Jenifer Newburn is 28 weeks pregnant. She is unemployed and currently living in a Pueblo, Colorado, motel; she hasn’t seen the father of her child in months. Her friends, she said, “are few and far between,” and her family isn’t in her life.
While currently not using drugs, Newburn, 34, has experienced stretches of addiction to heroin and methamphetamine since a 2002 car accident left her dependent on prescription painkillers.
“This is not the right time in my life to have a baby,” she said. But her last abortion had left her with feelings of guilt, and she is reluctant to have another: “I know me, and I would beat myself up.”
As the opioid epidemic rages, the increasing number of babies born dependent on opioids—a condition known as neonatal abstinence syndrome (NAS)—is capturing the nation’s attention. Images of sickly newborns experiencing withdrawal symptoms are splashed across newspapers, billions of dollars have been spent on treatment, and members of Congress have proposed bills to expand funding.
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But a related crisis has been overlooked. Nearly 90 percent of pregnancies among women with opioid addiction are unintended: twice the general population’s rate. Moreover, women with opioid dependence are almost five times more likely than women in the general population to have an abortion in their lifetime. These data suggest that women with opioid addiction may face unique barriers to accessing or using contraception services.
In general, people with addiction are less likely than non-drug users to receive preventive care. And in a 2015 survey of over 250 women with opioid addiction in Michigan, cost and fear that health-care providers will judge or mistreat them were commonly cited as barriers to seeking reproductive services.
Newburn’s barriers were complex. Due to a mix of inaccurate information, lack of timely access to care, and extensive health needs, she didn’t seek contraception. With uterine scarring and failed attempts to get pregnant with a previous boyfriend, she assumed she was infertile. Shortly before she got pregnant, she had a primary care visit, but confirming this assumption wasn’t a priority. Like many people who’ve struggled with addiction, Newburn has multiple chronic and mental health conditions. More urgent health needs accumulated during the three months she waited for her appointment. By the time she saw her doctor, she said, “I didn’t even think about asking about reproductive health. And there’s no Planned Parenthood here.”
An estimated hundreds of thousands of patients, however, visit programs for medication-assisted treatment such as methadone. Believing these programs have untapped potential to improve access to contraception education or services, a few National Institutes of Health (NIH)-backed researchers are testing variations on the idea to meet these individuals where they are by providing such options at opioid treatment programs.
Hendrée Jones, executive director of Horizons, a University of North Carolina-Chapel Hill drug treatment program, believes the opportunity won’t only meet patients where they are, but will also empower them to make the best decisions for themselves. For women to choose and sustainably use a contraception method, providing easy access to accurate information in a way that “unlocks internally driven change” rather than externally imposes direction is key, she said. Jones led a study investigating whether motivational interviewing—a counseling approach that studies show may change behaviors such as alcohol and drug use—could help people with opioid addiction overcome barriers to pregnancy planning and effective contraception use.
“Instead of saying, ‘You should use a certain type of birth control,'” said Jones, “You ask, ‘What role does birth control play in your life? What kind of options would you be interested in?'” This approach, coined by Jones as SAFE (Sex and Female Empowerment), was delivered over four 60-minute sessions at several drug treatment programs. One cohort received counseling through a computer-adaptive platform, while another received face-to-face counseling from nurses, counselors, or peer support specialists—people who’ve experienced addiction firsthand and are trained to assist others with addiction. Participants who wanted contraception were offered an escort and transportation to the health department. The study was completed in August 2017 and will be submitted for publication.
Deborah Rinehart, researcher at Denver Health, a public hospital affiliated with the University of Colorado School of Medicine, is studying a similar approach. Her study, however, is led exclusively face-to-face by a peer support specialist, known as a “peer navigator,” who meets with participants twice to educate them on contraception options and how to find a provider suited to their needs and relevant resources, such as free transportation options.
Knowing where to go and overcoming fear that they’ll feel judged aren’t always straightforward for people with addiction who don’t regularly visit health-care providers. But a peer navigator’s “lived experience” helps a client quickly build trust and ease fears about visiting a provider, said Rinehart. The study, which takes place at two University of Colorado-affiliated opioid treatment programs, will be completed by May 2019.
In addition to providing contraceptive counseling, a University of Vermont study is stationing a nurse practitioner at an opioid treatment program affiliated with the university and a local nonprofit to provide contraception directly—an expansion of a prior smaller-scale peer-reviewed study.
Sarah Heil, psychology professor and study lead, said that a behavioral economic theory called present bias informed this approach. It’s the tendency to prefer immediate rewards, even when long-term gain is greater, over an option with higher short-term financial, time, or energy costs.
For a woman with addiction, unintended pregnancy consequences are far removed from the present. But the short-term costs of getting birth control, such as finding transportation or child care for doctors’ visits, are significant, said Heil: “So she thinks, ‘I’ll do the other things I need to do today, like go to treatment or else I’ll get kicked out, or visit my probation officer because if I don’t, there will be a warrant for my arrest.'” Providing contraception in a place the woman frequents reduces these costs.
Study participants receive counseling on contraceptive options and a free supply of their preferred method. At follow-up visits, the nurse practitioner advises them on how to manage side effects and provides free refills. One cohort also earns a voucher—redeemable for retail items such as gasoline and groceries with approval by the research staff—that starts at $15 for each follow-up visit attended over six months. Heil said this is intended to test if a financial incentive helps improve contraception continuation rates. Women in the study receive the incentive regardless of whether they take the contraception in order to avoid coercion.
All the researchers are testing their interventions against control groups receiving usual care. This care varies depending on the study, but encompasses pamphlets with contraception information, condoms, or referrals to reproductive health providers. Study metrics include whether participants use contraception six months after the start and cost-effectiveness (Heil), whether participants started using a contraception method and for how long (Jones), and whether participants visited a provider for family planning (Rinehart).
Each researcher said avoiding coercion was a key consideration, given the nation’s history of coercing vulnerable people into sterilization. Throughout the 20th century, 32 states ran federally funded sterilization programs targeting groups such as people of color, poor people, and people with disabilities. All three studies exclude individuals who reported that they are currently seeking to get pregnant. Additionally, Heil said that only reversible methods of contraception are presented to participants in her study, while Rinehart and Jones said that many options including sterilization are presented, but impartially.
Ultimately, all these programs are trying to bridge the gap between drug treatment and sexual and reproductive health—an ambitious goal with little precedent. Although the federal government has started funding programs that integrate addiction treatment with primary care and mental health, health care has historically been segregated from drug treatment. This tradition originated from a longstanding social view that addiction is a moral failing, best managed through criminalization, rather than a medical condition to treat through the health-care system.
Sexual and reproductive health and drug treatment programs are especially fragmented. Treatment programs traditionally prohibited sex during some or all phases of recovery. Some still do. “It sends the message that sexual health isn’t a part of treatment and recovery,” said Mishka Terplan, a Virginia Commonwealth University OB-GYN who researches sexual health and addiction. He added that more public health programs exist for addiction and HIV/AIDS, which disproportionately affects men, than for addiction and other kinds of sexual and reproductive health, due in part to a history of male-centered addiction treatment.
Study results and scalability of the NIH-backed approaches remain to be seen. While offering only contraceptive counseling is less costly than providing contraceptive counseling and services, both options will require increased funding to scale.
Federal and state governments fund family planning services for people with low incomes primarily through Medicaid and the Title X family program. Medicaid, which covers nearly 40 percent of nonelderly adults with opioid addiction, currently reimburses contraceptive services. Title X, a federal grant program, can also cover these and associated operating costs such as clinician salaries and staff training.
Some drug treatment programs think these costs aren’t insignificant. In a 2015 survey of over 100 drug treatment programs in Michigan, concerns about reimbursement, limited clinic space, and lack of equipment and staff training were ranked as the largest barriers to offering reproductive health services.
But many opioid treatment programs may not qualify for Title X funds. According to a University of Pennsylvania and Montefiore Medical Center study, 58 percent of opioid treatment programs in the United States are for-profit. Only government and non-profit organizations are eligible to receive Title X funds.
Opioid treatment programs that want to offer family planning services without incurring associated operating costs could partner with Title X-funded providers who are willing. Baltimore’s health department and behavioral health authority tested this model in a pilot known as the Baltimore Reproductive Health Initiative. At three drug treatment centers, participants were asked during intake whether they wanted to get pregnant within the next year. For those not who said no, nursing student volunteers educated them on contraception options. Clients who wanted contraception received it on-site. Title X-funded providers set up weekly satellite clinics at two privately run nonprofit treatment centers, said Terplan, an advisor to the initiative. Scaling this model would likely require expanding Title X funding or accessing an alternative funding source.
Even if the NIH studies show that family planning in opioid treatment programs is beneficial and cost-effective, it’s uncertain whether the government will expand funding for it. The U.S. House of Representatives has proposed eliminating Title X in six of the last eight years, even though at least one projection suggests it’s a cost-effective investment. In a peer-reviewed study, the Guttmacher Institute estimated that Title X-supported centers yielded $7 billion of the $13.6 billion in net savings from publicly funded family planning services in 2010.
“Realistically, it’s unlikely we’ll see any increase in Title X funding any time soon,” said Kinsey Hasstedt, senior policy manager at the Guttmacher Institute, noting ideological opposition to family planning within Congress and the Trump administration.
If Title X funding isn’t increased, states or federal agencies with grants for addiction services could potentially fund family planning services in opioid treatment programs, but it’s hard to predict how feasible this is.
As these uncertainties demonstrate, providing family planning in opioid treatment is in early days. The approaches discussed may be the only formal initiatives in the United States, as resources have been concentrated on treating pregnant patients with opioid addiction and babies born with NAS. Moreover, the surface has been completely unscratched for groups such as transgender men or nonbinary people with addiction who may have unmet family planning needs.
For people like Newburn, help can’t come soon enough. “Resources are miles away from each other. If you’re struggling with addiction, it’s hard to get to all these places,” said Newburn, who’s struggling to come up with her next rent payment and torn over whether to give up her baby for adoption. “Addiction is not a weakness. It’s a disease. You can barely take care of yourself.”