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
- 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.
- Netherland, J., & Hansen, H. (2017). White opioids: Pharmaceutical race and the war on drugs that wasn’t. BioSocieties, 12(2), 217-238.
- 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.
- 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.
- 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.
- National LGBT Health Education Center. Addressing Opioid Use Disorder among LGBTQ Populations. (June 2018)
- 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.
- 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.
- Conley, K. E. (2016). An Analysis of Women’s Access to Acute Opioid Detoxification Services in Maine: Identifying the Barriers to Treatment.
