Advertisement

An unexpected path to addiction medicine

Open AccessPublished:December 25, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100849
      I am often asked, “Why did you leave full-time practice in obstetrics and gynecology to pursue a fellowship in addiction medicine?” My answer is that I was not having the influence on patients I had always imagined. I came to recognize that I was barely scratching the surface of the biopsychosocial aspect of “complete” health with the physical treatment I provided. When I learned about addiction medicine, I knew that this was the aspect of treatment I had been missing. As I began to explore the field, I realized that there is a dearth of providers dedicated to the care of patients suffering from substance use disorders (SUDs) and even fewer providing skilled reproductive healthcare for people with SUDs.
      The crucial need for clinicians trained in reproductive health and addiction medicine really hit home when a close relative shared her experience of giving birth and revealed how the event drew her back into the abyss of addiction. Her childhood was rife with trauma and abuse. This is not surprising in light of the research that consistently demonstrates that nearly 80% to 90% of women with SUDs have experienced traumatic events.
      • Frazer Z
      • McConnell K
      • Jansson LM.
      Treatment for substance use disorders in pregnant women: motivators and barriers.
      Her SUD has had lifelong consequences, including efforts toward recovery interspersed with multiple relapses. She faced stigma, successive losses, and an uphill battle to “straighten out my life.” After many years of abstinence, in her early 40s, she found love and an opportunity to create the family she had always dreamed of. Once pregnant, she was determined to do things the “right way.” After a vaginal delivery, she was discharged from the hospital with a prescription for opioids, which, to date, would be discouraged after a routine vaginal birth.
      • Ecker J
      • Abuhamad A
      • Hill W
      • et al.
      Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      With the physical pain and emotional stress of early motherhood, she found herself battling with opioid addiction, once again. It only took 1 prescription for opioids.
      Although medication for opioid use disorder would normally be advisable, she preferred to not use any agonist or antagonist therapy and instead presented for detoxification.
      • Blanco C
      • Volkow ND
      Management of opioid use disorder in the USA: present status and future directions.
      She thought that revealing she was a new mother would enable her to obtain the help she needed. However, she was immediately reported by social workers to child protective services. “I regret ever telling them I had a child,” she said.
      I was shocked to hear this story, which was heartbreaking, both personally and professionally. It was distressing to see the pain and new trauma an obstetrician-gynecologist, such as myself, had unwittingly caused my relative through a lack of awareness or understanding about her history or circumstances. During my addiction medicine training, I have sadly learned that this story is not unique. When people with SUDs seek help, particularly people with children, they often do so knowing that they may face stigma, the involvement of child protective services, and the potential repercussions of speaking honestly about their experiences. Thus, many people choose not to tell their providers about their struggles with addiction or not to seek care at all. Given the recent Supreme Court decision to overturn Roe v. Wade, supporting all patients’ distinct reproductive healthcare needs will become more crucial than ever. For this population, attending to reproductive health needs is of grave concern, as women with SUDs have substantially higher rates of unintended pregnancy and sexually transmitted infections and substantially lower rates of cervical cancer screening.
      • MacAfee LK
      • Harfmann RF
      • Cannon LM
      • et al.
      Sexual and reproductive health characteristics of women in substance use treatment in Michigan.
      I am currently leading an integrated program devoted to the treatment of addiction and the provision of reproductive healthcare needs of patients with SUDs. Few clinics of this kind exist, despite the unique needs of this population. I believe that having providers with expertise in both reproductive health and addiction medicine, who are specifically dedicated to this vulnerable population, is imperative. Through the case of my relative and pregnant people that I have cared for, I saw that patient advocacy is necessary at all levels of care. Providers need to be aware of the policies in place (eg, federal laws, state laws, and hospital-specific policies) and their patients’ circumstances. It is important that we are familiar with our state policies regarding mandated reporting, that we are aware of the consequences of making these reports, and that we ensure that our patients also have this understanding.
      • Ecker J
      • Abuhamad A
      • Hill W
      • et al.
      Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      Patients need, and deserve, education and support to understand how specific policies directly affect them. Patients should be made aware of their rights so that they can make well-informed decisions. The legal landscape is extremely complex and, as we have seen, is shifting dramatically. Policy questions may engage us in unprecedented ways, and new issues will certainly arise for those of us at the intersection of reproductive health and addiction medicine.
      Finally, although I was not surprised to find that patients with SUDs are concerned about stigma, I did not expect to experience stigma myself. Nonetheless, I have found that as a Black woman who has chosen to become an addiction medicine specialist, there is also a stigma associated with working in this field, a devaluing of the discipline or perhaps of our patients.
      Furthermore, a key element of the current opioid crisis has been the fact that those most affected have been White. As minoritized people begin to surpass their White counterparts in overdose deaths, we may find that this crisis takes a different level of importance within society.
      • Friedman JR
      • Hansen H
      Evaluation of increases in drug overdose mortality rates in the US by race and ethnicity before and during the COVID-19 pandemic.
      These realizations have reinforced my commitment to helping shape this developing interdisciplinary field.
      I hope that as the field grows, and awareness increases, I will never hear another family member or patient be regretful to inform their doctors about struggles with substance use. Being honest should enable patients to receive the care and support they need to succeed in overcoming addiction, in maintaining abstinence, and in managing their health. Working at the intersection of reproductive health and addiction medicine, we have the opportunity to help dismantle stigma and to offer lifesaving—and life-changing—treatment to improve the lives of our patients and their families.

      References

        • Frazer Z
        • McConnell K
        • Jansson LM.
        Treatment for substance use disorders in pregnant women: motivators and barriers.
        Drug Alcohol Depend. 2019; 205107652
        • Ecker J
        • Abuhamad A
        • Hill W
        • et al.
        Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
        Am J Obstet Gynecol. 2019; 221: B5-28
        • Blanco C
        • Volkow ND
        Management of opioid use disorder in the USA: present status and future directions.
        Lancet. 2019; 393: 1760-1772
        • MacAfee LK
        • Harfmann RF
        • Cannon LM
        • et al.
        Sexual and reproductive health characteristics of women in substance use treatment in Michigan.
        Obstet Gynecol. 2020; 135: 361-369
        • Friedman JR
        • Hansen H
        Evaluation of increases in drug overdose mortality rates in the US by race and ethnicity before and during the COVID-19 pandemic.
        JAMA Psychiatry. 2022; 79: 379-381