Overdoses, Reproductive Justice, and Harm Reduction

In this issue of AJPH, Kline et al. (p. 991) share essential learnings about the fourth wave of the US opioid overdose epidemic that look beyond national and regional patterns to state-specific variations in these deaths. Their landmark analyses reveal significant state-level heterogeneities in suffering during a sweeping 20-year period, including surging rates of fatal psychostimulant and opioid overdoses in West Virginia and Kentucky after 2015 and exceedingly high rates of cocaine-involved deaths in Washington, DC. Each uptick in overdose rates depicted in the authors’ Figure 1 represents a staggering loss, as communities mourn family members, friends, and neighbors.

Yet, even these geographically refined data are themselves aggregations across heterogeneous subpopulations. We dedicate this editorial to one population living at a particular intersection of race, ethnicity, sex, and life course: non-Hispanic Black (“Black”) pregnant or postpartum people who use drugs (PWUD). These PWUD are fighting to survive at the intersection of two of the gravest 21st-century US public health epidemics: (1) overdoses, and (2) maternal mortality. The United States has the highest maternal mortality rate of all high-income countries, and Black pregnant or postpartum people are approximately three times more likely to die than are their non-Hispanic White (“White”) counterparts.^1,2 Overdoses are a leading cause of maternal deaths in multiple states, particularly in the later months of the postpartum year,³ and the rate of drug-related maternal deaths increased 81% between 2017 and 2020, more than twice the increase in the rate among reproductive-aged women.⁴

Historically, maternal overdose deaths have been concentrated among White people,⁵ paralleling patterns in the general population. This historical pattern is, however, shifting, and in recent years overdose mortality rates among Black people in the general population have exceeded those among White people.⁶ Overdoses are now the fourth leading cause of death among Black women,⁷ and in multiple states maternal overdose death rates among Black pregnant or postpartum people now exceed or equal those among White pregnant or postpartum people.^8,9

Although US public health agencies and community-based organizations have mobilized to curb epidemics of overdoses and of maternal mortality, these mobilizations have been siloed, and pregnant or postpartum PWUD are falling through the cracks. To illustrate, states have formed maternal mortality review committees that are charged with conducting a social autopsy of each preventable maternal death to identify its cause and make recommendations to ensure that this cause drives no future maternal deaths. As recently as 2019, however, multiple state committees still deemed overdoses “not preventable” and thus outside their scope.⁹ Likewise, access to substance use disorder treatment programs offering specialty services for pregnant people remains inadequate (e.g., in 2018, just 23% of substance use disorder treatment programs offered these services).¹⁰

POSSIBLE POLICY DRIVERS

Kline et al. call for research on the role of state policies in driving overdose deaths. A common public health saying is that each overdose is a policy failure. We raise the possibility instead that each maternal overdose among Black PWUD reveals that our racialized capitalist policies are working as intended. To consider this possibility, we meld harm reduction and reproductive justice approaches. Although historically siloed, these approaches are highly complementary (Box A, available as a supplement to the online version of this article at http://www.ajph.org). Complementarities include centering structural drivers (e.g., policies) that interlock to forge complex social positions and to shape distributions of health and disease across these social positions, honoring and analyzing resistance, and conceptualizing research itself as a form of resistance that members of affected communities must guide. Indeed, a community advisory board of people with histories of using drugs while pregnant or postpartum identified select laws, which we describe in the next sections.

Laws Governing Drug Use in Pregnancy

Although public health research and practice neglect pregnant and postpartum PWUD, state lawmakers set their sights on them: 44 states have enacted at least one law governing drug use in pregnancy (Box B, available as a supplement to the online version of this article at http://www.ajph.org). Many of these laws are openly punitive (e.g., laws requiring that health care providers report pregnant PWUD to child protective services). Part of the war on drugs, these laws have roots in the racialized and gendered “crack baby” panic of the 1980s that framed Black women as unfit mothers willing to sacrifice their children to their all-consuming addiction.¹¹

These laws are devastating extensions of reproductive injustices committed during slavery, when slave owners tore families apart by selling Black children as commodities.¹² Then, as now, child removal was inflicted as punishment for “bad” parental behavior. Then, as now, the reach of these reproductive injustices extended far beyond those who actually lost children: the specter of such removals stalked and terrorized Black parents.¹² Consonant with their terrorizing purpose, these putatively race-neutral laws are hyperenforced against Black parents, from obstetricians, who are far more likely to test and report their Black patients for drugs, to child protective service workers, who are far more likely to remove the children of Black parents for drug-related causes.¹³

Research suggests that these removals devastate PWUD: punitive laws governing drug use in pregnancy are associated with a 45% increase in maternal overdoses.¹⁴ Notably, however, research on these ubiquitous policies is still new and rarely focuses specifically on Black pregnant or postpartum people or on resistance strategies they might implement to retain custody or prevent a subsequent overdose.

Abortion Rights

The escalating decimation of abortion rights is similarly intertwined with the war on drugs and may disproportionately increase overdoses among Black postpartum PWUD. Antebellum policies grotesquely conceptualized fetuses—including yet to be conceived fetuses—of enslaved people as property of their White owners that could be willed and inherited separately from the birthing parent.¹² War on drugs era laws governing drug use in pregnancy hew to this legal framework, sacrificing maternal rights—in practice, overwhelmingly Black maternal rights—to fetal personhood. Fetal personhood arguments are, in turn, foundational to antiabortion laws. The resulting escalations in forced birth will fall most heavily on Black people, who have historically exercised their right to abortion more than White people.¹² As Roe v Wade falls, essential research is needed on the impact of racialized erosions to abortion rights—and resistance to these erosions—on Black maternal overdoses, given that Black pregnant PWUD will face severe constraints to exercising this right and that these same PWUD will be at high risk for child removal.

Entitlements

Ongoing racialized and gendered erosions of government entitlements may also drive maternal overdoses among impoverished Black PWUD. The safety net woven in the 20th century to prevent malnutrition and houselessness by Temporary Assistance for Needy Families; the Special Supplemental Nutrition Program for Women, Infants, and Children; subsidized housing; the Supplemental Nutrition Assistance Program; and other entitlements was built to support White families and has systematically abandoned Black families.^15,16 The war on drugs worsened this abandonment, when federal and state governments excluded people with felony convictions, and sometimes specifically drug-related felony convictions, from these protections. These exclusions arose only after racialized criminal–legal systems had hyperenforced punitive drug laws against Black individuals. Given that houselessness and malnutrition create physiological and social vulnerability to overdoses,^17,18 a key but currently unexamined question is whether these exclusions—which are elements of a highly effective policy framework supporting White supremacy—generate overdoses among Black pregnant or postpartum women.

Reproductive justice advocates have successfully sought to extend Medicaid through the postpartum year in many states, and Medicaid is a bedrock of overdose prevention because it covers substance use disorder treatment. Unfortunately, people who are incarcerated for more than a month lose their Medicaid coverage, and many struggle to reenroll upon release. Because of racialized criminal–legal systems, Black PWUD are disproportionately more likely to be incarcerated for prolonged periods. Pressing, but as yet unexamined, questions are whether postpartum expansion reduces maternal overdoses and whether its effects are attenuated among Black pregnant or postpartum people.

CONCLUSIONS

The landmark article by Kline et al. opens new vistas for analyses of state-level heterogeneities in, and thus determinants of, the opioid overdose epidemic’s fourth wave. Reproductive justice and harm reduction approaches demand that this and related research center pregnant or postpartum Black PWUD, who are struggling to survive at the intersection of the ongoing and dynamic opioid overdose crisis, the US maternal mortality crisis, and racialized capitalism.