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Substance use disorder: contraceptive options counseling

What’s New in Contraception?

Contraceptive Technology Conference!

Biologic sexism of STIs

Excess breast cancer deaths after COVID-19

Contraception for patients with medical conditions

Pelvic Floor Dysfunction

Treating vulvodynia

Puzzling Over the Hurt Down-Under

Serious Mental Illness and Contraception

New 13-Cycle Vaginal Contraceptive System

The Future of Family Planning in Post-COVID America

New ASCCP Guidelines: Implications for FP

On the alert: mood disorders during 2020 stressors

Sex in the Time of COVID-19

Challenges old and new during the pandemic

Reproductive health in the time of Covid-19

Talking about toys

Missed Pills: The Problem That Hasn’t Gone Away

Find the “yes! . . . and” rather than “no” or “but”

Digital Family Planning: the Future is Now

Irregular Bleeding Due to Contraceptives

When she’s low on libido…

Ouch! Best approaches to menstrual pain

Contraceptive efficacy: understanding how user and method characteristics play their part

Strategizing treatment for chronic heavy menstrual bleeding

Perimenopause

Untangling the literature on obesity and contraception

High tech apps for no-tech FABM

Menstrual exacerbation of other medical conditions

From Princeton University: Thomas James Trussell (1949-2018)

The Short and Long of IUD Use Duration

Selecting a Method When Guidance Isn’t Clear-cut

Healthcare in the Time of Digital Expansion

The Scoop on Two New FDA-Approved Contraceptive Methods

Pregnancy of unknown location—meeting the challenge

Big “yes” (with caveats) to CHCs during perimenopause

The role of IUDs (LNG IUDs, too!) in emergency contraception

Combined pills’ effect on mood disorders

Abortion in the U.S.: safe, declining, and under threat

Hope for ovarian cancer screening test

Breast cancer still a small risk with some hormonal contraceptives

New treatment modality for BV

Record rate of HPV-related throat cancer

Viruses in semen potentially transmissible

Don’t Abstain from Your Role in Abstinence

Teens births declining but geographic ‘hotspots’ defy trend

Online Medical Abortion Service Effective and Safe

Do Women Really Need to Wait That Long?

Reassuring news on depression and OC use

PMDD: Genetic clues may lead to improved treatment

Breast cancer risk when there is a family history

Body weight link to breast and endometrial cancers (and 11 others)

Family Planning in 2017 and Beyond

Make Me Cry: Depression Link (Again)?

Managing implant users’ bleeding and spotting

Zika: Updated guidance for providers

Pharmacist-prescribed contraceptives

Hot off the press! 2016 MEC and SPR

Zika virus fears prompt increased request for abortion in nations outlawing abortions

Opioid use epidemic among reproductive-age women

Good news on the family planning home front!

War Against Planned Parenthood Hurts Women

Win-win for both treatment and prevention

Center of the Storm

Ambivalence

Menopause, mood, mental acuity, and hormone therapy

Emergency contraception for teens

Postpartum Contraception: Now, Not Later

Reproductive tract infections, sexually transmitted infections, or sexually transmitted diseases: “a rose by any other name…”

Are we practicing what we preach?

Be alert to VTE in hormonal contraceptive users

LARC among teens increased 15-fold, but not enough

Brain cancer and hormonal contraception

Free tools: Easy access to the US Medical Eligibility Criteria for Contraceptive Use

Alcohol consumption when pregnancy is unwanted or unintended

Latest Data on Contraceptive Use in the United States

LateBreaker sampler from Contraceptive Technology conference

Emergency Contraceptive Pill Efficacy and BMI/Body Weight

Handout on Unintended Pregnancy and Contraceptive Choice

Ask About Withdrawal (Really!)

Rules to Practice By: Safety First and Cleanliness is Close to. . .

What’s Vanity Fair Got Against the NuvaRing?

Promising New Treatment for Hepatitis C

Numbers matter, so make them simple for patients

The Recession’s Effect on Unintended Pregnancies

Lessons Learned from the Contraceptive CHOICE Project: The Hull LARC Initiative

Applying the “New” Cervical Cytology Guidelines in Your Practice

Acute Excessive Uterine Bleeding: New Management Strategies

Medical indications for IUD use in teens

Whatever happened to PID?

Update on Emergency Contraception

Contraceptivetechnology.com New and Improved

Substance use disorder: contraceptive options counseling
January 1970

 

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.