Women and the opioid crisis:

historical context and public

health solutions
Mishka Terplan, M.D., M.P.H.
Department of Obstetrics and Gynecology and Department of Psychiatry, Virginia Commonwealth University,
Richmond, Virginia

Driven by a legitimate but overly opioid-focused response to pain, the United States is currently experiencing an opioid crisis, a crisis
with parallels to the first opioid epidemic at the turn of the 20th century. Women, particularly white reproductive-age women, are
increasingly the face of the opioid crisis. Given the penetration of opioid misuse and addiction across all income and insurance strata,
any provider who cares for women needs to be prepared to assess and evaluate opioid use, misuse, and addiction. Although responsible
opioid prescribing is essential, treatment capacity must be expanded and be inclusive of the unique needs of women. However, the pub-
lic and public health response to the opioid crisis must include rolling back the war on drugs. The continued criminalization of the public
health issue of drug use and the medical condition of addiction is unethical, ineffective, and inhumane. (Fertil SterilÒ 2017;108:195–9.
Ó2017 by American Society for Reproductive Medicine.)
Key Words: Women, opioids, addiction, war on drugs
Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/
16110-fertility-and-sterility/posts/17545-24445

O
pioids have been part of human ported a maximum of 4.59 opioid- post-traumatic stress (5). Women have
culture and medical practice addicted individuals per 1,000 persons a higher prevalence of adverse child-
for millennia. Addiction to opi- (1), two-thirds of whom were women (2). hood experiences, such as physical or
oids, however, is a far more recent The U.S. is experiencing at least its sexual abuse (6), and are more likely to
development. The first opioid epidemic third opioid epidemic. With only 4.6% experience gender-based violence as
was concentrated in Western Europe of the world's population, the U.S. con- adults (6, 7). Women are more likely to
and the United States around the turn sumes more than 80% of the global report pain (especially category 3 or 4
of the 20th century. Women, primarily opioid supply (3) and estimates of pain) than men (8), owing to both their
white upper- and upper middle-class opioid misuse approach 4.7% of the reproductive capacity (for example
women, were prescribed opioids by phy- population (4). The current opioid dysmenorrhea and endometriosis) as
sicians for the treatment of ‘‘female ail- epidemic bears strong parallels to the well as to a greater prevalence of
ments,’’ such as dysmenorrhea and first. Not only is it driven by opioid pre- painful chronic conditions (such as
‘‘hysteria.’’ Opioid formulations were scribing and is thus iatrogenic in origin, arthritis and fibromyalgia) (7, 9).
widely available as so-called ‘‘patent but also as before, women figure prom- Consequently, women of reproductive
medicines,’’ almost all of which were inently in this epidemic. age receive more prescription
explicitly marketed to women and chil- Women bear a larger behavioral medications than men (10), particularly
dren. Alcohol, consumed primarily in health burden than men and are more for psychotherapeutic medications
public spaces, such as saloons, was the likely to report past year serious including opioids (4). Women also
province of men, and opioids became psychologic distress as well as any have a greater prevalence of longer-
the province of women. It is estimated mental illness including a major depres- term opioid medication use (11). Almost
that the opioid supply could have sup- sive episode, anxiety disorder, and 40% of women aged 15–44 years report
receiving at least one opioid prescription
Received June 1, 2017; accepted June 6, 2017; published online July 8, 2017.
in 2015. Of the 2.1 million initiators of
M.T. has nothing to disclose. opioid misuse per year, 1.2 million
Reprint requests: Mishka Terplan, M.D., M.P.H., Department of Obstetrics & Gynecology, Virginia (57%) are women, which translates to
Commonwealth University, Box 980034, Richmond, Virginia 23224 (E-mail: mishka.terplan@
vcuhealth.org). 3,300 women per day initiating opioid
misuse in the U.S. (12).
Fertility and Sterility® Vol. 108, No. 2, August 2017 0015-0282/$36.00
Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc.
Women have greater health care
http://dx.doi.org/10.1016/j.fertnstert.2017.06.007 utilization than men (13) and more

VOL. 108 NO. 2 / AUGUST 2017 195

VIEWS AND REVIEWS
physician visits not inclusive of maternity care (14). However,
providers are less likely to assess women for substance use
and misuse and tend to miss signs of addiction in women
(15). Even within an implementation trial of Screening, Brief
Intervention, and Referral to Treatment (SBIRT) women were
less likely to be screened for alcohol and, among those who
screened positive, even less likely to receive a brief interven-
tion or referral to treatment (16). This may be due to the fact
that providers do not associate substance use, misuse, and
addiction with women, much less with white insured women.
Although more men die from opioid overdose in the U.S.,
the rate of death is increasing more rapidly for women than
men. From 1999 to 2010, prescription opioid overdose deaths
increased 400% for women and 237% for men (17). Since
2007, more women have died from drug overdoses than
from motor vehicle crashes (18). In 2015, the last year for
which complete data are available, opioid-related overdose
(18) took the lives of 31 women per day.
Because opioid prescribing has perhaps peaked and lev-
eled off (19, 20), the epidemic is shifting to heroin (21).
Heroin use is increasing most rapidly among women,
individuals 18–25 years of age, and non-Hispanic whites
(22). Whereas <20% of individuals who initiated heroin use
in the 1960s were women, today >50% of heroin use initia-
tors are women (23). Among women who used heroin during
the previous year, 7 out of 10 reported also misusing prescrip-
tion opioids, and overall R75% of heroin use initiators began
their opioid use with a prescription (24). Interestingly, heroin
use has increased similarly across all income strata and more
among women with private insurance than among those with
Medicaid (22). This trend is likely to continue as heroin prices
fall and it becomes increasingly available in places where it
had been unknown (25).
Just as who a heroin user is has changed, so has heroin.
Since 2013 there has been a sharp increase in heroin seizures
testing positive for fentanyl, especially east of the Mississippi
(26). Fentanyl is a synthetic opioid 50–100 times more potent
than morphine or heroin. Often illicitly manufactured, it is
mixed into the heroin stream or sold as counterfeit pills and
has contributed greatly to the continued increase in overdose
deaths (27).
The opioid crisis, particularly the increase in overdose
deaths, has led to a measurable rise in mortality rates espe-
cially among non-Hispanic whites in midlife (28). This re-
verses the long-term decline in mortality rates in the U.S.
and is in stark contrast to the continuing falling mortality
rates in the rest of the developed world. This mortality
reversal resembles the AIDS epidemic, which took the lives
of 650,000 individuals in the U.S., but perhaps with less
public awareness (28). Mortality rates are higher in rural
than in urban areas, and, in rural areas, highest among
women (29).
PAIN, THE FIFTH VITAL SIGN
The current opioid crisis arose from changes in opioid-
prescribing practices that began in the 1990s (1). In response
to a recognition that pain was undertreated, untreated pain
led to chronic pain, and chronic pain was costly, common,
196
and interfered significantly with quality of life, a movement
arose to make pain more ‘‘visible’’ in clinical care (30). The
‘‘Fifth Vital Sign’’ was first introduced by the American
Pain Society in 1995 (31) and became a Joint Commission
(formerly the Joint Commission on Accreditation of Health-
care Organizations) standard in 2000. The uptake of the
10-point scale coupled with a growing emphasis on overall
patient satisfaction led to a remarkable increase in opioid pre-
scribing. Sales of prescription opioids quadrupled from 1999
to 2012 (32) with no change in the self-report of pain (33, 34).
Opioid prescription for the management of chronic pain
rested on a series of assumptions: opioid addiction was rare
in pain patients; opioids were safe and effective for chronic
pain; and opioid therapy could easily be discontinued.
Although the evidence supporting these assumptions was
thin at best, these talking points were widely disseminated,
in particular by Purdue Pharma (the manufacturer of Oxycon-
tin). From 1996 to 2002, Purdue Pharma funded more than
20,000 pain-related educational programs and pursued an
aggressive marketing campaign directed at physicians to in-
crease opioid prescribing (35). Additionally they provided
financial support to the American Pain Society, the American
Academy of Pain Medicine, the Joint Commission, and the
Federation of State Medical Boards, which issued guidance
to protect physicians from adverse outcomes associated
with opioid prescribing (36). With an annual revenue of 3
billion dollars, mostly from Oxycontin, the Sackler family,
which owns all of Purdue Pharma, became the ‘‘newcomer’’
to the Forbes 2015 list of richest U.S. families (37).
The evidence to support the assumption that opioid
addiction was rare in pain patients came from a 111-word let-
ter to the editor published in the New England Journal of Med-
icine in 1980. The authors describe a review of almost 40,000
medical records, of whom almost 11,882 received at least one
opioid prescription, with only four cases of ‘‘reasonably well
documented addiction’’ (38). To date, this letter has been cited
959 times (39). The evidence to support functional improve-
ment for individuals with chronic pain, which was commonly
cited in the 1990s, is of slightly better quality. Reporting a
case series of 38 individuals treated with opioids for nonma-
lignant pain, Portenoy and Foley concluded that ‘‘opioid
maintenance therapy initiated for the treatment of chronic
nonmalignant pain can be safely and often effectively
continued for long periods of time’’—a conclusion that stands
in contrast to the data, because only 11 individuals (29%) re-
ported adequate pain relief and there were no measurable im-
provements in social function or employment (40).
Contemporary meta-analyses and systematic reviews
support neither the safety nor the efficacy of opioids for
the treatment of pain. In a review of 38 studies, rates of
misuse averaged 21%–29% (95% confidence interval [CI]
13%–38%) and rates of addiction 8%–12% (95% CI 3%–
17%) (41). Meta-analysis comparing the efficacy of different
opioids demonstrated a nonsignificant reduction in pain
from baseline in the short term and no evidence regarding
long-term (>16 weeks) efficacy (42). Even the American
Pain Society's ‘‘Guideline for the Use of Chronic Opioid
Therapy in Chronic Noncancer Pain’’ similarly commented
on the absence of long-term data. Compared with placebo,
VOL. 108 NO. 2 / AUGUST 2017

they reported moderate pain relief for opioids in the short
term (<12 weeks) with a corresponding increase in adverse
events and further noted that 50% of opioid-naïve patients
who receive opioid therapy report no change or worsening
pain (43).
PUBLIC HEALTH SOLUTIONS TO THE OPIOID
CRISIS
Although the opioid epidemic is increasingly female, white,
and young, the public health response to the opioid epidemic
has been gender blind. Strategies proposed by the United
States Centers for Disease Control (44) and the Surgeon Gen-
eral (45) (Turn the Tide Rx) make no mention of the unique
needs of women. This is unfortunate, because there are mul-
tiple opportunities for intervention to prevent opioid misuse
and addiction in women.
First, we have to reduce exposure to opioids by adhering
to responsible prescribing. If opioid analgesics are used, the
goal should be functional improvement, not absent pain.
Therefore, it is essential that providers set clinical end points
in collaboration with patients. Reducing the amount of opi-
oids prescribed has individual and a population-level benefits
because most individuals who report misuse received opioids
not from a physician but from a friend or relative (46). Discus-
sion of safe storage and disposal of opioids is an essential
component of responsible prescribing. Assessment of opioid
misuse and addiction with the use of tools such as the Opioid
Risk Tool (47) and the NIDA (National Institute on Drug
Abuse) Quick Screen (48, 49) should become routine in
clinical care.
Second, overdose education and naloxone coprescribing
must become part of routine practice (50). Naloxone is an
opioid antagonist that reverses respiratory depression during
an opioid overdose. Overdose is often due to more than simply
opioids, because concomitant benzodiazepine use and under-
lying medical conditions (especially respiratory conditions)
are also associated with death. Furthermore, owing to differ-
ences in metabolism and drug absorption/elimination,
women may be more susceptible to overdose (51).
Third, we must increase access to treatment for addiction.
Reducing the prescription of opiates without commensurate
increases in treatment availability will only further the crisis.
Central to treatment is opioid pharmacotherapy, which in-
cludes methadone, naltrexone, and buprenorphine. Pharma-
cotherapy is associated with a marked reduction in overdose
(52, 53) as well as increased treatment retention and
reduced recidivism and human immunodeficiency virus and
hepatitis C virus transmission (54). Despite a wealth of
evidence supporting the efficacy of treatment, only 20% of
individuals with an opioid use disorder report accessing
treatment in the previous year (12). Access to treatment
may be even lower among women (55), in part because
most treatment facilities in the U.S. lack any women-
centered programming (56). Treatment need not be centered
exclusively in specialized practice settings, because bupre-
norphine can be incorporated into office-based practice.
Therefore, increasing the number of physicians with waivers
to prescribe buprenorphine is needed.
VOL. 108 NO. 2 / AUGUST 2017
Fertility and Sterility®
Finally, addiction must be approached through a public
health and not a criminal justice lens. The ‘‘War on Drugs’’
launched by Nixon in 1971 has been, by all measures, a fail-
ure (57). Since its inception, the U.S. has spent more than 1.5
trillion dollars on drug control, the majority of it going to
interdiction, eradication, and law enforcement, without any
decrease in the proportion of individuals who use drugs or
have an addiction. The spending has, however, led to
increased incarceration, and today the United States has
both the highest incarceration rate (67 per 10,000) and largest
number of incarcerated individuals (2.2 million) of any major
nation (58).
Although men account for a larger proportion of pris-
oners, the female prison population is growing at twice the
rate (59), owing in large part to harsh sentencing laws coupled
with the widening net of criminal liability which extends to
family members and bystanders of drug activity. More than
three-fourths of women behind bars are mothers (60), and
when a woman is imprisoned, her child is often displaced
(61). When women leave prison, they face barriers in employ-
ment and in receipt of federal services such as public housing,
food stamps, and Medicaid, which adds to the detrimental ef-
fects of mass incarceration on society.
CONCLUSION
Women, particularly white reproductive-age women, are
increasingly the face of the opioid crisis. Given the pene-
tration of opioid misuse and addiction across all income
and insurance strata, any provider who cares for women
needs to be prepared to assess and evaluate opioid use,
misuse, and addiction. Although responsible opioid pre-
scribing is essential, treatment capacity must be expanded
and be inclusive of the unique needs of women. However
the public and public health response to the opioid crisis
must include rolling back the war on drugs. The continued
criminalization of the public health issue of drug use and
the medical condition of addiction is unethical, ineffective,
and inhumane.
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