Understanding barriers and facilitators to women’s recovery from opioid use disorder: A focus group study

Abstract

This study examined barriers to accessing treatment and recovery support for opioid use disorder (OUD) among women and suggested solutions to overcoming them. Ten in-depth focus groups (27 participants) were conducted with women in recovery from August 2023 to January 2024. Transcripts were analyzed by two coders using an inductive approach guided by grounded theory methods. Major themes that emerged highlighted the ways compounding challenges make accessing treatment and entering recovery difficult, as well as the unique hardships encountered by mothers. Themes related to potential solutions included fostering supportive communities of women, improving the availability of gender-specific resources and support, and providing comprehensive, individualized recovery services. Further research on implementation strategies is needed to integrate these suggestions into treatment and recovery settings. Moving forward, it is critical that the hard-won victories of women in recovery are directly translated into action to improve OUD treatment and recovery settings for women.

Introduction

Between 1999 and 2022, the rate of fatal opioid-related overdoses among females increased more than tenfold, from 1.4 to 14.4 per 100,000 population (National Institute on Drug Abuse, 2024). According to the most recent prevalence estimates from the 2023 National Survey on Drug Use and Health (NSDUH), in the past year, 3.0% of adult females misused opioids (compared to 3.5% among adult males), and 2.1% of both adult females and males had opioid use disorder (OUD) (Center for Behavioral Health Statistics and Quality, 2025). Women with OUD differ from men with OUD in several ways and have unique needs that require tailored support: they are more likely to have experienced sexual or physical abuse, more likely to have co-morbid psychiatric disorders, and more likely to live alone with children or with someone else with a drug problem (Back et al., 2011; Campbell et al., 2018; Morrison et al., 2023; Parlier-Ahmad et al., 2021; Stone et al., 2021). Additionally, they are less likely to be employed and more likely to be dependent on someone else for socioeconomic support (Campbell et al., 2018; Parlier-Ahmad et al., 2021).

Although the most recent NSDUH prevalence estimates for OUD are the same for males and females, women with opioid use disorder (OUD) must overcome obstacles to treatment and recovery support that men do not experience in the same way. Barriers to care for women with OUD include interpersonal and community-based social stigma as well as fear and negative perceptions of pharmacotherapies to treat OUD, including medications for OUD (MOUD) (Fiddian-Green et al., 2022). There are also limited treatment resources available for women as compared to men, with fewer treatment centers available for women (Boeri et al., 2021). Additionally, pregnant and parenting women face a distinct set of problems when seeking treatment for OUD. Lack of access to childcare that creates difficulty in attending appointments, fear of losing custody of children, and providers’ reluctance to accept pregnant patients all contribute to lower rates of women with OUD receiving treatment (Apsley et al., 2024).

One example of the consequences of these barriers to treatment and recovery support for women is differential receipt of MOUD, which reduces the risk of death and overdose among people with OUD (National Institute on Drug Abuse, 2025). According to 2023 NSDUH prevalence estimates, 16.0% of females with an OUD received MOUD in the past year, compared to 20.3% of males with an OUD (Center for Behavioral Health Statistics and Quality, 2025). A recent study found that among parents diagnosed with OUD, the difference was larger: the predicted prevalence of receiving MOUD was only 19.7% among females compared to 27.4% among males (Gao et al., 2023).

Previous qualitative studies have explored barriers to treatment and MOUD experienced by pregnant and parenting women, as well as stigma experienced by mothers with OUD (Apsley et al., 2024; Bakos-Block et al., 2024; Boeri et al., 2021; Morton et al., 2023; Schiff et al., 2022; Tsuda-McCaie & Kotera, 2022). However, women in recovery from OUD who have successfully navigated obstacles to accessing care and recovery support may provide additional insights to inform potential solutions. The purpose of this study is to examine barriers to care and support from the perspective of women in recovery from OUD, and to explore their suggestions to address these challenges.

Methods

Study Design

We conducted a qualitative focus group study to explore barriers to engagement in care for women with OUD and potential solutions. The study was carried out in collaboration with a community advisory board (CAB) composed of women in recovery and/or women leaders in recovery-focused organizations, who provided insight crucial to the study. All members of the CAB were women in long-term recovery from substance use disorders. CAB members also had expertise in substance use treatment and recovery settings. Examples of members’ professional positions and certifications include: national or state certified recovery peer specialist, licensed clinical social worker, licensed chemical dependency counselor, certified addiction counselor, certified motivational interventionist, certified event interventionist, and behavioral health placement specialist. Additionally, CAB members have expertise in enhanced communication, as well as substance use and comprehensive mental health for military affiliated populations. Members also hold membership in the Association for Addiction Professionals (NAADAC) and have experience on federal, county, and local boards, including serving as a Regional Representative for SAMHSA’s Substance Use and Mental Health Block Grants Advisory Committee, chairperson for two Florida county Behavioral Health Community Health Improvement Plan Subcommittees, and board member for a local recovery community center. Combined, members of the CAB have more than 66 years of professional experience in substance use recovery settings, and more than 77 years in recovery.

A semi-structured focus group facilitation guide was developed after extensive iterative feedback on clarity and terminology from the CAB. The final facilitation guide included nine open-ended questions and accompanying probes; sample questions and prompts are shown in Table 1. Virtual focus groups were planned to address potential barriers to participation for women, including caretaking responsibilities and lack of transportation. Two pilot focus groups with CAB members were conducted by the first author. Study flyers were also created in collaboration with the CAB. Participants were recruited via study flyers distributed in-person and online through community organizations, treatment facilities, and CAB members, as well as through focus group participant referral. To be eligible for focus groups participation, women had to be 18 years or older and self-report being in recovery from OUD for at least three months, up to five years. Participants were also required to have access to a Zoom-compatible device; because of the virtual nature of the focus group discussion, the only geographic restriction on participation was residence in the United States. Individuals who screened positively for psychosis, reported a schizophrenia diagnosis, or reported a suicide attempt within the past six months were not eligible for participation. The Florida International University Social and Behavioral Institutional Review Board approved this study.

Table 1. Sample facilitation guide questions and prompts from focus groups conducted with women in recovery from OUD, August 2023 to January 2024.

Focus group question
Faciltator prompt
Imagine you have a female friend who is struggling with using opioids and wants to stop. If she came to you looking for help or resources for recovery, how would you guide her? Facilitator prompts for follow up: Where would you tell them to look for information? Where would you tell them to go? Thinking about the previous question, in a perfect world, what would make finding those recovery resources for women easier? Facilitator may need to remind participants of the previous question or recap responses. Prompt: That is, helping your female friend find recovery resources. I heard you say… What’s the most important thing we should know about women who have struggled with using opioids and found recovery? It's okay to share personal stories if you’re comfortable. Prompt, if participants share their own stories: How has being a woman impacted your journey to recovery? What has been helpful in getting women the support they need for recovery? Prompts, if participants share their own stories: Thinking back to your experiences with recovery… Were there any people that helped you? For example, a counselor, or a friend? What helped you the most when you were struggling? What was the space or program that helped you the most? What are some of the challenges that women face when trying to get support for recovery? Again, it’s okay to share personal stories if you are comfortable. Prompts, if participants share their own stories: Thinking back to your experiences with recovery… What were the things that made it hard when you were struggling? What’s something that stopped you from getting the care you needed? What was the biggest barrier separating you from getting the support needed? [After reading a definition of a recovery navigator] Have you ever received assistance from someone who fit that description of a recovery navigator? Facilitator: give participants time to think about their answer. Prompts: This might be more than one person. You may have had different experiences on different levels, interacted with people in positions like… [give examples]. Potential prompts, if yes: Could you tell us more about them? Where or in what setting did you interact with them? Potential prompts, if no: Does this sound like something that would be helpful? In what ways? What do you think would be the benefits? If you had a magic wand and could do anything you wanted, how would you create a program that made recovery navigators available to support women on their recovery journeys? What would that look like? Potential prompts: You mentioned… tell me more about that. Based on your experience, what would be helpful to include in a recovery navigator program? What would a helpful recovery navigator look like?

Data Collection

After completing screening for eligibility with study staff, participants completed an electronic informed consent form followed by a brief questionnaire to provide demographic information (Table 2). The questionnaire also inquired about the use of MOUD: “Have you ever taken methadone, buprenorphine (also known as suboxone or subutex), or naltrexone (also known as vivitrol) to treat opioid use problems?” Response options included: Yes, I am currently taking one of these medications; Yes, I have previously used one of these medications; and No, I have never taken one of these medications.

Table 2. Characteristics of women in recovery from OUD participating in focus groups, August 2023 to January 2024.

	N=27
	n (%)
Age (mean, range)*	35.9, 25-57
Federal Poverty Level *
<100%	14 (51.9%)
101-200%	6 (22.2%)
>=200%	6 (22.2%)
Sexual Orientation
Heterosexual	21 (77.8%)
Lesbian or Gay	1 (3.7%)
Bisexual	5 (18.5%)
Race **
Black/African American	3 (11.1%)
White	19 (70.4%)
American Indian/Alaska Native	2 (7.4%)
More than one race	1 (3.7%)
Other	2 (7.4%)
Ethnicity
Hispanic/Latino	5 (18.5%)
Non-Hispanic/Non-Latino	22 (81.5%)
Urban/Rural Residence *
Urban	14 (51.9%)
Suburban	12 (44.4%)
Rural	0 (0%)
Health Insurance *
None	8 (29.6%)
Medicaid/Medicare	10 (37.0%)
Employer	6 (22.2%)
Buys on own	2 (7.4%)
Use of Medications for OUD (MOUD) ***
Currently taking MOUD	17 (63.0%)
Previously taken MOUD	6 (22.2%)
Never Taken MOUD	4 (14.8%)
Born in the US
Yes	24 (88.9%)
No	3 (11.1%)
# of Children at Home *
None	16 (59.3%)
1	3 (11.1%)
2 or more	7 (25.9%)
Marital Status
Single	12 (44.4%)
Married/Living together	8 (29.6%)
Widowed	1 (3.7%)
Separated/Divorced	5 (18.5%)
Other	1 (3.7%)
Highest Level of Education
Some High School	6 (22.2%)
High School Graduate	3 (11.1%)
Some College	8 (29.6%)
College Graduate	9 (33.3%)
Other	1 (3.7%)

^*Data only available for 26 participants.

^**Participants could select more than one.

^***MOUD defined as methadone, buprenorphine, or naltrexone.

Focus group discussions were completed after participants provided demographic information. Focus groups were facilitated by the first author virtually via Zoom. Each focus group included two to four participants and lasted 60-120 minutes. Participants received a $75 cash incentive distributed through electronic payment applications after the focus group concluded. Focus group discussions were recorded using a digital voice recorder. Dragon Speech Recognition and Olympus transcription software were used to transcribe the focus group recordings verbatim. Software-generated transcripts were then edited and anonymized as needed. Data collection concluded when no new information emerged from the focus groups. The transcripts were imported into NVivo 20 (Lumivero) for data management and analysis.

Data Analysis

We used an inductive approach for qualitative analysis guided by grounded theory methods (Charmaz, 2006). Analysis using NVivo occurred over iterative stages involving systematic coding and comparative methods. An initial round of coding was done by two members of the research team (KM and AJ) who independently coded the first four interviews to identify key concepts and important comments by participants. As participant statements were analyzed, codes were developed, and their definitions were refined to construct the codebook. Themes were derived from the codes based on participants’ perspectives. Employing an iterative process of multiple rounds of coding and memoing, an inductive grounded theory approach was applied to categorize the data, highlighting similarities and differences in participants' perspectives to uncover the meaning and themes within the data. Using the finalized codebook for consistency in themes, the two coders (KM and AJ) each independently coded five of the ten interviews. Each interview was then validated by the other coder (KM or AJ) to ensure intercoder agreement and consistency in the application of codebook definitions. Any disagreements were resolved through discussion and consensus.

Results

Ten in-depth focus group interviews (27 participants) were conducted from August 2023 to January 2024. Most participants resided in the southern United States (n=25, 93%); one lived in the northeastern United States, and region of residence was missing for one participant. Demographic characteristics of participants are shown in Table 2. Most participants identified as White and non-Hispanic; 19% of participants were Hispanic and 11% were Black/African American. The majority of participants (78%) identified as heterosexual; 19% identified as bisexual and 4% as lesbian or gay. Approximately half (52%) of participants reported a household income below 100% of the 2024 Federal Poverty Level (Department of Health and Human Services Office of the Secretary, 2024). Approximately one third of participants (30%) had no health insurance and 37% received Medicaid or Medicare. Sixty-three percent of participants reported they were currently taking MOUD, 22% reported previously taking MOUD, and 15% reported never taking MOUD.

Participants expressed a range of experiences related to access to care, treatment, and recovery support for OUD. Major themes that emerged included the compounding nature of barriers to care and the unique challenges mothers experience in recovery. Themes highlighting potential solutions to these barriers emerged as well and included empowering and inclusive recovery through a supportive community for women, gender-specific support, and comprehensive and individualized recovery services. Although the themes are presented separately, participants’ accounts underscore the interrelated nature of structural barriers, community support, and accessibility, illustrating how these overlapping dimensions collectively influence women’s recovery trajectories. We detail these themes below.

Compounding Structural Barriers

Women described numerous compounding barriers—such as a lack of transportation, employment, insurance, legal, financial issues, childcare, and limited access to services—as critical challenges to seeking and receiving substance use treatment. As one participant shared, “rides [transportation], that’s a huge issue. There’s a lot of us that don’t have licenses and cars….” Another participant described, “if you tell somebody you don’t have insurance, it’s like a long process to try to find something [treatment services].” Participants emphasized the need for these barriers to be addressed simultaneously to promote successful recovery. One participant expressed:

“… there's so many different aspects of what the person is going through at any given time. It's not just having a safe haven to stay clean, it's getting the assistance to guide them to progress…to stay successful in their recovery.”

Addressing these structural and personal obstacles was viewed as essential to fostering long-term healing and stability.

Challenges Mothers Experience in Recovery

Participants described barriers mothers experience, such as lack of childcare, housing options that include their child(ren), limited resources, and navigating the child welfare system. As one participant said, “I think more resources [are needed] where you have a safe space to be with your kid, and I wonder if this is why a lot of women don’t get help.” Unique challenges faced by mothers in recovery included difficulty finding balance between caring for oneself and one’s children, described as follows:

“They do treat women differently especially when you have a child. You’re held to a certain standard; not only are you in charge of taking care of yourself, but you’re also in charge of taking care of a child. It’s hard to find that balance of taking the time that you need for yourself and still doing the other things that you need to do as a mom.”

Women also described fear of losing custody of their child(ren) while contending with the trauma, shame, and guilt associated with their addiction. One participant expressed:

“There's a lot of women that wanna get clean but they’re scared of DCF… maybe if they [treatment centers] were more welcoming to mothers with children, maybe women would want to ask for help sooner.”

Women described the need for treatment to be tailored to the needs of being a mother in recovery, knowing they will not lose custody of their child(ren) during the recovery process, and having professional support, mentorship, and a community of women with similar experiences to assist them in meeting both their own recovery needs and their responsibilities as parents.

Empowering and Inclusive Recovery Through a Supportive Community for Women

The importance of building a supportive community was highlighted as essential in overcoming isolation, fostering resilience, and developing a sense of belonging. Women described the recovery process as needing to be empowering, community-focused, and responsive to the complexities of their experiences, ensuring their needs are met without judgment. They emphasized the importance of building a network of both formal and informal supports, including personal connections and professional services, to navigate recovery. Participants expressed wanting a supportive community that understands their struggles and helps them advocate for needed services and programs. They highlighted connection, understanding, and a sense of belonging as essential to overcoming isolation and finding purpose in recovery.

Women described a sense of belonging as building a supportive network and connections with other women who have shared experiences as important elements to fostering healing. As one participant shared, “My sponsor’s big on that, women empowering other women.” Participants described feeling isolated, misunderstood, and disconnected from others, both during active addiction and in the early stages of recovery. One participant shared that “having somebody to emotionally support you is a huge thing and it’s a great need.” Finding a community of women offers a sense of belonging and reduces feelings of being "lost" or "alone." One participant expressed:

“They say when you first get clean that you can only keep what you have by giving it away. And just helping somebody else who is struggling and in the same situation, it’s so important.”

This network of support provides opportunities for connection, communication, and shared understanding, which are essential for emotional healing and self-discovery: “I’ve met women that haven't been through it [addiction] but are willing to listen and understand what you've gone through. That was important.” They described the importance of finding purpose, recognizing and managing emotions, and building confidence through these connections. Knowing they are not alone and having access to a community that understands their struggles helps them find hope, light, and a sense of pride in their recovery journey.

Gender-Specific Support

Women described gender-specific support as the support, resources, and treatment tailored to the unique needs of women. They described barriers faced in recovery, including limited access to treatment options, lack of women-specific treatment facilities, lack of safe and stable housing, and lack of support groups. As one participant expressed:

“There’s not many places I found when I was looking for women’s centers. Most detoxes we have, halfway houses, I found were for men… A lot of women come and go from jail and they don’t have options. A lot of women are stuck in homelessness because they can’t find a place to go…”

Many women expressed how difficult it is for women to find the information on resources they need that are not available only for men. One participant suggested addressing this issue using advertising directed at women specifically:

“If there were things that would catch your attention… so if a woman is scrolling on Facebook, and she sees, ‘hey… we’re looking for women who are struggling with addiction, abuse, homelessness,’ you know, calling out that it’s women… ‘reach out to us, here’s the number, here’s the website,’ something like that, because I feel like our world is just so evolved around social media, that that would get attention.”

They shared feeling vulnerable, experiencing stigma, not being heard, receiving misinformation, and a lack of recognition for their needs and experiences, which can hinder their recovery journey. As one participant stated:

“The system itself is, there’s so much stigma and there's so much distrust and disbelief, not only with substance abuse but with women in general and the medical system, it's like this is just one little part of that big problem.”

Participants recommended a range of gender-specific supports to aid recovery, including peer-led and trauma-informed groups where women could feel understood and validated, as well as access to co-occurring services such as mental health care, domestic violence support, employment assistance, and women’s healthcare (e.g., reproductive and maternal health). One participant expressed:

“I was pregnant, and I had to try to find resources. I found [facility name] through a Google search, and I think I called 5 places to try to find someone that could provide me some assistance…a lot of shut doors until finally I got the assistance that was meant to be for me.”

Women also underscored the importance of community-based programming and outreach that foster belonging, provide education, and normalize their experiences by connecting them with others who share similar recovery journeys.

Overall, participants emphasized the importance of comprehensive treatment options, knowing supports and services are tailored to the specific needs of women, and receiving empathetic and compassionate care from providers and support systems to foster their healing and foster self-compassion. They wanted assurance that resources and services were designed with women in mind and described the importance of women-specific resources, education, and advertising. They also expressed a desire to feel that their thoughts and emotions are normal compared to women with similar experiences.

Comprehensive and Individualized Recovery Services

Women described comprehensive and individualized recovery services as holistic and personalized care that is empathetic and compassionate, tailored to their specific needs, and addresses comorbid mental health and substance use issues. As one participant expressed, “recovering is emotional, spiritual, mental…you have to deal with all of those things at once when we start getting sober.” They emphasized the need for trust-building and community connection and shared that the effectiveness of recovery is perceived to depend less on the specific treatment provided and more on how individuals are received by the recovery community. One participant described:

“I know it’s difficult for somebody to walk in somebody else's shoes, but I believe in educating people as that’s where understanding and compassion comes from, and that's where you get your biggest help from, is the support of others.”

Participants shared wanting to be heard, believed, and validated while maintaining autonomy and safety throughout their recovery journey. One participant shared, “The kindness in rehab made a big difference for me because it can be such a cold system, and people should know that they’re loved and they’re cared for.”

In relation to services, they expressed a need for a recovery navigator—someone with a similar lived experience who can offer understanding and guidance throughout the recovery process. As one participant described their experience with a provider they identified as a recovery navigator:

“…he actually checked in with me. He would call the center and ask to speak with me, to make sure I was okay and make sure I was getting my services, make sure I was getting my therapy, make sure I was getting medication… he was making sure that I got everything.”

Participants emphasized the need for trust-building and community connection, noting that the effectiveness of recovery is perceived to depend less on the specific treatment provided and more on how individuals are received by the recovery community. They described the value of a peer recovery navigator—someone with similar lived experience who can offer understanding and guidance throughout the recovery process. They also highlighted the importance of tailored treatment options that cater to different circumstances and preferences, such as flexible scheduling to accommodate parenting responsibilities, trauma-informed approaches that recognize histories of abuse, gender-specific groups that reduce stigma and enhance safety, and supports that address cooccurring needs like mental health, employment, and healthcare. Access to diverse resources and treatment (including MOUD) within a nonjudgmental environment was described as essential to sustaining recovery.

Many participants highlighted MOUD as crucial to their recovery; for example:

“I’m 37, they put me on methadone first when I was 18 years old, and that was by far, it helped me, I don’t wanna ever take that away, because it did help me so much. I stayed clean for years on that…”

Conversely, some women emphasized the importance of having the agency to choose between treatment options. As another participant stated, “I wanted to be clean and sober and didn't want to have the [MOUD] taking care of me the rest of my life, so it wasn't an option for me.” Explaining in more detail, a participant shared the following personal example:

“It does work for some people, but the thing was when I went to Subutex, I’m an addict, and I wasn’t doing anything to take care of my addiction, so I started abusing them… I personally just don’t think that they worked very well because they were trading in one addiction for another…”

These diverging views on MOUD highlight the importance of having access to a range of therapeutic and pharmacologic approaches to treatment and recovery.

The participants’ experiences reflect interconnected themes of structural barriers, community support, and accessibility. Challenges such as lack of transportation, childcare, housing, and navigating the child welfare and healthcare systems were often described as compounding one another, making it difficult to seek or remain in treatment. These barriers overlapped with challenges specific to mothers in recovery, highlighting the need for services that accommodate parenting responsibilities while ensuring safety and stability for themselves and their children. At the same time, participants emphasized that recovery depends on more than just addressing these barriers. Having empathetic providers, peer mentors, and a supportive community of women with shared experiences was essential to fostering resilience, belonging, and hope. Participants described accessibility not only in terms of the availability of gender-specific resources and treatments, but also in how approachable and welcoming services felt, highlighting that recovery is shaped as much by how they are received as by the interventions themselves.

Discussion

The findings of this focus group study highlight the complex nature of the challenges women face accessing treatment for OUD, entering recovery, and maintaining recovery. The stark nature of the opioid crisis and the steep rise of OUD among women necessitates a response that ensures no one is lost to the gaps present in the current fragmented and uncoordinated systems of care for substance use disorders. Our results highlight the need for a woman centered approach to support recovery among women with OUD; such an approach would recognize the compounding nature of the challenges women in recovery are facing and provide specialized resources for those who are pregnant or parenting. Furthermore, the demographics of our participants, half of whom were living at or below the federal poverty level, emphasize the importance of no- or low-cost options for treatment and recovery support among women with OUD.

Our findings align with other studies that have examined barriers encountered by women with OUD, the complex stigma women with OUD experience, and the challenges pregnant and parenting women with OUD encounter in treatment settings (Apsley et al., 2024; Bakos-Block et al., 2024; Boeri et al., 2021; Mazure & Fiellin, 2018; Morton et al., 2023; Office on Women's Health, 2017; Patrick et al., 2019; Schiff et al., 2022; Tsuda-McCaie & Kotera, 2022). Our work contributes to the literature by providing insights from women in recovery about overcoming the barriers they repeatedly encounter. These include access to supportive community networks, targeted advertising, expanding service eligibility, and increasing the availability of beds in treatment and supportive housing facilities to include women and women with children. Focus group participants highlighted the impact of interacting with caring and empathic providers and staff across the entire spectrum of care, including clinicians, case managers and social workers, and peer recovery support specialists. This finding aligns with results from Fiddian-Green and colleagues (2022), who found that a facilitator to MOUD care for women includes a “sense of safety within treatment centers” (Fiddian-Green et al., 2022). Additionally, our finding related to the need for a supportive community of women aligns with the social capital component of Cloud and Granfield’s recovery capital framework, who note that “social capital is important during life crises because it affects the options, resources, information, and supports available to people as they attempt to resolve their problems” (Cloud & Granfield, 2008).

Bronfenbrenner’s socio-ecological model (SEM) is the most well-known ecological systems theory (Bronfenbrenner, 1979). The SEM examines the reciprocal relationships between individual characteristics and behavior (i.e., microsystem level, individual), interactions with others (i.e., mesosystem level, intrapersonal), indirect influences of social settings and environments (i.e., exosystem level, organizational), cultural ideologies (i.e., macrosystem level, community), and major events, transitions, and cultural shifts (i.e., chronosystem level, societal/public policy). When applied to women in recovery from substance use disorders, the SEM highlights how individual-level factors such as trauma histories, mental health conditions, or coping strategies influence recovery trajectories. At the mesosystem level, family dynamics, parenting responsibilities, and peer support play critical roles in sustaining recovery. The exosystem reflects indirect influences, such as access to childcare, transportation, housing stability, and treatment availability. At the macrosystem level, cultural ideologies including gendered expectations of motherhood and pervasive stigma around women’s substance use shape how women experience recovery. Finally, the chronosystem underscores how broader forces, such as punitive drug policies, shifts in public attitudes toward addiction, or societal responses to the opioid crisis, create long-term effects on recovery opportunities. By identifying these multilevel influences, the SEM provides an opportunity to explore life transitions, environmental pressures, and the reciprocal relationship between women, their families, and the larger environment throughout the recovery process (Kilanowski, 2017).

Participants' concerns about the potential loss of child custody reflect the influence of both the exosystem and macrosystem, where organizational practices and cultural ideologies intersect creating systemic barriers that deter parenting women from seeking substance use treatment (Bosak et al., 2024; Choi et al., 2022). Social workers and child welfare systems can reduce these barriers by implementing family-centered, trauma-informed approaches that reassure parents and provide safe, integrated pathways for treatment, including on-site childcare or parenting-friendly programs (Bunting et al., 2019; Morgan et al., 2024; Policy Center for Maternal Mental Health, 2025). At a broader policy level, prioritizing family preservation and reducing punitive responses to parental substance use can create a supportive environment for parents to seek help without fear of losing custody. Systemic changes are essential to support parenting women in recovery, including advocating for policies that reduce the criminalization of substance use during pregnancy and postpartum periods, to reduce unnecessary family separations (Shah et al., 2023). Fostering collaborative models between treatment providers and child welfare agencies may encourage parents to seek care earlier, ultimately improving both recovery outcomes and child well-being.

In the focus groups we facilitated, some participants noted that when seeking support, they were informed only men were eligible for services. Other participants noted the lack of physical infrastructure or treatment beds available for women in general, not solely women with children. Further research is needed to fully quantify this finding, although a recent secret shopper study documented the many barriers to MOUD women experience, particularly pregnant women (Elmore et al., 2023; Phillippi et al., 2021). One challenge in this area is that facilities are likely reluctant to formally report if they do not offer services to women. The widely used Substance Abuse and Mental Health Services Administration (SAMHSA) treatment locator, FindTreatment.gov, does not currently include a filter to search for facilities or service availability by sex (Substance Abuse and Mental Health Services Administration (SAMHSA), n.d.). Adding such a search option would improve transparency of service availability for women and reduce fatigue among women seeking care only to be told they are ineligible because a facility solely offers treatment for men.

Participants also expressed a strong desire for their needs to be met by providers who listened to them and took their preferences into consideration. One way this was exemplified was through divergent perspectives on MOUD. Research has shown MOUD produces the best OUD treatment outcomes, and early initiation of MOUD, increased treatment duration, higher doses, and more patient contact while receiving MOUD are associated with better OUD treatment outcomes (Larochelle et al., 2018; Mburu et al., 2024; Wakeman et al., 2020). However, MOUD is underutilized and is stigmatized among some recovery groups, perceived as replacing one substance use disorder with another as described by a focus group participant in the current study (National Institute on Drug Abuse, 2018). Additionally, women report being hesitant to use MOUD for several reasons, including mistrust of prescribing providers due to the role of physicians in the prescription opioid crisis, fears of side effects and interactions with other medications, and miscommunications with prescribers about the expected length of treatment with MOUD (Fiddian-Green et al., 2022). Participants in this study emphasized the importance of multiple paths to recovery, the recognition of which is gaining importance among the recovery community (Faces and Voices of Recovery, 2019). While the ongoing skepticism of MOUD emphasizes the need for continued education around its benefits, it also highlights the importance of providers who understand that there are multiple paths to recovery and will help women with OUD identify and maintain the path that is right for their individualized needs.

Additionally, providers should seek to meet the needs of women with OUD through enhanced training, as well as the implementation of existing frameworks and approaches to care that emphasize empathy and address individualized needs, taking lived experience into account. Continuing education trainings specific to the needs of women with substance use disorders are available to providers from the American Society of Addiction Medicine and the Association for Addiction Professionals (NAADAC) (American Society of Addiction Medicine Education, 2025; NAADAC, 2025). Examples of existing approaches include patient-centered care, shared-decision making, and trauma-informed care. Patient-centered care is a well-established framework that, when applied to women with OUD, would consider them equal partners in establishing plans for their treatment and recovery support and would take a comprehensive view of their physical and emotional wellbeing (What Is Patient-Centered Care?, 2017). Shared decision making is an extension of patient-centered care that emphasizes patient engagement in clinical decision making; Guille and colleagues have developed a shared decision-making aid to help perinatal women with OUD make decisions with their medical provider around MOUD continuation or tapering (Barry & Edgman-Levitan, 2012; Guille et al., 2019). Trauma-informed care acknowledges that women with OUD have a higher likelihood of experiencing certain traumatic events, such as sexual abuse, and emphasizes “understanding the signs and impact of trauma, recognizing the signs of trauma, responding appropriately to signs of trauma, and preventing the repeating of trauma” (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2020). The Office of Women’s Health and the Health Resources and Services Administration have released a toolkit for providing care for women with OUD that highlights organizational strategies for providing trauma-informed care (U.S. Department of Health and Human Services & Health Resources and Services Administration, 2020).

One limitation of this study includes the virtual nature of the focus groups. It is possible that interactions between participants would have changed if they were interacting in person, potentially impacting some of the information elicited. However, given the many challenges women in recovery face, the research team used a virtual format to improve the accessibility and convenience of participating in the study. Another limitation is the transferability of the study. Most participants resided in Florida at the time of the study, and the results may not translate to women in OUD recovery in the other parts of the U.S. Finally, self-reporting methods rely on the assumption that participants will provide honest and open responses. However, the subjective nature of these accounts may introduce variability and potential bias, as participants' experiences differ, and responses may be influenced by social desirability (Beam, 2017).

In focus groups conducted among women in recovery from OUD, participants highlighted the ways compounding challenges make accessing treatment and entering recovery difficult, as well as the unique hardships encountered by mothers in recovery. They also suggested ways to facilitate care and support for recovery: fostering supportive communities of women, improving the availability of gender-specific resources and support, and providing comprehensive, individualized recovery services. Further research is needed on implementation strategies to integrate these suggestions into treatment and recovery settings. Moving forward, it is critical that the lived experiences and hard-won victories of women in recovery are directly translated into action to address the inequities that currently exist for women in OUD treatment and recovery settings.