Reproductive Health Care for Women with Opioid Use Disorders
By – Angeline Ti, MD MPH
Assistant Professor, Emory University School of Medicine
Dept of Gynecology and Obstetrics/Family and Preventive Medicine
Guest Researcher, Fertility and Epidemiology Studies team – Centers for Disease Control and Prevention Epidemiology
The impact of the current opioid epidemic is a significant public health issue, particularly for women of reproductive age – negatively impacting their families and communities. According to the Centers for Disease Control and Prevention (CDC), in 2016 21.8 percent of women in the US filled at least one prescription for an opioid and an estimated 15.3 percent of women used illicit drugs or misused prescription drugs. (Centers for Disease Control and Prevention, 2017)
Opioids include illegal drugs such as heroin, as well as legal medications such as oxycodone, morphine or hydrocodone. Opioid use can fall on a spectrum ranging from medically-supervised low-risk use to risky use all the way to substance use disorder or “addiction.” The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) combines criteria from what was previously known as substance abuse and substance dependence in the DSM-IV into one diagnosis, substance use disorder. People with a substance use disorder can range from mild to moderate to severe, depending on the number and severity of symptoms – which can be related to impaired control, social impairment, risky use and certain pharmacologic criteria (e.g. tolerance or withdrawal). (American Psychiatric Association, 2013)
Research findings suggest women experience opioid use and opioid use disorders differently than men. Women have higher rates of chronic pain and use prescription opioids at higher doses and for longer periods compared to men. Women also tend to progress to physical dependence more quickly and at smaller drug amounts. Moreover, women appear to have different social risk factors for substance use compared to men. For women, histories of trauma, including intimate partner violence, sexual abuse, and childhood traumas have been associated with the initiation of substance use and the development of substance use disorders. (Office on Women’s Health, 2017)
In addition to the risk of death from overdose, opioid intoxication can cause slowed reaction time and confusion, as well as reduced consciousness thus increasing vulnerability to assault, including sexual assault. For women, prolonged opioid use can result in the decrease of certain hormones, leading to oligo or amenorrhea and infertility. While opioid use during pregnancy has not been clearly linked to any birth defects, it is associated with neonatal abstinence syndrome, or neonatal withdrawal. (American College of Obstetricians and Gynecologists, 2017)
- While pathways to opioid misuse are complex, health care providers must recognize their role in primary prevention by using evidence-based practices for prescribing opioids, including following prescribing guidelines from the CDC and utilizing Prescription Drug Monitoring Programs (Centers for Disease Control and Prevention, 2017).
- Universal screening, including screening of women and pregnant women, is crucial for identifying patients who have or are at risk for substance use disorders. A single question such as “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” may be used as the initial screen, followed by a more detailed questionnaire for those who screen positive (Shapiro, Coffa, & McCance-Katz, 2013). The Substance Abuse and Mental Health Services Administration (SAMHSA) has guidance on Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based approach to addressing substance use disorders in primary care (Substance Abuse and Mental Health Services Administration, 2017).
- Medication-assisted treatment (MAT) remains the prominent treatment for opioid use disorders which involves the supervised use of medications such as methadone or buprenorphine to prevent withdrawal and reduce cravings, in combination with counseling and support. Another important medication that is used to prevent overdose is naloxone, an injectable or inhaled opioid antagonist. MAT has been associated with improved patient survival and functionality, as well as improved birth outcomes for pregnant women. (Substance Abuse and Mental Health Services Administration, 2015)
- For women of childbearing age with opioid use disorder, family planning is a critical part of routine care. While there are not specific guidelines for this population, the CDC has multiple resources to guide evidence-based family planning care. The Quality Family Planning guidelines provide recommendations on how to provide family planning services, including what services to offer and how they should be offered. The US Medical Eligibility Criteria provide guidance on the safety of contraception for women with medical comorbidities that may be associated with opioid use disorder, including depression, sexually transmitted infections, viral hepatitis, and other chronic conditions. The US Selected Practice recommendations provide guidance on issues related to initiation and use of certain contraceptive methods, including necessary exams and tests prior to initiation, providing same-day or quick start contraception, and managing certain side effects. (Centers for Disease Control and Prevention, 2017)
- Pregnant and postpartum women with opioid use disorder have specific health care needs and vulnerabilities. Routine prenatal care should be tailored to the woman’s individual medical and social needs. MAT is recommended to optimize maternal and infant outcomes. Though initiation of MAT during pregnancy is safe, it must be done under close supervision, either inpatient or outpatient. Medically supervised withdrawal is not recommended, as it is associated with higher rates of relapse, however it may be considered if the woman is unwilling or unable to initiate MAT. Opioid use and MAT alone do not preclude breastfeeding, which should be encouraged if the mother is otherwise healthy. In labor, women with opioid use disorder should be offered the full range of options for anesthesia, however may require higher doses for adequate pain control. Women who are on MAT should continue their medications. More detailed clinical guidance should be consulted for those caring for pregnant women with opioid use disorder. (American College of Obstetricians and Gynecologists, 2017)(Substance Abuse and Mental Health Services Administration, 2018)
American College of Obstetricians and Gynecologists. (2017). Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. Obstet Gynecol, 120, e81-94.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
Centers for Disease Control and Prevention. (2017, September 18). Retrieved from CDC Contraceptive Guidance for Health Care Providers: https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm
Centers for Disease Control and Prevention. (2017). Annual Surveillance Report of Drug-Related Risks and Outcomes- United States, 2017. Surveillance Special Report 1. Department of Health and Human Services.
Centers for Disease Control and Prevention. (2017, August 29). CDC Guideline for Prescribing Opioids for Chronic Pain. Retrieved from https://www.cdc.gov/drugoverdose/prescribing/guideline.html
Centers for Disease Control and Prevention. (2017, October 3). What States Need to Know about PDMPs. Retrieved from https://www.cdc.gov/drugoverdose/pdmp/states.html
Office on Women’s Health. (2017). Final Report: Opioid Use, Misuse and Overdose in women. Washington, DC: US Department of Health and Human Services.
Shapiro, B., Coffa, D., & McCance-Katz, E. F. (2013). A Primary Care Approach to Substance Misuse. Am Fam Physician, 88(2), 113-121.
Substance Abuse and Mental Health Services Administration. (2015, September 28). Retrieved from Medication and Counseling Treatment: https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat
Substance Abuse and Mental Health Services Administration. (2017, September 20). Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT). Retrieved from https://www.samhsa.gov/sbirt/resources
Substance Abuse and Mental Health Services Administration. (2018). Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. Rockville, MD: Substance Abuse and Mental Health Services Administration.