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Health Inequities Among People Who Use Drugs in a Post-Dobbs America: The Case for a Syndemic Analysis

Published online by Cambridge University Press:  13 December 2023

Jennifer J. Carroll ,
Bayla Ostrach  and
Taleed El-Sabawi
Jennifer J. Carroll
Affiliation:
NORTH CAROLINA STATE UNIVERSITY, RALIEGH, NC, USA
Bayla Ostrach
Affiliation:
BOSTON UNIVERSITY, BOSTON, MA, USA
Taleed El-Sabawi
Affiliation:
FLORIDA INTERNATIONAL UNIVERSITY, MIAMI, FL, USA
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Abstract

Punitive policy responses to substance use and to abortion care constitute direct attacks on personal liberty and bodily autonomy. In this article, we leverage the concept of “syndemics” to anticipate how the already synergistic stigmas against people who use drugs and people who seek abortion services will be further compounded the Dobbs decision.

Keywords

PregnancySubstance UseOverdoseSyndemicsAbortion
Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 51 , Issue 3: Seeking Reproductive Justice in the Next 50 Years , Fall 2023 , pp. 549 - 553
Copyright
© 2023 The Author(s)

Substance use and reproductive health are deeply intertwined public health and reproductive justice concerns. These challenges compound each other: punitive responses to substance use place safe, equitable perinatal healthcare out of reach for many, and pregnancy and parenthood often coincide with structural barriers to effective treatments for substance use disorder (SUD).Reference Carroll1

In this article, we propose a theoretical framework for understanding the harms that emerge from the surveillance and punishment of pregnancy and parenting: syndemic theory. Syndemic theory is characterized by an interaction of biological factors that is caused and/or exacerbated by social and structural environments. It is this complex interplay of biological processes and social constructs that distinguishes syndemic theory from intersectionality.Reference Bulled2

We argue that, in the current moment shaped by Dobbs v. Jackson Women’s Health Organization, the syndemic framework may clarify a multiplicity of interactions between negative health outcomes associated with criminalized substance useReference Singer, Ziegler, Lerman, Ostrach and Singer3 and negative health outcomes associated with heavily surveilled and stigmatized pregnancy,4 with careful attention to the biological interactions resulting from socio-political environments that produce explicitly punitive responses towards both.Reference Singer5 Such an approach could enable a better understanding of how already synergistic harms of criminalized substance use and heavily surveilled pregnancy are exacerbated by legal restrictions on abortion. Further, a syndemic analysis could identify policy levers with the potential to mediate those harms on a population level.

The Synergistic Harms of Punishing Substance Use and Pregnancy

Even before Dobbs, the harms of criminal interventions, child welfare interventions, and institutional surveillance imposed upon people who use drugs (PWUD) and upon people who are pregnant and/or parenting were known to compound each other.6 The National Advocates for Pregnant Women (now Pregnancy Justice) previously documented more than 1,300 cases between 2006 and 2020 in which a woman was subject to arrest, detention, and other losses of personal liberty for alleged crimes in which pregnancy was a necessary element or “but for” condition,7 including prenatal exposure to diverted prescription medications or illicit substances.Reference Martin8 Family separation, deeply traumatic for both parents and children9 and disproportionately used against American Indian/Alaskan Native (AI/AN) and Black families, is yet another example of this relationship in action.Reference Meinhofer10 Such punitive policies actively deter people with SUD from seeking perinatal careReference Atkins and Durrance11 and are significantly associated with higher rates of neonatal opioid withdrawal syndrome (NOWS, formerly called neonatal abstinence syndrome or NAS) in substance-affected births.Reference Faherty12

This synergism flows both ways: pregnancy is also a known barrier to evidence-based treatment for SUDs, hindering treatment access on multiple fronts.13 One North Carolina study found nearly half of all clinics prescribing buprenorphine — an evidence-based medication for opioid use disorder that reduces the risk of death by half — refusesReference Patrick14 pregnant patients at intake, and that treatment options for pregnant people shrank even further during COVID-19.Reference Lensch15 Fear of child welfare involvement actively deters pregnant and parenting people from seeking SUD treatment,Reference Ostrach and Leiner16 and lack of childcare services constitutes an additional barrier for those seeking treatment.Reference Frazer17

Moreover, the public health impacts of substance use and reproductive choice are both shaped by the same powerful institutional and cultural systems that have been historically produced by — and continue to perpetuate today — racism,18 sexism,19 classism,Reference Tyndall and Dodd20 transphobia,Reference Radi21 and other drivers of harm. For example, compared to their White counterparts, AI/AN persons are more than twice as likely — and Black persons more than three times as likely — to die in childbirth in the United States.Reference Artiga22 Black people also experience higher rates of unintended pregnancy than any other racialized or ethnic group in the U.S. and utilize abortion services at a rate five-times higher than Whites.Reference Cohen23 At the same time, Black people represent approximately 13% of the population but nearly 40% of those incarcerated for drug law violations.24 Indeed, U.S. criminal drug laws were developed for the express purpose of oppressing Black communities.Reference El-Sabawi and Oliva25

The Syndemic Framework

The syndemic concept was first articulated in 1994 and later refined in 1996 by medical anthropologist Merrill Singer to describe “a closely interrelated complex of health and social crises”Reference Singer26 characterized by dynamics that include but also exceed those of synergistic relationships between biological pathogens. For example, tuberculosis (TB) and HIV are synergistic pathogens. HIV is a risk factor for TB, because HIV-infection increases the risk of reactivating latent TB infection and accelerates the progression of TB disease.Reference Castro27 Likewise, TB accelerates the progression of HIV disease and increases viral load by activating HIV transcription,Reference Corbett28 putting both diseases in a dangerous feedback cycle with each exacerbating the other.

Synergy between pathogens is not sufficient to demonstrate a syndemic interaction. The presence of population-level social, political, and/or environmental conditions that produce the synergistic interaction that exacerbates each of the synergistic health concerns to produce worse health outcomes is also necessary.Reference Singer29 This focus enables us to identify institutional and policy changes that both cause and could mitigate the harms inflated by synergistic interaction.

We argue that multifaceted systems of inequality that affect both PWUD and people who are pregnant are likely best understood through a syndemic framework that accounts for the social, structural, and policy environments that produce and exacerbate them. Below, we articulate how Dobbs likely produces negative effects that could be best assessed using a syndemic framework.

Dobbs Exacerbates Harms Faced by Substance-Involved Pregnancies

The Dobbs decision and the subsequent restriction of access to abortion care in several U.S. states have seriously exacerbated the negative health consequences of pregnancy generally, but especially for substance-involved pregnancies. Many states have created — or are poised to create — legal environments in which pregnant PWUD face civil or criminal punishment for any reproductive or parenting choice they could make. Seeking to terminate a pregnancy could result in civil or criminal liability where abortion restrictions or bans are enacted. Carrying a pregnancy to term also presents risk of civil or criminal punishment for substance use while pregnant — punishment that could be meted out during pregnancy as well as after delivery and well into parenthood. All conceivable choices could invoke statutorily mandated punishment.

Second, abortion bans will hinder access to substance use treatment even further. The threats of loss of liberty, child removal, and other punishments for substance use during pregnancy actively deter pregnant people living with SUD from seeking evidence-based treatment.Reference Angelotta30 Under punitive abortion policies, PWUD who have had their pregnancy documented by healthcare providers face potentially greater risk by terminating pregnancy than if they were to carry that pregnancy to term and face accusations of child neglect based on their history of substance use alone. In other words, pregnant people may feel coerced (by threat of punishment for abortion) into maintaining a pregnancy that effectively bars them from accessing substance use treatment. Importantly, homicide — often by an intimate partner — was the leading cause of death during pregnancy in the U.S. even prior to the Dobbs decision.Reference Lawn31 Abortion plays an important role in reducing intimate partner violence,Reference Roberts32 and the loss of abortion access may cause rates of intimate partner violence (already both associated with increased substance use and a known barrier to careReference Tobin-Tyler33) during pregnancy to surge.Reference Rodriguez34

The major insight of syndemic theory is not simply that the world and the risks we face within it are complex. Rather, it invites our consideration of an undeniable truth: that although nothing (including substance use and abortion services) can ever be entirely risk free, we as a society continually conspire — through policy, practice, structure, and values — to make the world a more hazardous place for those among us who already have the most to bear.

Third, many PWUD must cross state lines in order to access evidence-based care for an SUD.Reference Rosenblum35 Imagine a visibly pregnant person needing to drive regularly across the border into a neighboring state to obtain methadone or buprenorphine — both gold-standard treatments for opioid use disorder in pregnancy,36 and reside in a state where abortions are, in some cases, illegal. Many instances have been documented in which a pregnant person has been deprived of personal liberties and even criminally charged for taking action to end their own pregnancies.37 Thus, a pregnant person crossing state lines might be accused of seeking abortion services, with their traveling habits constituting probable cause for the arrest. They could be taken into custody at a local jail, interrupting their substance use treatment and dramatically increasing the risk of overdose upon release.Reference Ranapurwala38 Moreover, the American Society of Addiction Medicine’s 2020 Practice Guidelines recommend universal pregnancy screening for all who are able to become pregnant at the time of diagnosis for opioid use disorder.39 Such universal screening may create an evidentiary trail. In 2017, a Mississippi woman was indicted for second degree murder after seeking medical treatment for complications following the loss of a pregnancy,40 and her medical records (including statements she made to nurses while receiving medical care) were shared with prosecutors without her permission and used to make a case against her.41

Fourth, due to a combination of the biophysical effects of some substances and other social determinants, PWUD are, on average, more likely to find out that they are pregnant later in a pregnancy — sometimes as late as the second trimester, or from 13-26 weeks.Reference McCarthy42 Second-trimester abortion is more invasive with rare but serious medical complications.Reference Grossman43 Additionally, abortion care after the first trimester is far less available and requires greater travel, greater expense, and often multi-day appointments.Reference Kapp44 Today, PWUD may learn they are pregnant at a stage of pregnancy when safe, high-quality abortion care will require even greater efforts to obtain, or when an abortion is expressly criminalized.Reference Jones and Jerman45 This exposes pregnant PWUD to serious legal risks, health risks, and logistical challenges to overcoming both, relative to the general population.46 Travelling for second trimester abortion care may also cause them more difficulty in accessing effective substance use treatment and reduce their access to a safe and predictable drug supply.47 We posit this increases the risk for overdose.

A Syndemic Hypothesis and Pathways for Future Research

We strongly advocate for a syndemic analysis of the harms of criminalized substance use, surveilled pregnancy, and criminalized abortion in a post-Dobbs landscape. In other words, we posit that social-biological-biological interactions between these elements are present and discoverable. For example, a syndemic analysis might consider that a pregnant PWUD: (1) is more likely to discover their pregnancy later, more often in the second trimester, due to biophysical effects of substance use (biological-biological interaction);Reference Carroll48 (2) may have more trouble accessing or be forced to travel farther to access abortion care due to abortion restrictions in their home state (social-biological interaction); (3) may be more susceptible to overdose due to many factors, including barriers to effective substance use treatment due to pregnancy and exposure to unsafe or unfamiliar drug supplies caused by travel for abortion care (social-biological interaction); and (4) may be at risk of more severe general and obstetric health outcomes should they experience an opioid overdose while pregnant (biological-biological interaction).49 These interactions fully meet the criteria for syndemic pathways of interaction and are worthy of systematic research to assess their validity as such.

Similarly, if, as we anticipate, some pregnant PWUD hesitate to cross state lines to access their closest source of SUD treatment for fear of law enforcement scrutiny, another potential syndemic interaction emerges. In brief, a pregnant PWUD: (1) may be deterred from seeking evidence-based medication treatment for SUD across state lines by criminal abortion restrictions in some states (social-biological interaction); (2) may be most deterred from seeking perinatal care, risking worse pregnancy outcomes, by regimes that punish SUD during pregnancy or abortion (social-biological interaction); and (3) may experience even higher overdose risks from these above concernsReference O’Donnell and Jackson50 as stricter abortion bans mediate this biological-biological (pregnancy-substance use) interaction.Reference Jarlenski51 These interactions, if observed in the real world, would also meet the criteria for syndemic pathways of interaction.

Both of these hypothetical systems of interaction are important avenues of inquiry for understanding how biological-biological interactions produced by a structural environment heighten risks for negative health sequelae in pregnant and parenting PWUD.

Conclusion

Punitive responses that place criminal or civil liability on persons who have made a choice to use drugs and/or seek an abortion constitute direct attacks on personal liberty and bodily autonomy. We propose a syndemic framework for investigating the complex network of social and biological interactions that constitute the unique risk environments experienced by pregnant PWUD. This framework not only offers the benefit of wrestling theoretical order from a veritable Gordian knot of causal and mediating relationships, but it also highlights potential targets of structural or institutional intervention to make meaningful impacts on the attributable risks of these scenarios. The major insight of syndemic theory is not simply that the world and the risks we face within it are complex. Rather, it invites our consideration of an undeniable truth: that although nothing (including substance use and abortion services) can ever be entirely risk free, we as a society continually conspire — through policy, practice, structure, and values — to make the world a more hazardous place for those among us who already have the most to bear.

Note

The authors have no conflicts of interest to disclose.

References

Carroll, J.J. et al., “The Harms of Punishing Substance Use During Pregnancy,” International Journal of Drug Policy 98, no. 103433 (2021): 1–6, at 1–2, 4.CrossRefGoogle ScholarPubMed
Bulled, N. et al., “Syndemics and Intersectionality: A Response Commentary,” Social Science & Medicine 295, no. 114743 (2022): 1–3, at 1.CrossRefGoogle Scholar
Singer, M. and Ziegler, J., “The Role of Drug User Stigmatization in the Making of Drug-Related Syndemics,” in Foundations of Biosocial Health Stigma and Illness Interactions, eds. Lerman, S., Ostrach, B. and Singer, M. (Lexington Books, 2017): at 1–24.Google Scholar
4. C.L. Everson and B. Ostrach, “Pathologized Pregnancies & Deleterious Birth Outcomes: Iatrogenic Effects of Teen Pregnancy Stigma,” in Stigma Syndemics: New Directions in Biosocial Health, eds. B. Ostrach et al. (Lexington Books, 2017): at 61-94 B.Google Scholar
Singer, M. et al., “Syndemics and the Biosocial Conception of Health,” Lancet 389, no. 10072 (2017): 941–950, at 942.CrossRefGoogle ScholarPubMed
See Carroll, supra note 2, at 2-4.Google Scholar
National Advocates Pregnant Women, “Arrests and Other Deprivations of Liberty of Pregnant Women,” available at <https://shorturl.at/eouw7> (last visited August 17, 2023).+(last+visited+August+17,+2023).>Google Scholar
Martin, N., “Take a Valium, Lose Your Kid, Go to Jail,” ProPublica, Sept. 23, 2015.Google Scholar
Human Rights Watch, “U.S.: Family Separation Harming Children, Families 5-Year-Olds Held Without Adult Caregivers,” available at <https://shorturl.at/iyzPT> (Last visited August 17, 2023); J. Bouza et al., “The Science is Clear: Separating Families has Long-term Damaging Psychological and Health Consequences for Children, Families, and Communities,” Society for Research in Child Development (2018): 1-7, at 3.+(Last+visited+August+17,+2023);+J.+Bouza+et+al.,+“The+Science+is+Clear:+Separating+Families+has+Long-term+Damaging+Psychological+and+Health+Consequences+for+Children,+Families,+and+Communities,”+Society+for+Research+in+Child+Development+(2018):+1-7,+at+3.>Google Scholar
Meinhofer, A. et al., “Parental Drug Use and Racial and Ethnic Disproportionality in the U.S. Foster Care System,” Children Youth Services Research 118, no. 105336 (2020): 1–4, at 2, 4; S.C.M. Roberts and A. Nuru-Jeter, “Universal Screening for Alcohol and Drug Use and Racial Disparities in Child Protective Services Reporting,” Journal for Behavioral Health Services Research 39, no. 1 (2012): 3-16, at 12.Google ScholarPubMed
Atkins, D.N. and Durrance, C.P., “State Policies That Treat Prenatal Substance Use as Child Abuse or Neglect Fail to Achieve Their Intended Goals,” Health Affairs 39, no. 5 (2020): 756–763, at 758.CrossRefGoogle ScholarPubMed
Faherty, L.J., “Association Between Punitive Policies and Neonatal Abstinence Syndrome Among Medicaid-Insured Infants in Complex Policy Environments,” Addiction 117, no. 1 (2022): 162–171, at 163-164.CrossRefGoogle ScholarPubMed
See Carroll, supra note 2, at 2-4.Google Scholar
Patrick, S.W. et al., “Barriers to Accessing Treatment for Pregnant Women with Opioid Use Disorder in Appalachian States,” Substance Abuse 40, no. 3 (2019): 356–362, at 357-359.CrossRefGoogle ScholarPubMed
Lensch, A.C. et al., “Pregnant Patients Using Opioids: Treatment Access Barriers in the Age of COVID-19,” Journal of Addiction Medicine 16, no. 1 (2022): e44-e47, at e45e–46.CrossRefGoogle ScholarPubMed
Ostrach, B.M. and Leiner, C.B., “‘I didn’t want to be on Suboxone at first…’” — Ambivalence in Perinatal Substance Use Treatment,” Journal of Addiction Medicine 13, no. 4 (2019): 264–271, at 269.CrossRefGoogle ScholarPubMed
Frazer, Z. et al., “Treatment for Substance Use Disorders in Pregnant Women: Motivators and Barriers,” Drug Alcohol Dependence 205, no. 107652 (2019): 1–6, at 3.CrossRefGoogle ScholarPubMed
See Earp, supra note 1, at 4-5.Google Scholar
See Rosenthal, supra note 1, at 368-369.Google Scholar
Tyndall, M. and Dodd, Z., “How Structural Violence, Prohibition, and Stigma Have Paralyzed North American Responses to Opioid Overdose,” AMA Journal of Ethics 22, no. 8 (2020): E723–E728, at E725.Google ScholarPubMed
Radi, B., “Reproductive Injustice, Trans Rights, and Eugenics,” Sexual Reproductive Health Matters 28, no. 1 (2020): 396-407, at 396-97.CrossRefGoogle ScholarPubMed
Artiga, S. et al., Racial Disparities in Maternal and Infant Health: An Overview, available at <https://shorturl.at/gnQY8> (last visited August 17, 2023).+(last+visited+August+17,+2023).>Google Scholar
Cohen, S.A., “Abortion and Women of Color: The Bigger Picture,” Guttmacher Policy Review 11, no. 3 (2008): 2–12, at 2.Google Scholar
Drug Pol’y All., The Drug War, Mass Incarceration and Race, available at <https://shorturl.at/nuA48> (last visited August 17, 2023).+(last+visited+August+17,+2023).>Google Scholar
El-Sabawi, T. and Oliva, J., “The Influence of White Exceptionalism on Drug War Discourse,” Temple Law Review 94 no. 4 (2022): 649–661, at 650.Google Scholar
Singer, M., “A Dose of Drugs, A Touch of Violence, A Case of Aids: Conceptualizing the Sava Syndemic,” Hispanic Health Council 24, no. 2 (1996): 99–110, at 99.Google Scholar
Castro, K.G., “ Tuberculosis as an Opportunistic Disease in Persons Infected with Human Immunodeficiency Virus,” Clinical Infectious Diseases 21, no. 1 (1995): S66–S71, at s67.CrossRefGoogle ScholarPubMed
Corbett, E.L. et al., “The Growing Burden of Tuberculosis Global Trends and Interactions with the HIV Epidemic,” Archives Internal Medicine 163, no. 9 (2003): 1009–21, at 1009.CrossRefGoogle ScholarPubMed
Singer, M. et al., “Whither Syndemics? Trends in Syndemics Research, A Review 2015-2019,” Global Public Health 15, no. 7 (2020): 943–955, at 943.CrossRefGoogle ScholarPubMed
Angelotta, C., “A Moral or Medical Problem? The Relationship between Legal Penalties and Treatment Practices for Opioid Use Disorders in Pregnant Women,” Womens Health Issues 26, no. 6 (2016): 595–601, at 597, 599-600.CrossRefGoogle ScholarPubMed
Lawn, R.B., “Homicide is a Leading Cause of Death for Pregnant Women in US,” British Medical Journal 379, no. 2499 (2022): 1–2, at 2.Google ScholarPubMed
Roberts, S.C.M. et al., “Risk of Violence from the Man Involved in the Pregnancy After Receiving or Being Denied an Abortion,” BMC Medicine 12, no. 144 (2014): 1–7, at 6.CrossRefGoogle ScholarPubMed
Tobin-Tyler, E., “A Grim New Reality: Intimate Partner Violence After Dobbs and Bruen,” New England Journal of Medicine 387, no. 14 (2022): 1247–1249.CrossRefGoogle ScholarPubMed
Rodriguez, M. et al., “Intimate Partner Violence and Barriers to Mental Health Care for Ethnically Diverse Populations of Women,” Trauma Violence Abuse 10, no. 4 (2009): 358–374, at 359.CrossRefGoogle ScholarPubMed
Rosenblum, A. et al., “Distance Traveled and Cross-State Commuting to Opioid Treatment Programs in the U.S.,” Journal of Environmental Public Health 2011, no. 948789 (2011): 1–10, at 6-9.CrossRefGoogle Scholar
Committee on Obstetric Practice, American Society Addiction Med., Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy, Obstetrics Gynecology 130, no. 2 (2017): e81-e94, at e87.CrossRefGoogle Scholar
See National Advocates, supra note 10; see also L. Paltrow, “The Dangerous State Laws that are Punishing Pregnant People,” Think Progress, Sept. 28, 2016, available at <https://shorturl.at/nuR57> (Last visited August 17, 2023).+(Last+visited+August+17,+2023).>Google Scholar
Ranapurwala, S.I. et al., “Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015,” American Journal of Public Health 108, no. 9 (2018): 1207–1213, at 1209-12.CrossRefGoogle ScholarPubMed
American Society of Addiction Medicine, National Practice Guideline 2020 Focused Update, available at <https://shorturl.at/kuw05> (Last visited August 17, 2023).+(Last+visited+August+17,+2023).>Google Scholar
B. Ortutay, EXPLAINER: Data Privacy Concerns Emerge After Roe Decision, Associated Press, June 29, 2022.Google Scholar
Id. Google Scholar
McCarthy, M., “Predictors of Timing of Pregnancy Discovery,” Contraception 97, no. 4 (2018): 303–308, at 305-306.CrossRefGoogle ScholarPubMed
Grossman, D. et al., “Complications After Second Trimester Surgical and Medical Abortion,” Reproductive Health Matters 16, no. 31 Supplement (2008): 173–182, at 173.CrossRefGoogle ScholarPubMed
Kapp, N., “Medical Abortion in The Late First Trimester: A Systematic Review,” Contraception 99, no. 2 (2019): 77–86, at 77.CrossRefGoogle ScholarPubMed
Jones, R.K. and Jerman, J., “Abortion Incidence and Service Availability In the United States, 2014,” Perspectives Sexual Reproductive Health 49, no. 1 (2017): 17-27, at 24-25; U.D. Upadhyay et al., “Denial of Abortion Because of Provider Gestational Age Limits in the United States,” American Journal of Public Health 112, no. 9 (2022): 1687-1694, at 1687.CrossRefGoogle Scholar
See Everson and Ostrach, supra note 8, at 1-34.Google Scholar
Id. Google Scholar
Carroll, J.J., “The Protective Effect of Trusted Dealers Against Opioid Overdose in the U.S.,” International Journal of Drug Policy 78, no. 102695 (2020): 1–9, at 7-8.CrossRefGoogle ScholarPubMed
See McCarthy, supra note 42, at 2.Google Scholar
O’Donnell, F.T. and Jackson, D.L., “Opioid Use Disorder and Pregnancy,” Modern Medicine 114, no. 3 (2017): 181–186, at 183.Google ScholarPubMed
Jarlenski, M. et al., “Association of Duration of Methadone or Buprenorphine Use During Pregnancy With Risk of Nonfatal Drug Overdose Among Pregnant Persons With Opioid Use Disorder in the US,” Journal of American Medical Association 5, no. 4 (2022): 1–4, at 2-3.Google ScholarPubMed