The sociodemographic profile and the challenges associated with treatment and rehabilitation in female heroin users: A case series from Northeast India

Abstract

Females with opioid use disorder (OUD) rarely seek help for addiction. We present a series of seven females with OUD attending a tertiary care addiction treatment setting in Assam between December 2022 to August 2023. Most of the patients were primary-educated, young adults, housewives, from lower to middle socioeconomic strata, and were residents of rural or semi-urban areas. All were married, and around half of them were separated. All the patients were dependent on heroin and tobacco. Five of them initiated heroin use while modeling their spouse. Three patients were injecting heroin, and one was seropositive with both HCV and HIV. Five patients received sublingual buprenorphine-naloxone, and three of them followed up subsequently. Financial difficulty, poor family support, and intimate partner violence were major challenges for treatment-seeking and regular follow-up. This case series highlights the need for systematic study and gender-responsive care of females with OUD in Assam.

INTRODUCTION

Opioid use disorder (OUD) among women is frequently underestimated, often stemming from the misconception that a negligible proportion of women use substances. A national survey in India showed the prevalence of opioid use in females and males was 0.2% and 4%, respectively.[1] While these figures may disrate OUD in females, we must acknowledge that substance using females in India constitute a largely concealed population, bearing the burden of the illness yet seldom seeking treatment.[2]

Limited studies on female OUD in India reveal distinct characteristics among female injection drug users (IDUs). Compared to males, they were less educated, unemployed, engaged in sex work, had a faster transition to injecting drugs, and had more high-risk injection practices.[3,4] These gender-specific differences underscore the need for tailored interventions. Hence, the IDU Strategy Report for National AIDS Control Programme (NACP) IV planning emphasizes the importance of understanding this population's profile and specific issues.[5]

To the best of our knowledge, no published report on this population from Assam exists. Our center, a tertiary-care psychiatric institute in Assam, has had 11 treatment-seeking females among the 1,500 new OUD patients since December 2022. This report presents a case series of seven patients who consented to participate. The institutional ethical committee approved the study (vide no.—IEC/2022/07/16). The series aims to outline the sociodemographic and clinical profile of treatment-seeking females in this region and discuss their unique treatment and recovery challenges.

CASE SERIES

This series presents seven women with OUD from diverse backgrounds in rural Assam.

Case 1: Mrs. M (25 years)

Mrs. M, a Muslim housewife, initiated chasing heroin seven months ago. Her struggles with withdrawal and tolerance were complicated by a recent diagnosis of type 2 diabetes mellitus. Despite facing financial challenges, she and her husband enrolled in buprenorphine maintenance treatment. Unfortunately, they missed follow-up appointments.

Case 2: Mrs. R (26 years)

A homemaker introduced to heroin by a friend, Mrs. R's OUD escalated when she resorted to mortgaging jewelry for drugs. Despite enduring abuse from her husband, also an opioid user, she continued injecting heroin throughout pregnancy. Seeking treatment in June 2023, the patient, along with her husband, diligently followed up after receiving an 8-mg/day buprenorphine prescription.

Case 3: Mrs. S (25 years)

Divorced and unemployed, Mrs. S's three-year journey with injecting heroin began under the influence of her ex-husband. Despite attempts to abstain, she relapsed due to withdrawal and craving. Tramadol-assisted withdrawal management in June 2023 did not lead to follow-up, indicating the challenges of sustained recovery.

Case 4: Mrs. J (27 years)

An illiterate housewife in her second marriage, the patient's initiation to chasing heroin with her present husband led to financial difficulties. Seeking treatment in July 2023, she and her husband actively followed up, highlighting the potential for support in partner-based interventions.

Case 5: Ms. N (18 years)

A single mother started injecting heroin in Kerala, leading to conflicts and separation. Initiating buprenorphine treatment in August 2023, she faced challenges in follow-up, shedding light on the complexities of treating younger, single individuals.

Case 6: Ms. H (34 years)

The patient started chasing heroin, consuming alcohol, and smoking occasionally, influenced by her ex-spouse. She sought treatment in August 2023. Experiencing a relapse after a month, she has been on regular follow-up, emphasizing the persistence required in managing OUD.

Case 7: Mrs. A (36 years)

Mrs. A, a married vendor, turned to chase heroin three years ago to cope with conflicts. Seeking treatment in August 2023, she was prescribed clonidine and tramadol. Owing to poor family support, keeping her in the treatment loop was unsuccessful. See Table 1 for details.

Table 1.

Sociodemographic and clinical details of the female patients with OUD

Parameters	Case 1 (M)	Case 2 (R)	Case 3 (S)	Case 4 (J)	Case 5 (N)	Case 6 (H)	Case 7 (A)
Age (years)	25	26	25	27	18	34	36
Marital status/education/employment	Married/primary education/housewife	Married/primary education/housewife	Divorced/6th standard/unemployed	Married/no formal education/housewife	Separated/primary education/unemployed	Separated/no formal education/unskilled laborer (housemaid)	Married/primary education/vendor
Family income (INR)	15,000	15,000	14,000	12,000	9,000	16,000	20,000
Residence and distance from hospital (km)	Nagaon (around 53 km)	Nagaon (around 98 km)	Morigaon (around 105 km)	Nagaon (around 50 km)	Nagaon (around 113 km)	Nagaon (around 48 km)	Nagaon (around 64 km)
Age of onset (years); duration of opioid dependence	25 years; 7 months	24 years; 27 months	22 years; 36 months	26 years; 7 months	17 years; 12 months	33 years; 12 months	33 years; 36 months
Intake route	Chasing	Intravenous	Intravenous	Chasing	Intravenous	Chasing	Chasing
Average daily use	2 containers*	5 containers*	5 containers*	2 containers*	5 containers*	2 containers*	3 containers*
Concomitant substance use	Tobacco	Tobacco'around 6 cigarettes and alcohol 4 units/day	Tobacco two bidis/day	Tobacco 20 bidis/day	Tobacco 4 bidis/day	Tobacco around three bidis/day	Tobacco around three bidis/day
Comorbidity	Type 2 diabetes mellitus	HIV, HCV positive	RPR reactive	Nil	Nil	Borderline traits	Asthma
Treatment prescribed	T. BNX (2/0.5 mg) 1/day sublingual	T. BNX (2/0.5 mg) 4/day sublingual; T. Amitriptyline (25 mg) at bedtime	T. Tramadol 400 mg (tapering), T. clonidine (0.1 mg) HS	T. BNX (2/0.5 mg) 2/day sublingual	T. BNX (2/0.5 mg) 2/day sublingual	T. BNX (2/0.5 mg) 2/day sublingual; T. amitriptyline (25 mg) at bedtime	Cap. tramadol 300 mg; T. clonidine (0.1 mg); T. clonazepam 0.5 mg
Duration of regular follow-up	No follow-up	2 weeks from registration, 4 follow-ups	No follow-up	2 months 1 week from registration, 5 follow-ups	No follow-up	12 weeks from registration, 7 follow-ups	No follow-up
Reasons for relapse	Lack of family support Peer pressure Craving for the drug	Poor family support Poor understanding about IDU consequences	Lack of family support Craving	Maintaining well on regular follow-up for the last 2 months along with husband	Lack of family support Peer pressure Lack of motivation	Poor family support Lack of motivation Craving	Poor family support; no supervision; craving
Other psychosocial issues	Mortgaged jewelry and personal belongings to procure heroin In-laws expelled her for drug use	Alcohol dependence in father H/O domestic abuse by husband and in-laws for taking drugs	Divorced Currently unemployed	Mortgaged personal belongings to procure drugs Adequate support from in-laws and extended family	Broken family (parents divorced) Physical and psychological abuse by husband Single parent to 1-month-old baby	H/O intimate partner violence and forced sexual intercourse under intoxication by husband. Currently divorced with 2 children	Family members unaware of drug abuse Mortgaged jewelry
Psychosocial intervention	Information regarding harms of IDU Psychoeducation regarding OAT	Information regarding harms of IDU Family therapy planned for intimate partner violence	Information regarding harms of IDU	Information regarding harms of IDU, as part of harm reduction Psychoeducation regarding OAT	Information regarding harms of IDU Psychoeducation regarding OAT	Information regarding harms of IDU, as part of harm reduction Psychoeducation regarding OAT Family therapy planned	Information regarding harms of IDU, as part of harm reduction Psychoeducation regarding OAT

*1 container'approximately 250–400 mg. BNX=buprenorphine–naloxone, INR=Indian national rupees, HIV=human immunodeficiency virus, HCV=hepatitis C virus, RPR=rapid plasma regain, IDU=injection drug use, OAT=opioid agonist treatment

DISCUSSION

The nationwide survey in India has revealed a rising trend in heroin use. The study also highlights poor treatment-seeking, which is notably lower among female OUDs.[1] The registration of 11 female patients within nine months underscores a significant population of females with OUD requiring attention. Notably, six patients from a single district (Nagaon) suggest a potential high prevalence of OUD that has been overlooked. A tertiary-care addiction treatment facility in Chandigarh registered only 21 female OUD patients over three decades.[6]

These cases reveal common characteristics: OUD among teenage to young adult women with lower education, economic dependence, and residence in rural or semiurban areas of Assam. These findings align with studies in Northeast India, including Manipur and Nagaland.[4,5,6,7]

The predominant issue is the disadvantaged socio-economic status of the study population; five of seven patients belonged to lower socioeconomic strata; the majority were less educated and unemployed. Studies across the world revealed that lower literacy and harsh socioeconomic conditions are common in substance-using females, especially hailing from developing countries. The socio-economic vulnerability may increase risk-taking, high-risk IDU, limited treatment-seeking, and poor treatment engagement.[4,8]

A study of 31 female prescription opioid users in northern India reported that more than two-thirds were introduced to opioids iatrogenically for pain relief. Psychiatric diagnoses included depression and somatoform disorder.[9] These findings contrast with our case series, where heroin-dependent patients initiated use out of curiosity/peer pressure, reporting no pain disorder or psychiatric comorbidities. This showed the contrast between heroin and prescription opioid users.

The case series highlights concern about injection drug use in nearly half of the patients, influenced by economic constraints, socioeconomic status, partner modeling, and impulsivity in young adults. To address this, we routinely provide information regarding the potential risks of IDU to all OUD patients, irrespective of their mode of substance use. Incorporation of low-threshold harm reduction counseling in the management of OUD can prevent the spread of blood-borne viral infection. One patient faces HIV and hepatitis C co-infection. Recognizing female IDUs and their partners as a distinct entity, National AIDS Control Organization (NACO) aims to address gender responsiveness in the NACP IV.[5]

Three out of seven female patients are separated, contrasting sharply with their male counterparts’ low separation rate (3%). A nationwide study on women's substance use supports this gender difference in separation rate.[8] Women with substance use encounter higher social stigma, domestic violence, and less family support across the globe, especially in developing countries like India.[7,8,10] Six out of seven cases lacked family support, and four of them did not follow up after the initial visit. There is an urgent need of psychosocial intervention tailored to meet the unmet socioeconomic need for these patients. The interventions oriented toward housing, employment, financial, and social supports are more commonly available in Western countries.[8] To enhance female opioid users’ treatment, facilities need to be extended closer, integrating community and healthcare resources. Notably, buprenorphine showed better retention (three out of five) than tramadol-assisted withdrawal management.

Clinical implications

This case series reveals our experiences with OUD in females. Women in early adulthood initiated heroin use under diverse circumstances. The average duration of opioid use ranged from several months to years, with individuals facing challenges such as withdrawal, relapse, and poor treatment adherence. Some individuals diligently followed up with treatment, while the majority disengaged due to financial difficulties and lack of family support. This case series, limited to a single center, reduces its generalizability, and the lack of qualitative inquiry into patient perspectives impedes a thorough understanding and contextual insight. Still, these cases highlight the complexity of female OUD and underscore the importance of tailored interventions to address individual needs and circumstances effectively.

In conclusion, the series underscores the urgent need for a rigorous multicentric systematic study of females with OUD in Assam, emphasizing the deficiency in treatment-seeking and engagement. Scaling up treatment facilities and providing community-level OUD treatment are crucial for addressing this issue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.