Reproductive health care providers are highly likely to encounter patients who misuse substances such as opioids, alcohol, cannabis, and methamphetamines. In 2019, about 7.2 million women reported a substance abuse disorder, largely concerning alcohol use.[1] What about the opioid crisis that has been developed over the years? In that 2019 survey, about 5 million women reported misusing opioids, with about 700,000 of them meeting the criteria for opioid use disorder. And since 2019? Nearly one third of survey respondents who use alcohol or other drugs reported an increase in their use during the Covid-19 pandemic.[2]

Shallini Ramanadhan, MD, MCR, presented tips on providing care to patients with opioid or other substance use disorders at the recent Contraceptive Technology virtual conference.

Substance abuse disorders in general correlate with a lower likelihood of using contraception. A recent study showed that while contraceptives are used by 81% of women who do not abuse substances, they are used by only 56% of women who do have a substance abuse disorder (mostly opioid use disorders).[3] The risk, of course, is an unintended or unwanted pregnancy. Among patients with opioid use disorder, for example, 86% of pregnancies are unwanted and unintended, double the percentage (45%) among the general public.[4] Not only do patients with opioid use disorder become pregnant when they do not want to be, they also become pregnant more often: more than half (54%) report having had four or more pregnancies, in contrast with the 14% among the public at large.

Many factors influence whether or not patients with substance use disorders use a contraceptive even though they do not desire a pregnancy, but key among these is the misconception that the individual is not at any particular risk for getting pregnant. Among women who use opioids, for example, amenorrhea is common, due to the effects of the drug acting on receptors in hypothalamus, resulting in a reduction or disruption of pulsatility of gonadotrophin-releasing hormone.

Moreover, the vast majority of patients with substance use disorders tend to use contraceptive methods that are less effective. Only 8% use methods that are effective and only 7% use ones that are very effective.[5] Many factors also influence method selection. Interestingly, many of these patients, when they go to addiction or syringe exchange clinics or STI clinics, are exposed to the ubiquitous and heavy promotion of condoms, said Ramaladhan. Condoms are among the less effective methods of contraception. Few women with opioid use disorder (only 9%) get one of the highly effective long-acting reversible contraceptives, such as an IUD or implant, even though 42% say they want one.[6]

The good news is that no methods are contraindicated for patients on the basis of their substance use or treatment of it with medications such as methadone, buprenorphine, naltrexone. However, some of these patients do develop co-morbidities associated with their substance use disorder, and those medical conditions or the medications to treat them may pose contraindications for specific contraceptive methods. See Table 1. Ramanadhan advises clinicians to check the U.S. Medical Eligibility Criteria for Contraceptive use after obtaining a thorough medical and medication history.

Table 1. Medical conditions associated with substance use disorders [7],[8]

Substance use disorder	Medical condition
Alcohol	Cardiovascular diseases Cancers Injuries Stroke Cirrhosis
Opioids	Arthritis Chronic pain Headache Hepatitis C Musculoskeletal disorders Opioid related overdoses
Cannabis	Respiratory deficits Cardiovascular diseases Lung cancer
Methamphetamine	Hepatitis Cirrhosis COPD Asthma HIV

Just as with other patients, support those with substance abuse disorders by taking into account their reproductive and broader life goals; do not focus just on preventing unintended pregnancy. Consider, too, the context of the patient’s life. She’s struggling to overcome a high stigmatized disorder and may have had prior experiences in health care that were negative. One of the negative experiences she may have faced could include a sense of being coerced into considering a long-acting reversible method due to its very high efficacy and ease of use. Ramanadhan explains that sometimes there can be a disconnect between the priorities of a caring provider and the priorities of the patient.[9]

The underlying assumption, she said, is there is a lot of dysfunction in these patients lives, leading providers to assume that they should want ease of use and the best effectiveness to prevent an unintended pregnancy. But that is not always true. So many patients are concerned about future fertility, and some methods seem invasive to them. They also want to be in control of their reproductive destiny—trying to remember to show up for IUD or implant removal dates makes them anxious. Providers will need to ask patients what they want in a contraceptive method…and what they do not want. For example, one patient discontinued using the contraceptive patch because her peers made comments about how the patch resembled a fentanyl patch. Patients also worry about combined oral contraceptives and that they may interact with their medications or may worsen mental health by interfering with mood stabilizing medications. They need real information, said Ramanadhan.

[1] 2019 National Survey of Drug Use and Health: Women. Substance Abuse and Mental Health Services Administration. Accessed on December 13, 2021 at https://www.samhsa.gov/data/sites/default/files/reports/rpt31102/2019NSDUH-Women/Women 2019 NSDUH.pdf

[2] LifeWorks and Betty Ford Hazeltine Foundation. Mental health index report, June 24, 2021. Summary accessed December 13, 2021 at https://www.hazeldenbettyford.org/about-us/news-media/press-release/mental-health-index-report.

[3] Terplan M, Hand DJ, Hutchinson M, Salisbury-Afshar E, Heil SH. Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review. Preventive Medicine 2015;80:23–31.

[4] Heil SH,Jones HE,Arria A,Kaltenbach K,Coyle M,Fischer G,etal. Unintended pregnancy in opioid-abusing women.J subst Abuse Treat 2011;40:199–202.

[5] Terplan M, et al. Contraceptive use and method choice among women with
opioid and other substance use disorders: a systematic review. Prev Med. 2015;80:23-31.

[6] Collier et al. Does colocation of medication assisted treatment and prenatal care for women with opioid use disorder increase pregnancy planning, length of interpregnancy interval, and postpartum contraceptive uptake? J Subst Abuse Treat. 2019;98:73-77.

[7] Bahorik et al. Alcohol, cannabis, and opioid use disorders, and disease burden in an integrated health care system. Journal of Addiction Medicine 11(1):3-9, 2017.

[8] Han et al. Multimorbidity Among US Adults Who Use Methamphetamine, 2015–2019. J Gen Intern Med (2021).

[9] Sobel et al. Contraceptive decision-making amongst pregnancy capable individuals with opioid use disorder at a tertiary care center in Massachusetts. Contraception 2021 Jun 10;S0010-7824(21)00185-2.