Substance use in women: Current status and future directions

Abstract

Alcohol and substance use, until recently, were believed to be a predominantly male phenomenon. Only in the last few decades, attention has shifted to female drug use and its repercussions in women. As the numbers of female drug users continue to rise, studies attempt to understand gender-specific etiological factors, phenomenology, course and outcome, and issues related to treatment with the aim to develop more effective treatment programs. Research has primarily focused on alcohol and tobacco in women, and most of the literature is from the Western countries with data from developing countries like India being sparse. This review highlights the issues pertinent to alcohol and substance use in women with a special focus to the situation in India.

INTRODUCTION

Psychoactive substance use, until recently, has largely been perceived as a male problem and research, as a result, has been largely androcentric and insensitive to gender variations. Historically, women using substance have always been frowned upon. Rules on acceptability dates back as far as laws of Hammurabi[1] in the west and the Manusmriti in India which states that, “a wife who drinks wine … may be abandoned at any time.”[2] Only around the mid 1970s, partly prompted by the then ongoing women's liberation movement, institutes like the National Council on Alcoholism and Drug Dependence and National Institute on Alcohol Abuse and Alcoholism started making efforts to garner scientific and public attention on gender issues.[3] Subsequently, with the feminization of HIV epidemic and the obvious role of drug use in catalyzing its spread, focus on women and substance use became necessary.

Worldwide, alcohol use in women has received the widest attention. While problems related to illicit substance use and their treatment mirror the issues related to alcohol use in many ways, important differences also do exist, warranting need for independent research. The singular theme that cuts across any substance use in women in any country, however, is the intense stigma suffered by these women, which acts as a significant barrier to treatment and encourages the victimization of drug using women.[2] This review attempts to highlight such problems unique to substance using women, as knowledge of such issues is necessary for developing effective services and planning appropriate interventions.[4]

EPIDEMIOLOGY

Gender differences in substance use have been consistently observed in the west, in general population as well as in the treatment-seeking samples, with men exhibiting significantly higher rates of substance use, abuse, and dependence.[5,6] The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; n = 43,093) conducted in the US reported that men were 2.2 times more likely than women to have abused various substances and 1.9 times more likely to have substance dependence.[6] Data from the National Household Survey on Drug Abuse (NHSDA) in 2000 from US similarly showed that 5% of women, as compared to 7.7% men, presently used illicit substances. However, studies suggest that in the last couple of decades, this gender gap has narrowed.[7] Compared to the surveys of 1980s that reported 5:1 male/female ratio of alcohol-use disorders,[8] the ratio dropped to approximately 3:1 in a 2007 survey.[9] Further, in a recent 2012 study amongst 41.5 million illicit drug users, more than 42% were women, suggesting a male/female ratio of 1.4:1 at the present time.[10] In case of prescription drug abuse, several studies actually report their use to be higher in women than men, particularly for narcotic analgesics and tranquilizers.[11] Other alarming features brought to light by the NHSDA include the fact that rates of substance use were almost similar between girls and boys in the age groups of 12–17 years (9.5% vs. 9.8%) and tobacco use was higher in these adolescent girls (14.1% vs. 12.8%, respectively). While drug abuse significantly decreased as boys grew older (year-over-year reduction), the same was not seen in girls.[12]

The relative proportion of various drugs used by females varies from region to region. In “wet” culture countries like the US, alcohol use by women has more social acceptance, but for other drugs women have always represented a minority.[13] In “dry” culture country like India, rates consumption of alcohol is far less as compared to the west. The GENECIS study reported that 5.9% of females consumed alcohol at least once in the past year, as compared to 32.7% of men.[14] Direct comparison of most other drug use is not possible as no national level survey on substance abuse in women has been conducted in our country. The earliest national studies dating back to 1980s report negligible drug use rates among women with alcohol use in 3.2%, and barbiturates, cannabis, heroin, pethidine, morphine use in as low as 0.1–0.3% of women.[15,16,17] Four large epidemiological studies in the early 1990s, with sample sizes varying from 4000 to 30,000, revealed that 6–8% of women had ever used drugs in their lifetime.[15,18,19,20] North-Eastern States were an exception even then, where heroin use in women was found to be high at 14%.[20] With the NDPS (Narcotic Drugs and Psychotropic Substances) act criminalizing traditional opium and surge of smuggled heroin from Afghanistan, the 1990s also witnessed an increase in use of heroin among women. Multiple studies document increased heroin use in large cities like Mumbai,[21] Kolkota,[22] and Delhi,[23] during this time.

The only national epidemiological surveys of the country: “National Survey on Extent, Pattern and Trends of Drug Abuse in India” of 2001; sadly focused only on males. An exploratory “Rapid assessment survey (RAS study)” component of the same survey which used nonrandom sampling to collect information on drug-use from 14 cities of India and found that around 7.9% of women across cities used at least one type of substance. Heroin, alcohol, cannabis, and pain-killers were the dominant substances of abuse. Another component of the national survey, called “Focused thematic study on drug abuse among women (Women's study)” using snowballing sampling technique, interviewed 75 women substance users from Mumbai, Delhi, and Aizawl. The women's study is significant as it reported high rates of opioid and alcohol use in women substance users with an alarming 40% women reporting lifetime history of Injection drug use.[24]

A recent study focusing exclusively on substance using women which merit mention is the substance, women, and high-risk assessment study. The survey focused specifically on women in 110 Non-Governmental Organizations across the country,[25] and interviewed more than 6000 women which included both female substance users (FSUs) as well as female partners of male substance users. The study reported high rates of alcohol, cannabis, opioids, injection use as well as the use of solvents, which was hitherto unreported in Indian women. In addition, mean age of initiation for solvent use was found to precede even that of nicotine (16.5 vs. 18.4 years), thereby becoming the “gateway drug” in many cases.

In addition to these large-scale studies, several smaller reports look into various aspects of drug using females in India, which are detailed in Table 1. Data from the addiction treatment centers also report an increase in the number of women seeking treatment, which parallels the national trends in terms of high number of opioid users followed by alcohol and tobacco.[29,33]

Table 1.

Indian studies on substance use prevalence and patterns in past decade

Table 1 presents the studies on substance use in women in past decade.

RISK FACTORS ASSOCIATED WITH SUBSTANCE USE

Biological factors

Gender differences in neuroendocrine adaptations to stress and reward systems are known to mediate women's susceptibility to both substance use patterns as well as relapses.[36] Studies have reported that, among women substance-users, attenuated neuroendocrine stress response (that is, blunted adrenocorticotropic hormone and cortisol) is found following exposure to stress and drug cues and this hypothalamic-pituitary-adrenocortical dysregulation in females may be a key to enhanced vulnerability to relapse in response to negative affect.[37,38]

In terms of gender differences in the physiological effects, alcohol has been the most widely studied substance. The ovarian steroid hormones (e.g., estrogen, progesterone), metabolites of progesterone, and negative allosteric modulators of the γ-aminobutyric acid A receptor like dehydroepiandrostenedione are found to influence the behavioral effects of substances.[39,40] As compared to men, women are known to become intoxicated after consuming smaller quantities of alcohol indicating that women achieve higher blood alcohol concentrations (BACs) after consumption of the equivalent amount of alcohol. This may be due to less body water in comparison to size. In addition, lower levels of alcohol dehydrogenase enzymes in the stomach result in a higher amount of alcohol in the systemic circulation. Low antidiuretic hormone effect is reported to be more prominent with beverages of higher alcohol content,[41] so that among chronic alcoholic women virtually all the alcohol consumed tends to get absorbed. However, these gender difference tends to disappear in females older than 50 years.[42] Additionally, unlike the predictable and reproducible peak BACs in men, unpredictable day-to-day variability with higher peaks in the premenstrual phase has been observed in women.[43] Interestingly, women meeting the diagnostic criteria for the premenstrual syndrome are found to drink more heavily than controls and have higher rates of abuse and dependence.[44] Conversely, increased alcohol consumption during the premenstrual phase is associated with higher premenstrual symptomatology.[45]

Research is sparse for the biological difference in response in women for other addictive substances and is often limited to animal studies. For nicotine, even though women smoke similar numbers of cigarettes daily, heavy smokers exhibit lower nicotine plasma levels and also show greater exposure to smoke reflecting the need for more and larger puffs to achieve the same nicotine intake. This may be implicated in observed gender differences of smoking-related medical consequences.[46] Like alcohol, studies on female nicotine users showed a potential greater saliency in the luteal phase of the cycle.[40,47]

In animal studies, researchers have found sex-related differences of cannabis on corticotropin-releasing hormone and proopiomelanocortin gene expression in the hypothalamus in female rats.[48] Whether or not these differences also exist in humans is as yet unknown. With opiates, women report higher rates of nausea and analgesia than do men,[49] and it is suggested that the interaction between opiate receptors and sexual hormone receptors may be implicated in gender differences observed in the magnitude and potency of opiate response.

Genetic and environmental factors

Irrespective of gender, twin and adoption studies suggest robust role of genetic factors in the causation of addiction. However, genetic influences seem to be greater for men (heritability of 33% for men and 11% for women).[50,51] In women, initiation of illicit substances is found to be shaped more by environmental factors, whereas progression to abuse or dependence is determined by genetic influences.[52,53] Across cultures, the most important environmental factor that influenced drinking in women was found to be alcohol use or abuse by spouse or another close family member and either the women was coerced into drinking or started using alcohol to give company to their partners.[25,54,55] In the Women's study from the National Survey, the primary reasons reported by the women for initiating substance use were influence of friends (48%), stress and tension (16%), and influence of spouse or partner (11%).[24] Apart from a substance using family member or friend, having specific vulnerability such as transition and lifestyle changes increasing the risk of drug abuse in women have also been reported in various studies.[29,33,55] The evidence implies the important role of environmental influences in association with genetic factors in the development of drug abuse in females.

Psychological factors and psychiatric comorbidities

Co-morbid psychological factors have been strongly implicated in women with substance use disorders irrespective of the type of substance used.[56,57] History of early traumatic life events may precipitate the development of substance-use disorders in later life and studies report the lifetime prevalence of substance use to be 4 times higher in women with a history of sexual assault.[58] A population-based study in 1411 adult female twins reported a relationship between the severity of self-reported childhood sexual abuse and risk for developing drug dependence with those reporting genital intercourse comprising the highest risk group.[59] A more recent study of women who had experienced sexual assault as an adult (n = 1863) reported substance as a coping strategy for the resultant posttraumatic stress disorder (PTSD).[60] Significant association between substance use and major depression in women has also been reported,[61] with studies suggesting an odds ratio for developing alcohol abuse or dependence of 4.1 for females as compared to 2.67 for males with major depression. Rates of suicide attempts are also significantly higher in drug-dependent women.[62] The national survey on drug use and health (n = 133,221 adults) reported that though both genders were likely to have higher prevalence of anxiety disorder, only drug using women were more likely to have major depressive disorder as compared to men.[63] Secondary analysis of the NESARC revealed that drug using women were more likely to have mood and anxiety disorders; were at a greater risk for developing externalizing disorder and also experienced “telescoping” effects.[64,65] Eating disorders are also commonly found in women with substance use disorders.[66] A review of clinical populations reported that about 40% women reported comorbid lifetime eating disorders.[67] Among women with bulimia or binge-eating disorders, rates of substance use were higher in those with a history of physical or sexual abuse.[68]

Indian studies on treatment-seeking women users have found similar results with co-morbid depressive disorders in 12%, adjustment disorder in 5%, somatoform disorder in 3%, anxiety disorder in 2%, schizophrenia in 2%, obsessive compulsive disorder in 1% and bipolar affective disorder in 1%.[33] Similarly, from the national survey, the RAS respondents reported several psychological problems like insomnia, depression, anxiety, suicidal attempts and guilt feelings.[24]

Sociocultural factors

Social perception of women who use alcohol can be understood within the context of the relational model.[69] Society expects a woman to a wife, a mother, caretaker, sexual partner, and nurturer, and when she deviates from these prescribed roles, she tends to face stigma and discrimination. Thus, alcohol use in women is linked with sexual misconduct, promiscuity, and neglect of children and significant others, a set of conditions that cause stigma and social discrimination.[70] Early initiation into sex and forced or coercive sex to support drug use habit, also puts them at conflict with law resulting in harassment by both hardened criminals as well as police.[24]

In contrast to males, where substance use may affect occupation, women report more problems in family and social domains. FSUs are more likely to get separated or divorced than their male counterparts. Key informant interviews in the women's study of the national survey revealed that 31% of the women across the sites were single, and 32% were separated or divorced. FSUs in the RAS study were also mostly single and reported an early onset of substance use as well as high levels of alcohol and substance use in their families. The family attitude was generally harsh or indifferent to them, and domestic violence was frequently reported. Moreover, factors like poor education status, lack of job, young age at work, early marriage, and lack of social support increased vulnerability of such females.[24]

INITIATION AND COURSE OF SUBSTANCE USE IN WOMEN

Initiation of alcohol and substance use

The reasons for initiation of substance use among adolescent girls have been studied predominantly in Western cultures. Commonly cited reasons for initiation include adolescent depression, problems in adjustment, hanging out with older male friends, peer pressure, feeling of a sense of glamor and power, and disappearing stereotypes about femininity.[55] Research suggests that, while many of these reasons may be gender neutral, some factors like puberty may affect girls more than boys. A study on Latino females aged 14–24 years (n = 1411) receiving services from family planning clinic in California reported that cultural factors like nontraditional families and acculturation influenced initiation to tobacco use.[71] Another study, which determined critical incidents that contributed to initiation of substance use among women, reported family factors, social/environmental factors, life stresses, relationship issues, abuse, and peer pressure as contributory.[72]

Indian studies report elder males (friend, family member or spouse) as a common initiating agent.[33,35] Certain occupations such as sex work and working in alcohol joints, also served as risk factors for initiation of alcohol or substance use.[34,73] Curiosity and alleviation of stress or physical pains also emerged as important factors in some studies.[29,33] Positive expectancies regarding benefits of alcohol use like alleviation of depressed mood have also been cited. Older women were found to initiate alcohol as it was believed to have major restorative properties after childbirth.[55]

Course of alcohol and substance use

Unlike men, women seem to progress faster between landmarks associated with the developmental course of alcoholism (e.g., regular drinking or loss of control) and tend to experience greater medical, physiological and psychological impairment earlier in their drinking career. This accelerated progression of alcoholism in women is commonly referred to as “telescoping”[74,75] and is consistently observed in studies investigating gender and substance-use disorders. Thus, it has been observed that when women enter substance abuse treatment, they typically present with a more severe clinical profile than men, despite lesser frequency as well as the quantity of alcohol use.[76] Similar evidence have been reported for other substances like tobacco, opioids, and cocaine.[77,78] Studies have reported that, as compared to men, women use smaller amounts of heroin, use it for shorter periods of time, and are more likely to inhale it.[66,79] For cannabis, no gender differences in patterns of use were found in a large Australian survey of adolescents.[80] However, others report that as compared to men, women are initiate cannabis later[81] and use it occasionally.[82]

CONSEQUENCES OF ALCOHOL AND SUBSTANCE USE IN WOMEN

Health consequences

Women tend to develop alcohol liver disease with comparatively shorter duration and less amount of alcohol consumption than men; more women die from cirrhosis than men. Heavy alcohol consumption may also be associated with increased risk of menstrual disturbances, infertility and breast cancer. In women, alcohol intake is also found to be associated with higher risk for hypertension, overall cardiovascular mortality,[83] and subarachnoid hemorrhage,[84] an effect that seems to be related to lower levels of serum ionized magnesium.[85] Prolonged heavy drinking is also known to be an etiologic factor in many diseases of the gastrointestinal, neuromuscular, cardiovascular, and other body systems,[86] which women may develop more rapidly than men.

Similar findings have been reported in the Indian studies wherein women drug users were found to develop more severe pneumonia, rupture of lungs and tuberculosis (TB), hepatitis, HIV, and other adverse effects of AIDS.[87] Both the RAS and the women's study in the National Survey found several physical complications like sexually transmitted diseases (STDs), abscess, TB, irregular menstrual cycles, amenorrhea, and medical termination of pregnancy.[24]

The role of alcohol and substance use disorders in the spread of STDs has been highlighted by the AIDS epidemic. Alcohol consumption in heterosexual women was associated with less condom use and other high-risk sexual behaviors, posing additional risk of getting infected.[88] In Indian studies too, women drug users are reported to engage in unsafe practices more frequently. Moreover, while many women indulge in sex to sustain their alcohol and drug use habits, studies from sex-workers report that many of the female sex workers use alcohol and substances before sexual activity.[34,89]

Legal consequences

Although, as compared to males, criminal activity is less observed in substance using females, existing data indicate that dependency on drugs and increased vulnerability makes women more prone to participate in drug-related crimes. In the RAS component of National Survey, India, 7–20% of women substance users reported several legal problems due to drug abuse viz., being in a police lock up or prison. Almost 44% of the women in the women's study reported a history of incarcerations due to their peddling activities, sex work, pick-pocketing and theft charges.[24] These issues from the Indian studies reflect a global truth of more victimization of female drug users.

Social and familial consequences

As compared to men, women generally face poorer social support.[54] Social consequences of alcohol and substance use can range from interpersonal difficulties to homelessness, unemployment, poverty, and a general disengagement from the communities.[90] Women's study of the National Survey found that not only many FSUs were separated or divorced, but they also faced harsher treatment from family and were at increased risks for physical and verbal abuse.[24] Similar results have also been noted in women seeking treatment for de-addiction.[29,33]

TREATMENT PROCESS

The treatment process can be understood at three different levels: (1) Treatment entry and treatment seeking, (2) retention, and (3) treatment outcome.

Treatment entry and treatment-seeking

Western studies indicate that relatively low proportion of women enter substance abuse treatment programs.[91,92] The ratio of treatment seeking men to women was found to be 3.3:1 in alcohol treatment facilities while, for that time-period, the male/female ratio of alcohol use disorders in the population was estimated to be 2.7:1.[93,94] Similarly, the Australian National Household Survey showed a 2:1 ratio of high-risk drinking in males and females in the general population, but estimates of ratios of men to women in alcohol treatment services were found to range from 3:1 to 10:1.[95]

No gender differences were found in studies which looked at short time periods following disease onset (for example, 1–8 years), or those using broad definitions of treatment-entry (for example, ever consulting a professional).[96,97,98] Surveys that examined a longer period (>8 years) demonstrated a lower lifetime probability of women ever entering treatment for alcohol use disorders as compared to men.[93]

In India, data from treatment centers of Delhi, Jodhpur and Lucknow between 1989 and 1991 found 1–3% of treatment seekers to be female. Similarly, the Drug Abuse Monitoring System reports about 2.3–3% of new treatment seekers to be women.[24,99]

A retrospective analysis of all substance use cases registered in the de-addiction center at Chandigarh between 1978 and 2008 revealed that out of 6608 only 0.5% were females.[100]

Certain systemic, physical, social, and personal barriers are considered responsible for low rates of treatment-seeking among women.[101] Systemic Barriers include: Lack of decision making power in women, limited knowledge among the professionals due to lack of proper studies; lack of appropriate gender-specific treatment models; lack of appropriate treatment models to address co-morbid psychiatric disorders. Physical or structural barriers include: Lack of services for pregnant women; location and cost of treatment; rigid program schedules; lack of provision for female inpatient ward; lack of physical safety at treatment centers; fear of losing custody of children, fear of prosecution; lack of childcare outside of treatment or provided as part of treatment services. Social cultural and personal barriers include: Disadvantaged life circumstances; stigma, shame and guilt; lack of support from family; responsibilities at home; decreased perception of need for treatment and less education about treatment as a viable option.[98,102,103,104,105,106] Perhaps, stigma is the most important barrier to treatment-seeking, which is further compounded by a lack of gender focus in the substance abuse treatment delivery models, the staff not being trained in gender sensitive issues, a lack of resources for women and negative attitudes toward women drug users.[103,107] However, it has also been reported that once women enter treatment, no gender differences are observed.[107]

Treatment retention

In general, longer treatment episodes and successful completion of treatment are related to positive outcomes. However, as many as 50% of patients in substance use treatment programs tend to drop out within the 1^st month of treatment. Studies that have examined gender differences in substance abuse treatment retention and completion show inconsistent results. A longitudinal study (1996–1999) conducted in both public and private substance abuse treatment facilities (The Alcohol and Drug Service Study (ADSS)) in US, included data from 4689 individuals (including 1239 women) and found that after controlling for client and facility characteristics, gender was not associated with completion of planned treatment. Rather, factors like education level, primary source of referral for treatment, primary expected source of payment for treatment, and type of facility were associated more with treatment completion.[108]

A retrospective chart-review of individuals (1804 men and 667 women) seeking public-funded substance abuse treatment in Detroit found that female patients had significantly lower retention as well as treatment-completion rates, than male patients, even after controlling for problem severity, primary drug of abuse, and referred treatment setting.[109] In contrast a Los Angeles County study (n = 511) reported that female patients completed more months of formal treatment programs, as compared to men, and no gender-difference were found in 12-step self-help program participation duration.[110]

Over the years, studies have also attempted to look into certain characteristics that that may be associated with treatment retention and completion, specifically for each gender and those that may be applicable to both. Gender-neutral factors like having good financial resources and having fewer mental health problems,[111] having less-severe substance use problems,[112] being employed,[113] older age,[114] and referral from criminal justice system[112] results in better outcome. In women, treatment completion was predicted by legal or agency referral and higher income; failure to complete treatment was predicted in women by more severe substance dependence and higher employment scores.[111] Studies using women-only samples have reported associations between psychological function, personal stability and social support, levels of anger, treatment beliefs, and referral source with the rates of treatment-retention and completion.[111] On similar lines, Kelly et al. reported that among women attending a women-centered program, factors such as having fewer children, higher levels of personal stability, less involvement with child, protective services, and fewer family problems predicted higher treatment completion.[115]

Apart from individual characteristics, treatment-characteristics are also associated with retention rates among women. The Alcohol and Drug Service Study reported that women-only facilities or those with childcare services did not affect treatment completion, though it did influence length of stay. Completion was improved by programs providing nonhospital residential facility or those providing combined treatment for mental health and substance abuse.[108] In contrast, a review of 38 studies concluded that women have the best response when they attend women-only programs rather than mixed-gender programs.[116] A flexible philosophy, friendly staff, women only space, home visits, and childcare are the factors that have been found to ensure treatment continuation in studies from the developed world. Networking to handle issues like HIV and pregnancy, focus on empowerment (educational, vocational, life-skills) and addressing policies or laws discriminatory to women needs to be implemented.[25]

Treatment outcome

There is little research to indicate the best way to treat substance use in women. Though, there are concerns regarding the effectiveness of substance abuse treatment for women,[117,118] various studies have found few or no gender differences in treatment outcome across various populations.[107] In a study by Hser et al., no overall gender differences was found in 1-year drug and alcohol treatment outcomes, however some gender-specific baseline predictors of treatment outcomes like use of multiple drugs, readiness for treatment, and spousal drug use were reported.[119] Studies that have used relapse as a measure of outcome have reported better outcome for women as compared to men.[107] Findings from project MATCH revealed that women not only have fewer chances of relapse but also more willingly sought help following a relapse and speculated the findings of gender by treatment modality to have an effect on the outcome.[120]

Generally, studies focusing on the association of treatment completion and outcome have indicated that treatment completion is associated with better outcomes, irrespective of gender.[121] In a study of patients recruited from drug treatment programs in Los Angeles County,[119] longer treatment retention was associated with drug abstinence and crime desistence for both men and women at 1-year follow-up. However, another study reported that women who completed treatment were 9 times as likely to be abstinent for 30 days at 7 months follow-up, while men who completed treatment were only 3 times as likely to be abstinent.[122]

Clinicians do agree that sensitivity to women's special needs and problems is critical to treatment success and some of the specific issues related to outcome may be: Co-occurring psychiatric disorders, history of victimization, therapist-patient gender matching, and social factors.[123]

Having a psychiatric comorbidity, in general, tend to predict poorer treatment outcomes, irrespective of gender, wherein the outcome was measured by total number of drinking days, greater intensity of drinking, more craving, increased likelihood of having a pathological pattern of alcohol use, and more withdrawal symptoms.[124] A prospective study studied the effects of depression on drinking outcomes among in-patients being treated for alcohol dependence and again did not find a gender difference in association between depression and time to first drink; they did, however, found that a diagnosis of major depression was associated with shorter time to first drink for both males and females.[125] On similar lines, two studies of the association of a diagnosis of antisocial personality disorders reported that, regardless of the gender, this co-occurring diagnosis was related to poor treatment outcome.[126,127]

Thus, it has been consistently found that the presence of co-morbid psychiatric disorders has a negative impact on substance abuse treatment response regardless of gender. However, some studies do give contrasting information in this regard. Benishek et al.[128] assessed more than 500 patients at intake and follow-up and found that a global measure of psychopathology was predictive of more alcohol problems 6 months posttreatment for women, but not for men. In studies using women-only sample, it has been seen that among women with substance use disorders, presence of co-morbid psychiatric disorders (effective or anxiety-related) or greater severity of PTSD, at baseline, predicted relapse during 6 months follow-up.[129,130] Surprisingly, a 1-year follow-up study in Germany found that though men with or without co-morbid psychiatric disorder had similar relapse rates, women with co-morbid psychiatric disorders had a lower rate of relapse as compared to women with no co-morbidity.[131] It has been hypothesized that women with co-occurring depression and alcohol use disorders may have more severe depression and less severe alcohol dependence as compared to men with both the disorders and hence the difference in the outcome.[132] Co-morbid eating disorder and its impact on treatment outcome are an area less explored in this regard despite the fact that they are commonly reported co-morbid conditions in treatment-seeking women.[133,134]

Victimization and abuse also tend to predict treatment outcomes, and the association has been reported between abuse and shorter time to first drink and relapse, regardless of the gender.[135] However, this association disappeared after accounting for other factors like marital status, education, employment, and co-morbid psychiatric disorders. The Women, Co-occurring Disorders, and Violence Study, a quasi-experimental, multi-site cooperative study reported that certain individual-related variables, such as drug/alcohol use problem severity, mental health status, lifetime and current exposure to abuse and other stressful events predicted outcomes independent of intervention condition. They have also provided some evidence that comprehensive integrated services may be more effective treatment for women with co-occurring substance and psychiatric disorders and histories of physical/sexual abuse.[136,137,138,139]

Matching of therapist and client gender have also generated mixed results, with some studies not finding any effect on treatment-outcome,[140,141] while others reporting better outcomes in terms of abstinence.[142,143]

Other studies have sought social factors that might influence treatment outcome. MacDonald followed 93 alcoholic women for 1-year after inpatient treatment and found that the number of life problems and the number of supportive relationships were the best predictors of favorable outcome. Being married was less important as a predictor than the supportive quality of the patient's marriage.[144] Similar results have been reported by Havassy et al.,[145] who found a relationship between social support and time abstinent after detoxification from alcohol, methadone, and tobacco.

Thus, it can be said that both men and women benefit from the substance abuse treatment and that gender alone is not a predictor of outcome. However, certain characteristics of individuals, sub-groups of individuals, and treatment approaches may have a differential impact on treatment-related outcomes by gender.

GAPS IN KNOWLEDGE

Over the years, Western countries have recognized the need to study and address the issues pertaining to FSUs. However, in India, there is still a lack of research-based information on all aspects of women's substance use and related problems, including pattern and prevalence, physiological and psychosocial effects and consequences, characteristics of women with substance use problems, and their treatment experiences. Thus, drug abuse among women needs to be studied in a more systematic fashion using both qualitative and quantitative methods of research and through multi-centered studies.

SUMMARY AND FUTURE DIRECTIONS

Although predominantly thought to be a male phenomenon, drug abuse exists among women and in current urban settings appears to be associated with patterns of drug abuse similar to that of men. Though drug use generally starts later in women or is iatrogenically introduced, it follows a more rapid downhill course, with rapid progression through the stages of dependence and with more associated psychological and physical morbidity. The stigma of being a “fallen angel” makes these women an easy victim to the ills of the society and prevents them from seeking help early in the course of the illness. Stigma drives them to darkness, forcing them to resort to higher-risk behaviors of unsafe injecting and unsafe sexual practices. Though involvement in criminal activity and drug pedaling is less than it is in males, commercial or forced sexual activity to sustain drug use often brings them at conflict with law with all its ramifications, apart from the obvious health hazards of such behaviors. Social and familial support is minimal for them and particularly so if the spouse is nondrug using partner. When women do come forward for treatment, they are faced with the lack of gender-sensitive treatment programs and flexible treatment delivery systems that account for their limitations and increased home responsibilities. Many thus are left with no choice but to continue drug use in even more dangerous patterns without any hope for future. Thus, there is an urgent need for treatment and prevention approaches to consider the problem of drug abuse impact on women from all these angles, as well as from the context of empowerment, support, and de-stigmatization of women. It is thus imperative to evolve a focused policy to address gender issues in relation to drug abuse and to develop treatment modalities that are gender-responsive or sensitive to needs of women, such as counseling, family therapy. Ancillary services such as transportation, child-care, housing, vocational training, and diverse cultural contexts need to be taken care of. Only then will the country be able to provide its women drug user a ray of hope.