355

Social and Behavioral

Consequences of

Chemical Dependence

Rafaela R. Robles, Ed.D.; Carmen A. Marrero, M.P.H.;

Tomás D. Matos, M.S.; Héctor M. Colón, M.A.;

Lourdes I. Cancel, M.S.; and Juan C. Reyes, M.S.

INTRODUCTION

Chemical dependence is one of the greatest problems facing contemporary society. In the eagerness to tackle these problems, there

is a danger of generalizing too hastily and assuming that all users of

alcohol and other drugs are the same and therefore that the ways of

studying, identifying, diagnosing, and treating these problems also

should be the same. This is particularly true in the areas of research,

prevention, diagnosis, and treatment for drug-abusing women. Most

research, prevention, diagnosis, and treatment strategies to help

women cope with their addiction have been developed for men.

It was not until the mid-1970s that interest was shown in the

study of drug use among women (Sutker 1987, pp. 25-51). Reports that

show a dramatic increase in illicit drug use among women have raised

concern (Burt et al. 1979; Prather and Fidell 1978). Estimates of drug

use in the United States show a female-to-male ratio of 1:5 in the 1960s,

1:3 in the 1980s (Rosenbaum 1981), and 1:2 in the 1990s (Anthony

and Helzer 1991, pp. 116-154). Opiate use has been increasing among

women at greater rates than among men. A greater proportion of

women than men appear to be abusing barbiturates, sedatives, and

tranquilizers. There has been an overall decrease in gender differences

in illicit drug use among adolescents (Robles et al. 1991). Also, an

increasing proportion of women are becoming infected with the

human immunodeficiency virus (HIV) through their own drug-abusing

behavior or through sexual practices with drug abusers (Robles 1995,

pp. 143-174).

The pathways to abuse and the factors associated with drug use

appear to vary by gender. Women have been found to be more likely
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than men to be exposed to drugs by their sex partners (Rosenbaum 1981;

Stenbacka et al. 1992; Bresnahan et al. 1992). Drug use by women has

been explained as a coping strategy to deal with stress (Sutker 1987;

Rhoads 1983) or sexual abuse (Rohsenow et al. 1988; Inciardi et al.

1993) or as treatment for an illness (Marsh and Miller 1993). The

research literature also fails to bring attention to the different consequences of drug use among women and among men. Drug abuse

is believed to have more serious consequences for women than for

men (Rosenbaum 1981).

METHODS AND RESULTS

This chapter presents analyses of the impact of drug abuse on a

group of women who abused drugs and who participated in various

research projects among drug abusers in the San Juan, PR, metropolitan

area. Table 1 shows that more women than men had completed high

school, lived in their own homes, had a regular source of income, and

lived with their spouses or children. Women also reported fewer drug

treatment episodes than men. Table 2 shows that women were more

likely than men to use crack but were less likely to use speedball (a

mixture of cocaine and heroin). Women were also more likely than

men to practice risky behaviors such as anal and oral sex, have multiple

sex partners, and trade sexual relations for money.

Table 3 demonstrates that drug-abusing women were more likely

than drug-abusing men to report psychiatric symptoms and suicide

attempts, live in an unsafe place, have a history of physical abuse, and

report serious conflicts with mothers and their spouses or sex partners.

Women were also more likely to report use of health care services than

were men.

Social support and social integration are related to psychiatric

symptoms, morbidity, and mortality (Blazer 1982; Kobrin and

Hendershot 1977). Individuals who are well integrated at different

levels of the social structure and who have social support from family

and friends are less likely to report psychiatric symptoms or physical

illness and are more likely to live longer (Berkman and Syme 1979).

Because of the impact these variables have on well-being, the authors

decided to assess the degree of social integration and the types of social

support by gender.
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Percent

Drug Use and Sexual Practices Men Women p

Drug use*

Crack 58.6 69.7 0.035

Cocaine 95.6 88.0 0.008

Heroin 79.5 76.1 0.497

Speedball (cocaine and heroin) 71.8 57.7 0.005

Sexual practices†

Sexual activity 56.4 68.3 0.025

Vaginal sex 53.8 64.5 0.048

Oral sex 34.1 46.1 0.022

Anal sex 11.0 16.3 0.167

Multiple sex partners 11.7 20.4 0.026

Sexual relations for money 1.1 19.0 0.001

*Ever used

†Past 30 days

SOURCE: Robles et al., unpublished data (NIDA grant DA-06993)

Men Women

Sociodemographic Standard Standard

Characteristic Mean Percent Deviation Mean Percent Deviation p

Age 31.1 7.7 30.7 6.8 0.565

Completed high

school 24.2 34.3 0.002

Lives in own home 23.4 49.7 0.001

Has a regular source

of income* 67.9 77.3 0.046

Lives with spouse

and/or children 20.5 37.8 0.001

Size of support

network 4.4 2.6 4.0 2.3 0.115

Drug treatment

episodes 2.8 3.1 2.1 2.6 0.016

*Includes job or governmental assistance

SOURCE: Robles et al., unpublished data (NIDA grant DA-06993)

TABLE 1. Sociodemographic characteristics, by gender, among drug

users entering drug treatment in San Juan, PR (n=416)

TABLE 2. Drug use patterns and sexual practices, by gender, among

drug users entering drug treatment in San Juan, PR (n=416)
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Percent

Health Status, Life Events, and Network Disruptions Men Women p

Health status

Poor or fair physical condition* 34.8 51.0 0.002

Psychiatric symptoms 46.5 63.6 0.001

Suicide attempts 24.5 40.8 0.001

Use of health services* 51.3 62.2 0.042

Life events

Living at unsafe place 39.2 53.1 0.009

Loss of house or job 35.5 17.5 0.001

History of physical abuse 27.5 57.3 0.001

Network disruptions—recent serious conflict with:†

Mother 18.3 28.7 0.021

Father 11.7 10.5 0.831

Spouse or partner 19.8 28.7 0.054

Sibling 16.5 16.8 0.938

Child 2.6 5.6 0.194

*Past 6 months

†Past year

SOURCE: Robles et al., unpublished data (NIDA grant DA-06993)

TABLE 3. Drug use patterns and sexual practices, by gender, among

drug users entering drug treatment in San Juan, PR (n=416)

With regard to social integration, women were less likely to be

employed or to have lived in the same community for 1 year or more

(table 4). Women were also less likely to live with parents and siblings

currently, but a significantly higher proportion of women lived with their

children. Men and women reported a small number of friends, but on

average, men had twice as many friends as women did. Measures of social

support also revealed some gender differences, although there was no

significant gender difference in the number of people mentioned as

sources of support. Men were more likely to report family members as

sources of support. This was especially true of support received for

completing drug treatment. Men also reported receiving tangible support

from a larger number of people than did women. Table 5 compares rates

of conflictual relationships and events for men and women. Significantly

large differences were found in events of physical abuse during childhood

as well as during the previous year. Approximately one-third of the

women reported having been physically abused during childhood, and
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Men Women

Social Integration Standard Standard

and Social Support Mean Percent Deviation Mean Percent Deviation p

Employed during

past 30 days 36.3 16.8 0.001

Living in same

community for

a year or more 90.3 78.9 0.004

Currently in academic

or training program 13.2 16.9 0.308

At least monthly

attendance of

religious activities 24.5 19.7 0.268

Attending a selfhelp group 1.1 1.4 0.791

Lives with:

Father 28.9 11.9 0.001

Mother 60.4 32.9 0.001

Spouse or partner 29.7 25.9 0.416

Sibling 37.4 18.9 0.001

Children 24.9 59.4 0.001

Number of friends 2.9 5.1 1.5 2.6 0.001

Social support

Size of support

 network 4.4 2.6 4.0 2.3 0.115

Kin in support

 network 69.1 62.1 0.047

Spouse in support

 network 33.3 33.6 0.962

Receives support during

treatment from:

Parents 85.4 73.2 0.005

Spouse or partner 50.9 52.1 0.818

Siblings 77.7 59.9 0.001

Children 33.3 66.2 0.001

Other relatives 50.2 39.4 0.037

Friends 55.9 57.8 0.717

Number of persons

providing:

Tangible support 3.9 2.4 3.3 1.9 0.008

Emotional support 4.1 2.4 3.7 2.3 0.111

SOURCE: Robles et al., unpublished data (NIDA grant DA-06993)

TABLE 4. Social integration and support, by gender, among drug

abusers entering drug treatment in San Juan, PR (n=416)
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TABLE 5. Physical abuse and recent network conflicts, by gender,

among drug abusers entering drug treatment in San Juan,

PR (n=416)

Percent

Physical Abuse and Network Conflicts Men Women p

Physically abused:

During childhood 15.0 30.8 0.001

During past year 5.9 21.0 0.001

Serious conflicts during past year with:

Mother 18.3 28.0 0.030

Father 11.7 10.5 0.707

Spouse or partner 20.5 29.4 0.043

Sibling 16.5 17.5 0.796

Child 2.6 5.6 0.161

SOURCE: Robles et al., unpublished data (NIDA grant DA-06993)

21 percent said they had also been abused during the previous year.

Women were also more likely than men to have had serious conflicts

with their mothers and partners during the previous year.

A large proportion of the women who abuse drugs have been

exposed to HIV (41.6 percent) (Robles et al. 1993) as shown by HIV

test results (i.e., seropositivity). This high rate of seropositivity among

women is similar to that of Puerto Rican men participating in the same

study (48.9 percent). Among women ages 25 to 34 years, a history of

incarceration, injecting drugs for 6 or more years, and syphilis were

the variables significantly associated with HIV seropositivity (table 6).

Moreover, women who report always using condoms were significantly

less likely to be HIV seropositive.

CONCLUSIONS

Drug-abusing women in Puerto Rico are coping with the consequences of their addiction without the social support of significant

others and support for drug treatment. They are less integrated with

their families and networks of friends and receive less support from their

families than do drug-abusing men. Although women use health care

services, they are more likely to use emergency services, which limits

the possibility of having a regular source of care and followup for the

chronic conditions that are prevalent among this population.
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TABLE 6. Results of multiple logistic regression for HIV seropositivity

incorporating all previously significant variables among

329 women who are injection drug users

Variables Adjusted Odds Ratio 95-Percent Confidence Interval

Age

Younger than 25 years

25-34 years 2.69* 1.37-5.50

35 or older 1.63 0.92-3.71

Live with children 0.83 0.49-1.39

Ever been in jail 1.71* 1.02-2.85

Frequency of drug injection

Less than daily† –

1-3 times a day 1.43 0.64-3.18

Ever been in jail 1.71 0.86-3.83

Years of injection

0-5†

6-10 2.05* 1.11-3.79

11 2.68* 1.42-5.05

Sex risk behaviors

No sex 0.43 0.16-1.14

Sex, no condom use† –

Always use condoms 0.30* 0.12-0.71

Syphilis 2.62* 1.27-5.40

*p<0.05

†Reference category

SOURCE: Robles et al. 1993

Compared with men, women in the United States are seldom offered

HIV testing in health care facilities, particularly in inner-city emergency

rooms (Melnick et al. 1994). This health system policy does not facilitate the diagnosis needed for early intervention in the illness. Survival

time after diagnosis of AIDS may be shorter for women than for heterosexual men because of a tendency among HIV-infected women to show

up for treatment later in the course of their infection (Melnick et al.

1994). A low level of recognition of early HIV infection in health care

settings as well as poor access to HIV-related services may be a contributing factor to the different patterns of disease progression and survival in

women and in men.

According to field staff members in the research projects reported

on here, the low use of drug treatment by drug-abusing women, which

is common in Puerto Rico, is attributable to the criminalization of
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drug-abusing mothers and the close linkage between drug treatment and

the judiciary system. In Puerto Rico, as in the rest of the United States,

the legal reaction to women who use drugs during pregnancy may

include coercive interventions, such as removal of newborns from their

mothers, and court-ordered detentions of pregnant, drug-using women.

Therefore, women who need and want drug treatment or medical care

for themselves and their babies might not feel free to seek treatment

because of the threat of criminal prosecution. This criminalization

approach ignores the more pervasive problems that pregnant women

face, including inadequate access to prenatal care, insufficient and

inadequate access to substance abuse treatment, and a host of socioeconomic conditions that make it difficult for poor, drug-abusing women

to take care of themselves and their children.

Drug-abusing women report more psychological symptoms than

drug-abusing men and are less likely to be integrated into the family.

They are also less likely to receive support from their significant others.

However, they support a family unit along with their children in their

own homes, as provided by the public housing authorities. Furthermore,

they have steady incomes through cash provided by government assistance programs for their children. Drug-abusing women are more likely

to use the health care system for their drug and health problems; however, they stay away from drug treatment programs. This may be because

in the health care, housing, and social services systems, they can hide

their addiction and use the services without interrupting their relationship with their children, unlike in the drug treatment system. Children

may well be the only “significant others” on whom they can depend and

to whom they can offer the care and support they are able to give.

REFERENCES

Anthony, J., and Helzer, J. Syndromes of drug abuse and dependence. In:

Robins, L., and Regier, D., eds. Psychiatric Disorders in America. New York:

The Free Press, 1991.

Berkman, L.F., and Syme, L.S. Social networks, host resistance, and mortality:

A nine year follow up study of Alameda County residents. Am J Epidemiol

109:186-204, 1979.

Blazer, D.G. Social support and mortality in an elderly community population.

Am J Epidemiol 115:684-694, 1982.
363

Bresnahan, K.; Zuckerman, B.; and Cabral, H. Psychosocial correlates of drug

and heavy alcohol use among pregnant women at risk for drug use. Obstet

Gynecol 80(6):976-980, 1992.

Burt, M.R.; Glynn, T.; and Sowder, B. Psychosocial Characteristics of Drug-Abusing

Women. Rockville, MD: National Institute on Drug Abuse, 1979.

Inciardi, J.; Lockwood, D.; and Pottegier, A. Women and Crack Cocaine. New

York: MacMillan, 1993.

Kobrin, F.E., and Hendershot, G.E. Do family ties reduce mortality? Evidence

from the United States, 1966-1968. J Marriage Fam 39(4):737-745, 1977.

Marsh, J., and Miller, N. Female choice in substance abuse treatment. Int J

Addict 20:995-1019, 1993.

Melnick, S.L.; Sherer, R.; Louis, T.A.; Hillman, D.; Rodriguez, E.M.; Lackman,

C.; Capps, L.; Brown, L.S.; Carlyn, M.; Korvick, J.A.; and Deyton, L.

Survival and disease progression according to gender of patients with HIV

infection: The Terry Beirn Community Programs for Clinical Research on

AIDS. JAMA 272:1915-1921, 1994.

Prather, J., and Fidell, L. Drug use and abuse among women: An overview. Int J

Addict 13:863-885, 1978.

Rhoads, D. A longitudinal study of life stress and social support among drug

users. Int J Addict 18:195-222, 1983.

Robles, R.R. Providing substance abuse treatment to Puerto Rican clients living

in Puerto Rico. In: Amuleru-Marshall, O., ed. Substance Abuse Treatment in

the Era of AIDS, Volume II. Rockville, MD: Center for Substance Abuse

Treatment, Program Evaluation Branch, Office of Scientific Analysis and

Evaluation, 1995.

Robles, R.R.; Feliciano, C.; Colón, H.M.; and Aponte, L. Puerto Rico AIDS

Prevention Project: Final Report. (NIDA Grant DA-05743). San Juan, PR:

Research Institute, Department of Anti-Addiction Services, 1993.

Robles, R.R.; Moscoso, M.; Colón, H.M.; García, M.; and Rebollo, J. El Uso de

Drogas en los Adolescentes Escolares [Drug Use Among School Adolescents]. Research Institute, Department of Anti-Addiction Services and

Department of Family Medicine and Community Health, Universidad

Central del Caribe, Hato Rey, PR, September 1991. 42 pp.

Rohsenow, D.J.; Corbett, R.; and Devine, D. Molested as children: A hidden

contribution to substance abuse? J Subst Abuse Treat 5:13-18, 1988.

Rosenbaum, M. Sex roles among deviants: The woman addict. Int J Addict

16:859-877, 1981.

Stenbacka, M.; Allebeck, P.; and Romelsjo, A. Cannabis abusers: The role of

social and behavioral risk factors. Br J Addict 87:259-266, 1992.

Sutker, P. Drug dependent women: An overview of the literature. In: Beschner,

G.M.; Reed, B.G.; and Monderano, J., eds. Treatment Services for Drug

Dependent Women. Rockville, MD: National Institute on Drug Abuse, 1987.
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ACKNOWLEDGMENTS

This research was been supported in part by National Institute on

Drug Abuse grants DA-06993 and DA-05743.

AUTHORS

Rafaela R. Robles, Ed.D.

Senior Scientist

Carmen A. Marrero, M.P.H.

Research Analyst

Tomás D. Matos, M.S.

Research Analyst

Héctor M. Colón, M.A.

Researcher

Lourdes I. Cancel, M.S.

Research Analyst

Juan C. Reyes, M.S.

Research Analyst

Research Institute

Mental Health and Anti-Addiction

Services Administration

Center for Sociomedical Research

Medical Sciences Campus

University of Puerto Rico

Center for Addiction Studies

School of Medicine

Universidad Central del Caribe

P.O. Box 21414

San Juan, PR 00928-1414

(787) 764-2888 (Tel)

(787) 765-5439 (Fax)

mhaasari@coqui.net (E-mail)