Mishka Terplan, MD, MPH
Opioids are one of the most common illicit substances used by reproductive aged women and women who use opioids have unique reproductive health care needs. Compared to women who don’t use opioids, opioid-using women have more pregnancies. Additionally these pregnancies are more likely to be unplanned (at least 80% versus 50%) and end in an abortion – reflecting the fact that women who use opioids have an unmet need for contraception. Condoms remain the most common contraceptive method among women with opioid use disorders, a testament to the successful integration of HIV prevention in SUD treatment. However, in order to fully address the reproductive health needs of this vulnerable population, better integration of contraceptive services into drug treatment is needed.
Given the historical sterilization of women – without their consent – who were
considered “unfit” to be mothers, as well as the ethically dubious contemporary campaigns to sterilize active drug users, prescription contraceptive methods should be prioritized for women who do not seek pregnancy. Overall contraceptive uptake and method adherence is improved with counseling. Counseling should be evidence-based and informed by WHO effectiveness criteria. Highly effective methods such as IUDs and implants should be prioritized. These methods, also known as LARCs (long acting reversible contraception), are well tolerated and have a failure rate of less than 1 per 1000 per year. The duration of LARCs’ effectiveness ranges from 3 to 12 years depending on type and therefore can be considered a form of “forgettable” contraception: in other words from placement until removal the individual does not need to remember her birth control.
In contrast, moderately effective methods (such as the pill, patch or ring) need to be remembered daily, weekly, or monthly. These methods contain a combination of estrogen and progesterone and therefore are not recommended in women >35 years who are heavy smokers. Hence these combined hormonal contraceptive methods may not be the best choice for some opioid users. Clearly none of the prescription methods protect against STIs. Therefore for women at risk of STIs dual coverage – condoms plus a more effective
contraceptive method – should be encouraged.
It is important to note that women who use drugs have the same motivation for pregnancy and parenting as do all women. The decision whether and when to reproduce is an individual one. Therefore conversations regarding contraception should be client-centered, non-judgmental and stress autonomy.