Why Are Women Dying From Opioid Overdoses At Unprecedented Rates?

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The Face Of The Opioid Crisis Is ChangingArsh Raziuddin
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Arsh Raziuddin

Chelsey Moore’s back started hurting when she was in high school. She wasn’t sure how or why, but the pain wouldn’t stop. Finally, an MRI revealed a herniated disc, and a doctor told Chelsey that she was developing degenerative disc disease. He wrote her a Percocet prescription.

Back at home, Chelsey realized that when she took more than one Percocet at a time, she felt really good. Sometimes, she’d swallow five or six in a row.

“I always knew I should stay away from drugs,” she says. She’d smoked cigarettes and weed with her mom—who struggled with substance use disorder—but never anything harder. “Taking something prescribed by my doctor, it didn’t even register that there was a risk there. I didn’t think something like that could or would happen to me.”

When the prescription ran out, Chelsey didn’t feel the urge to take opioids, but she did remember how good it felt. A few years later, she started experimenting with "bath salts" (synthetic cathinones), and later, with Xanax, meth, and heroin. For years, Chelsey struggled to find treatment for her opioid use disorder. She would detox, then buy pills again, enroll in new programs, and relapse.

In 2021, she overdosed for the first time, snorting a Percocet before curling up in bed with her boyfriend.

“He tried to roll me over, and I was blue,” she says.

Her boyfriend called 911 and started doing CPR. What nobody knew at the time was that Chelsey was pregnant.

Chelsey is one of millions of women who’ve struggled with opioid use disorder over the past decade. But unlike the estimated 80,411 people who died from an opioid overdose in 2021, Chelsey survived.

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It’s been six years since the U.S. Department of Health and Human Services declared opioid misuse a national epidemic and a decade since opiates were prescribed freely and by the bottle. But the same horrific overdose stories that marked the early aughts are still playing out. In fact, for women, the situation is worse.

The opioid epidemic has been steadily snowballing for women in recent years—even though it tends to get less airtime and attention than what’s happening among young men—but it’s now impossible to ignore. From 1999 to 2021, overdoses in women grew 1,608 percent, compared with 1,076 percent for men. And during the COVID-19 pandemic alone, from 2019 to 2021, overdose deaths for women increased by 40 percent. (While men still outnumber women in overdose deaths at a rate of nearly three to one, women feel the epidemic’s strain in different and complex ways.) It can’t be overstated just how much the pandemic’s impact on social support systems, coupled with a growing supply of cheap, legal and illegal fentanyl in the U.S., has contributed to the current crisis.

Women of color and mothers have been particularly hard hit. From 2018 to 2021, overdose deaths more than tripled for pregnant and postpartum women between the ages of 35 and 44, according to a November 2023 study from the National Institutes of Health. And drug overdose deaths for Black women nearly tripled from 2015 to 2021, making overdoses the fourth-leading cause of death for Black women, after cancer, heart disease, and COVID-19, per a study from researchers at the University of Pennsylvania.

Yet, for the past decade, providers haven’t been focused on treatment tailored for women, says Caitlin E. Martin, MD, MPH, an ob-gyn and addiction medicine provider at Virginia Commonwealth University. “We’re just catching up to what’s been going on the whole time.”

Arsh Raziuddin

Women and opioids have a long history.

In the late 1800s, doctors began prescribing morphine—a strong opiate now used most often in pain management, small surgeries, and cancer care—to “hysterical” mothers. At that time, the drug was used to treat reproductive ailments, pain, and what today might be diagnosed as chronic fatigue.

“Uterine and ovarian complications cause more ladies to fall into the habit, than all other diseases combined,” Dr. Frederick Heman Hubbard wrote in an 1881 book on opiate addiction and alcoholism. By the early 1900s, women constituted 60 percent of people addicted to opiates.

That epidemic tapered off after the federal government began regulating pharmaceuticals in 1906, but it surged again in the 1990s when drug companies began aggressively marketing opioids such as OxyContin for quick, effective pain relief. By 2004, OxyContin had become a leading drug of abuse in the United States. And because women experience more chronic pain (like that caused by fibromyalgia or endometriosis), doctors wrote them more prescriptions, says Dr. Martin. In fact, women were twice as likely to use abusable prescription drugs as men, per a 2000 study from researchers at Brandeis University. By 2017, women were receiving 65 percent of all opioid prescriptions.

But between the first opioid epidemic and the second, the government–led effort to reduce the illegal drug trade in the U.S.—popularly known as "the War on Drugs"—had begun. And it hit women (and mothers) in a particularly punitive way.

“Our country has used drugs to weaponize society against specific communities,” says Chad Sabora, a nationally recognized expert in harm reduction and drug policy reform and the vice president of government and public relations at the Indiana Center for Recovery. In the 1980s, that vitriol was directed toward Black mothers and their so-called “crack babies.”

As policing of drug use ramped up, hospitals began drug-testing Black women they suspected of using crack cocaine during their pregnancies, reporting positive results to child protective services. In 2016, when Congress passed a massive funding package to fight the opioid epidemic, it leaned back into that practice: The law required doctors to report suspected child abuse—and many states interpreted positive drug screens as evidence of abuse.

And while the current opioid epidemic initially hit white rural communities the hardest, Black Americans living in urban areas have experienced disproportionately high rates of overdose deaths in recent years.

At her Kentucky high school, Adrianna “AJ” Kenley started drinking to ease the awkwardness of trying to fit in as a biracial teen. Then, during her senior year, she tore the ACL, MCL, and meniscus in one of her knees playing volleyball, subsequently losing the college athletic scholarship she was counting on. Her doctor prescribed pain medication, and her “alcohol use went on the back burner,” AJ says.

When she took the prescribed opioids, she didn’t “feel anything at all.” It helped ease her social anxiety. So, when the prescription ran out, she started driving to Florida with a group of friends who knew about the “pill mills” there, clinics that loosely prescribed opioids.

In her 20s, AJ was incarcerated on drug charges a handful of times. While in jail at one point, a family friend sent her a copy of The Big Book, the Alcoholics Anonymous handbook. “When I got out, I got in contact with that friend, and she’s still my sponsor today.”

AJ, who is nine years sober now and an ambassador with Shatterproof, a nonprofit dedicated to transforming addiction treatment, says the pandemic put a serious strain on her recovery. “My home group shut down completely,” she says. In-person meetings became conference calls, and the people who’d been so integral to her recovery became voices on the phone.

“It just wasn’t the same,” she explains.

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At the University of North Carolina Horizons Program, a substance use disorder treatment program for pregnant and parenting women and their children, Hendrée Jones, PhD, an obstetrics and gynecology professor and a UNC Horizons senior advisor, saw patients who had been stable and going to support groups, like Narcotics Anonymous, lose those spaces and sometimes their lives.

“There was such a priority on physical health and safety that psychological safety wasn’t given near enough attention,” says Jones. “And what is the perfect breeding ground for a substance use disorder? Isolation and loneliness and boredom and fear.”

But other factors came into play as well, creating a truly tragic perfect storm. Treatment and harm-reduction programs, like needle exchanges and Narcan distribution sites, closed their doors. Parents—especially mothers–-had to adapt to caring for children who were home from school. Women in abusive home environments had nowhere to go. Social distancing resulted in more people using substances alone, with no one around to help if they overdosed. At the same time, the U.S. drug supply turned increasingly toward illicitly made fentanyl, says Sheila Vakharia, deputy director of research and academic engagement at the Drug Policy Alliance.

“Overall overdose rates and fatal overdose rates have gone up more than I’ve ever seen in my entire career,” says Jones.

The pandemic laid everything bare, for women in particular.

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Arsh Raziuddin

There are effective treatments, but people don’t always know about them, and they can be stigmatized.

Scientists now understand that addiction is not a moral failing, but a chronic disease that rewires the brain—and that opioid use disorder (OUD) can be treated with medication and therapy. Opiates flood the brain’s reward system with dopamine, a neurotransmitter responsible for feelings of pleasure, creating a hormonal response that can be 10 times as powerful as that triggered by “natural rewards” (like eating your favorite food or talking with a friend).

While not everyone who tries drugs will develop a dependency, research shows that a person’s genetics can increase their risk by 40 to 60 percent, and that traumatic childhood experiences can further increase risk.

Understanding the biological mechanisms involved—and working to break down the stigma associated with opioid use disorder—has helped treatment centers develop programs that actually work.

“We have lifesaving medications for opioid use disorder,” says Dr. Martin. When used correctly, opioid agonists such as buprenorphine and methadone can reduce the risk of dying from an overdose by half. “No other medication I have prescribed has such a benefit to society.”

Opioid agonists can be taken once a day as a liquid, pill, or film dissolved under the tongue or in the cheek, and they bind to the same receptors in the brain as opioids—preventing withdrawal without making the user feel high.

As scientists and doctors better understand the brain mechanisms involved in this chronic medical condition, terms like “addict” and “user” are being phased out, replaced by ones like “person with substance use disorder” and “patient.” But that doesn’t mean the general public has caught on yet.

“Women face more and different and complicated stigma for their drug use,” says Vakharia, and that’s especially true if a woman is pregnant or a parent. That stigma incentivizes many women to keep their drug use a secret—which in turn puts them at greater risk of overdosing alone and avoiding health-care settings where they could get help. It also helps explain the tripling death toll seen over the past five years among pregnant and postpartum women who overdose.

On top of that, few substance use programs specialize in treating pregnant or postpartum women, and some doctors aren’t taught the warning signs of substance use disorders or how to help women get care.

Tara Hollingshead struggled to access treatment for her opioid use disorder because the options available to her weren’t meeting her needs as a new mom.

After she gave birth to her first daughter in 2018, Tara enrolled in a 90-day rehabilitation program and then moved into a sober-living facility. But she missed her daughter, and when she decided to return home, she relapsed. When Tara found out she was pregnant again in late 2020, her nausea, which got so bad that she duct-taped a trashcan to her bed, kept her bedbound.

The idea of enrolling in a treatment program that would require her to wait at a pharmacy every day—methadone and buprenorphine are often dispensed at a clinic—was overwhelming for Tara. When Tara did start calling rehab facilities after her second daughter’s birth, there were no beds available.

A few weeks later, when she was driving home from a doctor’s appointment, Tara was arrested. Initially, she was charged with drug possession. Then the prosecutor in her eastern Ohio hometown charged her with another crime: administering a controlled substance to a pregnant woman—in this case, herself. On May 18, 2022, she was sentenced to a minimum of eight years in prison.

Although she fought the charge and was released a year later, Tara is one of 1,379 people arrested for a behavior they engaged in while pregnant—from not wearing a seatbelt to an alleged lack of prenatal care—between 2006 and June 2022. More than 90 percent of those arrests were related to allegations of substance use while pregnant, and a third of those arrests were initiated in a health-care setting, says Lourdes A. Rivera, president of the legal advocacy nonprofit Pregnancy Justice.

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Arsh Raziuddin

Women are trying to find a path forward.

A couple of months after she overdosed for a second time, Chelsey’s dad helped her enroll in a substance use disorder treatment program at the University of North Carolina at Chapel Hill that specializes in treatment for pregnant and parenting women. When she arrived, Chelsey remembers thinking how nice it was just to have simple things like Ziploc bags and aluminum foil and cleaning supplies. The UNC Horizons program gave every woman enrolled in the program her own apartment, where she could live with her child after giving birth. “They offered what I felt like was literally wraparound care,” Chelsey says. Within a few days, she’d seen an ob-gyn, therapist, case manager, primary care doctor, and psychiatrist.

Just days after Chelsey arrived, Brandi Collins enrolled in the program. Brandi had been incarcerated on drug charges while she was pregnant, but a peer counselor told her there were treatment programs where she could receive care while keeping custody of her daughter.

“I didn’t even know programs like this existed. I wish more people knew that stuff like this is available—you can get help with your baby without the fear of losing your child,” said Brandi. “I would’ve never gone to treatment had I not been able to take my baby. I would have never agreed to get better, never.”

Only a quarter of treatment programs in the United States offer services specifically geared toward pregnant or postpartum women, according to the 2020 National Survey of Substance Abuse Treatment Services. Those programs are especially scarce in the South and Midwest.

Addiction programs that offer childcare in addition to gynecological and mental health care (women who use opioids are more likely to have co-occurring anxiety, depression, or PTSD, and may have a heightened risk of dying by suicide) under the same roof should be the norm, says Dr. Martin. For decades, the “base model” of addiction treatment has been curated for white male patients, she says, and “anything that’s specific for women is considered an ‘add-on.’” But Dr. Martin notes that this approach is not consistent with the roots of the opioid epidemic or drug war in overprescribing to, then penalizing, women.

“For women, there has to be a system of care that is not based on their fear of losing their children,” says Sabora. Rivera and her colleagues at Pregnancy Justice call for stronger privacy protections and revised drug testing and reporting requirements.

Jones, who oversees the center where both Chelsey and Brandi were treated, says there are ways to make opioid agonists—the medications that can treat opioid use disorder—more accessible. During the pandemic, the federal government loosened restrictions on methadone, a medication that reduces withdrawal symptoms and cravings, allowing patients to take their prescription at home instead of in a designated treatment center. And earlier this year, the Substance Abuse and Mental Health Services Administration eliminated an extensive training and registration process that had been a barrier to doctors hoping to prescribe buprenorphine. Those are important first steps, she says, and she’s eager to see how policies, like one that Washington State is rolling out to offer split-doses of methadone (allowing patients to take the medication twice, instead of just once, a day to reduce side effects for pregnant patients), play out.

Brandi and Chelsey initially shared a condo in Chapel Hill, but today they are each living independently, raising their children and working as peer-support specialists at a community behavioral health clinic. Brandi’s about to move into her first apartment and Chelsey’s finishing her associate’s degree.

“There’s nowhere near enough” treatment centers specifically for pregnant women and mothers, says Chelsey. She and Brandi hope to do their part to help others who’ve been in their position. “If you treat the mother and give her the support and resources she needs, then you’re fixing a whole family.”

And while there’s still a lot more that medical professionals can do to normalize substance use disorders as mental health conditions and provide better treatment so that the opioid epidemic in women starts to chart a much different course, people are starting to wake up and pay attention. “I see change,” Jones says. “More providers are coming into the field that take a more person-centered, compassionate care approach, so I think that is exciting.”

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