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Published in final edited form as: J Subst Use Addict Treat. 2023 Apr 25;150:209052. doi: 10.1016/j.josat.2023.209052

Women with substance use disorders are highly impacted by the overturning of Roe v. Wade: Advocacy steps are urgently needed

Melissa N Slavin a,*, Brooke S West a, Frances R Levin b,c, Nabila El-Bassel a
PMCID: PMC10433178  NIHMSID: NIHMS1919376  PMID: 37105267

Abstract

The Supreme Court’s ruling to overturn the 1973 Roe v. Wade verdict represents a major setback for women’s reproductive freedoms in the United States. This ruling revokes constitutional protection for abortion rights and returns the decision to the states. Since this ruling in June 2022, numerous states have adopted total or near total abortion bans, with many of these bans offering no exception for rape, incest, or nonfatal maternal health risks. Legal experts also warn that this ruling can open the door to restrict contraceptive rights previously protected under the same implied constitutional right to privacy as abortion. Already, this decision has increased momentum for states to place restrictions on specific forms of contraception. Certain groups of women will be disproportionately harmed by these bans, such as women with substance use disorders (SUDs). Women with SUDs face unique barriers to sexual and reproductive health services that exist at the structural level (e.g., criminalization; costs and accessibility), interpersonal level (e.g., higher rates of intimate partner violence) and individual level (e.g., reduced reproductive autonomy). These synergistic barriers interact to produce lower contraceptive use, increased unintended pregnancy rates, and subsequently a greater need for abortion services among this population. This ruling will exacerbate the effects of these barriers on women with SUDs, resulting in even greater difficulties accessing contraceptive and abortion services, and ultimately increasing rates of criminalization among pregnant and parenting women with SUDs. This commentary describes these barriers and highlights potential advocacy steps that are urgently needed to assist reproductive-aged women with SUDs during these challenging times when essential health services are increasingly inaccessible.

Keywords: Sexual and reproductive health, Substance use disorders, Roe v. Wade

The Supreme Court’s ruling to overturn the 1973 Roe v. Wade verdict represents a major setback for women’s reproductive freedoms in the United States. This ruling revokes constitutional protection for abortion rights and returns the decision to the states. Since this ruling in June 2022, 13 states have adopted abortion bans, with many of these bans offering no exception for rape, incest, or nonfatal maternal health risks. An additional 10 states have severely restricted abortion access, with several of their state courts currently determining whether new bans can take effect (New York Times, 2022; Planned Parenthood, 2023). Furthermore, legal experts warn that this ruling can open the door to restrict contraceptive rights previously protected under the same implied constitutional right to privacy as abortion. Already, this ruling has increased momentum for states to place restrictions on specific forms of contraception. Access to sexual and reproductive health services (SRHs), including contraceptive and abortion services, allows women to decide whether, when, and with whom they would like to have children. These decisions have vital health, social, and economic benefits for women and their families (Johnston et al., 2022).

Certain groups of women will be disproportionately harmed by the overturning of Roe v. Wade, such as women with substance use disorders (SUDs). Women with SUDs face unique barriers to SRH services that exist at the structural level (e.g., criminalization; costs and accessibility), interpersonal level (e.g., higher rates of intimate partner violence) and individual level (e.g., reduced reproductive autonomy). These synergistic barriers interact to produce lower contraceptive use (Griffith et al., 2017; Terplan et al., 2015), increased unintended pregnancy rates (Heil et al., 2011), and subsequently a greater need for abortion services among this population. This ruling will exacerbate the effects of these barriers on women with SUDs, resulting in greater difficulties accessing contraceptive and abortion services, and ultimately increasing rates of criminalization and stigmatization among pregnant and parenting women with SUDs. This commentary describes these barriers and highlights potential advocacy steps that are urgently needed to assist reproductive-aged women with SUDs during these challenging times when essential health services are increasingly inaccessible.

Barriers to contraceptive access and utilization

Women with SUDs should have the same reproductive autonomy as women without SUDs to decide if and when they wish to become pregnant and raise a child, including the choice not to use contraception due to preferences to avoid hormonal or invasive birth control methods, feeling ambivalent about pregnancy, or other reasons (Dehlendorf et al., 2010; Johnston et al., 2022). However, women with SUDs who do wish to use contraception often face barriers to accessing and utilizing SRH services, including lack of transportation (e.g., losing one’s driver’s license due to alcohol or drug-related offenses or lacking reliable social networks who can provide rides; MacAfee et al., 2019). Many women with SUDs also lack insurance, or use Medicaid, which can be difficult to navigate (MacAfee et al., 2019). Furthermore, women with SUDs have reported avoidance of health care services due to fear of criminalization or health care providers’ stigmatization or coercion (Johnston et al., 2022). Women of color with SUDs face additional barriers of structural racism from health care systems that have been historically coercive (American College of Obstetricians and Gynecologists, 2017b; Harris & Wolfe, 2014). Additional barriers to services stem from higher risk of sexual violence and intimate partner violence (IPV) among women with SUDs, including reproductive coercion—behavior that interferes with a woman’s reproductive health, including birth control sabotage and/or pressure to carry a pregnancy to term or have an abortion (Crane et al., 2014; Maxwell et al., 2015; Pallatino et al., 2021). Collectively, these barriers, in combination with co-occurring mental health conditions and challenges related to alcohol and substance use, can lead to lowered contraceptive use among women with SUDs, including reduced reproductive autonomy, self-efficacy, and motivation to seek and maintain their SRH. Although overturning Roe v. Wade does not directly affect contraception, it has far-reaching implications in this area as it may further reduce women’s ability to access and use contraception and manage their sexual health, thereby deepening health inequities related to SUDs.

In the context of Roe v. Wade, we must ensure women with SUDs are provided the full array of contraceptive services specific to their needs while mitigating potential barriers. The World Health Organization (WHO) divides contraceptive methods into four tiers of effectiveness for preventing pregnancy (Terplan et al., 2015; World Health Organization Department of Reproductive Health and Research & Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs Knowledge for Health Project, 2018). The top tier includes “very effective” methods that do not require any additional effort of the user to maintain effectiveness. These methods include tubal ligation (sterilization) and long-acting reversible contraceptives (LARC), such as intrauterine devices (IUDs) and implants. As LARC are less likely than other forms of contraception to be detectable and thereby tampered with by others, the American College of Obstetricians and Gynecologists (ACOG) recommends SRH providers provide women experiencing reproductive coercion the option to use these forms of contraception (American College of Obstetricians and Gynecologists, 2013). Consistently, research has indicated that women who have experienced IPV may be more likely to use contraception that they can hide from their partners or that do not require negotiation with their partners (de Bocanegra et al., 2010; Maxwell et al., 2015). After the recent Supreme Court verdict, women with SUDs may experience exacerbated barriers to accessing these contraceptive methods, described below, which must be addressed. Nevertheless, providers need to take a patient-centered approach and should not overemphasize specific forms of contraception for women with SUDs (American College of Obstetricians and Gynecologists, 2019). For instance, although sterilization is a relatively straightforward surgical procedure and the most common method of contraception among married couples (American College of Obstetricians and Gynecologists, 2017b), it has an extremely problematic history in the United States, with many women with SUDs, women with low income, and women of color being involuntarily sterilized as part of state and federally funded programs (American College of Obstetricians and Gynecologists, 2017b; Harris & Wolfe, 2014; White, 2014). Additionally, targeted strategies to promote LARC as a first line contraception to women considered “high risk” is limiting to women’s reproductive freedoms (Gomez et al., 2014), and these methods should always be provided in the context of more comprehensive sexual and reproductive health counseling, which includes information and access to other methods (Sufrin et al., 2019).

The second tier of contraception includes “effective” methods of preventing pregnancy that require continued effort from the user to take or replace the contraception, including injections, oral contraceptive pills, vaginal rings, and transdermal patches. The third tier consists of “moderately effective” methods of contraception that require continued effort by the individual at or around the time of intercourse, including condoms, diaphragms, sponges, and fertility awareness methods. The fourth tier contains the “less effective” methods of spermicides and withdrawal. Last, emergency contraception can prevent pregnancy when taken up to 5 days following sexual intercourse if contraception was not used during sex or the contraception did not work (Gemzell-Danielsson et al., 2014). Emergency contraception is an important option for women who have experienced sexual violence, and is often legally required to be offered to sexual assault victims in hospital emergency rooms (Guttmacher Institute, 2022d). Regardless of unintended pregnancy risk, women with SUDs should receive education about all forms of contraception so that they can make their own decisions about which to use based on their own priorities and accurate information (e.g., effectiveness at reducing pregnancy risk; protection against sexually transmitted infections; forgettability; lack of user compliance; ability to discontinue without the assistance of a health care provider; effects on a menstrual cycle; detectability by a partner; and pregnancy ambivalence; Gomez et al., 2014).

Since the overturning of Roe v. Wade, several state bills have attempted to ban or restrict certain types of contraception, like IUDs and emergency contraception, which may alter the uterine lining, by inaccurately referring to “abortion services” as drugs and devices “used to prevent the implantation of a fertilized ovum.” This label of abortifacients is in contrast to the medical community—notably ACOG’s consensus that a pregnancy is not established until implantation is complete (Benson Gold, 2005). Due to the IUD’s higher cost compared to other birth control and its requirement to be inserted at a doctor’s office, women with SUDs may face substantial barriers to obtaining it, which may be amplified in states attempting to restrict comprehensive contraception services. Indeed, access to contraception was already under threat before this ruling, with twelve states allowing certain providers, including pharmacists, to deny services related to contraception (Guttmacher Institute, 2022c), and 20 states and the District of Columbia allowing certain employers and insurers to legally refuse to cover the cost of contraception in employee health insurance plans (Guttmacher Institute, 2022a). Studies also show that emergency contraception pills are not consistently stocked on store shelves as pharmacies are not required to carry them, and misinformation often exists regarding age and ID requirements among pharmacy staff and consumers (American Society for Emergency Contraception, 2018), which may be exacerbated under new legislation. Proposed contraceptive bans would place undue restrictions on women as they manage their contraception, with disproportionate impacts on women with SUDs. Even if such bans are not passed, the misinformation about IUDs and emergency contraception being propagated during legislative discussion is damaging and can increase stigma and reduce the provision of highly effective methods of birth control, leading to a range of health harms, including unintended pregnancies.

Barriers to abortion services

State abortion bans will also lead to increased costs and reduced availability of abortion services, which will profoundly impact women with SUDs. Most women do not become aware that they are pregnant before 6 weeks gestational age (American College of Obstetricians and Gynecologists, 2017a), and women with unintended vs. intended pregnancies often find out that they are pregnant later and are less likely to seek prenatal care (Kost & Lindberg, 2015). Abortion bans at 6 weeks will make it more difficult for women to obtain abortions legally, likely resulting in delayed care and further pushed out gestational age. Although some states developed measures to protect out-of-state travelers seeking abortion, this most likely will only benefit women with the resources to leave their state and access these services, excluding the most vulnerable women with SUDs, typically young, low-income, women of color, who use Medicaid, and who also face disparities in substance use treatment access (Cummings et al., 2014; Hollander et al., 2021; Mennis & Stahler, 2016; Pinedo, 2019). Medicaid-funded abortions are already uncommon, as most states follow the federal government’s lead, established by the 1976 Hyde Amendment, in restricting public funding for abortion, except in limited cases such as rape, incest, or life endangerment (Guttmacher Institute, 2021). Many states also restrict what private insurance plans can cover. With abortion now expected to be prohibited in at least half of the states after this verdict, legal experts warn that state restrictions on Medicaid usage for abortion services are likely to become even greater. Furthermore, many state abortion bans do not make exceptions for rape or sexual violence, which disempowers women to seek out care. Even when states allow this exception, the barriers can make seeking out SRH services insurmountable, including reporting the abuse to law enforcement. This can be re-traumatizing or frightening for a woman in a relationship with an abusive partner and more challenging for women with SUDs who may also fear criminalization due to drug use. Concerningly, women who are denied abortions have been found more likely to remain in contact with a violent partner (Advancing New Standards in Reproductive Health and UCSF, 2020).

After effects: Increased criminalization and stigmatization

When neither contraceptive nor abortion services are widely accessible, women with SUDs will unjustly suffer the consequences. Reproductive-aged women with SUDs, particularly women of color, are already deeply impacted by punitive and discriminatory policies that criminalize and stigmatize drug use or addiction while pregnant and parenting (MacAfee et al., 2020; Paltrow & Flavin, 2013). Fear of law enforcement and child protective services (CPS) serve as major barriers to women with SUDs’ access to and utilization of the health care system (MacAfee et al., 2020). Nearly half of all U.S. states have policies that require health care professionals to report suspected prenatal drug use, and that consider substance use during pregnancy to be child abuse; 3 states consider it grounds for civil commitment, or involuntary hospitalization. The number of states with these punitive policies has more than doubled since 2000 (Guttmacher Institute, 2022e); however, rates of infants displaying drug withdrawal symptoms is higher in states with more punitive policies than in states without such policies (Faherty et al., 2019). Furthermore, women of color are often reported and arrested for using alcohol or drugs during pregnancy at disproportionately higher rates than white women, with one study finding that Black women were 10 times more likely to be reported than white women, even when substance use was similar between both groups. (Chasnoff et al., 1990). Rather than preventing substance use and harm to children, such punitive policies increase harm through family separation and incarceration, which has increased by more than 475 % between 1980 and 2020 among women (The Sentencing Project, 2020). Thus, the impact of limited options for pregnancy prevention and/or forced pregnancy through a ban on abortion services will have a profound impact on the health and well-being of both women with SUDs and their children.

Treatment and policy advocacy steps

The overturning of Roe v. Wade and related contraceptive bans will impact all people in need of family planning services; however, as service access decreases, women with SUDs will be one of the most deeply impacted populations. To minimize the harms associated with restrictive SRH policies and to advance the health and rights of women with SUDs, researchers, providers, and policymakers must therefore take action.

Treatment

To reduce barriers to SRH and abortion services for women with SUDs, especially in this current climate, a need exists for integrated SRH and SUD services delivered in trusted settings such as SUD treatment centers (Johnston et al., 2022). These programs can provide support and access to an array of services, including substance use treatment and family planning services consistent with women’s goals and needs. Integrated treatment programs are important for each choice and stage of women’s family planning, including contraceptive services, abortion services, and prenatal care for pregnant women with SUDs. Consistently, women with SUDs have expressed that they would prefer to receive SRH services in SUD treatment centers to avoid feeling stigmatized, punished, or coerced into certain family planning decisions based on their drug use (Johnston et al., 2022). Furthermore, providers in both specialties can obtain cross-disciplinary training and consultation to help deliver culturally effective, well-rounded treatment services and referrals. For instance, SUD treatment providers can receive training to educate women with SUDs on SRH services and refer them to on-site or local services, as needed. SRH providers can treat women with SUDs and consult with SUD specialists to help reduce potential reservations that they may have treating this population. Consultation between SRH providers and SUD specialists may be particularly relevant at this time due to the policy change in December 2022 allowing all physicians and other health care professionals with a regular DEA license to prescribe buprenorphine for patients with opioid use disorder (Substance Abuse and Mental Health Services Administration, 2023).

Furthermore, SUD treatment centers and SRH services must offer lower cost options and telemedicine options to increase accessibility. For the first time, the WHO recently recommended the use of telemedicine for abortion pill prescriptions in its abortion pill guidelines, prioritizing both the option of mail delivery abortion pill prescriptions and in-person appointments (Geneva: World Health Organization, 2022). Consistently, a systematic review comparing telemedicine with in-person medical abortion care services found similar success rates and safety outcomes between groups, and high satisfaction among patients receiving telemedicine (Endler et al., 2019). Providers should discuss all forms of contraception, including emergency contraception with their patients, inform them of its availability, and provide women with an advanced supply of pills if the patient requests them to ensure that women have them if needed. Last, providers should thoroughly screen women with SUDs for sexual violence and IPV and make referrals and recommendations accordingly to ensure that women can prevent pregnancy, if that is their goal, or to access abortion services, if needed. As we advance integrated treatment options, there is also a need to shift toward a more holistic model using supportive, culturally-appropriate intervention that emphasize women’s overall health and well-being, rather than just pregnancy prevention (Johnston et al., 2022).

Policy

As we attempt to mitigate the fallout of overturning Roe v. Wade, new legislation is needed to protect women’s remaining access to SRH services, as well as increase access for women who will face exacerbated barriers to services, such as women with SUDs. For instance, The Protecting Access to Medication Abortion Act (Congress.Gov, 2022) would defend access to abortion pills (mifepristone and misoprostol) in states in which the right to an abortion is still protected by codifying the current Food and Drug Administration mifepristone Risk Evaluation and Mitigation Strategy (REMS; U.S. Food and Drug Administration, 2021). This regulation allows women to access abortion bills through telemedicine and certified pharmacies, including mail-order pharmacies. Furthermore, state or federal support is needed to offer protection for clinicians in “sanctuary states” to provide abortion services, including telemedicine and delivery of abortion medications to women across state lines. Last, state legislatures can pass proactive legislation to preserve the right to all forms of contraception. For instance, 17 states and Washington D.C. now allow pharmacists to prescribe hormonal birth control (Guttmacher Institute, 2022b). Not only do these strategies reduce the prohibitive time and cost associated with going to a doctor, but they also help to mitigate the reluctance to utilize health care systems due to stigma associated with having an SUD.

Additionally, bills like the Equal Access to Abortion Coverage (EACH) Act of 2021 (Congress.Gov, 2021) are crucial to address disparities in SRH services access that will be exacerbated among women of different socioeconomic statuses. The bill proposes to reverse the Hyde Amendment and ensure that every person who receives care or insurance through the federal government would receive coverage for abortion services. It would also prohibit the federal government from interfering with the private insurance market and preventing abortion coverage. Reproductive justice advocates can write to their local and federal representatives to show support for these new bills. Additionally, people can donate to organizations such as the National Network of Abortion Funds (National Network of Abortion Funds, 2022), to help pay for reproductive services that some women are not able to afford, and the Center for Reproductive Rights (Center for Reproductive Rights, 2022), to help fund advocacy work to defend legal protections for reproductive rights around the world.

Just as the “war on drugs” did not reduce drug use, criminalizing abortion will not prevent abortion, but will instead make it less safe, less accessible, more costly, and put women’s health at risk by having them turn to unsafe alternatives. Overturning Roe v. Wade may also increase momentum for states to place restrictions on contraception further limiting women’s options. Women with SUDs, particularly women of color, who are already targeted by punitive and discriminatory policies for having an addiction while pregnant and parenting, will be deeply affected by these bans. Harm reduction approaches and research show that people benefit most from policies and health services that allow them the right to choose their own goals, and that equip them with information and resources, such as affordable and accessible SRH options, that support reduced harm and positive change (Marlatt et al., 2012; Marlatt & Witkiewitz, 2010). Women should have access to nonjudgmental health care and policies that allows them autonomy over their bodies and lives. Policymakers, treatment providers, and supporters of women’s sexual and reproductive health rights can help to advocate and assist women with SUDs by considering these multi-level barriers in the development of policy and treatment responses.

Funding

Dr. Slavin is funded by NIDA 1K01DA055762-01.

Dr. Levin receives research support from the NIDA, NCATS, SAMHSA, US World Meds and Aelis Pharmaceuticals. She also receives medication from Indivior for research and royalties from APA publishing. In addition, Dr. Levin served as a nonpaid member of a Scientific Advisory Board for Alkermes, Indivior, Novartis, Teva, and US WorldMeds and is a consultant to Major League Baseball.

Footnotes

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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