David Otiashvili

Access to treatment for substance-using women in the Republic of Georgia: Socio-cultural and structural barriers

BACKGROUND In the Republic of Georgia, women comprise under 2% of patients in substance use treatment and to date there has been no empirical research to investigate what factors may facilitate or hinder their help-seeking behaviour or access to treatment services. METHODS This study included secondary analysis of in-depth interviews with 55 substance-using women and 34 providers of health-related services. RESULTS The roles and norms of women in Georgian society were identified as major factors influencing their help-seeking behaviour. Factors that had a negative impact on use of drug treatment services included an absence of gender-specific services, judgmental attitudes of service providers, the cost of treatment and a punitive legal position in regard to substance use. Having a substance-using partner served as an additional factor inhibiting a womans willingness to seek assistance. CONCLUSION Within the context of orthodox Georgian society, low self-esteem, combined with severe family and social stigma play a critical role in creating barriers to the use of both general health and substance-use-treatment services for women. Education of the public, including policy makers and health care providers is urgently needed to focus on addiction as a treatable medical illness. The need for more women centred services is also critical to the provision of effective treatment for substance-using women.

Drug Use and HIV Risk Outcomes in Opioid-Injecting Men in the Republic of Georgia: Behavioral Treatment + Naltrexone compared to Usual Care

BACKGROUND To test the initial feasibility of a novel 22-week comprehensive intervention pairing behavioral treatment with naltrexone that aimed at engaging, retaining, and treating opioid-injecting men in the Republic of Georgia. METHODS Forty opioid-injecting male and their drug-free female partners participated in a two-group randomized clinical trial at the field site of the Union Alternative Georgia, in Tbilisi, Republic of Georgia. The comprehensive intervention that paired behavioral treatment with naltrexone for the male participants (n=20) included counseling sessions using Motivational Interviewing for both the male participant and the couple, monetary incentives for drug abstinence, and research-supported detoxification followed by naltrexone treatment. Male participants in the usual care condition (n=20) had the opportunity to attend once-a-week individualized education sessions and upon request receive referrals to detoxification programs and aftercare that could or could not have included naltrexone. Outcome measures included entry into inpatient detoxification and naltrexone treatment, urine drug screening, reduction in illicit substance use, use of benzodiazepines, injection of buprenorphine, and needle and syringe sharing. RESULTS The comprehensive intervention condition showed significantly more weekly urine samples negative for illicit opioids during weeks 1-22 (7.0 vs. 1.4; p<.001) and reported significant declines in use of benzodiazepines and injection of buprenorphine (both ps<.004). CONCLUSIONS The first behavioral treatment randomized clinical trial in the Republic of Georgia found that the use of tailored behavioral therapy paired with naltrexone is both feasible and efficacious for treating drug use and reducing HIV drug-risk behavior in Georgian men.

Policing, massive street drug testing and poly-substance use chaos in Georgia – a policy case study

BackgroundSince early 2000, intensive policing, wide scale street drug testing, and actions aimed at limiting the availability of specific drugs have been implemented in Georgia. Supporters of this approach argue that fear of drug testing and resulting punishment compels drug users to stop using and prevents youth from initiating drug use. It has been also stated that reduction in the availability of specific drugs should be seen as an indication of the overall success of counter-drug efforts. The aim of the current review is to describe the drug-related law enforcement response in Georgia and its impact on illicit drug consumption and drug-related harm.MethodWe reviewed relevant literature that included peer-reviewed scientific articles, stand-alone research reports, annual drug situation reports, technical reports and program data. This was also supplemented by the review of relevant legislation and judicial practices for the twelve year period between 2002 and 2014.ResultsEvery episode of reduced availability of any “traditional” injection drug was followed by the discovery/introduction of a new injection preparation. The pattern of drug consumption was normally driven by users’ attempts to substitute their drug of choice through mixing together available alternative substances. Chaotic poly-substance use and extensive utilization of home-made injection drugs, prepared from toxic precursors, became common. Massive random street drug testing had little or no effect on the prevalence of problem drug use.ConclusionsIntensive harassment of drug users and exclusive focus on reducing the availability of specific drugs did not result in reduction of the prevalence of injecting drug use. Repressive response of Georgian anti-drug authorities relied heavily on consumer sanctions, which led to shifts in drug users’ behavior. In most cases, these shifts were associated with the introduction and use of new toxic preparations and subsequent harm to the physical and mental health of drug consumers.

Behavioral treatment + naltrexone reduces drug use and legal problems in the Republic of Georgia.

Background: Known drug users in the Republic of Georgia are 99% male. Georgian social context includes close family social structure, intense police scrutiny over daily life, and minimal social service infrastructure. Drug use is dangerous and individuals rely on family support to address socially stigmatizing problems. Objective: The aim was to examine the changes in problem severity over time experienced by 40 adult opioid-injecting men with drug-free female partners in the Republic of Georgia who participated in a randomized clinical trial examining the feasibility and efficacy of a 22-week comprehensive intervention that paired behavioral treatment with naltrexone. Methods: This secondary data analysis study examined the results from a project that had randomized participants to either a comprehensive intervention that paired behavioral treatment with naltrexone or usual care (UC) and examined changes in Addiction Severity Index (ASI) composite scores. Results: The comprehensive intervention showed three times the decline in ASI drug use and legal composite scores than did the UC condition in males in the Republic of Georgia, both p < .009. Conclusion: The results suggest that the use of a comprehensive behavioral intervention paired with naltrexone leads to significant reductions in drug use and legal problems in opioid-injecting males in the Republic of Georgia. Scientific Significance: A comprehensive intervention that paired behavioral treatment with naltrexone provides a promising approach to protect drug users against relapse and legal risks. Trial registration: ClinicalTrials.gov identifier: NCT00496990.

Opioid addicted buprenorphine injectors: drug use during and after 12-weeks of buprenorphine-naloxone or methadone in the Republic of Georgia.

AIMS The aim of this study is to assess the prevalence of non-opioid drug use among opioid-addicted, buprenorphine injecting individuals in Georgia, during and after a 12-week course of buprenorphine-naloxone (Suboxone®) or methadone. METHODS Randomized controlled trial with daily observed Suboxone® or methadone and weekly counseling, urine tests and timeline followback (TLFB) in weeks 0-12 and 20, and the Addiction Severity Index (ASI) at weeks 0, 4, 8, 12, 20. RESULTS Of the 80 patients (40/group, 4 women), 68 (85%) completed the 12-weeks of study treatment and 66 (82.5%) completed the 20-week follow-up. At baseline, injecting more than one drug in the last 30 days was reported by 68.4% of patients in the methadone and 72.5% in the Suboxone® groups. Drug use was markedly reduced in both treatment conditions but there were significant differences in the prevalence of specific drugs with more opioid (1.5 vs. 0.2%; p=0.03), less amphetamine (0.2 vs. 2.8%; p<0.001) and less marijuana (1.7 vs. 10.2%; p<0.001) positive urine tests in the methadone vs. Suboxone® groups. At the 20-week follow-up, TLFB results on the 34 that continued methadone or the 3 on Suboxone® showed less opioid (5.6 vs. 27.6%; p<0.001), illicit buprenorphine (2.7 vs. 13.8%; p=0.005), benzodiazepine (13.5 vs. 34.5%; p<0.001), and marijuana (2.8 vs. 20.7%; p<0.001) use than the 29 who did not continue opioid substitution therapy. CONCLUSIONS Despite small but significant differences in opioid and other drug use, both treatments were highly effective in reducing opioid and non-opioid drug use.

Women Who Inject Drugs in the Republic of Georgia: In Their Own Words

Abstract This study describes the initiation and maintenance of illicit drug use, risky behaviors, and the substance use treatment experiences of women in Georgia. Qualitative interviews with 55 drug-using women (mean age 36 years; SD = 9.52), were conducted during April–September 2011. 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.

Process and Product in Cross-Cultural Treatment Research: Development of a Culturally Sensitive Women-Centered Substance Use Intervention in Georgia

Women who inject drugs (WID) are highly marginalized and stigmatized and experience ongoing discrimination in Georgia. Few opportunities exist for WID to receive publicly funded treatment for substance use disorders. The IMEDI (Investigating Methods for Enhancing Development in Individuals) project was developed in response to the need for women-specific and women-centered treatment services. This paper described our approach to understanding the Georgian culture—and WID within that culture—so that we could integrate two interventions for substance use found effective in other Western and non-Western cultures and to outline how we refined and adapted our integrated intervention to yield a comprehensive women-centered intervention for substance use. Reinforcement Based Treatment (RBT) and the Womens CoOp (WC) were adapted and refined based on in-depth interviews with WID (N = 55) and providers of health services (N = 34) to such women and focus groups [2 with WID (N = 15) and 2 with health service providers (N = 12)]. The resulting comprehensive women-centered intervention, RBT+WC, was then pretested and further refined in a sample of 20 WID. Results indicated positive pre-post changes in urine screening results and perceived needs for both RBT+WC and a case management control condition. The approach to treatment adaptation and the revised elements of RBT+WC are presented and discussed.

Secrecy and risk among MSM in Tbilisi, Georgia.

Abstract There is concern that the tremendous economic, social, and political upheavals that the Republic of Georgia has undergone in the years since the fall of the Soviet Union may have created an environment fertile for HIV transmission. Notably absent from official statistics and HIV-related research in Georgia is discussion of men who have sex with men (MSM) and, therefore, little is known about the MSM population or its potential to acquire or transmit HIV. Data were collected from 30 MSM recruited through a testing and counseling center in Tbilisi, the capital of Georgia. Two focus groups with six men each and 18 individual in-depth interviews were conducted between October 2006 and February 2007. The study participants described a Georgian culture that is largely intolerant of sexual contact between men. In describing the various forms of discrimination and violence that they would face should their sexual identities be discovered, the MSM in this sample described a variety of behaviors that they and other Georgian MSM undertake to conceal their sexual behavior. Many of these could put these men and their partners at risk for HIV. Although official HIV rates in Georgia are still low, results from this qualitative study indicate that efforts to educate and to provide unobtrusive and anonymous testing and counseling services to MSM may be critical to the deterrence of an HIV epidemic in the Republic of Georgia.

Comprehensive women-centered treatment for substance use disorders in Georgia: Current status and future directions

Abstract This article examines the current status of women-centered substance use disorder treatment in Georgia. Four major issues are identified that adversely impact the delivery of effective services for women with substance use disorders: Policy Issues, Sociocultural Issues, Programmatic/Structural Issues and Personal/Interpersonal Issues. These four issues are seen to form a complex, dynamic system that serves to maintain the current ineffective service delivery system and suppresses movement toward an effective service delivery for this highly marginalized and at-risk population. How these issues, and their interplay, present continuing barriers to the development and implementation of effective treatment for this population are outlined and discussed. In order to overcome these barriers, solutions must be sought in four areas: Policy reform, Public health campaigns, Development and implementation of comprehensive women-specific confidential treatment models and Empowering women. Specific goals in each of these areas that would achieve a positive impact on various aspects of the functioning of the current service delivery system for women with substance use disorders are suggested. Simultaneously seeking solutions in all four of these areas would improve the service delivery system and benefits women with substance use disorders.

Female partners of opioid-injecting men in the Republic of Georgia: an initial characterization

BackgroundHIV and Hepatitis C virus (HCV) infections are strongly related to injection drug use in the Republic of Georgia. Little information is available about HIV and HCV status, sexual risk, support for their partner, and risk for physical violence among the female partners of opioid-injecting men in the Republic of Georgia, many of whom may not be using drugs, yet may be at high risk of being infected with HIV and HCV from their drug-using partners.MethodsIn order to better understand the risks for females whose partners are injecting drugs, the present study conducted an initial investigation of the non-substance-using female partners of 40 opioid-injecting men who were participating in a clinical trial examining the feasibility and efficacy of a 22-week comprehensive intervention that paired behavioral treatment with naltrexone. The 40 female partners were assessed at their male partners’ study intake.ResultsThe female sample was 32.3 years old (SD=6.7), 37 (93%) were married, with 15.5 years of education. A majority reported at least partial employment the majority of the time during the past 3 years, with only one woman reported being unemployed most of the time during the past 3 years. They self-reported they were 3% HIV-positive and 8% HCV-positive. Their HIV sex risk scores indicated a relatively low risk. However, only 4 (10%) women reported using a condom most of the time while having sex and 15 (38%) report not having had sex during the last 30 days. Experiences of interpersonal violence were common, with 42% reporting physical abuse by their partner during the last year and 48% reporting feeling unsafe in their current relationship.ConclusionsThe alarmingly high rate of failure to use barrier protection methods, together with the high percentage who did not know their HIV and HCV status, suggest that it may be beneficial to include non-substance-using female partners in prevention programs along with their partners to reduce the risk of HIV and HCV spreading from the population of injection-drug–using males into the general population. [This secondary analysis study was funded by an international supplement to the parent randomized clinical trial “Treating the Partners of Drug Using Pregnant Women: Stage II (HOPE)”. ClinicalTrials.gov Identifier: NCT00496990.]