Women, the LGBTQIA Community, and the Opioid Epidemic

At the intersection of Kensington Avenue and Allegheny Avenue, in the epicenter of Philadelphia’s Opioid epidemic, “Breanna” lives outside of a Walgreens. She has been homeless for two years, and bears many of the morbidities from long-term injection: a chronic leg wound, endocarditis, and HIV. She always keeps 8 doses of Narcan on her and is known to be someone who responds quickly to overdoses. Her use is related to a desire to numb from the trauma of losing her father, and sexual violence. On her wrist, she has a rainbow band. “It’s hard being a lesbian out here. The loneliness is hard.”

 

We often would not think of Breanna when we think of someone struggling with opioid use disorder. For three decades, opioid overdoses have increased in the United States culminating in 70,000 opioid-related overdoses deaths in 2017. Starting in 1994 with a boom in prescription opioids, The Opioid Epidemic has progressed and shifted from prescription opioids, to heroin, and currently to illicitly manufactured fentanyl as the agent causing most overdoses in the US (Scholl et al, 2019). The Opioid Epidemic is often described in media as consuming white, suburban America (Netherland and Hansen, 2017). Multiple reports have described how opioid-related overdose deaths are one of the main factors of why white, middle-aged men have had a decrease in life expectancy (Alexander et al, 2018). We often do not hear that women have been disproportionately impacted by the Opioid Epidemic. The Overdose Crisis has a distinct story for women and LGBT individuals, a story masked due to continued focus on how opioids impact white, cis men.

 

In a CDC study analyzing fatal drug overdoses presenting to emergency rooms, women had a fivefold increase in opioid related overdose deaths from prescription opioids from 1999 to 2010. Men had a 3.6-fold increase in the same time period. While more men died from opioid overdoses in this period, women had a strikingly larger increase (Mack et al, 2013). Moreover, though women in a nationally representative cohort on average received lower doses of prescription opioids, they were more likely to have a fatal overdose (Liang et al, 2016). Women also have a greater risk of fatal overdose after release from prison (Binswanger et al, 2013). Little is known of why women have higher risk of fatal overdose than men, and less is known about LGBT substance use. While we know LGBT individuals are more likely to have a substance use disorder compared to cis, heterosexual adults, there are no epidemiological studies analyzing overdose risk and rate in the LGBTQIA community (NLHEC, 2018).

 

Women and LGBTQIA individuals can have distinct risk factors and use patterns. Women are more likely to receive prescription opioids in primary care settings. This could account for how in the early days of the Opioid Epidemic when prescription opioids were the leading cause of overdose deaths, women had a larger increase in overdoses from pills compare to men (Bateman et al, 2016).  Opioid analgesics prescribed after Caesarion delivery can also be a conduit for introduction to opioid misuse. In a cohort of women, 1 in 300 women who had a C section developed persistent opioid misuse. Women with psychiatric conditions, pain conditions, and previous substance use disorder were more likely to develop opioid use disorder (Bateman et al, 2016). The National LGBT Health Education Center attributes higher rates of substance use disorder among LGBT populations to self-medicating stigma (NLHEC, 2018). This “minority stress” is essential for clinicians treating Opioid Use Disorder in LGBT populations, as it relates to relapses, cravings, and can be further explored in therapy sessions.

 

It is imperative for healthcare providers to understand that substance use disorder impact women and the LGBTQIA community. Men are more likely to enter detoxification and initiate treatment with the gold standard treatment buprenorphine. Some authors attribute this disparity to greater mental health burden among female users (Conley, 2016). Alarmingly, sexual orientation and gender identity have not been studied in the context of access to buprenorphine. Much more work is needed to demystify opioid use disorder, overdose risk, and access to treatment for women and the LGBTQIA community. 

 Rohit Mukherjee  DUCOM 2020

 

1. Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2019). Drug and opioid-involved overdose deaths—United States, 2013–2017. Morbidity and Mortality Weekly Report, 67(5152), 1419.
2. Netherland, J., & Hansen, H. (2017). White opioids: Pharmaceutical race and the war on drugs that wasn’t. BioSocieties, 12(2), 217-238.
3. Alexander, M. J., Kiang, M. V., & Barbieri, M. (2018). Trends in Black and White opioid mortality in the United States, 1979–2015. Epidemiology (Cambridge, Mass.), 29(5), 707.
4. Liang, Y., Goros, M. W., & Turner, B. J. (2016). Drug overdose: differing risk models for women and men among opioid users with non-cancer pain. Pain medicine, 17(12), 2268-2279.
5. Mack, K. A., Jones, C. M., & Paulozzi, L. J. (2013). Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999–2010. MMWR. Morbidity and mortality weekly report, 62(26), 537.
6. National LGBT Health Education Center. Addressing Opioid Use Disorder among LGBTQ Populations. (June 2018)
7. Girouard, M. P., Goldhammer, H., & Keuroghlian, A. S. (2019). Understanding and treating opioid use disorders in lesbian, gay, bisexual, transgender, and queer populations. Substance abuse, 1-5.
8. Bateman, B. T., Franklin, J. M., Bykov, K., Avorn, J., Shrank, W. H., Brennan, T. A., ... & Choudhry, N. K. (2016). Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women. American journal of obstetrics and gynecology, 215(3), 353-e1.
9. Conley, K. E. (2016). An Analysis of Women’s Access to Acute Opioid Detoxification Services in Maine: Identifying the Barriers to Treatment.