Communities across the country are struggling to gain control over the growing rates of opiate addiction, injection drug use, overdose and Hepatitis C (HCV) infection. Those affected by substance use issues, mental health issues and HIV/Hep C run into daily challenges on the path to recovery and health care. Many say their experiences of social and structural stigma has an impact on their willingness to access healthcare. The importance of addressing patient reported barriers to treatment will continue to be crucial in the pursuit of improving poor overall health outcomes.
Socioeconomic factors such as poverty, education, race and gender increase the likelihood of HCV contractioni and despite the fact that baby boomers are the majority of persons living with HCV (i.e. prevalence), young persons who inject drugs (PWID) are contracting it at uncontrollable rates (i.e. incidence), and have proven difficult to help and cure. These two groups are often front and center when discussing HCV treatment and care, and for good reason. However, it is important to highlight other vulnerable populations affected by hepatitis C.
Women with substance use issues seem to be viewed and treated by society more critically than men who have substance use issues. A primary cause for this is the underlying fact that women have been historically marginalized in our society. Over time, this has influenced how women are perceived, responded to, and ultimately treated.
Women battling opiate addiction face social stigma that is, for lack of a better term, brutal. When women also identify as injecting drugs, and are pregnant, the social and structural stigma is more pointed and biting. Unfortunately, many individuals who have opiate addictions are injecting and sharing equipment, which means there is a higher chance of contracting hepatitis C.
Across the U.S., there are a growing number of babies born addicted to drugs and opiatesii.
This phenomenon is so prevalent it is medically identified as Neonatal Abstinence Syndrome (NAS). A diagnosis that includes many different complications and health issues that arise from babies becoming addicted to opiates in the mother’s wombiii. In recent weeks, I have heard individuals detail their experiences seeing an infant going through withdraw. One individual described the chilling sound of a newborn shrieking in agony, another described the heart wrenching experience of placing their hand on an infant who is shaking uncontrollably.
Such experiences are undoubtedly jarring, and elicit emotions such as sadness, frustration, anger and resentment. Harsh emotions are often aimed at the mother of the child, “How could a mother do that to her baby, she is a terrible person,” might be the nicest thing I’ve heard said about mothers battling addiction. The truth is, however, that if this is the only lens we are looking through then there is likely no other viewpoint we will reasonably end up at.
Consider this; would you respond differently if you knew that between 2009-2013, 20% of women continuously enrolled in New York’s Medicaid program filled a prescription for opiatesiv, and in case you were wondering, this occurrence isn’t isolated to New York State, or women on Medicaid. In a large study from 2008-2012, 29% of women with private insurance between the ages of 15-44 filled a prescription for opiatesv. These findings are especially important when looking more broadly at the experience of women and substance use issues. Keeping all of this in mind one of the best things we can do is to frame the situation in a light that reflects addiction as a mental health issue, rather than a character flaw.
Many women battling substance use issues experience intimate partner violence and sexual coercionvi. In fact, about 9% of women in one study reported they experienced reproductive coercion in the previous 3 monthsvii. These acts of sabotage to reproductive health add to domestic violence issues and might lead to higher probabilities of unplanned pregnancies that may go undiscovered till late in the gestation period.
We don’t ask these questions enough, but we need to be asking them now more than ever. Women who have substance use issues are often aware of how they are perceived. A fact I didn’t fully understand until recently when I began leading group sessions with women who have substance use issues. Often, there are deep rooted feelings of shame, fear of losing their child, of law enforcement, of treatment, hopelessness and anger.
It is important to change the lens through which we view women with substance use issues to address the growing epidemic of hepatitis C and opiate addiction. Doing this means we will need to ask ourselves hard questions and explore difficult answers to a complex problem.
Vertical transmission of hepatitis C is the most common route of infection from mother to childviii. In a research study out of Philadelphia, data shows that 84% of infants born to hepatitis C positive mothers were not being adequately tested for hepatitis Cix. Further, prenatal and perinatal screening of hepatitis C is severely lacking, leading to increasing numbers of infants born with hepatitis C. Something that is completely preventable. When vertical transmission occurs things like viral load and history of injection drug use may have an effect on the likelihood of mother to infant transmissionx.
Increasingly, women living with hepatitis C & substance use issues represent a growing area that needs special attention. Physical dependency on opiates or other substances can lead to complex problems that limit the likelihood of seeking help. Seeing a baby born addicted to opiates who is hepatitis C positive is difficult, and something we all want not to happen; but to truly make progress we must replace our anger, disgust and resentment with empathy, compassion and tenacity.
I think we would all benefit from understanding that a woman before us battling substance use isn’t an opiate addicted, selfish, waste of space person. It’s your sister, your mother, your wife, your grandmother, your aunt, your friend, and they need you; they need us. They deserve our efforts in understanding their plight.
Authors Note: This article was originally published in the July issue of the HCV Advocate Newsletter.
i G. Searson et al., “Treatment of Chronic Hepatitis C Virus Infection in the United States: Some Remaining Obstacles,” Liver Int 34, no. 5 (2014).
ii S. W. Patrick et al., “Prescription Opioid Epidemic and Infant Outcomes,” Pediatrics 135, no. 5 (2015).
iii M. W. Stover and J. M. Davis, “Opioids in Pregnancy and Neonatal Abstinence Syndrome,” Semin Perinatol 39, no. 7 (2015).
iv Gallagher BK, Shin Y, Roohan P. “Opioid Prescriptions Among Women of Reproductive Age Enrolled in Medicaid – New York – 2008 – 2013. MMWR Morbidity Mortality Weekly Report 2016:65:415-417. DOI:http://dx.doi.org/10.15585/mmwr.mm6516a2.
v PhD Elizabeth C. Ailes, April L. Dawson, MPH, Jennifer N. Lind, PharmD, Suzanne M. Gilboa, PhD, Meghan T. Frey, MPH, and PhD Chery S. Broussard, Margaret A. Honein, PhD, “Opioid Prescription Claims among Women of Reproductive Age — United States, 2008–2012,” Morbidity and Mortality Weekly Report 64, no. 2 (2015).
vi Weaver Terri L., Gilbert Louisa, El-Bassel Nabila, Resnick Heidi S., and Noursi Samia. Journal of Women’s Health. January 2015, 24(1): 51-56. doi:10.1089/jwh.2014.4866
vii Kazmerski, Traci, Healther L. Mccauley, Kelley Jones, Sonya Borrero, Jay G. Silverman, Michele R. Decker, Daniel Tancredi, and Elizabeth Miller. “Use of Reproductive and Sexual Health Services Among Female Family Planning Clinic Clients Exposed to Partner Violence and Reproductive Coercion.” Maternal and Child Health Journal (2014): 1490-496.
viii R. Jhaveri and G. K. Swamy, “Hepatitis C Virus in Pregnancy and Early Childhood: Current Understanding and Knowledge Deficits,” J Pediatric Infect Dis Soc 3 Suppl 1 (2014).
ix D. E. Kuncio et al., “Failure to Test and Identify Perinatally Infected Children Born to Hepatitis C Virus-Infected Women,” Clin Infect Dis 62, no. 8 (2016).
x J. W. Wen and B. A. Haber, “Maternal-Fetal Transmission of Hepatitis C Infection: What Is So Special About Babies?,” J Pediatr Gastroenterol Nutr 58, no. 3 (2014).