Opioid use in women is not just ‘a fetus problem’

Opioid abuse among American women has reached epidemic proportions: The Centers for Disease Control this month released a report showing that 28 percent of privately insured women aged 15 to 44 fill prescriptions for opioids like Percocet, Vicodin, and Oxycontin every year. For Medicaid-enrolled women, the figure goes up to 39 percent. Previous research suggests that more than 16,000 deaths are attributed to use of prescription opioids annually.

The stark finding that nearly one-third of women are filling prescriptions for opioid medications has those in the medical and public health communities understandably alarmed. Yet most media coverage of the CDC study disconcertingly offered some variation on a narrower message: “Opioid use among women of reproductive age is a concern because opioid medications have been linked to birth defects and other adverse pregnancy outcomes.”

Or, in other words, women’s opioid use is a “fetus problem.”

Never mind that pregnant women were not even identified in the CDC study. Repackaging the issue of opioid abuse in this manner ignores the complex health effects of substance use on the women themselves.

No doubt there are a number of well-defined health issues that arise when women use opioids while pregnant, and this is the core focus of the CDC’s initiative,“Treating for Two,” which sponsored the report.

But scientific data about opioid use in pregnancy is murky. Birth complications, in particular preterm birth and neonatal drug withdrawal, are well documented. Some birth defects have been associated with opioid medications, but it is unclear whether the effect is causative. One of the two studies to find an increased risk of birth defects among children born to mothers who used opiates during pregnancy found a neurological defect — neural tube defects — in just six out of 10,000 women, translating to a twofold increase in risk.

A recent US Food and Drug Administration report went so far as to state that the demonstrated risks of pain medication use during pregnancy are inconclusive, and that the agency could not make any definitive recommendation for or against their use. As much as possible, pregnant women want to avoid medication use that might increase risks of birth defects. But there are reasons to be concerned about women’s health — and about the risks of substance use — that go beyond the fact that she might be carrying a fetus.

While it remains essential to address a neonate’s welfare, it should not be at the expense of a woman’s health and well-being. The “fetus-focused” public health message about women’s opioid use is a disservice to women, because it reduces women’s health to child-bearing capacity issues, while ignoring the many health and social effects opioid use has on women themselves.

When a 15-year-old girl starts popping Vicodin for non-medical reasons, it is a health crisis for her — not just for her potential future children. Women who use drugs are at greater risk for medical side effects that include infections in and damage to nearly every bodily organ: skin, brain, heart, lungs, kidneys, and liver.

Because of the frequent overlap of sexual risk behaviors and drug use, women who use drugs are doubly at risk of acquiring HIV, experiencing intimate partner violence, and being involved in commercial sex work. For some women who use drugs, their substance use is the driving socioeconomic force behind homelessness and incarceration.

Furthermore, by ignoring the “women” in women’s opioid use, a reductionist approach only compounds the stigmatization and public shaming of female drug users. When women are reprimanded and isolated for their drug use in this way, they are less likely to engage in treatment.

The upside is that despite the shortcomings of its message, the CDC report draws public awareness to women’s substance use. This collective moment of recognition grants an opportunity for intervention. Substance use disorders are chronic, relapsing, and treatable medical conditions. Opioid use disorders, unlike other drug addictions, can be very effectively addressed by a number of medication-assisted treatments such as methadone, buprenorphine, and naltrexone. These treatments are time-tested, cost-effective, safe, and efficacious.

Without treatment — in the context of increasingly regulated prescription practices designed to prevent opioid use — opioid dependent women may shift to more available and less expensive opioids such as heroin, which carry their own associated injection use-related dangers.

Instead, the CDC findings ideally should be harnessed to energize the conversation on women’s opioid use and deliver a new, more productive public health focus. One that expands access to and availability of drug treatment. Yet, perhaps it is easier or more appealing to focus on birth outcomes — a baby born to an opioid-using mother is viewed as an innocent bystander.

But to focus only on birth outcomes is to miss the crux of the issue. Think about the familiar mantra of air travel: In the event of a loss in cabin pressure, put an oxygen mask on yourself before helping small children. We should take these instructions to heart when considering pregnant women who are struggling with an opioid use disorder. These women are not just the carriers with their unborn children as their “passengers” — but individuals whose health we need to protect as much as their offspring with life-saving treatment.

• Letter: Pushing pain medication opens gateway to opiate addiction

• Joanna Weiss: Could group care be the new model for pregnancy?

• Steven Kassels: The scourge of heroin addiction

Dr. Jaimie Meyer is an infectious disease physician and assistant professor of medicine in the Yale AIDS Program. Dr. Lynn Fiellin is an associate professor of medicine at Yale School of Medicine, is board-certified in addiction medicine, and has been caring for individuals with opioid use disorder for the past 12 years. Both are OpEd Project Public Voices Fellows at Yale.