Women with opioid use disorder who also come into contact with the criminal justice system face unique challenges and stigma that may prevent them from seeking treatment for their substance use and harm reduction measures that could prevent overdose deaths, according to a new study led by a team at Penn State. They published their findings in Psychology of addictive behavior.

Harm reduction strategies are evidence-based methods of engaging drug users and providing them with tools and information to reduce their risk of overdose. These methods can play a critical role in addressing the overdose crisis in the United States, especially when tailored to the needs of women.

Through in-depth interviews with women with opioid use disorder and professionals who work with them, researchers identified recommendations for more effective drug treatment programs. Recommendations include improving accessibility of harm reduction tools, expanding harm reduction education, and moving away from “abstinence only” paradigms within substance abuse treatment programs.

“Improving engagement in overdose prevention and harm reduction is a challenge that must be addressed to mitigate the impact of the overdose crisis in the United States,” said Eric Harrison, a doctoral student in human development and family studies at Pennsylvania State University and lead author of the study.

“To reduce the risk of overdose for women with opioid use disorder, it is imperative to find ways to educate women with opioid use disorder about harm reduction, more effectively teach them harm reduction tools, and reduce stigma among providers and professionals.”

According to the Centers for Disease Control and Prevention, nearly 108,000 people died from drug overdoses in 2022, 76% of which involved opioids. However, there is limited research on the risk factors for overdose, particularly among women, who may face different challenges than men.

“Women who use drugs face strong stigma because many of them are also mothers. This stigma may prevent women from seeking harm reduction programs and substance abuse treatment,” says Abenaa Jones, Ann Atherton Hertzler Early Career Professor of Health and Human Development, assistant professor of human development and family studies, and lead author of the study.

Women who use drugs and are involved in the criminal justice system are particularly at risk, the researchers said. Not only are they at high risk of overdose immediately after release, but involvement in the criminal justice system also presents longer-term challenges to their recovery.

“These stigmas and barriers can make it difficult to obtain the kind of ‘rebuilding capital’ that is so important to sustain recovery,” said Kristina Brant, assistant professor of rural sociology and co-author of the study. “To promote well-being, it is imperative to find unique ways to support this group that faces so many overlapping vulnerabilities.”

The researchers conducted in-depth interviews with 20 women with opioid use disorder and a history of criminal justice involvement, 12 substance use disorder treatment professionals, and 10 law enforcement professionals who have worked with women with opioid use disorder. All of these individuals lived in Pennsylvania.

Interviews addressed women’s personal experiences with overdose, their use or knowledge of overdose prevention techniques, barriers to accessing or using these techniques, and professionals’ experiences in dealing with women with opioid use disorder.

In these discussions, the researchers also analyzed the challenges that pregnant women and mothers face in seeking treatment, and they explained these results in detail in an article published earlier this year.

These interviews also revealed a lack of knowledge about harm reduction measures. Women may not know that resources such as naloxone – or Narcan, a drug that can reverse an opioid overdose – or fentanyl test strips exist, and may not know where to get them or how to use them. This greatly limits their usefulness in preventing overdoses.

In some cases, this could be due to a lack of communication between drug treatment providers and patients or inadequate aftercare after an overdose. Without appropriate tools or knowledge, women may resort to strategies that may be ineffective or even harmful.

“Today, harm reduction drugs like Narcan are more common, but we need to consider the consequences of actually getting Narcan into everyone’s hands. Even though Narcan is available over the counter, there are still people who may never buy it,” Harrison said, explaining that stigma could prevent purchase, especially among women who fear potential legal or custody implications.

“Improved accessibility and more comprehensive education about naloxone and other harm reduction tools, especially for people not directly involved in substance use, is an important consideration.”

The findings also highlight important differences in the perspectives of women with opioid use disorder and the professionals who work with them, the researchers said. While both groups noted an increased vulnerability to overdose due to a drug supply increasingly tainted with substances such as fentanyl and xylazine, some of the professionals relied on the narrative that people were putting themselves at risk by seeking stronger substances and were not concerned about overdoses.

“The women do not blame themselves or other drug users. Instead, they tell us about the dangers of a toxic drug supply and the lack of access to tools that can help identify drug types, such as fentanyl test strips, and support people in making decisions to minimize risk,” Brant said.

To prevent opioid overdoses, researchers say there needs to be improved access to naloxone and other harm reduction medications, increased education about these medications, and a move away from the abstinence-only paradigm in substance abuse treatment programs.

“Some people may not seek help because they are not seeking total abstinence,” Harrison said. “We need more open discussions about overdose prevention and harm reduction, as well as more socially acceptable options to save lives by meeting people where they are, without bias or judgment.”

The study’s findings will inform the design of a comprehensive intervention for women with opioid use disorder who are involved in the criminal justice system. The program integrates substance use treatment with peer support, overdose management training, access to overdose treatment medications, and assistance with transportation, child care, and housing. Half of the women will be randomly assigned to participate in a trauma support group.

“These components are rarely offered along with substance abuse treatment. This research examines whether this comprehensive program is associated with better substance use and social outcomes,” Jones said.