As the opioid crisis continues to unfold, it's having an increasingly deadly impact on women. Whether their path began with prescriptions or illegal drugs, opioids affect women in a way that intersects with the various parts of their lives much differently than men. Medical professionals tend to point to pregnancy as one of the main concerns facing women who misuse opioids, but the reality is much more complicated than that.
While the number of men who die from opioid overdoses is significantly higher than the number of women — men have accounted for about two-thirds of fatal opioid overdoses in the United States since 2002 — women “are closing that gap,” according to a 2017 report examining opioid misuse among women from the Department of Health and Human Services’ Office on Women’s Health (OWH).
The Centers for Disease Control and Prevention (CDC) first declared that there was an opioid epidemic in the United States in early 2011. Since then, the nature of the country’s problem with opioids has changed: While it first began with the overprescribing of prescription opioids, it shifted to heroin in 2010, and now to fentanyl, a potent and often illicitly made opioid. From 1995 to 2015, deaths from prescription opioid overdoses increased 471% and deaths from synthetic opioids like fentanyl skyrocketed 850% among women, according to CDC data.
Opioids affect women in ways not confined to physiological explanation alone. Data and expert opinion point to the fact that women who use these drugs face a variety of additional challenges that make the way they experience opioid use disorder incredibly nuanced and complex.
Gender aside, mental health issues are linked with opioid use disorder, but there are some ways in which women may be impacted differently than men. According to the OWH report, which reviewed dozens of studies about gender differences and opioid use to examine prevention, treatment, and recovery strategies for women, those who use the drugs often have histories of physical or sexual trauma. Those serious psychological and emotional stressors may increase a woman’s risk of developing an opioid use disorder.
Rachel Heyman, a licensed clinical social worker and the site director at the Center for Comprehensive Health Practice (CCHP), a community health center in New York City’s East Harlem, says that while there’s no way to predict who will have an opioid use disorder, two of the main paths she sees among women are either prescription misuse after an injury, or using prescription or illicit opioids as a way to cope with some sort of hardship in their lives.
"It doesn’t mean that if you have a mental health issue, you therefore must be an addict or someone who needs to be in recovery."
She does emphasize, though, that it’s not that trauma causes opioid misuse, or vice versa. “There are many facets of what builds a perfect storm that then creates what is addiction or dependence, and one of those pieces is very often mental health,” Heyman says. “It doesn’t mean that if you have a mental health issue, you therefore must be an addict or someone who needs to be in recovery.”
But a person who is struggling with their mental health can be “more vulnerable” to substance misuse, she adds. Even when a person is on medication-assisted treatment, it’s important to focus on mental health as part of treatment to help prevent potential relapse.
At CCHP, there is a primary care office where providers can prescribe buprenorphine, which, along with methadone, is a main form of medication-assisted treatment. There is also a methadone clinic a few floors away. But to receive such treatment, CCHP places expectations on the patients to prioritize their mental health.
“The expectation is that they're at least initially coming for weekly therapy, and in order to get additional bottles [of take-home medication],” Heyman says. “We are also really encouraging people to come to the therapy groups.”
CCHP has group therapies for survivors and for pregnant and parenting women, as well as a group called Healing Circle. The Healing Circle group focuses on getting well through yoga and mindfulness, and Heyman says it’s seen amazing turnout, specifically among women who hadn’t been to a group at CCHP in 10 to 15 years because they felt like there wasn’t anything new to learn.
They think, “‘Oh, I got this,’ even though maybe their recovery was not fully under control,” Heyman says. “And they're coming to this group, and they're working on themselves and their recovery.”
Shannon Graves works at Elizabeth Gregory Home in Seattle, which offers services for women who are experiencing homelessness or a substance use disorder. She says she was first prescribed opioids after she broke her arm while horseback riding, when she was just 12 years old.
That one prescription kicked off a 10-year-long struggle with opioids, Graves, who is now 24, says. She recalls smoking OxyContin with friends when she ran out of Vicodin. “It turned into an everyday thing very, very fast, within a month or two,” she says. At age 15, she was introduced to heroin, and she says used the drug for seven years.
Graves celebrated her second year of sobriety in April. She tells Bustle she believes her opioid use disorder would have started no matter how the substance made its way to her, though. It was American Behavioral Health Systems (ABHS), a treatment center that Graves went to in Spokane, Washington, that helped her recover by focusing not just on her opioid use disorder, but her mental health as well.
“I learned a lot about my codependency, and my lack of self-love and self-respect and self-worth,” Graves says.
“They basically just taught us to be social and how to be a part of a community,” she tells Bustle. “And so that was really mind-blowing to realize that I've been isolating myself. I was just so alienated from the rest of the world, and it was really cool to see some of the skills that they taught us in there.”
Not only is sexual abuse correlated with substance use disorders, but the likelihood of being sexually abused is also substantially higher for women than it is for men. A 2015 New York University study found that 41% of women and 11% of men said they were forced to have sex while using drugs.
Dr. Nabila El-Bassel, PhD, DSW, a professor at Columbia University's School of Social Work who has done research on women and opioids, tells Bustle the lifetime rate of intimate partner violence reported by women who misuse substances is much higher than the national rate. In the context of relationships and substance misuse, she says physical and sexual violence is a huge issue.
"[Sexual abuse] doesn't discriminate, and neither does opioid dependency."
For women who are survivors of sexual assault, CCHP has a survivors group where the counselor uses the Seeking Safety model, an evidence-based approach that does not require participants to relive their traumatic experiences. Instead, it aims to treat both trauma and substance misuse in patients through a lens of achieving “safety in their relationships, thinking, behavior, and emotions.” Heyman, the CCHP site director, points out that it’s vital to have counselors who are trained in evidence-based care and treating trauma.
“Sexual assault, sexual abuse, any kind of sexual misconduct or unwanted advances can happen to literally anyone,” she says. “It doesn't discriminate, and neither does opioid dependency.”
El-Bassel has also researched the experiences of women who misuse substances and engage in sex work.
“A number of women said that they are forced to do sex work to bring in money for drugs for her and her partner,” El-Bassel says her research shows. “However, after the fact, they tend to be abused by the same partner” because of their engagement in sex work and risky use of drugs.
Sex work can be a means of survival for some women who are using opioids, but it can also lead to retraumatization. Women who repeatedly experience trauma may cope by continuing to misuse drugs to escape, El-Bassel says.
She believes that prevention of violence like this should begin well before a person experiences a substance use disorder. Teaching young kids and teens about violence and gender inequality is critical in preventing the abuse many women who use opioids have faced.
“Gender inequalities, as we know, are amplified by all the other things,” El-Bassel says.
Pregnancy & Parenting
In East Harlem, people coming in to CCHP for an appointment may sometimes find toddlers running back and forth in a hallway that separates the practice’s playroom and a room where around a dozen women meet for a pregnant and parenting group therapy session. The child care resource that CCHP offers is rarer than experts say it should be at centers that offer treatment for substance use disorders.
Only 22% of facilities that offer substance use treatment offer specialized programs for pregnant or postpartum people, according to SAMHSA. For people who are pregnant, substance misuse has adverse effects on both their bodies and on the fetus. The number of pregnant women who were using opioids at the time of delivery more than quadrupled from 1999 to 2014, and it has become a serious concern for health care professionals.
One risk of using opioids while pregnant is neonatal abstinence syndrome (NAS), a drug withdrawal syndrome that occurs in newborns “caused primarily by in utero exposure to opioids,” according to the CDC. Symptoms include tremors, high-pitched crying, seizures, feeding difficulties, and temperature instability. In the United States, the rate of NAS sharply increased from 2000 to 2013, the CDC reported.
For pregnant women with opioid use disorder, the American College of Obstetricians and Gynecologists recommends medication-assisted treatment. Not only do these treatments reduce the risk of NAS, but they also reduce the likelihood of women relapsing after giving birth.
There’s a stigma around giving this treatment to pregnant women, however. Dr. Mariely Fernandez, MD, the chief medical officer at CCHP, tells Bustle that mothers have told her about experiences where “the whole visit goes out the window” once their OB/GYN finds out they’re on methadone or buprenorphine. Fernandez finds this frustrating, because the medication helps women keep their doctor appointments, remember to take their prenatal vitamins, and take care of themselves. Plus, abruptly stopping opioid use while a person is pregnant could induce pre-term labor.
It’s just as difficult for women to get treatment after a child is born. “If you're trying to get into treatment, it can be a real challenge to seek care and have children and have nobody to care for them,” says Kathie Kane-Willis, chair of the Women's Committee for the Illinois Advisory Council on Alcoholism and Other Drug Dependency, which works on gender-specific strategies for women with substance use disorders.
"Child care has to be part of the treatment model."
There’s a parenting expectation on the mother to get well, but there are often few options for her. Heyman points out that, while this is a simplified example and not true in every case, it’s easier for a father to leave the home to detox or enter rehab because of gender norms around child care and parenting. When a mother needs that same level of care, the question of “what about the kids?” is much harder to answer, she says.
That’s why CCHP offers the playroom for parents to leave their kids while they attend therapy, attend a parenting education class, or check in with their doctor. Scarlett Luna, CCHP’s child care supervisor, tells Bustle the practice wouldn’t be able to do the work it does without the playroom. It’s more than a daycare, she says — it’s an important tool in the parents’ recovery.
Chicago’s The Women’s Treatment Center (TWTC) is one of the few substance use treatment facilities in Illinois that offers child care services for mothers who enter its program. Whether women are undergoing detox or preparing for intake, a child care staff member is on site to watch their young children in the meantime.
“Child care has to be part of the treatment model,” Dr. Althea Jones, PhD, TWTC’s program director of parenting education, tells Bustle. “The bond between [parent and child] is able to continue without the mother having to sacrifice the treatment she needs to overcome her addiction.”
People who have an opioid use disorder face stigma regardless of their gender. But for women who are facing additional challenges on top of that, the stigma can feel magnified tenfold. Women who misuse opioids often find themselves feeling isolated, and it affects their mental health, their substance use, and their ability to get well, Lisa Etter Carlson says. Etter Carlson co-founded Aurora Commons in Seattle in 2011 and serves as its director of women’s health and initiatives. Aurora Commons is a “neighborhood living room” that offers people who are experiencing homelessness or misusing drugs a place to feel a sense of community and also be bridged to services.
“What we’re seeing is a group of women that are truly treated as ex-humans in this world,” she adds.
Ericka Frodsham’s journey to recovering from her opioid use disorder began seven years ago outside Aurora Commons, when Etter Carlson offered her a cup of coffee. They sat down together and just talked.
“At some point during that conversation I found just enough hope — or [remembered] that I had children, or that I had something to live for — that I changed my mind, and I just kept going to the Commons,” Frodsham tells Bustle.
Frodsham has been in recovery for about three years now, and she credits the time she spent at Aurora Commons and the love she felt from Etter Carlson for that. That’s why Aurora Commons focuses not on fixing people who come to their space, but instead, as its employees and volunteers will tell you repeatedly, on loving people where they’re at.
“We just got really tired of seeing that they’re not welcomed anywhere, and wanted to do our best to create a place where they can feel welcome and seen and loved and utilized, and where we can acknowledge that they’re needed in this world, too,” Etter Carlson says of the people she serves.
The stigma is still a struggle for Frodsham. She talks about how she’d like to work at Aurora Commons (she’s currently a nighttime monitor at a local shelter) but she feels she carries too much shame right now to make that happen. She has to love where she’s at, first, before she can love other people where they’re at.
“It’s unfathomable to me that in America, you’re so dehumanized,” Frodsham says. “I still have a hard time viewing myself as a part of the community. It takes a lot of work to rebuild your value as a human being.”
Paige Tortorelli and Kaisha Young contributed to this report, which was produced in partnership with the Social Justice News Nexus at the Medill School of Journalism, Media, Integrated Marketing Communications at Northwestern University.
If you or someone you know has been sexually assaulted, call the National Sexual Assault Telephone Hotline at 800-656-HOPE (4673) or visit online.rainn.org. For help for mental health concerns, visit the National Alliance on Mental Health (NAMI) website, or call 1-800-950-NAMI(6264). For help with substance use, call the SAMHSA National Helpline at 1-800-662-HELP(4357).