Women & the Opioid Epidemic

January 26, 2018
Taken from the January/February 2018 issue of the Women's Health Activist Newsletter.

In 2016, more than 64,000 Americans died from a drug overdose; about 60 percent of these deaths involved an opioid, such as prescription painkillers or heroin.2 The U.S. Council of Economic Advisors recently estimated that, in 2015, the opioid epidemic’s costs were about half a trillion dollars ($504 million).3

Opioids have been heavily promoted to physicians by the pharmaceutical industry, which convinced health care providers that they were undertreating pain, and downplayed the risks of addiction and death.4 Opioid manufacturers continue to woo physicians; between 2013 and 2015, 1 in 12 physicians took money from opioid manufacturers, for a total of more than $46 million.5  

Although the epidemic of opioid addiction and death has been fueled by prescription opioids, and the dangers of over-prescribing are well-known, the practice continues. In 2016, one in five (19.1%) Americans received an opioid prescription, including 21.8% of women and 16.4% of men.6 Reproductive age women who receive Medicaid may be more likely to be prescribed opioids.  Among women aged 15-44, one-quarter of privately insured women and one-third of female Medicaid beneficiaries were prescribed opioids between 2008 and 2012.7

That is a lot of women to put at risk of opioid use disorder! Yet, there has been relative silence about the opioid epidemic’s disproportionate impact on women. Women are more likely than men to become dependent on opioids because, compared to men, they are more likely to:

  • Experience pain, including chronic pain;8
  • Be prescribed opioids;9
  • Become dependent after using a smaller amount of opioids for less time;10 and
  • Use more potent opioids for longer periods of time.11

Women are more likely to report chronic pain, compared to men. We now know that opioids are not highly effective for treating chronic pain; over time, they actually cause increased sensitivity to pain.12  Nevertheless, pain patients are likely to receive an opioid prescription. As little as a week of opioid use can cause dependence, and women appear to be more susceptible than men to becoming dependent after taking even a small amount of opioids for a short period, a phenomenon called “telescoping.”13 Even though women are more likely to become dependent with smaller doses of opioids, they are actually prescribed higher doses of opioids – and over a longer period of time – than men.14

Not all women are at equal risk of excessive opioid prescribing; middle class white women are more likely to be prescribed opioids than women of color15. For example, African American and Latinx patients are less likely to receive opioids for abdominal or back pain than white patients.16 Although the reasons are unclear, this may be part of a pattern of undervaluing reports of pain in people of color, or could reflect unconscious bias on the part of health care providers who  may erroneously believe that white patients are less likely to become addicted than people of color.

Besides over-prescribing, it is unclear what makes women more susceptible to opioid dependence than men. Smaller body size may play a role, along with psychological and societal factors. Women often report using substances to cope with negative emotions; distress is a risk factor for nonmedical prescription opioid use among women, but not men.17 Women are more likely to have risk factors, including trauma and Post Traumatic Stress Disorder (PTSD), that increase their risk of substance abuse.18 Among women, a history of traumatic childhood events (including sexual abuse, domestic violence, and emotional abuse) is linked to substance use and subsequent adverse events.19, 20 Opioid use disorder is also associated with relationship violence victimization, which affects women more than men.21

Once opioid-dependent, only one in five addicted adults receive treatment annually. Barriers include high costs of treatment and lack of access to effective options, including inpatient rehabilitation programs and medication-assisted therapy (MAT)22. Treatment for opioid abuse is less likely among women who have lower socioeconomic status and women who are incarcerated.23

Women face additional barriers to accessing MAT beyond cost and availability, however. Some treatments are not approved for women who are pregnant or breastfeeding.24 Pregnant and parenting opioid users may also avoid seeking treatment because they fear that their children will be taken away from them if they seek treatment.25, 26

And, opioid-related deaths among women have increased at a faster rate than men. Between 1999 and 2010, overdose deaths increased 400 percent among women, versus 237 percent among men.27  Alarmingly, women who overdose are less likely to get lifesaving treatment on the way to an emergency department. An analysis of 124 opioid overdose deaths in Rhode Island found that men were three times more likely than women to be given naloxone, a medication that reverses the effects of opioids, by emergency paramedics.28

These are depressing facts, but advocates who care about women’s health need to get them out there. We also need to share information about what works: educating prescribers on opioids’ risks and benefits; effective non-opioid treatments for pain; expanding access to MAT and naloxone; reducing the stigma of seeking treatment; and a comprehensive, society-wide approach to effectively preventing and treating opioid use disorder.  

Editor’s note: Watch for more from the NWHN on this important subject.  

Megan Whiteman is a public health science student at University of Maryland and an intern at PharmedOut, a Georgetown University Medical Center project that exposes inappropriate pharmaceutical marketing tactics and fosters rational prescribing.

Alycia Hogenmiller is the project manager of PharmedOut and a law student at the American University Washington College of Law.

Adriane Fugh-Berman, MD, is a former NWHN Board Chair whose research presents a critical analysis of the marketing of prescription drugs. Adriane educates prescribers on pharmaceutical marketing practices as Director of the PharmedOUT program, and created the Health in the Public Interest program at Georgetown University School of Medicine where she trains a new generation of consumer advocates.

Read more from Adriane Fugh-Berman.

The continued availability of external resources is outside of the NWHN’s control. If the link you are looking for is broken, contact us at nwhn@nwhn.org to request more current citation information.

References

[1] Katz J, “Opioid Epidemic Deaths are Risking Faster than Ever, The New York Times, June 5, 2017. Online: https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html; Centers for Disease Control and Prevention (CDC), Wide-ranging online data for epidemiologic research (WONDER). Atlanta (GA): CDC, National Center for Health Statistics; 2016. Online: http://wonder.cdc.gov.

[2] National Institute on Drug Abuse, Overdose Death Rates. 2017. Online: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.

[3] The Council on Economic Advisors (CEA), The Underestimated Cost of the Opioid Crisis, Washington, DC: CEA, November 2017. Online: https://www.whitehouse.gov/the-press-office/2017/11/20/cea-report-underestimated-cost-opioid-crisis

[4] Massion CM, Fugh-Berman A, “Obfuscating Opioid Risks,” Women’s Health Activist 2017; 42(5):10-11.

[5] Hadland SE, Krieger MS, Marshall BDL, “Industry Payments to Physicians for Opioid Products, 2013–2015,” American Journal of Public Health 2017; 107 (9):1493-1495. Online: http://ajph.aphapublications.org/doi/10.2105/AJPH.2017.303982.

[6] Centers for Disease Control and Prevention (CDC), Annual Surveillance Report of Drug-Related Risks and Outcomes, Atlanta: CDC, 2017. Online: https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf

[7] Ailes EC, Dawson AL, Lind JN, “Opioid Prescription Claims Among Women of Reproductive Age — United States, 2008–2012,” Morbidity and Mortality Weekly Report (MMWR) 2015; 64(02): 37-41. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6402a1.htm?s_cid=mm6402a1_w.

[8] Nahin RL, “Estimates of pain prevalence and severity in adults: United States, 2012,” Journal of Pain, 2015; 16(8):769-780. Online: http://www.jpain.org/article/S1526-5900(15)00679-3/pdf

[9] Centers for Disease Control and Prevention (CDC), Vital Signs: Prescription Painkiller Overdoses, Atlanta: CDC, 2013. Online: http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html.

[10] National Institute on Drug Abuse (NIDA), Substance Use in Women, Bethesda (MD): NIDA, 2016. Online: https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women.

[11] Centers for Disease Control and Prevention (CDC), Vital Signs: Prescription Painkiller Overdoses, Atlanta: CDC, 2013. Online: http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html.

[12] Massion CM, Fugh-Berman A, “Obfuscating Opioid Risks,” Women’s Health Activist 2017; 42(5):10-11.

[13] Substance Abuse and Mental Health Services Administration (SAMHSA), National Survey of Substance Abuse Treatment Services (N-SSATS): 2014. Data on Substance Abuse Treatment Facilities. BHSIS Series S-79, HHS Publication No. (SMA) 16-4963. Rockville, MD: SAMHSA, 2015.

[14] Centers for Disease Control and Prevention (CDC), Vital Signs: Prescription Painkiller Overdoses, Atlanta: CDC, 2013. Online: http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html. http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html.

[15] Institute of Medicine (IOM), Committee on Advancing Pain Research, Care, and Education, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, Washington, DC: National Academies of Science, 2011.

[16] Ballesteros C, “Racism might have spared Black and Latino communities from opioid epidemic, drug abuse expert says,” Newsweek, November 7, 2017. Online: http://www.newsweek.com/racism-opiod-epidemic-blacks-latinos-trump-704370.

[17] Back SE, Lawson K, Singleton L, and Brady KT, “Characteristics and Correlates of Men and Women with Prescription Opioid Dependence,” Addict Behav. 2011; 36(8): 829-834. Doi:10.1016/j.addbeh.2011.03.013.

[18] Covington, SS. Women and Addiction: A Trauma-Informed Approach. Journal of Psychoactive Drugs. SARC Supplement 5, November 2008: 377-385.

[19] Agrawal A, Gardner CO, Prescott CA, Kendler KS, “The differential impact of risk factors on illicit drug involvement in females,” Social Psychiatry and Psychiatric Epidemiology 2005; 40(6):454–466.

[20] National Library of Medicine (NLM), 2013 Trans-HHS Intimate Partner Violence Screening and Counseling: Research Symposium, Bethesda (MD): NLM, 2015. Online: http://whr.nlm.nih.gov/ipvsymposium.html#b00.

[21] Smith PH, Homish GG, Leonard KE, Cornelius JR, “Intimate partner violence and specific substance use disorders: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions,” Psychol Addict Behav. 2012; 26(2). Online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883081/

[22] Saloner B, Karthikeyan S, “Changes in Substance Abuse Treatment Use Among Individuals With Opioid Use Disorders in the United States, 2004-2013,” JAMA 2015;314(14):1515-1517. Online:  http://jama.jamanetwork.com/article.aspx?articleid=2456156

[23] Blanco C, Iza M, Schwartz RP, et al., “Probability and predictors of treatment seeking for prescription opioid use disorders: A National Study,” Drug and Alcohol Dependence 2013;131(0):143-148. doi:10.1016/j.drugalcdep.2012.12.013.

[24] National Institute on Drug Abuse (NIDA), Substance Use While Pregnant and Breastfeeding, Bethesda (MD): NIDA, 2016. Online: https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-usewhile-pregnant-breastfeeding.

[25] American College of Obstetricians and Gynecologists  (ACOG), “Opioid abuse, dependence, and addiction in pregnancy,” Committee Opinion No. 524. Obstet Gynecol. 2012; 119:1070-6. Online: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Health-Care-forUnderserved-Women/Opioid-Abuse-Dependence-and-Addiction-in-Pregnancy

[26] Substance Abuse and Mental Health Services Administration (SAMHSA), Advancing the Care of Pregnant and Parenting Women With Opioid Use Disorder and Their Infants: A Foundation for Clinical Guidance, Rockville (MD): SAMHSA, 2016. Online: http://www.regulations.gov/document?D=SAMHSA-2016-0002-0001.

[27] Centers for Disease Control and Prevention (CDC), Vital Signs: Prescription Painkiller Overdoses, Atlanta: CDC, 2013. Online: http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html. http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html.

[28] Sumner SA, Mercardo-Crespo MC, Spelke MB, at al., “Use of naloxone by emergency medical services during opioid drug overdose resuscitation efforts,” Prehospital Emergency Care 2016; 20(2): 220-225. http://www.tandfonline.com/doi/full/10.3109/10903127.2015.1076096