Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting

Abstract

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply.

Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence.

Results. Participants’ substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants.

Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women’s overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent–child relationships. (Am J Public Health. 2022;112(S2):S191–S198. https://doi.org/10.2105/AJPH.2022.306776)

The epidemic of overdose deaths driven by fentanyl- and fentanyl analog‒adulterated drugs in the United States and Canada represents a pressing public health concern.^1,2 While overdose mortality rates are significantly higher among men than women in both countries, overdoses among women in the United States (aged 30–64 years) have increased at higher rates than among men, and are disproportionately high for Indigenous women in British Columbia (BC), Canada.^3–5 Despite making up approximately 3.3% of BC’s population, Indigenous Peoples accounted for 12% of overdose deaths in 2018 and 16% in early 2020,^4,5 with Indigenous women 8.7 times more likely to have a fatal overdose than non-Indigenous women.⁵ The toxic drug supply in BC is the leading cause of unnatural deaths, with unprecedented numbers of drug poisonings.² In response, a range of overdose prevention interventions have been implemented, including peer-led, low-barrier supervised consumption sites (SCS), buprenorphine and naloxone (Suboxone; BC’s first-line treatment of opioid use disorder), and the expansion of access to opioid-agonist medications.^6,7 However, women’s, especially Indigenous women’s, and gender-diverse persons’ (e.g., nonbinary, transgender, Two-Spirit) needs are underserved by harm-reduction services.^8–11

Women (inclusive of gender-diverse persons) who use drugs are disproportionately affected by social violence, which shapes health, overdose risk, and access to and uptake of overdose prevention interventions.^10–14 They are subject to gendered patterns of interpersonal violence (e.g., intimate partner violence)¹⁵ and state violence (e.g., punitive sex-work and drug laws, regulation of reproduction and mothering)^13,16,17 compounded by intersecting systems of oppression (e.g., White supremacy, capitalism). In Canada, colonialism begat systemic social and legal discrimination resulting in the forced removal of Indigenous children from their homes (residential schools, child apprehension) and an alarming epidemic of racialized, gendered violence (including homicide) among Indigenous women and girls.^18–22 Despite evidence that structural factors intersect with social context and individual circumstances to shape drug use, research is limited as to how those factors operate to compound overdose risk among cisgender women and gender-diverse persons who are parents.

Concepts of social violence operating across the structural, interpersonal, and internal levels are useful in examining overdose risk and drug use among mothers (including, hereafter, gender-diverse parents who have given birth). Structural violence refers to how social structures and institutions (e.g., drug criminalization, child protection services [CPS]) sustain, perpetuate, and normalize inequalities and resulting harms.²³ Internalization of social‒structural subordination because of its ubiquity and resulting self-blame is understood as symbolic violence.²⁴ Structural and symbolic violence frame the “everyday” interpersonal violence and normalized social violence while rendering it invisible.²⁵ Analyses applying this lens have highlighted how gender-specific macrocontexts (e.g., social dynamics of gendered violence) have an impact on microcontexts (e.g., injection practices) in women’s health outcomes (e.g., overdose).^19,26

The systematic surveillance and regulation of mothers, particularly those who are poor, racialized, and gender diverse, is heightened for those who use criminalized drugs.^{13,16,27–29} Stigmatizing discourses construct them as “irresponsible” and “unfit” parents and serve to justify and uphold diverse forms of social control,^27,29–31 including punitive drug policies (e.g., child protection and apprehension) that deter mothers who use drugs from accessing health and social services because of risk of disciplinary actions that can include involuntary drug testing, forced drug treatment, incarceration, forced sterilization, and involvement of CPS.^{8,14,16,27,32,33} CPS disproportionately affect families marginalized by structural violence, criminalization, poverty, and systemic racism.^30–34 In Canada, social services overregulate and surveil Indigenous, Black, and poor mothers, leading to gross overrepresentation of their children in care.^{21,27,35–37}

Fear of custody loss, stigma, and limitations to child-accommodating services can inhibit mothers’ use of overdose interventions, treatment, and harm-reduction services,^8,9,14,31 yet scholarship on the socio‒structural contexts contributing to mothers’ overdose risk is limited. Custody loss has a profound effect on health outcomes, including heightened drug use and overdose,^{10,22,38–41} warranting further investigation. In this study, we drew on findings from qualitative interviews of women accessing SCS in Greater Vancouver, BC, one of the epicenters of Canada’s overdose epidemic, to examine the experiences of mothers who use criminalized drugs, including perceived gaps in harm-eduction responses, amid intersecting epidemics of violence and overdose.

METHODS

We drew on semistructured interviews with 40 mothers who used criminalized drugs (opioids and stimulants) undertaken between May 2017 and September 2019 as part of a larger study on the implementation of 2 women-only low-barrier SCS (inclusive of gender-diverse persons; 77 total participants).^9,42 These official sites allow people to consume preobtained drugs, without arrest for drug possession, under the supervision of overdose responders (including people with lived and living experience of drug use).⁶ Women were recruited directly from SCS by research team members, including peer researchers (team members who lived in the neighborhood, had lived experience of criminalized drug use, and were trained in research), and by referral from SCS (peer) staff. Interviews were conducted onsite or at a nearby field office.

Developed in consultation with a community advisory board of women with living experience of criminalized drug use, interview guides sought to examine experiences of criminalized drug use amid a fentanyl-driven overdose epidemic. Though participants were asked if they had children, parenting experiences were not the focus of the interview guide. Rather, the subject emerged through open-ended questions on social violence, caretaking responsibilities, and interactions with institutional services and systems. Participants received CA $30 honoraria. Interviews averaged 45 to 60 minutes, and were audio-recorded and transcribed verbatim with identifying information removed and pseudonyms assigned.

Data were imported into NVivo and coded thematically deductively (codes from interview guide) and inductively (codes developed through team discussions after reviewing transcripts).⁴³ Transcripts were coded by multiple team members with discrepancies resolved by consensus. Data pertaining to mothers’ experiences were further analyzed via these methods by the research team and in consultation with community advisory board members who had children to further refine themes.⁴³ Emergent themes were analyzed with attention to intersecting systems of oppression⁴⁴ and informed by theories of social violence.^23–26 Data generation and analysis were further enriched by researcher familiarity with the setting, including several years of community-engaged research.^9,12,45

RESULTS

Participants’ drug use and overdose risks were shaped by the loss (or feared loss) of child custody and barriers to reunification. No participants were living with their children at the time of the interview. All reported daily use of criminalized drugs and severe socioeconomic marginalization (Table 1). Thirty-one participants had experienced homelessness in the previous year, 21 had been in foster care, and 30 had previously been incarcerated. Fifteen participants reported experiencing at least 1 overdose in the year before the interview. Analysis identified 3 primary themes: (1) mother–child separation resulting from gender-based interpersonal and institutional violence, (2) child separation as a risk factor for overdose, and (3) contesting discourses and stigmatization of mothers who use drugs.

TABLE 1—

Characteristics of Mothers Recruited From Two Low-Barrier Women-Only Supervised Drug Consumption Sites: Greater Vancouver, Canada, 2017‒2019

Participant Characteristics (Mothers)	Total (n = 40), No. (%) or Median (Range)	Women-Only SCS 1 (n = 19/45), No. (%) or Median (Range)	Women-Only SCS 2 (n = 21/32), No. (%) or Median (Range)
Age, y	40.5 (22–55)	37 (26–52)	43 (22–55)
Race/ethnicitya
White	20 (50.0)	10 (52.6)	10 (47.6)
Indigenous	20 (50.0)	9 (47.4)	11 (52.4)
Gender identity
Woman	39 (97.5)	18 (94.7)	21 (100.0)
Transgender	1 (2.5)	1 (5.3)	0 (0.0)
Housing
Yes	13 (32.5)	6 (31.6)	7 (33.3)
No	27 (67.5)	13 (68.4)	14 (66.7)
Homeless in year before interview
Yes	31 (77.5)	14 (73.7)	17 (81.0)
No	8 (20.0)	4 (21.1)	4 (19.0)
NA	1 (2.5)	1 (5.3)	0 (0.0)
Overdose in year before interview
1	6 (15.0)	3 (15.8)	3 (14.3)
2	2 (5.0)	2 (10.5)	0 (0.0)
≥ 3	7 (17.5)	2 (10.5)	5 (23.8)
No	25 (62.5)	12 (63.2)	13 (61.9)
History in foster care
Yes	21 (52.5)	11 (57.9)	10 (47.6)
No	16 (40.0)	5 (26.3)	11 (52.4)
NA	3 (7.5)	3 (15.8)	0 (0.0)
History of incarceration (jail or holding)
Yes	30 (75.0)	13 (68.4)	17 (81.0)
No	10 (25.0)	6 (31.6)	4 (19.0)

Note. NA = not available; SCS = supervised consumption site.

^aSome participants identified as more than 1 race/ethnicity (i.e., Indigenous and White). However, having 1 Indigenous category is to reflect that Canada’s colonial policies homogenize Indigenous women, regardless of their heterogeneity, particularly in relation to the high number of child apprehensions and overdose-related deaths.

Mother–Child Separation and Gender-Based Violence

Everyday gendered violence

Escaping gendered, everyday violence occurring within intimate partnerships was cited as a significant factor driving participants to flee their homes, resulting in separation from their children. “Marisol,” a 30-year-old Indigenous woman, described having to leave her children: “I got raped, that’s why I left home.” Another participant described leaving their children because of spousal violence:

I had to leave him because it was just like too crazy of a relationship and too abusive and I finally left that like six years of abuse and I came up this way and he ended up raising our daughter by himself. (“Demi”: age 52 years, Indigenous)

“Catherine” described mothers as especially vulnerable to gendered and racialized violence, noting that lack of overdose prevention supports that address violence can lead to criminalization and overdose:

There is not enough support for women [with children] who have experienced violence or are, or just had a bad date, to be able to talk about some of the things that they went through or going [through] in violent relationships; there is not enough spaces to deal with those kinds of situations and so many women fall through the cracks and end up overdosing or just don’t give a shit and they go to jail. (age 55 years, Indigenous)

Structural gendered violence

Institutional mother‒child separation was routine among participants and experienced as structural violence (e.g., institutionalized discrimination and stigma against mothers who use drugs). Participants often described the Ministry of Child and Family Development (MCFD), BC’s CPS, as being in the “business of taking children”—something that loomed over their interactions with support systems subject to reporting requirements around child welfare. “Serena” relayed how being surveilled by welfare resulted in the forced removal of her children:

When I first had my baby, because I am a junkie and a drug addict, of course they got fucking welfare and all that shit on you right, because a lot of times they just come in and snatched the baby out of your fucking arms and don’t say hi, bye, boo, fuck you. I had been up all night because they both had fucking runny noses and were crying, fucking, you know, no sleep I had, and they’re fucking judging me and stuff. (age 55 years, White)

“Paige” described the pain she and her Indigenous children (aged 5 and 8) felt because of forced separation by CPS. She attributed her drug use to the agony of separation from her children and positioned child apprehension as an extension of the forcible removal of Indigenous children for residential schooling:

The system should . . . go to great lengths, to keep the children and the parents together . . . The only reason I’m even using heroin is because it became so stressful that it was unbearable. I wanted to kill myself, I was in so much pain . . . There wasn’t a second during the day when I didn’t feel completely fucking overwhelmed with grief . . . And my children still feel like that, and so do I. Thank god for heroin . . . It’s worse than residential school. They just changed the name. Residential school to adoption and foster care. (age 34 years, White)

Participants noted that, with few supports, drug use provided a way of dealing with the pain and grief of child loss.

(Fear of) Child Separation and Overdose Risk

Numerous participants described an increase in overdose risk (e.g., injecting alone to hide drug use) following mother–child separation or in response to the stress associated with custody-related drug-use surveillance, which included increased drug use in a setting characterized by an increasingly toxic drug supply. When asked when her drug use began, “Lauren” explained, “When I lost my kids.” Many participants reported significant increases in drug use after separation from children as a means to cope with their grief, while simultaneously navigating expectations to abstain to regain custody:

They expect people to be sober and healthy in order to see their kids [after apprehension], but how are they supposed to be sober and healthy without their kids? (“Simone”: age 32 years, White)

The predicament resulted in what one participant, “Lori,” described as a “Catch-22.” Similarly, “Maya” described wanting to “numb” herself to deal with the loss, guilt, and shame of having her children taken, yet hiding her use because of expectations of sobriety:

Like, because I don’t have my kids with me and you know if I’m being a sober woman taking care of her kids and then [they] get taken away from you, it’s out of your control and um, I intend to hide and just shame, guilt, and I just want to numb myself but at the same time it’s not making any changes, right. (age 31 years, Indigenous)

To minimize risk of child apprehension, some participants reported having a “responsible” adult care for their children when they consumed drugs but would often then consume drugs alone, which placed them at an increased risk of overdose and other drug-related harms:

No, they [my children] were always with me. They were never ever taken. I was kind of the closet case mother. I hid it [drug use]. I tried to. I tried to hide from myself mainly I guess. (“Abby”: age 52 years, Indigenous)

Other participants described mechanisms of surveillance associated with the social control of mothers who use drugs as driving increased drug use and potential overdose risk. “Doro,” a 33-year-old White woman, attributed her overdose to significantly increasing her drug use to deal with stress after being subjected to hair drug testing by MCFD, with results used to deny custody of her daughter.

“Sam,” a 32-year-old Indigenous woman, noted that she was in the process of “fighting [her] ex for custody” of their 3-year-old daughter that she had raised alone until recently, and had a court date looming. “He won’t let me see my daughter, so . . . I’ve had this problem with street drugs for about a year now. And I’ve been drug testing for them [MCFD] for about a year and just stupid.” She described routinely being subjected to drug tests by authorities and maintained she was trying to “get back on Suboxone” to pass the tests. “Sam” attributed surveillance by staff at her single-room occupancy hotel as exacerbating her drug use and chances for custody:

I shouldn’t have moved there . . . . So many children have got apprehended in this building . . . . There’s staff there 24/7 and they write down everything you do and . . . yeah, so many children got apprehended there and I think I was the only person that got . . . that actually got their kid back.

Structural violence framed the everyday surveillance practices across the settings occupied by participants.

Contesting Stigmatization and Dominant Discourses

Several participants resisted abstinence-based frameworks that contribute to the social control of motherhood through their refusal to accept and internalize these discourses (e.g., that drug use is inherently harmful). They challenged their stigmatization and the related symbolic violence. “Elyta,” emphasizing autonomy, rejected opioid-agonist treatment:

Let’s be realistic, I am not going on [Suboxone]. Yeah, that stupid one. I’m not a quitter. I’m not quitting drugs because you know what, I’ve already brought up my son. I’m going to be selfish for once and I’m sorry but I always think of everyone else and I’m not harming myself. I’m going to the right places and it’s my life. If I can get a job and I can maintain, these girls are doing it, I can too. So it’s my life. (age 42 years, Indigenous)

Similarly, “Paige,” whose children were removed by MFCD, explained that drug use is not, as it is commonly understood, universally problematic. She instead described her use as a means to temper social suffering:

I use it in a healthy way. People are using it to maintain. People use it for relief because when we wake up in the morning we don’t feel normal like other people. We have so much pain and sadness and grief during the day that we’re suffering so immensely that people wake up and do drugs in order to feel normal . . . . Thank god for drugs. (age 34 years, White)

Many participants described their drug use as mitigating social suffering, including the impact of child apprehension. “Rose” felt that mothers would be discouraged from accessing even a women-only SCS for fear of being reported to CPS:

But if the community wasn’t so stigmatized, and if their kids were getting taken care of while you go and use, like in daycare or something, but it’s . . . I don’t know. If they have it under control. It’s like smoking a doobie [cannabis, legalized in Canada] once in a while or having a beer. It’s like going to the bar and doing your thing and leave the bar and go home and you’re back to dealing with your family life. But there’s so much stigma. (age 35 years, Indigenous)

She indicates a need for alternative approaches to regulating parenting and drug use that are more akin to legalized drugs.

DISCUSSION

Building on limited research on social‒structural contexts of mothers’ overdose risk,^10,22,41 we documented social violence as a contributing factor. Participants described their lives as negatively impacted by gendered violence, punitive policies, and intersecting regulation and surveillance. The structural violence of gendered drug laws that shaped health, child protection, and social and housing-based policies and services framed their experiences. For many participants, the stigma of being perceived as a “bad” mother, along with the institutional and social pressures around drug abstinence in hope of regaining custody or visitation, compounded the grief of child removal. Stigma and fear of institutional and partner scrutiny compelled participants to consume drugs alone to avoid detection, or to increase drug use in response to the trauma of parent‒child separation (child removal, fleeing violence)—increasing overdose risk in the context of a toxic drug supply. Institutional practices oriented toward drug abstinence (e.g., surveillance) thus produced paradoxical impacts with potential for severe health-related harm.

The intersection and experiences of drug use, overdose risk, and custody loss cannot be divorced from the ongoing effects of colonialism and systemic racism, which permeate Canada’s criminal justice, health, and social services, for which Indigenous women bear a disproportionate burden.^{21,22,39,46,47} Structural and everyday violence (including intimate partner violence)^19,26 poses obstacles for mothers, including some of our study participants, attempting to escape domestic violence with their children. Criminalization, surveillance, and stigma,^{13,16,27–32} alongside a dearth of apprehension-free integrated harm-reduction and domestic violence services,⁴⁸ can result in grave health outcomes and custody loss. Forced child separation disproportionately affects mothers marginalized by criminalization, poverty, and racism.^27–32 Participants in our study, all of whom were poor and half of whom were Indigenous, similarly noted the negative impacts of surveillance systems (e.g., drug testing, housing-based surveillance). Fear of child removal and profound stigma among mothers who use criminalized drugs can deter parents from accessing health and social services.^{8,14,29,31,33,39}

Research has highlighted the “Catch-22” identified by our participants. Custody loss precipitated heightened structural vulnerability, including poverty and increased drug use. This, in turn, decreased the prospect of regaining custody and had negative health implications, including feelings of hopelessness and increased overdose risk.^10,30,38,39 The profound social suffering²⁵ resulting from custody loss is well documented^27,30,39 and continues to be cast as self-orchestrated.²⁶ Obscured is the sustained institutional and state-orchestrated violence,²³ including that of CPS, which has been critiqued for failing to account for social‒structural forces impacting parents’ lives.^{30–32,34,39}

This study has limitations. The data are not reflective of the experiences of women who did not feel safe disclosing personal information or accessing the SCS. Further research is needed that directly addresses the unique barriers diverse mothers experience in addressing overdose-related risks and harms. Nevertheless, our findings have implications for overdose prevention. Using drugs alone is a significant barrier to timely overdose responses,⁴⁹ and, yet, the majority of overdose deaths in BC occur under these circumstances.⁵⁰ Previous research in Vancouver has found a high burden of accidental nonfatal overdose among marginalized women, particularly Indigenous, who have experienced child removal, indicating an unmet need for unique overdose prevention responses for this vulnerable population.²²

Our study adds to this work by detailing how the confluence of structural violence of institutional policies and practices and everyday gendered violence produce these drug-use dynamics—intersections that have received scant attention. In Canada, drug use alone is not a specific cause for child apprehension; however, it continues to influence child protection outcomes,^21,22,27 and it is unclear how mandated reporting would play out in SCS. There exist significant barriers to accessing support and services while punitive state surveillance continues. Our findings indicate that fear of surveillance can be a deterrent to accessing SCS (and likely drug services more broadly) and an incentive for using drugs alone, even before child apprehension.

While some participants described hiding their drug use, others challenged abstinence-based expectations⁵¹ and instead emphasized minimization of harm from drug use through a range of strategies (e.g., leaving children with a relative when consuming drugs). Given that women are disproportionately and negatively affected by the criminalization of drug use, broader policies focused on support rather than punishment, including access to safe, nontoxic drug supplies⁵² and legalization of drugs, are critical first steps.

Public Health Implications

Needed, yet scarce, are community-based mother-focused strategies as alternatives to parent‒child separation, including apprehension-free integrated services⁴⁰ that are culturally informed, gender-inclusive, and child-friendly, including women- and gender diverse‒specific, (Indigenous) peer-led programs. Even with the above actions, as long as drug use is inaccurately conflated with child abuse and neglect, mothers will continue to be negatively impacted as subjects of regulatory scrutiny. Without extensive overhaul of criminal justice, medical, and child welfare systems, mothers will continue to be at risk for custody loss, and efforts to reduce fatal overdose among these marginalized populations will remain constrained.

Mothers who use drugs navigate a complex matrix of institutional and social control that exacerbates gaps in overdose response. Heightened surveillance, regulation, and discrimination intersect to create barriers to accessing harm-reduction and overdose-prevention interventions. Prevailing discourses framing mothers who use drugs as unfit parents have a negative impact on their lives and exacerbate drug-related harms. There is a need to reimagine CPS and mothers who use drugs. While the BC and federal governments recently passed legislation to hand over child welfare services to Indigenous governments in response to systemic racism, implementation has been slow.⁵³ Noncriminalizing and decolonizing alternatives that better support community-based and peer-led initiatives to maintain and reinforce positive parent–child relationships are critical. Meanwhile, addressing social‒structural conditions (e.g., criminalization, systemic racism, poverty, misogyny) that drive health inequalities and increase overdose risk among this vulnerable population remains imperative.