Women on the Edge: Opioids, Benzodiazepines, and the Social Anxieties Surrounding Women's Reproduction in the U.S. "Opioid Epidemic"

The Clinical Evolutions of Surveillance and Violence During Three Contemporary US Crises: Opioid Overdose, COVID-19, and Racial Reckoning

In 2020, three crises coalesced to transform the clinical care landscape of addiction medicine in the United States (US). The opioid overdose crisis (crisis #1), which had been contributing to excess US mortality for over two decades, worsened during the COVID-19 pandemic (crisis #2). The racial reckoning (crisis #3) spurred by the murder of George Floyd at the hands of police impacted clinical care, especially in safety net clinical settings where the majority of people targeted by police violence, and other forms of structural violence, receive healthcare to mend both physical and psychological wounds. Collectively, the three crises changed how providers and patients viewed their experiences of clinical surveillance and altered their relationships to the violence of US healthcare. Drawing from two different research studies conducted during the years preceding and during the COVID-19 pandemic (2017-2022) with low income, safety net patients at risk for opioid overdose and their care providers, I analyze the relationship between surveillance and violence in light of changes wrought by these three intersecting health and social crises. I suggest that shifting perceptions about surveillance and violence contributed to clinical care innovations that offer greater patient autonomy and transform critical components of addiction medicine care practice.

The REPAIR Project: A Prospectus for Change Toward Racial Justice in Medical Education and Health Sciences Research: REPAIR Project Steering Committee

Amidst ongoing efforts to address racial injustice, U.S. medical institutions are grappling with the structural roots of anti-Black racism. The REPAIR (REParations and Anti-Institutional Racism) Project is a 3-year strategic initiative at the University of California, San Francisco aiming to address anti-Black racism and augment the presence and voices of people of color in science, medicine, and health care. The REPAIR Project was designed in response to an unmet need for critical dialogue, cross-disciplinary research, and curriculum development addressing structural racism. It offers a framework for thinking and acting to achieve repair in relation to racial injustice and is anchored by 3 concepts-reparations, abolition, and decolonization-which have been deployed as annual themes in academic years 2020-2021, 2021-2022, and 2022-2023, respectively. The theme of medical reparations builds on the longstanding call for slavery reparations and the paying of debts owed to Black Americans for the harms of slavery. The REPAIR Project focuses on the specific debts owed to Black Americans for racial harm in health care settings. The theme of medical abolition examines the intersections of incarceration, policing, and surveillance in health care and the role of clinicians in furthering or stopping oppressive practices that bind patterns of Black incarceration to health and health care. The theme of decolonizing the health sciences targets "othering" practices entrenched in scientific methodologies that have arisen from colonial-era beliefs and practices around imperialism, including how the colonial-era concept of race contributes to ongoing racial harm. In this article, the authors describe the REPAIR Project, preliminary outcomes from its first year, and potential future lines of inquiry for medical educators and health sciences researchers. The authors argue that the full damage from slavery and its legacies cannot be undone, but everyone can work in new ways that reduce or eliminate harm.

"That's what I'm supposed to do at work": Gendered labor, self-care, and overdose risk among women who use drugs in Vancouver, Canada

Through rapid ethnography undertaken in Vancouver, Canada's Downtown Eastside - one of Canada's overdose epicenters - this article examines how gendered expectations of labor shape overdose risk for structurally vulnerable women and gender diverse people who use drugs. Drawing on two participant narratives, we explore how structural, symbolic, and everyday violence frame the lives of women and gender diverse people who use drugs in ways that drive their overdose risk as they balance self-care with caretaking, paid work, and basic survival. This article underscores the need for structural reform of peer overdose response work and funding for gender-attentive harm reduction and ancillary supports to better mitigate overdose risk for these populations.

Intersections between patient-provider communication and antenatal anxiety in a public healthcare setting in Pakistan

This study explores pregnant women’s and healthcare providers’ perspectives on the role of patient-provider communication in experiences of antenatal anxiety within a low-resource setting. In 2017–18, we consecutively sampled pregnant women (n = 19) with at least mild anxiety and purposively sampled antenatal care providers (n = 10) from a public hospital in Punjab Province, Pakistan. We then conducted in-depth interviews and thematically coded them with a combination of inductive and deductive coding methodologies. We found that patients expressed a desire for warm, empathetic communication from providers who demonstrate respect, attentiveness, and a shared lived experience. Providers revealed an awareness that their heavy caseloads, high stress levels, and discourteous tones adversely influenced communication with pregnant women and may exacerbate their anxieties, but also reported that compassionately addressing women’s concerns, providing financial problem-solving and/or assistance, and moderating conflicting healthcare desires between patients and their families could alleviate anxiety in pregnant women. Patients reported feelings of anxiety stemming from a belief that they received lower quality communication from antenatal providers at public hospitals than patients received from antenatal providers at private hospitals, an experience that they partially attributed to their low socioeconomic status. Meanwhile, some providers disclosed potentially stigmatizing views of women from particular sociocultural backgrounds or low socioeconomic status, including perceptions that appeared to shape communication with these patients in antenatal care encounters. Our findings provide preliminary evidence that communication between pregnant women and antenatal providers that is warm, normalizes patient fears, and integrates patients’ interpersonal and financial considerations can mitigate pregnant women’s experiences of anxiety and reduce barriers to accessing antenatal care in Pakistan’s public healthcare facilities.

(Re)shaping the self: An ethnographic study of the embodied and spatial practices of women who use drugs

While gendered experiences of drug use have been well-established, understanding how women resist structures that constrain their agency is important for mitigating drug-related harms, especially as overdose has become North America's leading cause of accidental death. Drawing on the intersectional risk environments of WWUD, this ethnographic study examined how gendered expectations of women's drug use, appearance, and comportment influenced vulnerability to overdose within the context of a fentanyl-driven overdose crisis. This community-engaged ethnography, conducted in Vancouver, Canada from May 2017 to December 2018, included in-depth interviews with 35 marginally-housed WWUD (transgender-inclusive) and approximately 100 h of fieldwork in single room accommodation (SRA) housing and an established street-based drug scene. Data were analyzed thematically with attention to embodiment, agency, and intersectionality. Findings highlight how gendered expectations and normative violence impacted women's use of space, both in the drug scene and SRAs. To resist efforts to 'discipline' their bodies, participants engaged in situated gender performances. Physical appearance was also deemed critical to managing drug use disclosure. Participants adopted gendered embodied practices, including altered consumption methods or injecting in less visible areas, to conceal their use from peers and at times, their partners. To resist harms associated with involuntary disclosure, participants often used alone in SRAs or in public spaces. While such practices allowed women to exert agency within constraining systems, they concurrently heightened overdose risk. Findings demonstrate how women engaged in everyday acts of resistance through embodied drug use practices, which increased their agency but elevated overdose risk. Implementing gender-specific programs that increase bodily agency and control (e.g. low-threshold services for personal care, women-focused harm reduction support) are needed to reduce risk of overdose for WWUD.

Women's utilization of housing-based overdose prevention sites in Vancouver, Canada: An ethnographic study

BACKGROUND

In response to a fentanyl-driven overdose crisis, low-threshold supervised consumption sites, termed overdose prevention sites (OPS), have been rapidly implemented in Vancouver, Canada. Since approximately 88% of fatal overdoses in the province occur indoors, OPS have been integrated into select non-profit-operated single room accommodations (SRA) housing. We examined the social-structural features of these housing-based OPS (HOPS) on women's overdose risk.

METHODS

Ethnographic research was conducted from May 2017 to December 2018 in Vancouver. Data included 35 in-depth interviews with women who use drugs living in SRAs and approximately 100 h of observational fieldwork in SRAs and surrounding areas. Data were analyzed using an intersectional risk environment approach, with attention to equity and violence.

FINDINGS

Findings demonstrate that the social and structural environments of HOPS created barriers for women to access these interventions, resulting in an increased overdose risk. Primary barriers included uncertainty as to who else was accessing HOPS, rules prohibiting smoking, and a lack of trust in staff's abilities to effectively respond to an overdose. Most participants considered HOPS to be unsafe environments, and expressed fear of violence from residents and/or guests. The perceived risk of violence was informed by previous experiences of assault and the witnessing of violence. Many participants thus consumed drugs alone in their rooms to better control their safety, despite heightened overdose risk. Further, most participants did not perceive themselves to be at risk of an overdose due to drug use practices and tolerance levels, and viewed using alone as a safer option than HOPS.

CONCLUSION

Findings highlight how the low-barrier design and operation of HOPS can undermine women's engagement with HOPS. Overdose prevention strategies in SRAs should also include gender-specific models (e.g. women-only HOPS, women peer workers) to help mitigate barriers to these services within the context of the current overdose crisis.

The intersectional risk environment of people who use drugs

Current conceptual models for examining the production of risk and harm (e.g. syndemics, 'risk environment') in substance use research have been fundamental in emphasizing broader environmental factors that shape health outcomes for people who use drugs (PWUD). However, the application of these frameworks in ways that highlight nuance and complexity has remained challenging, with much of this research focusing on select social positions (e.g. race, gender) and social-structural factors (e.g. poverty, drug policies). It is crucial that we move to better accounting for these relations in the context of substance use research to enhance equity in research and ensure understanding of diverse and complex needs. Building on the risk environment framework and complementary approaches, this article introduces the 'intersectional risk environment' as an approach to understanding the interconnected ways that social locations converge within the risk environment to produce or mitigate drug-related outcomes. This framework integrates a relational intersectional lens to examine how differential outcomes across populations of PWUD are produced in relation to social location and processes operating across social-structural dimensions. In doing so, the intersectional risk environment highlights how outcomes are products of processes and relations that are embodied, reflected, and challenged while situated within social, historical, and geographic contexts. Incorporating this framework into future research may improve understandings of health outcomes for PWUD and better orient structural interventions and public health approaches to address differential risks and experiences of PWUD.

Drug Use During Pregnancy Policies in the United States From 1970 to 2016

As U.S. states legalize marijuana and as governmental attention is paid to the “opioid crisis,” state policies pertaining to drug use during pregnancy are increasingly important. Little is known about the scope of state policies targeting drug use during pregnancy, how they have evolved, and how they compare to alcohol use during pregnancy policies.

Method:

Our 46-year original data set of statutes and regulations in U.S. states covers the entirety of state-level legislation in this policy domain. Data were obtained through original legal research and from the National Institute on Alcohol Abuse and Alcoholism’s Alcohol Policy Information System. Policies were analyzed individually as well as by classification as punitive toward or supportive of women.

Results:

The number of states with drug use during pregnancy policies has increased from 1 in 1974 to 43 in 2016. Policies started as punitive. By the mid- to late 1980s, supportive policies emerged, and mixed policy environments dominated in the 2000s. Overall, drug/pregnancy policy environments have become less supportive over time. Comparisons of drug laws to alcohol laws show that the policy trajectories started in opposite directions, but by 2016, the results were the same: Punitive policies were more prevalent than supportive policies across states. Moreover, there is a great deal of overlap between drug use during pregnancy policies and alcohol/pregnancy policies.

Conclusion:

This study breaks new ground. More studies are needed that explore the effects of these policies on alcohol and other drug use by pregnant women and on birth outcomes.