Ethical Issues in Providing and Promoting Contraception to Women with Opioid Use Disorder

Abstract

Women with opioid use disorder (OUD) face unique challenges meeting their reproductive goals. Because rates of unintended pregnancy in this population is almost 80% rate¹, there has been a push to increase contraceptive uptake among reproductive-aged women with OUD. The patient level ethical issues of such initiatives, however, are often overlooked. This review discusses the ethical issues in two realms: obtaining contraception when it is desired and avoiding contraceptive coercion when contraception is not desired. It is important that access to reproductive education and care be improved in order to ensure autonomous decision-making for women with OUD. However, it is also necessary to be mindful of the history of oppressive and coercive contraception and sterilization policies in the United States. These policies have left a legacy of mistrust and continue to manifest in the form of more subtly-oppressive policies in contemporary medical practice today. Such policies also point to the ongoing stigmatization of and implicit biases held against women with OUD. Thus, based on these ethical issues, solutions are suggested at the clinical, systemic, and societal levels.

Introduction

The US opioid epidemic began with the rise in opioid prescription rates in the late 1900s. This increase was predated by a paradigm shift in the way pain was conceptualized and treated. Prior to the 1970s, pain was often discounted by medical professionals². The pendulum swung in the opposite direction, however, in the late 1900s with pain being over-emphasized and over-treated after numerous societal and policy-level changes³. One of the main drivers of this shift was the declaration of pain as a fifth vital sign by the American Pain Association⁴ and the subsequent requirement by the Joint Commission for strict standards of pain management⁵. This emphasis on pain treatment, the concomitant approval of opioid use for chronic, non-cancer pain, and the downplaying of the addictive potential of opioids catalyzed increased rates of prescribing with a concomitant increase in the number of pills per prescription⁶. The rates increased so drastically that in 2012, “there were 259 million prescriptions written for opioid pain relievers in the US - more than one for every American adult”⁷. Once introduced to prescription opioids, people often turn to its cheaper, more widely-available, and injectable form, heroin. In 2018, 80% of people who used heroin first used a prescription opioid⁸. Thus, increasing rates of prescription opioids are also associated with increasing rates of heroin usa and overdose⁹.

The use of opioids can lead to the development of opioid use disorder (OUD), a chronic disease characterized by problematic use of opioids¹⁰. While people from all races, backgrounds, locations, and socioeconomic statuses have been diagnosed with OUD, some trends in characteristics of people with OUD have been identified. In 2010, 90% of those entering addiction treatment programs were white, most were women, and a large portion were from middle class backgrounds and rural areas¹¹. One study revealed that reproductive age women represented approximately one third of nonelderly, uninsured people using heroin, prescription opioids, or both¹².

This review focuses specifically on women with OUD and the unique challenges they face regarding their reproductive and contraceptive choices. Importantly, we use the term “women” in an inclusive sense to represent all people with pregnancy potential though are mindful that much of the data on the subject has not necessarily been gender-inclusive. We have chosen this language intentionally as it also replicates the terminology used in the empirical studies we cite, since we cannot confirm their gender inclusivity. We first review the background and clinical context of the impact of OUD on mothers and their babies, and recommendations for women with OUD who do not want to get pregnant. We then outline the ethical issues surrounding contraception for women with OUD.

Preventing unintended pregnancy among women with OUD by promoting contraception is widely discussed within public health spheres, yet the ethical implications of initiatives that promote contraception, especially as they relate to coercion and stigmatization, are often not explored. Thus, we aim to fill this gap by using a reproductive autonomy lens to discuss two types of ethical issues women with OUD face: 1) issues of access to contraception when it is desired and 2) issues of coercion when contraception is not desired. Finally, we propose potential solutions to the outlined ethical issues on three levels: clinical, systemic, and societal, with a focus on justice-based solutions.

Background & Clinical Context

With a substantial population of reproductive-age women using opioids, it is critical to recognize the unique reproductive health challenges women with OUDs face. It is estimated that 70–80% of pregnancies in women with opioid use disorder are unintended¹³, compared to 45% in the general population¹⁴. Within the unintended pregnancy general category, it is important to note, however, the distinction between mistimed and unwanted pregnancies. Mistimed pregnancies are unintended pregnancies in those who wanted to become pregnant in the future but not at the time they conceived, while unwanted pregnancies occur in those who did not want to become pregnant at all¹⁵. Further, it is also important to recognize that unintended pregnancies are challenging to quantify; conflate pregnancy planning, intention, and decision to continue the pregnancy; and may confer value-laden judgements regarding these personal and complex attributes of reproduction¹⁶. For the purpose of this review, we refer to unintended pregnancies more generally as a public health measure used by others, while recognizing the call to shift away from this indicator towards a more nuanced understanding of pregnancy planning, intention, and the decision to continue (mistimed) versus not continue (unwanted). Similar to the general population, not all unintended pregnancies in women with OUD are unwanted¹⁷ and women with OUD who want to get pregnant should be supported with patient-centered care aligned with their own goals.

In the past three decades, opioid use during pregnancy has increased four-fold¹⁸, with 20% of pregnant women filling an opioid prescription¹⁹. The increasing rates of opioid use during pregnancy have led to an increased prevalence of maternal and infant morbidities, such as preterm birth, growth restriction and neonatal abstinence syndrome ²⁰. Neonatal abstinence syndrome is a condition that results from the use of certain substances, including opioids, during pregnancy that can have effects on the newborn such as respiratory issues, irritability, problems with feeding, and in extreme cases, seizures and even death ²¹. While there are treatment options for pregnant women with OUD, only 19 states offer substance use treatment programs explicitly intended for treating pregnant women and 13 states prioritize pregnant women for admission into state-funded treatment programs²². As a chronic disease, treatment must be long-term rather than episodic. Thus, even in states where short-term treatment programs are available, 40–60% of women relapse during treatment ²³.

For all people wishing to avoid pregnancy, including women with OUD, contraception is recommended. The recommendation to expand access and education regarding contraception for women with OUD is endorsed by the Center for Disease Control and Prevention (CDC) ²⁴, American Academy of Pediatrics ²⁵, and the American College of Obstetricians and Gynecologists ²⁶. Yet, contraceptive uptake is approximately 25% lower among women who use opioids compared to the general population²⁷. Between 2017 and 2019, 65% of reproductive age women (15–49) in the United States used contraception, with most using sterilization (18%), oral contraceptives (14%), LARCs, including the implant and IUD (10%), and male condoms (8%) ²⁸. In contrast, the most popular contraception method for women with OUD was external condoms ²⁹. While external condoms are essential for preventing STIs, their efficacy in preventing pregnancies is lower than other contraceptive methods.

In a survey studying the contraceptive opinions of women with OUD, over 70% of respondents agreed or strongly agreed that avoiding pregnancy was important to them ³⁰, despite low contraceptive uptake. This inconsistency may be partially attributed to a commonly-held misconception that pregnancy is not possible in the setting of amenorrhea that often accompanies opioid use ³¹. Studies show that when women with OUD are provided education about their pregnancy risk, contraceptive counseling, and free access to contraception, they will overwhelmingly adopt a contraceptive method. In one study, 75% of women who received comprehensive contraceptive counseling and free access to a range of methods ultimately chose long-acting reversible contraceptives (LARCs). However, the incongruency between pregnancy intention and contraceptive uptake for women with OUD should be further explored empirically.

Ethical Issues Surrounding Contraception among Women with Opioid Use Disorder

We categorize ethical issues related to contraception use among women with OUDs into two groups: those related to justice-based concerns that hinder reproductive autonomy by preventing desired contraceptive use and those related to coercion, implicit bias, and stigma that obstruct reproductive autonomy by forcing women toward involuntary contraceptive use.

Accessing Contraception When Desired.

Applying a justice-based framework allows us to examine a variety of barriers to accessing contraception for women with OUD, which may, in part, explain the incongruence between lack of contraceptive uptake and desire not to get pregnant among women with OUD. Examining these barriers provides a deeper insight into the contraceptive behaviors of women with OUD and may help guide policies that promote equitable contraception access. Barriers to contraceptive access generally occur at three different levels: the patient level, provider level, and systems level, although some barriers may overlap across levels.

Patient level factors relate to a patient’s own beliefs and life experiences. Some patient level factors include misconceptions about pregnancy risk, experiences of intimate partner violence, concerns about loss of custody, and difficulty discussing their substance use ³². These factors may prevent women from seeking out care and obtaining contraception. Among patient level factors related to contraception, education about contraception is especially salient. One study among women in treatment for OUD found that about 40% of women were unaware of the superior efficacy of IUDs compared to other reversible methods ³³, suggesting that women with OUD may not have complete and accurate contraceptive information when making reproductive decisions. Other studies show that women with OUD frequently overestimate the costs and risks of using a LARC, while also overestimating the efficacy of other forms of contraception ³⁴. Efforts should be made by clinicians to improve patient education about pregnancy risk, contraception options, and efficacy in order to combat these misunderstandings.

While LARCs and other contraceptive methods may be financially accessible for women with insurance in the US given the comprehensive contraceptive coverage mandate of the Affordable Care Act, women who are uninsured, such as undocumented immigrants, and those with low-income may face significant financial challenges to LARC insertion and removal. The total estimated cost of obtaining and removing a LARC without insurance coverage can be between $400 and $1000 ³⁵. In addition to problems with financial accessibility, physical access to care in order to obtain a LARC remains a challenge, as LARCs require physician consultation and an office visit. Moreover, the provider-dependent nature of LARC insertion and removal can be fear-inducing for some women who may prefer to control cessation of their method themselves ³⁶. Women with unstable insurance or financial situations may be reluctant to use a LARC method if there is a financial barrier to its removal. While financial barriers are not unique to those with OUD, they confound upon the many challenges this population already faces in accessing contraception.

Other barriers to contraception uptake can stem from the provider knowledge and biases. While accessing a provider can be a barrier itself, issues can also arise when providers lack a comprehensive understanding of LARCs or bring their own beliefs and biases into contraceptive counseling. Lack of provider knowledge about LARC efficacy and safety or lack of training or experience in LARC insertion and removal are frequently cited barriers to LARC provision ³⁷. Some providers also have inaccurate perceptions of LARCs, and think that they cannot be used by women who have not had children, right after birth, or after an abortion ³⁸. Such provider beliefs and perceptions have been shown to influence contraceptive decision-making ³⁹. Without comprehensive, accurate knowledge about all FDA-approved contraceptive methods, providers are unable to educate patients and help them make informed decisions that align with their reproductive goals. Further, physicians may harbor biases against those with opioid use disorder that impact contraceptive counseling. In a recent study of women with a history of OUD, one woman reported “ feeling automatically judged because of her tattoos and ‘junkie’ appearance”, while another cited an experience being refused her desired method, tubal ligation, due to her young age ⁴⁰.

Physicians have a responsibility to guide a patient through the informed consent process without allowing their personal biases to interfere with or shape a patient’s decision.

Finally, there are barriers to accessing contraception among women with OUD at a systems level including healthcare accessibility, complicated payment policies, and clinic limitations. With high rates of OUD in rural areas, concerns about accessing providers in general, and specifically providers who are knowledgeable about OUD and contraception can present a challenge ⁴¹. Additionally, navigating the healthcare system, even in non-rural settings, can lead to difficulties obtaining appointments or referrals ⁴² and decoding eligibility for obtaining contraception through the ACA or Title X Act. Lack of understanding the nuances of payment policies can pose as a barrier to contraception, even when contraceptive care can be funded by the government ⁴³. These systems level challenges require high-level solutions that address healthcare access and funding.

Overall, the wide variety of barriers to contraceptive access among women with OUD highlights the restrictions on reproductive autonomy that these women likely face. Efforts to reduce patient-, physician-, and systems level barriers may aid in promoting reproductive justice and allowing women with OUD to make their own decisions about their reproductive lives.

Avoiding Contraceptive Coercion When Contraception Is Not Desired.

The United States has a history of coercive and oppressive contraceptive policies that must be understood as a backdrop to current issues in the quality of contraceptive care for women with OUDs. Many of these policies were driven by the eugenics movement, which aimed to reshape the composition of the US population by promoting the reproduction of those deemed the “fittest” while repressing the growth of “unwanted populations”, often disadvantaged minorities, including women of color, women with disabilities, and low income women ⁴⁴. Women with substance use disorders were also targeted, with mandatory sterilization policies for “alcoholics” and “addicts” in place until the 1950s ⁴⁵.

Following the eugenics movement, the US government spread fear about the notion of “crack babies,” or babies born to mothers who used crack cocaine during pregnancy. These babies were described as inhuman, fundamentally damaged, and robotic, and such claims were used to stigmatize, prosecute, and control the reproduction of primarily Black women ⁴⁶. This practice of stratified reproduction, defined as valuing the fertility of some women over others, implemented throughout the eugenics movement and “crack baby” epidemic demonstrate the clear racist, sexist ⁴⁷, ableist, and classist motivations underlying these policies. It is essential to understand current attempts to promote contraception within this historical context to prevent the perpetuation of injustices under the guise of public health improvement.

As part of efforts to promote contraception among women with OUDs, a variety of interventions have been developed and evaluated. These include interventions that increase education about contraception ⁴⁸, co-locate OUD treatment and contraceptive care ⁴⁹, provide telehealth alternatives to in-person care ⁵⁰, and financially incentivize follow-up contraceptive visits⁵¹. While many of these interventions are framed around increasing access to contraception among women with OUDs, nearly all are evaluated solely using measures of contraceptive uptake, with success defined as an increase in contraceptive use. Thus, interventions that promote access to contraception and also allow women who do not want to adopt a method to opt out may be viewed as failures by these evaluation techniques, despite their ultimate success in increasing access and promoting autonomy. Global family planning scholars have criticized this approach to program evaluation, calling for the development of new measures that assess whether women are able to make informed, full, and free choices about their reproduction ⁵². Autonomy-focused measures of contraceptive care are especially important when promoting access to contraception in vulnerable populations that have historically been targeted by eugenics, like women with substance use disorders.

Additionally, studies examining contraceptive use among women with OUDs often focus on LARCs. Given their safety, efficacy, few contraindications, and long duration, LARCs are often viewed as a panacea to unintended pregnancy and reproductive health equity ⁵³ for all women. LARC promotion is particularly prominent among research on women with OUDs, with myriad studies assessing prevalence of long-acting method use ⁵⁴. While long-acting methods should undoubtedly be an option for all women desiring contraception, overemphasizing LARCs and/or underemphasizing other contraceptive options through biased or directive counseling could lead to pressure or coercion. Research demonstrates that biased LARC promotion is most commonly targeted at marginalized women ⁵⁵, with one study reporting that low-income Latin and African American patients were more likely to be recommended an IUD compared to European Americans of the same socioeconomic status ⁵⁶. Charron et al report that emphasis on LARC methods in contraceptive counseling for women with OUDs is especially prevalent ⁵⁷. Unbiased contraceptive counseling that provides women with a plethora of contraceptive options and allows them to choose what fits their own reproductive desires is imperative for all women, including those with OUDs.

Furthermore, because LARC methods are provider dependent and require a skilled provider for removal, promotion of these methods among women who may lack access to care or who are uninsured or financially unstable could lead to issues related to their removal. While no studies have explored LARC removal specifically among women with OUDs, previously enacted state-sanctioned initiatives have created financial barriers to removal for women with Medicaid insurance. One policy, for example, did not allow for use of Medicaid funding for LARC removal among women who intended to get pregnant ⁵⁸. Again, while to our knowledge no similar policy is in place for women with OUDs, there may be instances of provider refusal to remove LARCs or financial barriers to LARC removal that restrict reproductive autonomy.

Finally, some interventions to promote contraceptive use among women with OUDs offer financial incentives, which may constrain reproductive autonomy. Two studies by Heil et al. examined the effects of an intervention which incentivized attending 13 follow-up visits over six months after receiving contraceptive counseling. Women were paid $15 for their first contraceptive visit, with the incentive increasing by $2.50 for each consecutive visit. Both women who initiated contraception and those who did not were eligible for the incentive at each follow-up. The intervention was evaluated by examining contraceptive uptake. The financial incentives in this study pose an ethical conundrum. Women who chose not to adopt contraception but continued to attend follow-up visits for the financial incentive were repeatedly counseled on contraception, more than twice per month if all study visits were attended. In this situation, while women were not explicitly being paid for adoption of contraception, financial incentives may have pressured some women to adopt a method simply because of the frequency and repetitiveness of counseling.

A much more severe example of financial incentives used as a means of contraceptive coercion among women with OUD is Project Prevention, formerly named C.R.A.C.K. (Children Requiring a Caring Kommunity). Project Prevention was founded in 1997 in California by Barbara Harris with the purpose of decreasing the number of pregnancies and births by women with substance use disorders. The program pays women with substance use disorders to either undergo permanent sterilization or adopt a long-term method of contraception ⁵⁹, offering women $300 for a tubal ligation, and $75 for insertion of an IUD along with $100 for a biannual checkup as long as the device is in ⁶⁰. As of April 2021, over 7,500 people with substance use disorder have been paid by this program in exchange for their ability to reproduce ⁶¹.

This program has many common features with the previously mentioned eugenic initiatives of the 1900s. First, they target women with substance use disorders as an “undesirable” population, and promote reducing their rate of reproduction. Although sterilization by this program is not mandatory, offering vulnerable women large sums of money to comply with an initiative is coercive. Financial difficulties may make many of these women vulnerable to such a program without a full understanding of the risks and benefits of forfeiting their ability to reproduce. Additionally, the program perpetuates the stigmatization of women with substance use disorders by propagating the message that these women are not fit to reproduce. This type of messaging wholly embodies and promotes the concept of stratified reproduction. Finally, the actions of Project Prevention reduce the reproductive autonomy of the women involved, as the program makes no effort to present all reproductive options nor does it attempt to educate women on the risks and benefits of certain procedures in an unbiased and honest manner. Overall, Project Prevention is an unethical, coercive, and eugenic-based initiative that demonstrates how stigmatization and reduction of autonomy for people with substance use disorders still endures in programs today.

While Project Prevention is a particularly stark example of coercive practices to prevent women with substance use disorder from reproducing, more subtle restrictions of reproductive autonomy, like promotion of contraception to everyone regardless of contraceptive desires, LARC-first counseling approaches, and incentives for attending follow-up visits, are also problematic. Future research exploring how biased or directive contraceptive counseling may influence decision-making among women with OUD and evaluating contraceptive access interventions used autonomy-based indicators would fill an important gap in the literature.

Looking at solutions from a social justice perspective requires an awareness of what may constitute as a coercive or discriminatory policy. Policy makers must combat “entrenched views that women who use substances during pregnancy are unfit to be mothers” ⁶², and instead focus on listening to what women in these populations need and find solutions based on their suggestions, rather than on paternalistic assumptions. Taking on the perspective of the reproductive justice movement, which “calls for family planning services that support each woman in identifying her family planning priorities and adopting the method that best meets her current needs” ⁶³, can be helpful for guiding policy making decisions in an ethical and equitable way. It is also important not to lose sight of the fact that decisions surrounding contraception, family planning, and sexual activity are deeply personal⁶⁴, dependent on each individual woman’s values and goals, and should not simply be viewed as metrics of public health. Rather, health care that aims to reduce the gap between a patient’s informed goals of care and the actual care received should be prioritized, measured, and achieved.

Solutions

Many ethical issues arise in the promotion and provision of contraception for women with OUD. These include issues of access and distributive justice, which can stem from the patient-, provider-, and systems levels, as well as social justice issues that arise from historical abuses, discriminatory practices, and coerced promotion of contraceptive methods. As a result, it is imperative to develop solutions that promote justice, reduce discrimination, and increase autonomy for women with OUD. This review proposes three levels at which these problems may be addressed: the clinical level, systemic level, and societal level. Each of these levels addresses the problem through a different lens, allowing for a comprehensive solution that goes beyond the surface, while assigning guidelines for change to various agents involved.

On the clinical level, providing proper, patient-centered contraceptive counseling through a shared decision making process ⁶⁵ could substantially resolve many central tensions of this dilemma. One of these tensions is that of clinicians may heavily promote LARCs to further the public health goal of reducing unintended pregnancy rather than valuing the patient’s autonomous decision about their own contraception, recognizing that the efficacy of a method may not be the woman’s top priority ⁶⁶.

Numerous leaders in the field of patient care have published recommendations for how to provide effective contraceptive counseling that respects the patient and their autonomy, while also guiding the patient towards a choice that is in line with their lifestyle goals, preferences, and reasonable expectations.

The first of these guidelines centers around developing a trusting and respectful relationship with the patient ⁶⁷. While recommendations on the specific avenues for building this type of relationship vary, they include discussing various contraceptive options ⁶⁸, focusing on patient preferences ⁶⁹, addressing side effects and risks ⁷⁰, and cultivating a compassionate and nonjudgmental mindset and communication style ⁷¹. Some have even recommended a more straightforward approach to combatting mistrust by directly discussing historical attempts of reproductive coercion with patients who may have this concern ⁷².

The second guideline highlights the importance of providers recognizing and addressing their implicit biases ⁷³. While in an ideal world, clinicians would be free of their own biases, we recognize that healthcare providers are human and inevitably will hold biases. While they may exist, they must not permeate the provider’s practice and professional advice. Before counseling patients, providers must self-assess for the implicit biases they hold, such as their personal contraceptive preferences, and be prepared to recognize and place the patients’ preferences before their own ⁷⁴. In practice, this means not making assumptions for patients on the basis of their background or condition, in this case – OUD. Yee and Simon recommend that clinicians utilize a standardized process for learning about the values and preferences a patient may hold in order to reduce potential implicit biases ⁷⁵. Recognizing implicit bias in contraceptive counseling can aid in resolving the current disparities in the recommendation rates of LARCs, can assist with the first guideline of building a trusting relationship, and is essential to providing care in line with reproductive autonomy and justice ⁷⁶.

The final recommendation for contraceptive counseling is taking on the role of an educator as the clinician and presenting accurate, unbiased, information about various options, and addressing potential misconceptions ⁷⁷. The provision of accurate information facilitates the shared decision making process, as conversations centered around facts and patient preferences can allow the provider to give their own input without seeming coercive. Studies show that many women underestimate the risk of getting pregnant from unprotected sex, emphasizing the importance of providers eliciting the patient’s understanding of risk and addressing misconceptions if they exist. In addition, providers should also be sure to educate patients on proper usage and address any potential barriers to consistent and correct use ⁷⁸. Overall, providers fulfilling their roles as patient educators facilitates respectful shared decision making and ensures the validity of the patient’s informed consent.

Issues like accessibility and legality need to be addressed on a more systemic level. One way to increase access to contraception for women with OUD is integrating contraceptive services into drug health clinics ⁷⁹. This would allow women to access multiple services in one location and would reduce the burden of finding a clinician and setting up appointments on their own. Additionally, it would offer a less threatening environment, where women with OUD might have reduced fears of stigmatization, leading them to be more open with their providers. Further, integrated services could be especially helpful for women with a history of sexual abuse, which is more prevalent among women with substance use disorder compared to the general population ⁸⁰. The integration of services is not limited to only drug health clinics, but could also be extended to other locations where there are high rates of OUD, like needle exchange programs or prisons ⁸¹. A study by Robinowitz et al. demonstrated that both the women visiting substance use clinics and the staff working there favored the idea of integrating family planning services into their location ⁸². Of note, evaluations of colocations interventions have focused exclusively on contraceptive uptake, and the effects of such programs on contraceptive autonomy have not been assessed.

Examining and correcting the ways the legal system addresses women with OUD is another systemic solution that could lead to promotion of reproductive autonomy among women with OUD. Laws in the US punish and criminalize pregnant women with substance use disorders instead of rehabilitating them. The prosecution of substance use during pregnancy dates back to 1989 with the case of Jennifer Johnson, who was the “first woman in the United States to be criminally convicted for exposing her baby to drugs while pregnant” ⁸³. Since then, eighteen states have made it possible to prosecute women for substance use during pregnancy or to characterize it as criminal child abuse ⁸⁴. These laws represent a fundamental misunderstanding of addiction that places the blame on the individual and their willpower, rather than recognizing it as a medical condition. Additionally, this view of addiction advocates for criminalization, rather than treatment, as a solution. This approach results in an increased stigmatization of substance use disorders and may lead to women avoiding care or not disclosing their use to providers ⁸⁵. This ultimately will interfere with their ability to explore contraceptive options and cultivate a relationship with their provider that is conducive to the shared decision-making model. Additionally, these policies may be counterproductive; as women with substance use disorders who are uncomfortable seeking care may be less likely to obtain contraception, and more likely to have unwanted pregnancies. These laws have been criticized by all major medical organizations ⁸⁶. Pivoting from this type of legislation and instead focusing on treatment and access to contraception will help women with OUD get the care they need, free of stigma, and in accordance with their own goals. Although more research is needed into what types of systemic changes are effective, other ideas for reducing barriers at this level include reducing the financial burden by ensuring full insurance coverage of contraception ⁸⁷ and making policies surrounding payment easier to understand and navigate.

Finally, solutions at the societal level target these problems from the broadest and widest lens. This perspective requires the examination of factors that lead to OUD in the first place and how they can be addressed to prevent the onset of OUD. Many factors associated with OUD are tied to systemic inequalities, demonstrating how injustice on the societal level can manifest in the form of disorders on a personal level. Some of the structural factors associated with higher rates of women with OUD are elevated unemployment levels, shortages of mental health professionals, and struggling economies. These factors disproportionately affect people living in rural counties, suggesting the need for increased attention in these areas ⁸⁸. Implementing solutions for these problems at the societal level requires a wide-range of solutions, such as promoting or incentivizing job creation and increasing the number of mental health professionals in rural areas. Expanding access to telemedicine for mental health services and providing adequate reimbursement for these services is another way to address these root-cause problems. By promoting equitable access to employment and mental health care, OUD can be targeted from the root, providing a more long term solution to the previously mentioned ethical issues.

Conclusion

The US opioid epidemic has touched the lives of millions of Americans, with an estimated 2 million people currently living with OUD in the US ⁸⁹. Reproductive aged women represent a significant portion of people with OUD. Since this population has high rates of unintended pregnancies ⁹⁰, contraception, and more specifically LARCs, are often seen as a simple solution. However, the ethical issues in providing and promoting contraception to this population are often overlooked and seldom addressed. This review sought to fill that gap by highlighting the ethical issues relating to obtaining contraception when it is wanted and avoiding contraception when it is not desired.

All of these ethical issues ultimately represent hinderances of reproductive autonomy. In terms of obtaining contraception when it is desired, ethical issues arise in barriers to accessing contraception, which occur on the patient, provider, and systems level. Patient level barriers encompass factors like misconceptions, education, insurance, and ability to attend appointments. Provider level barriers include providers biases and promotion of an agenda that is inconsistent with their patients’ goals. Finally, systems level barriers include the accessibility of healthcare providers, complicated policies, and underfunded clinics.

There are also issues on the opposite end of the spectrum, with policies that coerce or even force women to give up their ability to reproduce when they do not want to. The US has historically participated in coercive and oppressive initiatives that have reduced the reproductive autonomy of many marginalized groups. The legacy of these initiatives lives on today in the form of new policies that use public health reasoning to justifying infringing on the reproductive autonomy of women with OUD.

While many interventions focused on promoting contraception among women with OUD are motivated by the reduction of unintended pregnancies, such initiatives become ethically blurry when they focus on contraceptive uptake alone, rather than reproductive autonomy. Reducing unintended pregnancies is only a respectable public health goal when it is achieved by increasing reproductive autonomy.

This review concludes by suggesting solutions that can be implemented on the clinical, systemic, and societal levels. Clinical-level solutions focus on cultivating a strong and trusting provider-patient relationship that is conducive to shared decision-making, with a recognition and addressal of the provider’s implicit biases, and a promotion of a clinician’s responsibility to educate. Recommendations on the systemic level include increasing accessibility through integrated health clinics, same-day services, and abolishing punitive laws that target pregnant women with OUD. Finally, at the widest-sweeping scale, societal-level solutions urge an examination of the root causes of OUD, like economic issues and lack of mental health providers, and recommend the creation of government policies and initiatives that help to alleviate them and ultimately reduce the amount of people with OUD in the first place.

More work needs to be done to study what types of initiatives have the greatest impact in terms of increasing reproductive autonomy. Potential future research could test whether increasing education and access, and reducing implicit bias and coercion, results in higher rates of reproductive autonomy among women with OUD. Additionally, creating new policies that impact women with OUD should consider the ethical implications. Addressing these ethical issues should be a priority for all providers, administrators, and legislators that work with or have an impact on women with OUD in order to help women make reproductive choices in line with their goals, which will also ultimately aid in accomplishing the public health goal of reducing unintended pregnancies in a manner that does not infringe upon reproductive autonomy.