At the beginning of the Oscar-nominated short documentary Heroin(e), centered on the town of Huntington, West Virginia, deputy fire chief Jan Rader speeds to a local pub, sirens blaring. By the time she arrives, a woman is already being wheeled out on a stretcher after overdosing in the bathroom. Not a minute passes before another call comes over the scanner: a second overdose, this time a 23-year-old who didn’t make it. This is an everyday reality for Rader, and she’s not alone. Across the country, as the opioid crisis continues to worm its way into rural outposts and cities alike, fatality rates are staggering: The epidemic claims as many as 115 Americans lives daily, according to recent statistics from the Centers for Disease Control and Prevention, with a newly published study recording a 30% increase in emergency visits for overdoses across all states between 2016 and 2017.
The 39-minute Netflix Original, directed by Peabody Award–winning filmmaker Elaine McMillion Sheldon, tracks the issue on an intimate scale, following three women as they confront the scourge of addiction in their hometown. Judge Patricia Keller presides over drug court, Necia Freeman supplies meals to local sex workers through the town’s ministry, and Rader patrols the streets. Their front-lines perspective shines a light on an overlooked truth: While the majority of such fatalities are men, the toll on women is grim, with an 850% increase in opioid-related deaths between 1999 and 2015, almost double the rate for men, according to Linda Richter, Ph.D., director of policy research and analysis at the National Center for Addiction and Substance Abuse. Digging into the reasons for this disparity reveals a patchwork of factors tied to opioid-use disorder, ranging from gender-biased biological data to treatment centers without child care. The point, as outlined below, is that this national crisis is just as much a women’s health one, and treating it as such is crucial.
Beginning in the mid-’90s, the medical community embraced long-term painkillers as the holy grail of relief: Efficient and effective, the pills were also widely thought to be addiction-proof. Prescriptions soared among post-operative patients and chronic-pain sufferers, but dependency often kicked in, leading to the current crisis. The fact that women have a greater predisposition for chronic conditions like arthritis, endometriosis, and multiple sclerosis—all of which require long-term treatment and daily pain management—means that addiction can come as an unintended side effect.
“A lot of patients start out with a legitimate injury or legitimate complaint,” says Sharon L. Walsh, Ph.D., who advises the FDA and sits on the board of FORCE (Female Opioid Research Clinical Experts), referring to the slippery slope that follows prolonged use. “If you had some accident and were in the hospital and took an opioid for seven straight days around the clock, you would develop a physical dependence where your body needs that drug in order to feel normal.”
That is a strikingly short timeline, roping in another at-risk group: new mothers recovering from cesarean sections, who encounter pain medications at a time when they’re already grappling with new pressures and ravaged sleep. For them and other patients, the medical industry has taken note, steering away from default opioid prescriptions when designing pain-management treatments.
The effects of any substance on a human body are far from universal, with biological makeup—gender included—shaping the response. “Women experience something called telescoping,” says Andrea Grubb Barthwell, M.D., a founding chairwoman on the board of FORCE and director of the North Carolina substance-use treatment center called Two Dreams. The phenomenon she describes entails a rapid spiral into addiction as well as an inflated set of medical, social, and psychological problems. “Even with later onset use [of a substance], we [as women] advance faster and have consequences earlier” than men, she continues. One reason is basic physiological differences: Compared with men—taking into account variations in body size, fat-to-lean body-mass ratio, metabolic rate, and hormones—women tend to be more susceptible to opioid addiction.
Shame and Stigma
Opioid-use disorder is a medical diagnosis, not a moral failing. But too often, especially for mothers and pregnant women, there is a net of shame cast over their dependence and treatment choices. Instead of discussing the condition as one would address diabetes—as a long-term, treatable disease that affects our bodies and lifestyle choices—the court system and general public routinely cast judgment. This only raises the already-high bar to getting help; mothers often avoid treatment out of fear that admitting a need for assistance could mean losing custody of their children.
“You’ll have women who get in trouble with the law, lose their children, and get into treatment with a physician and are doing well—and then go into court to obtain custody, [only] to have a judge tell them they can’t have custody unless they come off of their medication,” says Walsh. “That’s illegal. In what other condition would a judge or a lawyer or a social worker be giving someone a medical dictum? That just doesn’t happen anywhere else.”
More and more, the stigma surrounding opioid-use disorder and the treatments available today are shifting, offering up new opportunities for timely intervention, such as when soon-to-be mothers come to emergency rooms seeking prenatal care. “It would be a thing of beauty if we could wrap our arms around all those people and immediately get them into care someplace—care that was individualized to meet patient needs,” says Walsh.
Trauma and Motherhood
As Heroin(e) follows Freeman on her night drives, delivering food and hygiene kits to local sex workers, she encounters a woman whose recent relapse has landed her back on the streets—“the only place [she] could turn to” after losing her job. Selling one’s body to feed an addiction sits at one end of the extreme when considering gendered trauma, but experiences of rape, domestic abuse, and even childbirth are also risk factors. “Not all sexual violence ends up in a woman with substance-use disorder,” says Barthwell, “but it’s rare to find a woman with a substance-use disorder who wasn’t attacked prior to the onset of the disease—or certainly attacked during the expression of her disease.”
Insurance coverage, socioeconomic status, and lack of education often put high-cost treatment out of reach, yet women have added barriers, especially when they are caretakers. There’s the aforementioned stigma; of those who do seek addiction treatment, about 70% of those women have children, yet most residential programs do not allow them, according to Richter. Alternative child care and missed work days are seldom an option, and recovery plans—and attendant withdrawal symptoms—are not just physically grueling but time-consuming. Implementing legislation that gives women and families greater access to health care and resources across the board might enable more women to find support in long-term recovery.
The Way Forward
“Everyone is talking about doing something,” says Walsh. “There is not a day that goes by where someone doesn’t send me a link to this new program or that new program.” Organizations like FORCE are changing the stigma around opioid-use disorder; their all-female board of specialists and academics is dedicated to putting inclusivity at the forefront of the national conversation. Through fundraising, research, and education, like-minded groups are using their platforms to bring awareness to how this crisis affects women. State legislation is following suit. Maryland is launching coalitions to help women in recovery by providing supportive housing that welcomes children. New Jersey has allocated funding for gender-specific addiction plans that include family-centered treatment and trauma-informed care. “Aside from the programs and initiatives that focus specifically on the needs of women, it is important to note that any progress made to address the lack of access to prevention and affordable treatment for the larger population benefits women and families,” adds Richter. And on a micro-level, persistent community efforts matter, as seen in Heroin(e). As Rader says in the film, “I don’t care if I save somebody 50 times. That’s 50 chances to get into long-term recovery.”