Addiction Experiences of Women with Substance Use Disorder: The Case of Manisa Province

This study aims to examine the reasons for starting and continuing to use substances, the changes they expe - rience in accessing and receiving treatment, and the changes observed in family and social support systems with a biopsychosocial approach. Qualitative research method was used in this study. In addition, it was conducted with women who received inpatient treatment at the addiction rehabilitation center of Manisa Mental Health and Disorder Hospital and who did not use substances in the last year. The research sample was determined according to the principle of maximum diversity. Data were collected through in-depth tele - phone interviews with 31 women. In addition, the data were analyzed by content analysis using the Maxquda is qualitative data analysis (MAXQDA) program. Most of the participants stated that their relationships with their families deteriorated during substance use; they faced economic problems, and they were stigma - tized more deeply because they were women. The disadvantaged situations experienced by women within the scope of gender inequality are deepened by the phenomenon of addiction, making it difficult for them to access health and social services.


Introduction
Addiction is a phenomenon and a relationship type that has psychological, physiological, sociological, and economic dimensions and harms the health of individuals and threatens community life as a whole by preventing individuals from continuing their daily and social lives (Gövebakan & Duyan, 2021).According to the European Drug Report data, it is revealed that approximately 84 million adult individuals between the ages of 15 and 64 living in the European Union, approximately 50 million of whom are men and 34 million of whom are women, have used illegal substances before (EMCDDA, 2022).
Although substance use disorder is more common among men, it is stated that the rate of women with substance use is increasing gradually, and physiological differences between women and men affect the rates and forms of substance use between genders (Poole & Dell, 2005).According to the Drug User Profile Analysis 2021 Narcologist Report (2022), women begin and continue using heavy drugs such as methamphetamine, heroin, cocaine, and ecstasy.Women have difficulty to access health services, and they therefore avoid seeking treatment due to the negative attitudes of the society and stigmatization practices they may be exposed to (Samuelsonn, 2015;Ögel, 2004;Ünübol et al., 2019).In addition, some studies show that women with substance use disorders have employment problems and are exposed to physical and sexual abuse due to their criminal history, poor working conditions, low educational attainment, and stigma related to substance use (Kalechstein, 2000;Tuchmann, 2010;Ögel, 2004;Ünübol vd., 2019).
In this context, it is possible to say that women with substance use disorder experience the problems arising from being a woman in a more prominent way.In addition, the study aims to provide an in-depth analysis of the reasons for initiation and continuation of substance use, risk factors, difficulties and needs of women with substance use disorder, factors that prevent their participation in the treatment process or delaying it, treatment methods used during the treatment process, and changes in family and social support systems by using a qualitative method within a biopsychosocial approach (SEU, 2004).

Material and Methods
This study was conducted using the qualitative research method.The purpose of using the qualitative method in this study is to gain an in-depth understanding of the factors that play a role in the emergence and continuation of the addiction experience of women with substance use disorders.The research was carried out in the addiction rehabilitation center of Manisa Celal Bayar between November 15, 2021, and August 1, 2022.Manisa Celal Bayar University has granted the permission to carry out the research with its decision dated 08.12.2021 and numbered 1080.
The participants of the study are women with substance use disorder who are hospitalized in the addiction rehabilitation center of Manisa.The sample was determined according to the principle of maximum diversity sampling, and a total of 70 people were contacted.The inclusion and exclusion criteria of the participants for the study are defined as follows: the participant has applied for inpatient treatment at addiction rehabilitation center Manisa; she successfully completed the treatment and has not used substances in the last year; she has been in regular outpatient follow-up within the last year; she has not been found to be substance positive in urine toxicology tests performed by liquid chromatography-mass spectrometry; she has not received additional psychiatric diagnosis other than substance use disorder; she has sufficient cognitive and functional levels for clinical interview; and she is willing to participate in the study.The female patients who continued to use substances, who lost the ability to distinguish reality, or who had an impaired perception of themselves and their surroundings were not included in the study.The research data were collected via telephone, using a semi-structured interview form, and in-depth interviews carried out with 31 participants diagnosed with substance use disorder.Participants were informed about the research before the interview and the interview took place after their consent was obtained.
Thematic content analysis was used in the analysis of the research data.The interviews were deciphered, and after the in-depth interviews were transferred to the Professional Data Analysis Engineering for Qualitative and Mixed Methods Program (MAXQDA), they were categorized depending on the purpose of the research and the repeated statements by the people.Themes were determined according to these categories, and the coding was done accordingly in the program.
In the thematic analysis, while expressing the participants' thoughts, the participants were coded as F (female), and the number of participants was numbered next to it, and age information was given after the hyphen sign.

Sociodemographic Findings
Upon examination of the sociodemographic findings of the participants, it is apparent that the women included in the study ranged in age from 18 to 68.Among women with substance use disorder, the mean age was 32.8, and the majority were unemployed primary school graduates who were primarily single.The first substance used by most women was heroin, with initial use occurring between the ages of 10 and 18.A summary of all the data collected is provided in Table 1.

Thematic Content Analysis
In the thematic analysis of the study, five main themes related to the addiction experiences of the participants were determined: life experiences of women with substance use disorder before substance use, life experiences related to substance use period, life experiences related to substance use treatment, posttreatment life experiences, and thoughts on substance use, respectively.All the main themes and sub-themes are shown in Table 2.
Main theme 1: Life experiences before substance use In accordance with the information obtained in terms of life experiences before substance use, family, and friendship relations of the participants, the biggest problem they experienced in life and the support mechanisms for overcoming the obstacles came to the fore.All sub-themes are shown in Figure 1.
It has been revealed that the majority of women with substance use disorders within the scope of family and friendship relations The majority of the participants stated that the biggest problem they faced in their lives was substance use and that they had health problems related to substance use. " The biggest problem I've ever faced in my life is, of course, using drugs."(F2-41) "I didn't have any problems.Problems started with the substance."(F29-40) When examining the sources of support received by women with substance use disorder, it was found that most of them received support from their family to overcome their problems.However, some of them sought help from institution staff, consulted with a psychiatrist, or relied on support from their friends to address their issues.
"I received support from my two sons and my husband while I was tackling this misery."(F25-37) "My supporter is my family."(F27-32) Main theme 2: Life experiences in substance use period It has become obvious that getting to know about how the substance is used and the stages of using it, the reasons for substance use, the effects experienced when using the substance for the first time, the process of sharing the substance, the substances used and their effects, the process of obtaining the substance, and finally, the problems experienced by women in the addiction stage are all significant factors.All these subthemes are shown in Figure 2.
The vast majority of women with substance use disorder stated that they did not have knowledge about substance use; they said they were scared even when the name of the substance was mentioned; and they first used it thinking that nothing would happen because of substance use.
"I didn't have any knowledge about drugs.My mother smoked then.When I was a child, I used to be bothered even by the smoke.In fact, as a child I was so happy when smoking was banned indoors that I threatened my mother directly, 'I will report you if I am disturbed by your smoke at home.'" (F11-27)  When it comes to life experiences related to periods of substance use, most of the participants stated that they met the substance through their circle of friends.
"I started to use the substance because of my circle of friends."(F2-41) "I started using substance because of my circle of friends in Istanbul.That's why I had to come to İzmir to quit.You can find drugs with your eyes shut anywhere in Istanbul."(F27-32) Within the scope of reasons for substance use, the following were among the reasons given by the participants: They had been exposed to domestic violence during their childhood, they experienced violence from their parents, or they were exposed to sexual abuse by their closest relatives.
"I was exposed to violence a few times also by my mother."(F11-22) "There were a lot of reasons that led to my substance use, the most important being the fact that I was abused and raped by my own father."(F20-28) "I experienced so much violence and I had so many nightmares and hallucinations that these pushed me to use more substance."(F28-40) The participants stated that they used the substance to cope with the problems or difficulties they encountered in their lives; they turned to substances when they lost a family member, and they tried to forget their problems through substance use.
"I think that my feelings emerge while entertaining myself with drug use due to my childhood trauma and environmental factors."(F12-27) When the participants were asked whom the substance use was first shared with, most of them stated that they shared it with their family members, mostly with their mothers.
"With my family.I didn't hide anything from my family, and I told them all about my substance use." (F22-36) "I shared it with my mom; she cried."(F1-27) In this context, female participants with substance use disorder stated that they mostly said they bought the substance by paying a drug dealer.
"I was buying directly from the seller by texting."(F4-24) "I was financially comfortable, and no one would mess with me.I had a car, and I went by my car to buy drugs.I used drugs in my car, I had all the means; I grew up comfortably."(F27-32) However, many of the participants stated that women were able to obtain the substance through sexual attractiveness, sex appeal, and femininity.
"Some women are literally self-sacrificing."(F2-41)  Within the scope of the information obtained in terms of life experiences related to substance use treatment, the process of recognizing the individual's need for treatment, their motivation for treatment, the treatment and therapy methods used in the treatment process, the changes they encountered in their lives during the treatment period, and the factors that prevented or delayed their seeking treatment came to the fore.All subthemes are shown in Figure 3.
It would be right to say that the majority of female participants with substance use disorder who participated in our study needed treatment due to psychiatric complaints.
"Being under control is very important in addiction treatment.In a way, it's all in your mind; this is both a psychological disorder and a psychological addiction.It is also very important to be conscious, important for families to be con-scious… because my mother did everything for me.She even had a microchip installed in my head."(F10-31).
While some participants emphasized that they did not want to receive treatment themselves and that they were hospitalized with the compulsion of their family members, a great majority of the patients stated that they preferred to receive treatment themselves.
"I refused to be treated at first, but then I accepted.I am happy I did."(F17-25) "I was already hiding it from my family and as soon as they found out about it, they took action for me to be treated in Manisa."(F7-23) When the patients who were in the treatment stage were asked about the sufficiency of the services offered to them, they stated that both their family problems and personal problems continue, they are stigmatized by the society, and the services provided are rather insufficient due to these reasons.
"I don't think any treatment given is adequate" (F11-27) "The treatment's not enough.I'm still using substance; I'm craving for it."(F17-25) "If only you knew the attitude of employees towards us… and how the society looks at us." (F27-32) In this context, 19 female participants with substance use disorder stated that the continuity of treatment could not be ensured, there were no services for women, the number of beds was very few, and they were not suitably differentiated from other hospitalized patients according to their individual needs, which causes them to be badly affected by other hospitalized patients.
"The hospital treated me, but there is no continuity in it.You can stay for two or three weeks, but this is possible only in the case of compulsory hospitalization."(F10-31) "I stayed in the hospital for 9 days.There were a lot of people who were trying to quit and craving, and they affected me so badly that I had to leave my treatment early to avoid them.
My reason for leaving was the other addicted patients staying there."(F16-45) When the data obtained within the scope of the changes in the treatment process of substance use are examined, it is seen that women with substance use disorders experience mainly individual changes during the treatment process.Within the scope of individual exchanges, the majority of the participants say that their life is better without substance, that they realize their mistakes and that they can do everything on their own."My life's changed so much, it's got a lot better.Would you believe it, I don't even smoke anymore.Within the scope of the changes in family relations, the majority of the participants stated that their relations with their families were weaker and they had less contact with their family during the substance use period; yet, their family relations returned to normal after the treatment, and they regained the trust of everyone they had previously lost, especially family members.
"My relationship with my family, meeting with them, going out together… everything started to get better and better..." (F23-24) "I have a child, a son, who started to work as a civil servant.My husband is my biggest supporter.We are a family.And I can say that I now have even more friends than my husband."(F28-40)

Main theme 4. Posttreatment life experiences
In line with the information obtained within the scope of posttreatment life experiences of substance use, the systems recommended by women with substance use disorders in the fight against addiction and their expectations for the future come to the fore.All subthemes are shown in Figure 4.
Within the scope of recommendations regarding substance use elimination and rehabilitation processes, the majority of the participants stated that a more comprehensive treatment plan should be implemented, and treatment durations should be longer.
"We need a more comprehensive treatment plan."(F24-33) "I changed my social circle completely.My family couldn't be with me all the time.I myself had to change in the first place, and so I did."(F13-36) Within the scope of suggestions for making family support visible in the fight against addiction, the majority of the participants stated that family support should be given more importance and families should be given awareness training on this issue."Actually, there isn't much to say about the system.I just want to say that family support could have been included more in the system."(F21-25) "I don't know what type of system it takes to fight it.I just can't stand seeing my mother crying because family is very important to me." (F8-41) One of the systems recommended by female participants with substance use disorder in the fight against addiction is the protection of confidentiality.In this context, one of the participants stated that substance use is something that is done in secrecy, but it is treated openly, and added that confidentiality should be ensured during the treatment process.
"For one thing, you use drugs in secret.No one knows that you are using drugs--unless of course it is clear from your actions, but the treatment process is open.You become a drug addict, and the society stigmatizes you.So, it would be better if a method was developed to maintain a balance between us and the society.Everyone knew it when I started treatment.Their impressions of me changed."(F1-27) When the data obtained from the participants within the scope of their posttreatment life experiences are examined, future expectations of the participants came to the fore.The words frequently used by the participants are shown in Figure 5. Within the scope of their individual life expectancy, the majority of the participants stated that they wanted to live properly, have a job, and continue their education.
"You may have also heard; a student amnesty was recently released.I will benefit from the amnesty.I want to continue my education.I want to finish university."(F4-24) "I just finished high school.I took the exams; I hope to go to university."(F5-21) Within the scope of family and social life expectations, the majority of the participants stated that they wanted to establish a new way of life, start a family and have children, and improve their relations with their families or reunite with them.
"I want to be a good wife to my husband and a good mother to my child.I am very satisfied with my life."(F18-23) "I got strength from my children in the treatment process.My biggest hope is that they will be happy, and I will be a good mother to them."(F25-37) Within the scope of future expectations, some participants stated that they want to shape their future in a substance-free and clean manner, and that they are also trying to gradually quit the drugs they use in treatment.
"I intend to never use drugs in the future."(F3-35) "I try to set goals for myself and constantly keep focused on the goals in my head, in an effort to stay away from substance."(F7-23) Most of the participants stated that substance use should be avoided and that drugs should not be considered as something that is harmless in one use because addiction starts from the moment it is first used.They expressed their opinions as "I will never use it again," adding that they are very worn out both physically and mentally.
"Don't say there is nothing wrong with using it once."(F21-25) "I will never use it again."(F3-35) "People should never dare to be in such environments with a sense of emptiness.They shouldn't even say 'I'll just have a try.'" (F5-21) The participants, who defined addiction as "feeling like dying every day," emphasized that the substance is not a cure for anything, that family support is very important in the treatment of substance use, and that it is very difficult to get rid of the Figure 5. Word Cloud.
substance without support and if the person does not have the will to get rid of the substance."Most importantly, I want to say drugs can never be a remedy for anything.Don't get involved with drug use because of family issues."(F2-41) "Parents should not exclude their children who use drugs, and try to talk to them instead--ask them about their problems.Family support is very important."(F31-28)

Discussion
Studies on women with substance use disorders are very limited in the literature.In the studies carried out, the reasons for starting substance use in women with substance use disorder were examined, and although no definite reason has been found, the effect of friends has been stated to be among the main reasons (Danışmaz Sevin, 2017).Our research findings support the study in the literature and show that women with substance use disorders come into contact with substances because of their friends.
A study in the literature revealed that substance use disorder brings along many interrelated problems into people's lives and that individuals turn to drugs as a means of escaping from these problems (Akcan et al., 2000).Our research findings, which are in alignment with the literature, reveal that women turn to drugs in order to forget their problems or to escape from them.
In another study in the literature, it was found that heroin, which is one of the most frequently used substance types by women with substance use disorders, is highly likely to cause both physiological and psychological addiction, and it has been determined that women with substance use disorders use heroin the most (Güleç et al., 2015).In addition to economic barriers such as low educational attainment and low employment among women who use heroin, lack of family and partner support, lack of household and child care as part of treatment services, lack of services for pregnant women, fear of losing a child through legal proceedings (Simmat-Durand, 2007;Simpson, McNulty, 2008), and physical and traumatic life experiences such as sexual abuse, these barriers differ from those of men (Campbell, 2000;EMCDDA, 2023).For example, Wechsberg et al. (1998) found that women who entered substance abuse treatment had lower levels of education and employment, were more likely to experience health and mental health problems and physical and sexual abuse, and had more fear of having children than men.
The study by Akcan et al. also reveals that women with substance use disorders have deterioration in their relationships with their families, have difficulty in finding a job, face economic problems, and are exposed to stigmatization during substance use (Akcan et al., 2000).Similarly, within the scope of family problems in the addiction process, our research findings reveal that family relationships of women with substance use disorder have weakened.
Women account for about a quarter of people with severe drug problems and about a fifth of participants in drug treatment programs in Europe (EMCDDA, 2023).According to this report, women are more affected by stigma and economic disadvantage than men (Sattler et al, 2021;Miller & Carbone-Lopez, 2015).Women who use drugs tend to come from families with drug problems, and they can be said to have less social support than men, mainly because their partners also use drugs (EMCDDA, 2023;NİDA, 2022).Women are more likely to be held responsible for caring for children than their partners.This burden of raising children plays a very important role in women's drug use and recovery (Ettorre, 2004).Women delay treatment mainly because of their duties as mothers, which significantly affect their functionality.
It is stated that women with substance use disorders have great difficulty in accessing health services and avoid seeking treatment due to the stigma they may experience (Samuelsonn, 2015).
In addition, another study in the literature found that the health services offered to women were insufficient, the bed capacity for women was very low compared to that for men, and there were no treatment programs specific to women (Laanemets, 2002).When our research findings are examined, it is revealed that the treatment applied to women with substance use disorder within the scope of health services is usually drug therapy.Regular interviews with them are made by psychologists or psychiatrists, but there is no specific treatment program for them.
Studies reveal that women with substance use disorders cannot participate in the treatment process due to the stigma problem, and the data in the literature are therefore insufficient and limited (Altıntop, 2017).Because of the increasing stigma against women with substance use disorders, many women delay or avoid seeking the help they need.This makes things worse rather than better.Society defines women by their role as mothers and holds them responsible for childcare and housework.Because addiction threatens this role, they are tested more harshly than men in the same situation.However, because of the double stigma associated with both drug use in general and being a woman with a drug problem, women are less likely than men to seek specialized services (Sattler, at all, 2021;Ettorre, 2004;Lee & Boeri, 2017;Neale et al, 2014;NİDA 2022;Simpson & McNulty, 2008).In addition, it was determined by our research findings that women could not defend their rights as a result of the stigma they were exposed to and that the support they received was insufficient.
The research was carried out to examine the presubstance use, substance use, treatment process, and posttreatment life experiences related to substance use.One of the striking findings that emerged within the scope of the research results was that women with substance use disorder turned to substances in order to cope with the problems they faced in their lives.
When the problems experienced by women with substance use disorders were examined, it came to the forefront that women experience more familial, physiological, environmental, psychological, economic, and social problems, and they are more exposed to violence and have to make greater efforts not to use the substance.
Another significant finding was that women are exposed to "violence" during their addiction process.In this context, the point that should be noted is that although violence might be the cause that leads women to turn to substance use, women are also exposed to violence during the substance use process and after substance use treatment.The study shows that it is of great importance to activate family support and support from the social circle to prevent stigma and other problems faced by women with substance use disorders during the addiction stage.In this context, such support ensures that it gets easier for women with substance use disorders to regain their social functionality and reintegrate into society after treatment.
However, the short duration of treatment, the lack of specialized services for women, and the low number of beds prevent women with substance use disorders from applying to treatment and receiving it.In this context, it is recommended to establish specialized units for women in addiction rehabilitation centers and to provide services for their needs in these units.It is thought that the treatment process will be more effective, and the motivation of women regarding treatment will also increase in this way.

Limitations and Directions/Suggestions for Future Research
The most important limitation is that we did not use the faceto-face interview method during the hospitalization process.This decision was influenced by factors such as limitations in the data collection process, privacy concerns of the participants, and logistical difficulties.The results of our study were nevertheless obtained using the methods outlined, and we have taken these limitations into account when interpreting our findings.
The research was conducted in a single rehabilitation center.Therefore, benefiting from the treatment and rehabilitation process of this center is limited to women who have accepted the interview.Future studies may be planned quantitatively and qualitatively across Türkiye with women who have benefited from different centers.This study is important to see how women experience addiction.This study contributes to the field in terms of understanding the addiction cycle of women.
Ethics Committee Approval: This study was approved by Ethics Committee of Manisa Celal Bayar University (Approval No: 1080, Date: 08.12.2021).
Informed Consent: Informed consent was obtained from the patients who agreed to take part in the study.
Peer-review: Externally peer-reviewed.Funding: The authors declared that this study has received no financial support.
Figure 1.Sub-Themes Related to Life Experiences Before Substance Use (MAXQDA 22-Hierarchical Code-Sub Code Model).

Table 1 .
Sociodemographic Findings of Women with Substance Use

Table 2 .
Main Themes in Addiction Experiences of Women with " (F12-27) "Consider yourself as a cancer patient.You wouldn't think about what others say.Because if you worry what others say, you can neither seek treatment nor can your family support you properly.You are so innocent at treatment that people's attitudes change positively after you ask for it yourself.I just don't know the exact words to express it."(F10-31)