Use of psychoactive substances in women in outpatient treatment.

OBJECTIVE
to characterize the sociodemographic and psychiatric profile of women users of psychoactive substances in treatment for drug addiction.


METHOD
descriptive study of quantitative approach performed with women attended at a Psychosocial Care Center for Users of Alcohol and Other Drugs (CAPS ad) from the interior of São Paulo State.


RESULTS
the sample consisted of 349 adult women, single, low educational level and unemployed, users of alcohol, cocaine, crack and tranquillizers. Among the consequences of use include withdrawal syndrome, overdose, depressive and suicidal symptoms. Most were referred for treatment by the family or health services. Almost 20% of these women had previously started treatments.


CONCLUSION
The results suggest marked morbidity and high levels of psychosocial vulnerability, which require thorough investigation at the patient's admission, as well as damage associated with use, withdrawal symptoms and depressive symptoms.


INTRODUCTION
The use of psychoactive substances by women is not a contemporary phenomenon, the fact is that in both genders, use has increased significantly, despite this, women still have a use three times lower than men (1)(2) .The scientific literature shows evidence that women have more severe levels of addiction to alcohol and/or other psychoactive substances when they seek health care, so this group needs to be investigated and treated in its particularities (3)(4) .
Recent studies point to the existence of socioeconomic, geographical, organizational and cultural barriers that expose the weaknesses in women's access to treatment services, which often tends to underestimate the reality of this problem in this group (5)(6) .
It is noteworthy that, even though the use of psychoactive substances is lower among women, epidemiological surveys show an alarming increase in use by this group.Specifically in Brazil, use prevalence is considerable, such as alcohol (6.9%) and tobacco (9,0%) (7) , as well as cocaine use (smoked and inhaled) (0.7%) (2) .According to II Brazilian National Alcohol and Drugs Survey, there was an increase in both prevalence and intensity of use among Brazilian women, especially the binge pattern, which represents an intake of four or more units of alcohol every two hours.This report showed that between the years 2006-2012 there was a 36% increase in the proportion of use in binge (8) .
In addition, gender-specific characteristics and gender identity contribute to high morbidity and mortality rates in the population (3) .The complex interaction between the use of these substances and the various social, genetic, hormonal, cultural, neurophysiological and environmental factors make women more vulnerable to a more severe intoxication (4) , as well as a shorter period of time between first use and addiction (3) .
Although women accumulate innumerable risk factors, the specificities in the health-disease process of this group are not always observed in mental health care (9)(10) .For example, while men tend to attribute more hedonistic meaning to substance use (11) , women relate use to depression, feelings of social isolation, family and professional pressures, health problems, as well as various attempts to lose weight (12)(13)(14) .
Studies that investigate the use of alcohol and/or other psychoactive substances in women are the majority in portraying a sociodemographic profile of social exclusion, composed mostly of unemployed women, with low educational level, single, with no social support, victims of intrinsic violence to the phenomenon of the use of these substances (3,9,13,(15)(16) , and more vulnerable to the physical and psychiatric sequelae resulting from this interaction when compared to men (12) .
In this way, considering the complexity of the phenomenon and the social impact that the use of psychoactive substances entails in the life of the person, added to the increasing index of use, abuse and addiction in the female population, the investigations are still scarce (3) .In addition, initiatives to address topics relating to women's health and substance use are still incipient in psychoactive substance addiction treatment programs (detoxification and rehabilitation) (5)(6)17) .
In the last decades, women were underrepresented in studies conducted in treatment settings and, consequently, this fact had an impact on the results of research.Differences between men and women were ignored, delaying the development of programs designed for female gender (5) .In programs aimed at women's health, these problems are relegated to invisibility (17) .
Knowing the profile of women users of psychoactive substances that seek treatment in specialized services is a necessary condition to improve nursing care, considering this situation one of the barriers that hinder the maintenance and adherence to the treatment of dependent women.

OBJECTIVE
To characterize the sociodemographic and psychiatric profile of women users of psychoactive substances in treatment for drug addiction.

METHOD Ethical aspects
The study followed ethical standards and procedures in accordance with Resolution 466/2012, was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing.

Design, place of study and period
Descriptive study of a quantitative approach carried out in a Psychosocial Care Center for Users of Alcohol and Other Drugs (CAPS ad) in the state of São Paulo.The service offers service to users of all age groups and both genders, with mental disorders due to abuse and addiction to psychoactive substances, with emphasis on the prevention of relapse and harm reduction.The assistance is carried out by a multiprofessional team that works in an integrated way, with an assistance proposal that incorporates therapeutic and preventive activities.

Population or sample; inclusion and exclusion criteria
To compose the sample, a survey of service records was performed since the beginning of the service operation (1996), listing a total of 5889 (100%) registered customers; of these, 843 (14.3%) were women.From the application of the eligibility criteria, being aged 18 years old or older, being in the aforementioned service for the first time to treat addiction to alcohol or other psychoactive substances, a final sample of 349 (41.3%) users was obtained.
To collect data, sociodemographic information and clinical and psychiatric profile were extracted from the patient records: use of psychoactive substances (in the last 12 months and last 24 hours, consequences of the use (symptoms of withdrawal syndrome and overdose), symptoms which were characterized by depression, suicide attempts, previous treatments, origin of referral to the referred service.The instrument was elaborated from the screening sheet used in the routine of the service.A formal authorization for the coordinators of the institution concerned was requested and granted.

Analysis of results and statistics
For statistical analysis a database was prepared in the Statistical Package Social Science (SPSS) version 19.Double typing was used to Use of psychoactive substances in women in outpatient treatment Santos JAT, Perruci LG, Pegoraro NPJ, Scherer ZAP, Souza J, Santos MA, et al.
ensure the reliability of the data.The information was systematized in simple frequency, percentage and measures of central tendency.

RESULTS
The predominant characteristics of the sample were: adult women, age ranging from 18 to 73 years old, average of 32.2 years (Sd±13,3), single, with low educational level, did not work, had their own residence, as shown by Table 1.
Of the depressive symptoms, 252 (72.2%) of the women felt sadness to the point of not being able to perform their daily activities, 166 (47.5%) had tried suicide at least once in their life and 122 (34.9%) presented suicidal thoughts in the last two years.
Regarding previous participation in treatments, 159 (45.5%) women had never sought health care for problems related to the use, abuse and addiction to psychoactive substances, 48 (13.7%) had a medical visit at least once, and 26 (7.4%) started treatment several times but did not conclude.
Figure 2 shows that 104 (29.7%) women were referred to treatment by their own relatives and/or friends.Regarding work, among those who worked in paid work, 48 (13%) worked full time, but had no formal bond.
In the last 24 hours preceding the interview, one third had consumed alcoholic beverages or used some other type of psychoactive substances, being the highest use of alcohol 42 (36.2%),marijuana 17 (4.8%),crack 16 (4.5%)and cocaine 11 (11.8%).
Regarding the use of psychoactive substances in the last 12 months, there was a predominance of alcohol use, followed by cocaine and crack, as shown in Figure 1.

DISCUSSION
Women with psychoactive substance addiction have peculiar characteristics, however, as observed in this study, investigations conducted in similar services are unanimous in portraying a profile of women marked by biopsychosocial weaknesses, single, with low educational level, and without formal employment bonds (9,13,15) .This suggests that these services have served a socioeconomically disadvantaged population (18) .
The women in treatment were young (mean 32 years old).The literature shows that the average age of seeking treatment for women is 21 to 40 years old (14)(15) .It is also added that between 2006 and 2013 there was an increase of 3.8% per year in alcohol abuse for women aged between 30 and 39 years old (19) .A North American study that analyzed the cumulative probability of development of addiction in the course of life, found that women over the 44 years old present an increased chance of being dependent on alcohol, marijuana and cocaine (4) .
The age of the woman and the type of psychoactive substances used are indicated as factors of difference between women.In   Of the women, 180 (51.5%) had signs and symptoms that may indicate some negative consequences of psychoactive substances such as: panic attacks 58 (32.2%), heteroaggression 43 (23.9%),

Use of psychoactive substances in women in outpatient treatment
Santos JAT, Perruci LG, Pegoraro NPJ, Scherer ZAP, Souza J, Santos MA, et al. period preceding the initial consultation.National study showed that alcohol as the main substances of use and use pattern are directly related to retention and maintenance of treatment, daily use was more common among women who abandoned in the first month (9) .
The use of crack can also be conceived as a maladaptive strategy of managing negative physical or emotional symptoms experienced, since women tend to perceive that health services do not promote an effective understanding of their demands and experiences (13) .Approximately 72% of users accessing outpatient treatment services for addiction treatment experience significant life traumas (24) , particularly in women, the presence of trauma and the use of psychoactive substances often occur simultaneously (3,21) .
The acute symptoms of the use of psychoactive substances observed in the sample reinforce the already recognized biological singularities of the female gender.The literature shows that the use of these substances potentiates mental health problems and vice versa, such as anxiety, depression and sleep disorders, and more than half of women (50.8%) do not seek professional help for treatment (13) .
From the psychiatric evaluation, depressive symptoms predominated (sadness, ideation or suicide attempt).This set of manifestations are very commonly associated with the use of alcohol and/or other psychoactive substances, can also mean physical and psychological suffering, and still have triggered the search for treatment.Women with psychiatric comorbidities (or dual diagnosis) are generally more likely to choose mental health services rather than substance abuse treatment services (3) .A national study that traced the profile of women treated in a CAPS-ad found that the reasons for the search for treatment were the demands arising from nervous, mental, psychiatric or psychological problems (21) .
The nursing professional should be sensitive to such needs and provide relief that supports the motivation of the user to engage in the search for help and maintenance of the treatment, increasing the state of readiness for behavioral changes in relation to the use of psychoactive substances and the self-care in health.
Regarding suicide attempts and thoughts, the literature indicates that individuals who abuse or are addicted to alcohol present such symptoms with higher frequency and higher risk, in addition to a greater number of attendance in health services, or due to clinical or psychiatric diseases (25) .
Regarding the treatment, although the first contact with the service was the criterion of selection of the sample, it was noticed that 26 women presented innumerable passages through hospital treatment units.Studies have identified that the average stay in treatment for women addiction was approximately 21 days (10,17) .general, adolescent girls, besides using alcoholic beverages, use illicit substances such as marijuana, cocaine and crack cocaine, whereas older women prefer cigarettes, alcohol and medications, especially anorectics and tranquillizers (3,19) .The profile of women users of psychoactive substances is not only a consequence of the use, but also of the circumstances intrinsically linked to socioeconomic factors (16) , social-cultural environment, physiological peculiarities (3,12) , and mainly by historical determination of the phenomenon, involving issues related to gender.
Occupational and educational levels are still factors of socioeconomic victimization among women, and reinforce the vulnerability of those who are addicted to psychoactive substances.Purchasing power shapes dependency, while men have access to a greater variety of substances because of income facilities, some women have access to prescription drugs, and cheap substances, often acquired through sexual intercourse (13,16,20) .
As observed in the sample, the low educational level was predominant among women.Another study carried out with a female crack user identified that 77% of women had only primary education, and attributed this to school dropout, substance use and addiction, the need to work, and the onset of pregnancy (15) .
As for work, most did not work and among those who worked in paid work, most did not have a formal employment bond.A study with women users of crack in the city of São Paulo also presented a high rate of unemployment, 91% (15) .It is worth noting that the precariousness of labor relations is often the result of low female empowerment and constitutes an additional factor of vulnerability, which keeps this group hidden from society's eyes and hinders access and adherence to treatment (17)(18) .
The marital status identified among the women in this study, as well as in other research with women using psychoactive substances, showed that the majority were single.In this sense, it is necessary to consider other factors such as situations of intrafamily, physical and psychological violence (21) , or the condition aggravated by the use of substances, since women who use crack tend to social isolation (22) .A population study conducted in Brazil found that women tend to have less stable partners than men, 76.3%, and 82.1%, respectively (20) .
It is noteworthy that most of the women had their own dwelling, which can be seen as a protection factor because it provides a safe place to use and reduces the damage intrinsic to a possible street context.International study has identified dwelling as a safety enhancement, since it is a safer place where women can smoke crack with people they trusted and who would help keep them less vulnerable (13) .
The use with affective pairs was also identified in a national study (15) performed with pregnant women using crack, however, this practice can often result in situations of various violence (13) .A review study in South American countries found that 10% of women reported that their partners were almost always intoxicated (23) .
Reflecting on the sociodemographic characteristics of this group, in the context of gender inequality, which constitutes a significant aspect of Brazilian society, it is apparent that health professionals, especially nurses, should make specific efforts so that such vulnerabilities are not barriers to access and continuity of care among women.
The first choice psychoactive substances among women was alcohol, both in the evaluation of use in the last 24 hours and in the last 12 months.It should also be noted the use of marijuana, cocaine and crack as the substances of choice, in the A national study carried out in outpatient treatment for addiction, found a lower trend of abandonment of a participant in a psychosocial therapy group only for women compared to mixed groups (10.2% versus 17.8%) (18) , although a review of the international literature showed that the composition of therapeutic groups did not influence the treatment outcome very much (3) .
In any case, the increase in auxiliary services for women, such as childcare, perinatal support and encouragement of potential sources of income, could improve women's access to treatment.Further research is needed to fill this gap in the literature, to identify interventions for the efficient treatment of substance abuse in the subgroup of women.
It is also added that women who completed the treatment and are accompanied by specialized treatment are 29% less likely to be arrested for involvement in substance trafficking or use (10) , that is, maintaining unproblematic social interaction and consequent greater reintegration social.
The search for specialized care for the substance addiction observed in this study was through the intervention of the peers that make up the socio-cultural environment, such as family and friends.The social network of the individual has a fundamental role in the search for treatment and in the rehabilitation of the subject with mental disorder and/or user of psychoactive substances mainly among women (26) .Despite the psychological pressure that these same social components can exert, they are key supporters for problem detection and motivation for treatment in this group (21,26) .
Thus, planning health actions from social network perspective constitutes a promising proposal for expanding early detection and seeking professional help before the symptoms are as severe as those presented in the sample studied.

Limitations of the study
The limitations of the study are the fact that it is a study based on secondary data, there may be low information reporting in these women's records, since the screening instrument often does not have scales, standardized questionnaires, to be used in the first consultation, which identifies not only the presence of symptoms, but not the intensity of the diseases.