Women with opioid use disorder (OUD) face many challenges, among them the risk of poor outcomes in conditions involving reproductive and sexual health (RSH). Factors contributing to risk include less use of contraceptives, a higher incidence of unintended pregnancies, and an increased chance of contracting sexually transmitted infections and passing them on.
What can be done to help these women?
This article highlights a study from the September/October issue of Journal of Addiction Medicine addressing this question.
In planning their study, researchers chose opioid treatment programs (OTPs) as their study site. Their reasons:
- Their “unique setting and structure” gives OTPs an opportunity to improve access to health care services. Access could “enhance patient-centered care, treatment retention, and recovery outcomes.”
- OTPs are accredited, certified, registered, and monitored by respected agencies.
- RSH interventions carried out in OTPs might be especially useful in reducing unplanned pregnancies and fetal opioid exposures. They could also help improve the health of women in their reproductive years who have OUD.
- Previous studies have shown women to be receptive to using contraception if offered onsite during treatment for substance use disorders.
- Contact between OTP staff and patients is a frequent, often daily occurrence, providing opportunities for developing trusting relationships. This is important because “women may be more likely to use RSH services in an environment where they trust their providers and the support staff.”
RSH services include contraception, pregnancy testing, HIV/STI testing, perinatal depression screening, and cervical cancer testing (Pap smear).
The study was supported by grants from the National Institutes of Health, the National Institute on Drug Abuse, and several other groups.
Integrating Reproductive and Sexual Health Education and Services Into Opioid Use Disorder Treatment Programs: A Qualitative Study is part of a larger study using mixed methods.
The objective of the study was to better understand factors that could influence the use and effectiveness of intervention, at all levels—patient, provider, and organization—when treating women at OTPs.
Study participants were providers and staff (nurses, counselors, medical directors, program directors, office manager, administrative assistants) at nine OTPs in North Carolina.
The team developed an interview guide to identify factors that might make effective intervention easier or more difficult to implement. In developing the guide, they used five constructs from the Consolidated Framework for Implementation Research (CFIR): patient needs and resources, peer pressure, networks and communication, relative priority, and culture.
The study’s first author, Stacey L. Klaman, PhD, MPH, currently a postdoctoral research fellow at Family Health Centers of San Diego’s Laura Rodriguez Research Institute, conducted 31 structured interviews based on the guide the team had developed. The interviews took place between November and December 2017, and were audio-recorded, transcribed, coded, then analyzed to identify key themes. Each interview lasted approximately 45 minutes. During the interviews, participants shared their perspectives about integrating reproductive and sexual health education and services into existing treatment programs.
Consolidated Framework For Implementation Research
The CFIR identifies barriers and facilitators that could influence the clinical applications of research findings. It is a tool often used to help put research findings into practice.
In this study, the CFIR:
- Addresses why and how barriers and facilitators to the integration of RSH care might exist
- Identifies factors that might influence patient outcomes
- Determines how those factors might best be used
- Indicates how effective use of those factors is likely to be
Key Point: the CFIR enabled the team “to move beyond describing the barriers and facilitators to RSH care integration … and address questions of why and how the barriers and facilitators might exist.”
(Key findings are presented here; see the published study for details.)
Researchers identified many barriers—factors interfering with effective intervention, and many facilitators—factors helping with implementation. They categorized the factors as shown below.
Barriers and Facilitators of Effective Implementation
|Patient||Transportation, childcare, time constraints||Group education approach|
|Provider(nurse, counselor, medical director)||Lack of communication between providers||Strong communication|
|Organization||Lack of political will, competing priorities, shortages of available resources||Culture of collaboration|
- Participants (providers and support staff) acknowledged that women in OTPs need access to RSH services and education. But most participants reported they didn’t talk with the women about their needs in these areas, or about pregnancy intentions. Nor did they know if women of reproductive age needed counseling about family planning.
- Transportation and childcare needs were the most important barriers to accessing OUD treatment. Unmet needs in these areas probably would hinder patients from taking part in RSH education and services as well.
Commented a support staff member: “Transportation is probably the biggest issue I see, a lot of them don’t have licenses or don’t have cars.”
From a counselor: “A lot of times we have people who can’t really stay here because they got kids at home, they got a babysitter just … to come here and get back home.”
- Group settings and tangible incentives would make it easier to participate in RSH education sessions–but not in RSH services.
Steps that might mitigate important barriers:
- Public transit passes, or coverage for transportation
- Onsite childcare
- RSH education
- Services with flexible or expanded hours
The authors envision a two-step process for providers and programs to integrate RSH education and services into OTPs:
Step 1: Make more time available, or provide special staff, or both. Provide ongoing training. “Then,” they note, “educating women about RSH could be a great addition to OTP programming.”
Step 2: Address barriers to clinical services integration. “Medical providers in treatment programs know how to provide nonjudgmental care,” they write, “which is critical to the provision of RSH services for women with OUD.”
They also recommend more research to find the best way to implement RSH education and services across program settings.
In closing, the authors emphasize that integrating RSH education and services into OTPs can have a far-reaching impact:
Integrating a broad range of RSH education and services has the potential to improve women’s overall health and empower women to achieve their reproductive goals … which can have a profound impact on the health of women with OUD and their children, their families, and their communities.
Klaman SL, Turner K, Lorvick J, Jones HE. Integrating reproductive and sexual health education and services into opioid use disorder treatment programs: A qualitative study. J Addict Med. 2020;14(5):e175-e182. doi:10.1097/ADM.0000000000000657