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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.