. In contrast to the two noise exposed groups, the animals from the two groups that were not exposed to the noise trauma i. Right ear cytocochleograms from the same animals depicted in Fig. Gaps in the cytocochleograms reflect tissue damage from fragmentation that was too severe to accurately calculate missing IHC and OHC. Paired t-tests indicated that both MDMA-treated groups showed significant body weight decreases the day following their MDMA treatments from Day 0 to Day1 , but the other two groups did not. There were no significant interactions of any kind. Body temperatures during the click stimulus conditions showed no significant treatment group, day, or group-by-day differences. There were no significant differences for the day factor. The only significant interaction was for day-by-frequency. This finding suggests that persons attending the loud noise environments of nightclubs and rave parties are greatly increasing the amount of NIHL whenever they take MDMA. In addition, prior studies evaluated neural, myocardial and behavioral toxicities; whereas the current study investigated hearing toxicity. Hearing loss in association with MDMA consumption has been reported in just one case study Sharma, It showed that a year-old polydrug-abusing male patient, who was found unconscious following MDMA use and subsequently complained of a ringing in his ears tinnitus. Audiological examinations revealed that the patient had permanent bilateral sensorineural hearing loss of 45—55 dB at 4 to 8 kHz. Because the patient denied listening to loud music during the onset of tinnitus, the author concluded that the tinnitus and hearing loss were both caused by MDMA alone. Unfortunately, the amount of pre-existing hearing loss and other drug use in this patient were not documented. Thus, the cause of his hearing loss is actually uncertain. In contrast to this case report, our MDMA-only group had normal hearing, strongly suggesting that MDMA by itself would not cause hearing loss unless there was a catastrophic event such a hemorrhage in the inner ear. For example, a high-dose binge-pattern administration of MDMA causes neural toxicity from reductions in various neuroprotective mechanisms such as antagonism of adenosine receptor activity Vanattou-Saifoudine et al. It is also possible that the present study did not have enough statistical power to adequately test this hypothesis and that brain or tympanic temperature would have been a more appropriate outcome measure. Thus, the temperature results should not be considered conclusive. One difference between MDMA and the above toxic agents is that the latter have some ototoxicity when used alone, whereas MDMA alone caused no ototoxicity. An inherent problem with an animal model is that drug metabolism, and therefore dosing, will be different from the human experience. Typically, the rat requires more of a drug than a human, because of its faster metabolic rate. A recent article pointed out that the rat metabolizes MDMA times faster than a human. Thus, the rat needs a higher and more sustained dosing regimen to achieve the same level of toxicity experienced by humans. Our MDMA dosing regimen was based on prior rat models of serotonin depletion, behavioral, electrophysiological, and hyperthermic effects. Also, the present study used a dosing regimen that was substantially more moderate than several recent rat Darvesh et al. Our dosing was well within the acceptable limits of dosing as well as physiologically and allometrically relevant to the rat, whereas some studies seemed to exceed these boundaries Green et al. The present findings may have broad clinical implications. Listening to loud sounds are major causes of hearing loss in teenagers and adults Le Prell et al. As a secondary intervention, anti-oxidant therapies used to treat NIHL may ameliorate the amount of hearing loss Le Prell et al. Finally, the observation that an abused or psychotherapeutic drug can enhance NIHL opens a new field of research with important clinical implications. Experiment 2 went beyond the scope of these two previous studies by examining ABR wave amplitudes in addition to wave latencies and by using an auditory stress test of rapid stimulus repetition rates in rats. Thus, we conclude that MDMA, by itself and at a standard psycho-active serotonin-depleting dosing regimen for the rat model, had no effects on the rat ABR. Some of these methodological differences may explain the differing findings, whereas others do not: A It has been noted that the CNS effects of MDMA in primates are more profound than in rats Fischer et al. B The dosing regimen used by the previous monkey studies resulted in a higher cumulative dose and possibly higher peak MDMA blood levels than the present rat study. C The differences in stimulus parameters for the click-evoked ABRs were minor. There was no documentation that such precautions were taken in the monkey studies. Considering these issues, the differences in animal species monkey versus rat and dosing regimen are the most likely explanations for the different findings between the current study and the previous monkey studies. The present study used a dosing regimen that has created profound effects in the rat, including enhancing NIHL, temporary weight loss, increased body temperatures, and causing serotonin depletion Perrine et al. Thus, the present study used a standard psycho-active dosing regimen that was physiologically and allometrically relevant, and therefore was not under-dosing the rats Green et al. Thus, using MDMA in combination with loud noise or other sensory trauma is likely to be a fruitful and insightful line of investigation, perhaps more so than studying the effects of MDMA alone. Thus, MDMA-induced depletion of these neurotransmitters should have adverse effects on auditory information processing and possibly sensory receptor and neural damage when combined with sensory trauma. This is a major health concern because MDMA is a psychotherapeutic drug with increasing patient applications. Also, it is a widely abused recreational drug that is commonly used in conjunction with listening to loud music, and the resulting hearing loss has debilitating intellectual, functional and social effects. These results also suggest that MDMA might be a useful drug for studying the roles of serotonin and dopamine in auditory function, and suggest that other psychotherapeutic and abused drugs should be investigated for potential enhancement of NIHL. These results do not support previous findings in monkeys. Differences in dosing regimens, animal models, and possibly other factors could explain the discrepancies. These observations will help guide future studies in terms of selecting animal models, dosing regimens, stimulus parameters, noise and other forms of sensory trauma, and body temperature regulation. Church , DA S. Perrine and 5P30DC R. Altschuler and J. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. As a library, NLM provides access to scientific literature. Hear Res. Published in final edited form as: Hear Res. Find articles by Michael W Church. Jinsheng S Zhang , Ph. Find articles by Jinsheng S Zhang. Megan M Langford , B. Find articles by Megan M Langford. Shane A Perrine , Ph. Find articles by Shane A Perrine. Issue date Aug. All rights reserved. The publisher's version of this article is available at Hear Res. Open in a new tab. Disclosure Statement There are no conflicts of interest to report. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

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Official websites use. Share sensitive information only on official, secure websites. Please address correspondence to Irma Kirtadze, M. This study describes the initiation and maintenance of illicit drug use, risky behaviors, and the substance use treatment experiences of women in Georgia. Participants presented diverse histories of drug use initiation and substance use, risky behaviors, and drug treatment participation. All participants reported concurrent use of different substances, including home-produced injection preparations. Women described their experiences of both the positive and negative effects physical and psychological that they attributed to their use of drugs. Findings enrich our understanding of the environment in which substance use is initiated and maintained in a female population in Georgia, and illustrate the importance of culture and the role of social factors in the development of injection drug use. Results can provide direction for tailoring the development of interventions for substance use disorders, public policy discussions regarding the treatment of women who use drugs, and future research on substance use among women in Georgia and other post-Soviet nations. Keywords: Caucasus region, homemade drugs, injection drug use, substance use, women-focused treatment. In Georgia, a country of 4. Intensive policing of opioid markets resulted in PWIDs switching to alternative drugs that required less involvement in the illegal drug marketplace and were considerably cheaper. Agonist maintenance with methadone or buprenorphine has been steadily expanding in recent years and, in , more than 2, people received maintenance pharmacotherapy. In the same year, only people received drug-free in-patient treatment two-weeks detoxification with no or few cases of post-detoxification psychosocial treatment Javakhishvili et al. HIV status is closely tied to the injection-drug-using community Chkhartishvili et al. Although HIV prevalence is low in the general population 0. Bouscaillou et al. Although this sample is small, there are no other studies that have estimated HCV rates for women who inject in Georgia. Women with substance use disorders are one of the most hidden and underserved populations in Georgia Javakhishvili et al. Given that drug treatment in Georgia has been designed to serve male beneficiaries, when treatment is available, it lacks sensitivity to the unique needs and challenges that injection-drug-using women face International Harm Reduction Development Program ; Javakhishvili et al. Empirical data on drug use by women in Georgia are scarce. Our previous research has examined the factors that motivate women who inject drugs to seek health care and the barriers they encounter when they do, and identified factors that may encourage or inhibit the disclosure of substance use to health service providers by women in Georgia Kirtadze et al. However, little is known regarding substance use initiation and the environment in which a substance use life course of women who use drugs in Georgia develops. This study examined the attitudes, beliefs, life circumstances, and contexts of drug use among injection-drug-using women in Georgia. A qualitative study was conducted during April-September in three cities: Tbilisi, Zugdidi, and Gori. These cities provide diversity in population numbers 1,,, 75,, and 49, inhabitants, respectively and geographic locations. Both Gori central Georgia and Zugdidi west Georgia border on two uncontrolled separatist regions South Osetia and Abkhazia, respectively and are characterized by a high prevalence of drug use. In all three cities, agonist treatment and low-threshold programs are available. Research staff briefly described the study to potential participants. Study-eligible and interested candidates made an appointment with staff to consent and interview them at a mutually convenient time and at a private location. All participants provided written informed consent prior to participating in an audiotaped interview. Of the 67 potential participants contacted, four refused participation during initial assessment and eight were ineligible, leaving a final sample of 55 women: 20 from Tbilisi, 20 from Gori, and 15 from Zugdidi see Figure 1. Eligibility criteria included: conversant in Georgian; 18 years or older; able to provide informed consent; injection of illicit drugs in the past 30 days as verified by venipuncture stigmata; and sexually active at least once in the past 30 days. Four respondents were in medication-assisted treatment, 14 were participants of needle and syringe programs at the time of interview, and two women were pregnant. The data collection strategy involved in-depth interviewing Goldstein ; Rosenbaum ; Waldorf Interviews lasted approximately 60 to minutes and covered six main topics: role of women in Georgian society; initiation and consumption of tobacco, alcohol, and drugs; gender differences in drug-using individuals; forms of violence associated with drug use; what drug treatment services are needed for women; and barriers to such services. All interviews were audio-recorded with participant written consent. Digital audio files were transcribed directly into Georgian in Unicode text format. Transcripts were exported as. The analytic process involved six key stages: 1 familiarization with the transcripts; 2 identifying a thematic framework focusing on the six specific issues; 3 coding—applying the thematic framework to the data using textual codes to identify specific statements corresponding to differing themes; 4 creating a node matrix from Matrix Coding query results and visualization; 5 mapping; and 6 interpretation, which included searching for associations, patterns, concepts, and explanations in the data, aided by visual displays such as cluster analyses, word frequency query, and connection mapping of thematic results. The aim of this procedure was to visually display ideas from the data as an aid in developing and testing interpretations. This process was intended to create an in-depth cultural model of the social reality of the participants from their point of view, the so-called emic perspective Pike The goal of the model was to describe how they perceived and categorized the environment in which they lived, their rules for behavior in a male-dominated network, what has meaning for them, and how they imagine and explain things. All transcripts were translated into English to permit review and discussion with US collaborators, and then back-translated into Georgian and the English-language transcripts corrected, if necessary , in order to ensure accuracy of translation. More than half of the sample smoked cigarettes, with 15 years being the mean age of smoking initiation. Participants indicated that their first drug experience was smoking marijuana or taking pills e. Four women were in medication-assisted treatment at the time of interview, and 14 were in a syringe and needle exchange program. This paper focuses on three main themes representing the major gaps in knowledge about the contexts surrounding substance use behavior among women in Georgia: initiation and maintenance of injection use, risk behaviors, and experience with substance use and general health services. Initiation of injection drug use was typically connected with a drug-injecting sexual partner husband or boyfriend and happened within a social network supportive of injection drug use. Although in rare cases a woman might make a deliberate decision to initiate drug use, in most cases first drug use was encouraged by and occurred in the presence of a male significant other—sex partner, friend, or relative. The man also was typically the drug supplier. Soon, the injection-drug-using woman became dependent on the man for both financial support and drug supply. The common belief among respondents was that a man is interested in a woman becoming dependent son drugs so that she would partner with him in terms of both a sexual relationship and financing their drug use—18 respondents disclosed that their current sexual partners had been the initiators of their first injection. 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. When a woman became part of a group that injected drugs, she preferred not to inject in front of men and moved to another room. When a woman lost her male partner due to arrest, death, separation, or other reason, she faced challenges and was pushed to search for alternative drug sources. She was forced to become part of a network of drug users, often desperately looking for money, and began injecting in male-dominated groups. Respondents highlighted that, due to this lack of access to drugs, women experienced more episodes of withdrawal compared to men. The usual scenario suggests that, when left alone, woman lack the requisite knowledge and skills to navigate through tightly woven, male-dominated drug networks. With few possibilities to find drugs and often limited knowledge of homemade drug production, such women often ended up partnering with a new man and may become part of a male-dominated group of injectors. All members of the group had their specific roles during the pre-consumption process. Women were usually assigned to get needles and cookers, get ingredients like potassium permanganate or red phosphorus, buy pills from pharmacies such as pregabalin, rivotril, antihistamines, cough and cold medicines , or just to be transporters of drugs. In addition to the predetermined non-privileged status of a woman in this group, she received very little respect from the group members and was considered untrustworthy. There are a lot of men who are squealing, each of them have been divulged now, so everyone knows who were cooperating with the police. As for woman, it does not really matter whether she is a user or not, after pressure they will all squeal. Knowledge about injection-associated risks for blood-borne infections was relatively high. However, in real-life situations, unsafe injection practice routinely occurred International Harm Reduction Development Program ; Rukhadze et al. In every male-dominated injector group discussed, the person contributing the most money defined the rules. Condom use among participants was not a usual practice. The common belief was that condoms should be used with a partner whom women trusted less, but not with a regular partner. In addition, women typically obeyed socio-cultural norms and traditions and so hardly dared to request protected intercourse, even when they knew their partner had sexual contacts outside their sexual relationship. Some respondents believed that refusal to have unprotected contact with their regular partner could lead to violence. Respondents also stated that condom use was widely perceived to be associated with commercial sex work. When used, condoms were utilized primarily for pregnancy prevention, not STI prevention. Some can beat their women for sexual intercourse refusal. Respondent: Again violence. Few participants were aware of female condoms 7 women out of Sexual contact in exchange for drugs or money was reported to be a frequent practice. In striking contrast with other behaviors and themes that emerged in our interviews, none of the respondents admitted ever practicing this behavior. Sex in return for drugs or money appeared in a majority of interviews, but exclusively as a behavior of others, not the respondent herself. Testing appeared to be a threat for women and they were afraid to hear positive results. Only a few participants indicated that they had been tested regularly for STIs. Some participants had fragmented information about either medication-assisted withdrawal or medication-assisted treatment; others were ignorant of the types of treatment available in Georgia. The majority of respondents indicated that there are no available treatment programs that would address the specific needs of women. Various issues related to the structure of programs were mentioned, such as absence of a separate entrance to the building for women, standing in a line for agonist medication at a dispensing area together with male patients and taking the preparation in front of them, and lack of privacy when speaking with their doctors in the presence of other patients and medical personnel. However, myths and prejudice towards medication-assisted treatment were common, including among the respondents who are engaged in such treatment. I prefer to ask some friend and overcome physical and psychological craving on my own. It affects teeth, liver, stomach. We found that sometimes, when a woman wished to enter treatment, either a male partner or a family member made the final decision about her treatment. Therefore, family members were reluctant to take any action that would risk disclosure. However, respondents indicated that, in many cases, family support might depend on the level of education and of socio-economic status of a family. In many cases, a common practice was to provide treatment at home with medical personnel visiting the patient at her residence and promising confidentiality to the family. Constant fear that this information will leak. I was working on a good position and when they found out that I was using, it was spread like a rumor or something, they dismissed me next day…. Furthermore, with many women having a history of imprisonment, employment opportunities were further reduced. Believe me, everyone would know in one week about her drug use status and prison history. In all public sectors they ask certificate of conviction, test employees several times a month, and those who have positive urine test or have imprisonment history are dismissed. Respondents shared a variety of experiences they had with health professionals: obstetricians and gynecologists, emergency room doctors, general practitioners, addiction physicians, psychologists, and nurses. Some comments were positive and suggested that, in certain cases women do receive appropriate treatment. When she learned that I was a user she must have felt pity for me and she thoroughly examined me. I felt very warm attitude from her, like mother and daughter attitude, but such things happen very seldom. Finally he told us to get away; otherwise he threatened to call the police. You can see it on their faces, how they treat you! This study enriches our understanding of the environment in which substance use is initiated and maintained in a female population in Georgia, and illustrates the importance of culture and the role of social factors in the development of injection drug use. This heightened risk of infection through unsafe injecting practices can be directly linked to the inequitable power distribution in male-dominated drug injection networks. In Georgia and elsewhere in the region, compared to men, women who use drugs have reported higher levels of sharing injecting equipment, drug paraphernalia, and needles International Harm Reduction Development Program ; Rukhadze et al. The majority of respondents were unemployed and never had held a job. In general, probably reflecting the traditionally good level of literacy and education in Georgia UNICEF , our participants were comparatively well-educated; however, they lacked job skills and social or economic support. Some had criminal records that were a major barrier to finding gainful employment Javakhishvili et al. Respondents believed it was particularly difficult for them to be hired because of what they saw as greater social stigma attached to jail time for women who use substances. Our previous reports identified socio-cultural and personal factors shaping help-seeking behavior of women with substance use problems in Georgia Kirtadze et al. The fear of social isolation and rejection causes substance-using women to delay seeking help, not just for the treatment of their substance use, but also for their general health and psychosocial needs. With the gradually narrowing gender gap in substance-use-related disorders, there has been increased attention from treatment providers focusing on issues related to substance use by women Greenfield et al. In Georgian reality, most women who use drugs do not seek treatment for their drug-related problems. The interviews underscore both the lack of and the need for the development of women-focused substance-use treatment services. As emphasized in our previous report Kirtadze et al. These gender disparities help to explain the lack of women in low-threshold and drug treatment programs in Georgia. Study limitations include a sampling approach which was purposive and not random, and the sample may not be representative of injection-drug-using women in Georgia. Findings rely on self-reports provided during in-depth interviews, creating a potential bias. However, to minimize bias, participants were guaranteed confidentiality and individual face-to-face interviews were conducted in private settings. With these cautions in mind, our findings provide information on several major issues that can be used to shape the direction for tailoring the development of interventions for substance use disorders, public policy discussions regarding the treatment of women who use drugs, and future research on substance use among women in Georgia and other post-Soviet nations. As a library, NLM provides access to scientific literature. J Psychoactive Drugs. Published in final edited form as: J Psychoactive Drugs. Find articles by Irma Kirtadze. David Otiashvili , M. Find articles by David Otiashvili. William Zule , D. Find articles by William Zule. Evgeny Krupitsky , M. Petersburg, Russia. Find articles by Evgeny Krupitsky. Wendee Wechsberg , Ph. Find articles by Wendee Wechsberg. Irma Kirtadze : M. David Otiashvili : M. William Zule : D. Evgeny Krupitsky : M. Wendee Wechsberg : Ph. PMC Copyright notice. The publisher's version of this article is available at J Psychoactive Drugs. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Professional education 2 years after high school education.

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