Reproductive Health of Women in North Carolina’s Opioid Treatment Programs

 

 

 

 

 

The November/December issue of the Journal of Addiction Medicine, (Volume 13, Number 6), published a great article based on a 2017 survey of opioid treatment programs in North Carolina. This study was done by the University of Chapel Hill, and the article was titled, “Provision of and Barriers to Integrating Reproductive and Sexual Health Services for Reproductive-age Women in Opioid Treatment Programs.”

Of course, since this data is from my state of North Carolina, I read it with extra interest.

The article reminds us of what we know about women with opioid use disorders: they are more vulnerable to reproductive health issues. These women tend to have more pregnancies, with about 54% having four or more lifetime pregnancies, compared to 14% of women without opioid use disorder having four or more lifetime pregnancies. About 85% of the pregnancies of women with opioid use disorder are unintended, compared to around 45% for women without opioid use disorder. Women with opioid use disorders are less likely to use contraception and about five times more likely to have had an abortion.

Opioid use disorder increases the risk of gender-based violence and increases the risk of infections, for Hepatitis C and B, HIV, and sexually transmitted diseases. Adverse childhood events, termed ACEs, include stressful or traumatic life events, and are associated with reproductive health problems. Women with ACE history are much more likely to develop substance use disorders in general, including opioid use disorder, so a large portion of women enrolled in treatment at OTPs have this additional mental health burden affecting reproductive health.

Since medication is recommended for all patients with opioid use disorder, the authors of the article say pregnant and nonpregnant women with opioid use disorders could get care for reproductive health services within the opioid treatment program. They suggest this would be a way to reduce unwanted pregnancies, opioid-exposed pregnancies, sexually transmitted infections, and improve the overall health of women in these treatment programs.

The article described a survey sent to the medical directors and program directors of all forty-eight opioid treatment programs in the state, in order to assess the extent of reproductive health services offered to reproductive-age women enrolled in NC OTPs, as well as to explore perceived barriers to integrating such services into the care provided at OTPs.

Of the forty-eight OTPs surveyed, thirty-eight completed the survey. Of the programs that responded, 37% were private nonprofit organizations and 63% were private for-profit organizations. Thirty-four percent were in rural counties, 29% located in urban areas and 37% in suburban areas.

Only 21% of the responding OTPs offered female-specific programs.

Most OTPs accepted Medicaid, at 68%, and those programs served more women of reproductive age than did the non-Medicaid programs, which makes sense. The average length of treatment was longer for women in Medicaid program compared to non-Medicaid programs.

Twenty-one percent of OTPs offered non-prescription contraception, while only one program offered prescription contraception.

Only 89% of OTPs did on-site pregnancy tests, meaning 11% are not performing this simple and necessary test for patients.

To summarize this study, the OTPs of NC aren’t doing all they could to address female patient’s reproductive and sexual health issues.

I agree with this finding, and yet, I was a bit offended with the accompanying commentary in this issue of Journal of Addiction Medicine. Dr. Tricia Wright says that OTPs believe it’s outside the scope of their service to provide reproductive and sexual health services, and that this view is “dangerous and wrong.” She says such care is basic care and OTPs can and should do better for their female patients.

Now you’ve stepped on my toes and I’m going to have to step back.

I agree that more services should be provided, including female sexual and reproductive health. After all, as the article’s authors concluded, such efforts have the potential for great good. Increasing reproductive health of our female patients promotes health of children and families, and ultimately, society.

However, as this survey or providers discusses, there are obstacles to providing such services.

First, OTPs care for people with other equally important challenges. Our patients struggle with homelessness, lack of food, serious mental and physical health issues, all of which need addressed. Our resources are limited, both of time and money.

For example, a new patient injecting heroin might be homeless, with no way to afford food, and have serious mental health issues. Such a sick patient needs inpatient care which usually is not available. For example, our state-run program refused to admit a homeless diabetic because her blood sugars weren’t under control. They refused to admit an HIV positive patient because she wasn’t on proper medication for her HIV. Of course, with substance use disorders raging out of control, those goals weren’t realistic.

Our OTP takes care of many such challenging patients as best we can, because usually it’s their only option for care. Ultimately, we do hope to get them care for their other issues, in the form of referrals, because we don’t have the time or personnel to provide those services.

Second, OTPs may not have personnel with the expertise to manage reproductive health needs

I am trained in Internal Medicine. This means I could manage some simple primary care and even some uncomplicated gynecologic and mental health care for OTP patients. But my time is spent providing medication-assisted treatment to those patients. I would have to work additional hours if we provided primary care, probably at least double the hours that I now work. I would need a way to care for those patients for after-hours emergencies. I don’t work for free, and neither do the nurses. The company I work for would have to pay for this expense. They could bill Medicaid, but at least half our patients don’t have any insurance at all. Most uninsured patients get their OTP treatment paid for with grant money, but that doesn’t cover primary care services.

Many OTPs have a psychiatrist as a medical director. They could address mental health needs, but probably wouldn’t be comfortable doing and primary care, and certainly not reproductive health.

In order to meet even some of the reproductive and sexual health needs of just the female patients (ignoring male patients completely for some reason), additional providers would have to be hired. Who pays for that?

It makes more sense to me to have providers come to our OTP to provide essential services under one roof. One day could be for obstetric/gynecologic care. A local OB could come to our facility and see patients all day. Another day could be for a psychiatrist to come and treat patients, and maybe two days for primary care providers to see our OTP patients. It’s an ideal solution, except for finding willing providers, and a way to pay them.

Don’t even get me started on our patients’ dental care needs. We could hire a full-time dentist and keep her busy with only our opioid treatment program patients. But again, who would pay?

I get weary of unfunded mandates and recommendations for opioid treatment programs. I feel like much is expected of providers at opioid treatment programs, mainly because no other providers want to treat these patients.

Our patients often get superficial and substandard treatment from the local emergency department and local providers’ offices due to the stigma against people with substance use disorders in general. Part of this could be because some of our patients offend providers with their desperation and neediness. Patients enrolled at “that methadone clinic” face extra judgment from some providers, making it more difficult for our patients to access appropriate medical treatment.

It’s not feasible for OTPs to provide all the services that patients need, and certainly not fair to expect OTPs to provide this care for free because other providers don’t want to deal with our patients.

OTPs have and will pick up what pieces we can, but maybe it’s not fair to ask OTP providers to fix a broken healthcare system.

5 responses to this post.

  1. I wish there were more like you in the health care industry. Everything you say is always so spot on. Becoming stable on methadone is the first step in getting an addict’s health under control, but it certainly is not a “cure-all”. I ruined my life and the lives of my future children during 16 months of active addiction when I was 20 & 21. Though I’ve been clean for 17 years (only with the help of methadone) the mistakes I made during that time still haunt me and will forever. It doesn’t matter that I have an AS in Accounting because I also have a felony in obtaining funds under false pretenses when I wrote checks out of my mother’s account. That’s just one of the stupid things I did that effect me two decades later. All my teeth in the back are broken at the gum line. I’d been told it was because I must have had terrible hygiene while using, but that didn’t ring true. Thankfully I do get Medicaid or I’d never have known I have severe TMJ & teeth grinding, which has been breaking my teeth.
    I keep erasing what I type because I could discuss forever the stigma of MAT & the way I’m treated by everyone in every hospital or doctor’s office. I don’t understand why it is so hard for people to comprehend that preventative healthcare, including OBGYN services, would drastically cut healthcare costs caused by untreated medical conditions in the recovering community? The same people complaining about “their” tax dollars paying my Medicaid bills are the same people that don’t think people on methadone are truly clean or deserving of preventive medical care. These people refuse to think through their arguments and even consider that a little extra help now means much less medical costs later fixing what have now become serious conditions that need expensive hospital care, when it could have been a prescription or something akin to diabetes management years ago. But, I’m on methadone, so who cares if I’m treated like a human by a doctor? Who cares if all my teeth fall out making my entire body sicker and causing heart disease? When you think about how much less some basic dental care would have cost as opposed to inpatient hospitalization, you realize it’s common sense for ALL humans to have access to needed medical treatments. No one wants to hear from an addict, so I truly thank you for bringing attention to so many issues affecting the addicted and the recovering. You might be heard, and you should be.

    Reply

  2. Posted by william taylor, MD on December 11, 2019 at 10:19 pm

    If I had to pick one ancillary service to offer in the OTP, it would be mental health. But OTPs should be celebrated for safely administering a dangerous medicine day after day, and offering desperate patients lifesaving treatment.

    Reply

  3. Posted by william taylor on December 11, 2019 at 10:26 pm

    A second candidate for in-house ancillary service would be testosterone measurement and supplementation for male patients, since hypogonadism is common in methadone patients and is seldom even mentioned in the voluminous warnings we hand out to patients.

    Reply

    • You are SO right. As a female, I had been thinking about how hormones and my endocrine system is adversely effecting my health, particularly as I age. However, testosterone wasn’t on my radar, I’ve been looking more at thyroid and adrenal health. It wasn’t until I read a methadone Reddit thread to my husband that discussed how many male methadone patients seem to have issues directly related to low testosterone, and in fact, my husband is a prime example at age 50. I wish the program MD or a counselor had mentioned it before, I’m not sure many patients themselves are even considering it as a possibility for declining health in the form of muscle weakness, constant lethargy, lowered sex drive and energy in general…these are all symptoms of every ailment out there. Without the benefit of a PCP that understands how longterm methadone maintenance might affect our bodies, our hormones, most of us are assuming more obvious (but in reality, less likely) answers.

      Reply

  4. Posted by Alan Wartenberg MD on December 12, 2019 at 2:56 am

    Jana, a great condemnation of not only all that is wrong with our medical care system in terms of what MAT patients both need and lack, but in fact of all marginalized, impoverished and disadvantaged populations in the US. People think we have a great system, and we do – for the upper middle class, union members with good insurance and the rich (and even they are plagued by lack of communication and disjointed and discontinuous care). The rest have a third world medical care system, and a BAD third world system at that.

    Reply

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