Interested in working with us?

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1 Interested in working with us? Our patient survey data collection is ongoing ANONYMOUS survey of opioid using women in treatment, ages All participants receive $20 for time and effort Survey is completed on computer tablets, a member of our research team will come directly to your facility location to administer surveys on agreed upon day/time If you think your substance use treatment program or facility is interested in getting involved, please contact me by phone or . Roxanne Harfmann, Study Coordinator harfmann@med.umich.edu Phone: (989)

2 Barriers to Reproductive Health Services for Women with Opioid Use Disorders in Substance Use Treatment Roxanne Harfmann, B.A. Research Coordinator University of Michigan OB/GYN

3 Program on Women s Healthcare Effectiveness Research Research focused on: Women s healthcare policy Reproductive health curricula Access to women s healthcare in US and Globally

4 Goals of Presentation Describe epidemiology of reproductive health service use for women in substance use treatment Brief description of mixed methods, qualitative and quantitative research Explain perceived barriers and facilitators to integrating reproductive healthcare to substance use treatment programs

5 Outline of Presentation Reproductive Healthcare Scope of services Disparities among women with substance use disorders Our Research Methods and results Discussion Questions

6 Reproductive Healthcare Pregnancy testing HIV/STI testing and treatment Domestic violence screening Provision of contraception Abortion care Pap smears/cervical cancer screenings

7 Unintended Pregnancy In the US: 45% of all pregnancies are unintended (2011) 1 Generates $5 billion in direct and indirect costs on healthcare system In MI: 54% of all pregnancies are unintended (2010) $662 million in costs 1. Finer,

8 Contraception Most unintended pregnancies occur among women who don t use or inconsistently use contraception Low rates of long acting reversible contraception 10% of contraceptive users have IUDs 1% of contraceptive users have implants Publicly supported family planning centers In MI, met 18% of contraceptive needs In US, met 36% of contraceptive needs

9 Sexually Transmitted Infections 20 million new cases of STIs each year in the US In 2013, MI ranked 15 th in chlamydia infections (45,000 cases) 12 th in gonorrhea infections (10,500 cases) 16 th in HIV diagnoses (814 cases)

10 Cervical Cancer Screening Pap smear Screening test for cervical cancer Performed every 3-5 years depending on a patient s age and prior pap smear Human Papillomavirus Family of viruses that causes genital warts and cervical, anal and throat cancers Most common STI in the US >80% of sexually active women infected at some point in their lives Vaccine prevents transmission of the most common types that cause warts and cancer ONLY vaccine that prevents cancer In MI, 67% of adolescents years old had received the vaccine (2015)

11 Opioid Use and Women Disproportionate impact on women More likely to have chronic pain More likely to be prescribed painkillers More likely to be given higher doses and for a longer time period Less likely to be screened by health professionals As a result: Dramatic increase in overdoses, perinatal use 500% in treatment admissions CDC 2014, Darnell 2012, Volkow 2014, SAMHSA TEDS 2014

12 Opioid Use Disorders and Reproductive Health Higher Rates Unintended pregnancy Adverse perinatal outcomes Lifetime prevalence of abortion Sexually transmitted infections Gender-based violence Sex work Lower Rates Contraceptive use Cervical cancer screening 1. Heil, Black, Finer, Armstrong, Jones, Stanhope, Terplan 2015

13 Importance of Reproductive Healthcare for Women with Substance Use Disorders Preconception care and pregnancy prevention Pregnancy care Encouraging safe sex behaviors Screening and treatment for STI s Cervical cancer screening

14 Importance of Reproductive Healthcare for Women in Substance Use Treatment Opportunistic time Women in substance use treatment already interacting with healthcare system Lost opportunity once out of treatment

15 Research Question What are the barriers and facilitators to reproductive healthcare among women with opioid use disorders engaged with substance use treatment in Michigan?

16 Objectives 1) To describe what reproductive health services are currently available for opioid using women in substance use treatment 2) To examine providers; perspectives on the needs for and barriers to reproductive health service for opioid using women 3) To examine opioid using women's self reported needs for and access to reproductive healthcare

17 Methodology Quantitative data: Can be measured Written down with numbers eg. Survey responses, electronic health record data Qualitative data: Not numerical in nature eg. In-depth interviews excerpts, narratives, anecdotes

18 Mixed-Methods Research An approach to research in which both quantitative and qualitative data is collected and integrated Enables comprehensive assessment of current reproductive healthcare of women with opioid use disorders

19 Our Study Phase 1 Facility Service Assessment

20 Phase 1: Facility Service Assessment SAMHSA Treatment Locator 404 Substance use treatment facilities across MI listed Electronic survey link was sent via

21 Questions in the Survey Survey Measures: Facility characteristics Facility services (screening/testing, treatment, counseling and support) Knowledge/beliefs about reproductive health Patient and staff demographics

22 Phase 1: Facility Service Assessment 404 Facilities Identified 49 didn t respond to request 5 declined to participate 350 Sent Survey 97 Responses (representing 113 facilities) 32.3% response rate

23 Results: Phase 1 Medical Services Offered at Facilities Medical Screening Offered n % Screening for hepatitis B Screening for hepatitis C Screening for HIV Screening for STI's Pregnancy testing Screening for Tuberculosis Formal Referral Agreements n % A federally qualified health center A hospital A medical clinic A reproductive health provider Other 4 12 Exam Room 27% report the presence of an exam room where gynecologic exams could be performed

24 Results: Phase 1 IMPORTANCE OF SERVICES FOR WOMEN IN TREATMENT Tobacco cessation counseling Domestic violence screening Education on safe sex practices Cervical cancer screening Pregnancy testing Contraception Prenatal care Access to abortion care Important 59.2 Not Important 40.8

25 Results: Phase 1 WILLINGNESS TO PROVIDE REPRODUCTIVE HEALTH SERVICES Pregnancy testing STI Testing/Treatment HIV testing Domestic violence screening Pregnancy prevention education/counseling Provision of contraception Referral to reproductive health provider Referral for abortion Already Provide Willing Don't Know Not Willing

26 Importance Provision Pregnancy Testing 84% Pregnancy Testing 27% Contraception 78% Contraception 9% Education on Safe Sex 91% Prenatal Care 86% Pregnancy Prevention Counseling/Education Referral to Reproductive Healthcare Provider 24% 39% % of facilities that indicated service is important % of facilities that indicated service is provided

27 Willingness of Facilities to Provide Reproductive Health Services Of the facilities that do not currently offer services: 62% are willing to provide pregnancy testing 58% are willing to provide contraception 75% are willing to provide pregnancy prevention counseling and education 84% are willing to refer patients to a reproductive healthcare provider

28 BARRIERS TO OFFERING REPRODUCTIVE HEALTH SERVICES FACILITY CHARACTERISTICS BARRIERS Limited clinic space Lack equipment COST BARRIERS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Reimbursement concerns STAFF BARRIERS 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Staff lacks training Limited time Staff opposition % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Agree Neutral Disagree

29 Our Study Phase 1 Facility Service Assessment Phase 2 Provider and Patient Interviews

30 Phase 2: Interviews with Patients and Providers 29 interviews conducted at 4 different facilities in MI 12 providers, 17 patients Averaged 15 minutes Interviews were semi-structured Interview guide, but no order Other questions may be asked, interviewer lets discussion flow freely

31 Phase 2: Interviews with Clients and Providers Interviews were transcribed into text format for analysis Three categories for topics covered in interviews: 1. Barriers to reproductive health services while in treatment 2. Facilitators to reproductive health services while in treatment 3. Preferred models of reproductive healthcare

32 Phase 2: Results Themes Identified: 1. Barriers to reproductive health services for women in treatment 2. Interest in integration of reproductive health services into substance use treatment

33 Phase 2: Fear of Stigma/Mistreatment We have had clients who hid things from us because they don t want the stigma or the assumptions to be made. -Provider All we are asking for is to be treated like you would treat anybody else. We have an illness, just like a diabetic and you wouldn t kick somebody off of their insulin because they were out eating Krispy Kreme donuts. It reinforces the stigma I already felt within myself. -Patient

34 Phase 2: Health Care is a Low Priority for Women with Active Substance Use The desire isn't there because their addiction is so encompassing. They are not paying attention to their kids, not paying attention to their jobs, and [health care] is a real low priority for them. -Provider It s not a priority to get treatment from a doctor when you are using. Your main priority is hustling and getting high. -Patient

35 Phase 2: Child Protective Services You would almost have to offer [reproductive health care] on the street because they are not going to walk into a clinic; they know that if they are using, there is a chance they are going to lose that child -Provider You are constantly afraid of CPS and your kids are going to be taken away from you, so you are not going to say the truth. It s not because people are trying to be deceitful, just because you are addicted to opiates, but it doesn t mean that you want your children just ripped out of your arms. -Patient

36 Phase 2: Integration of Care Well, I think in a perfect world, this clinic this outpatient clinic would be part of a physical health care clinic so it could all happen right here, in the same place. Definitely. Because then women wouldn t have to go from one place to another; it could all happen right in the same place. The doctors and the therapists could all talk to each other. There would just be a lot more coordination. -Provider [Women in treatment] are afraid to get tested [for STIs] to find out if something happened during their use. But it s part of being healthy and clean, getting your life back on track and dealing with what might have happened. In here is a perfect place to deal with that if something does come up and you are in a safe environment and people care and they can get you literature and help you deal with it. So I think it s a great idea. -Patient

37 Our Study Phase 1 Facility Service Assessment Phase 2 Provider and Patient Interviews Phase 3 Patient Survey

38 Phase 3: Patient Survey Qualified participants are: Women currently in treatment for opioid use disorder years old English-speaking Anonymous computer-assisted self-interview on tablet at facility Data collection ongoing 200 responses collected at 20 facilities across MI

39 Phase 3: Preliminary Demographics of Surveyed Opioid Dependent Women Average age - 33 years old 86% identify as white 45% indicate unemployment 76% have Medicaid 85% are mothers

40 Phase 3: Adverse Reproductive and Mental Health Outcomes Reproductive Health History (n=142) Percent Sex for money/drugs 55 PID 20 Hepatitis C 24 HIV/AIDS 1 Obstetric History (n=132) Percent Miscarriage 40 Abortion 41 Stillbirth 8 Unintended pregnancy 67 Mental Health (n=147) Percent H/o intimate partner violence 82 Positive PTSD screen 51 Depression 81 Anxiety 84

41 Phase 3: Low Use of Contraception Current Contraceptive Use Sterilization 13% IUD 15% Implant 8% No 61% Yes 39% Injection 13% Pill/patch/ring 19% Condoms 11% *46% reported dual method use with condoms Withdrawal 8% Other 11%

42 Phase 3: Multiple Barriers to Accessing Reproductive Care Barriers to Reproductive Health Percent (n=147) Cost 40 Stigma/fear of mistreatment 35 Fear of results 26 Fear of CPS 23 Lack of transport 23 Don t know where to go 21

43 Phase 3: Desire for Integration of Services within Substance Use Treatment Programs Integration of Services (n=141) Percent Currently Receiving Percent Interested in Receiving Pregnancy testing Birth control services Prenatal care STI testing/treatment HIV testing Abortion 14 32

44 Putting It All Together Facilities Importance of RH Few services or referrals provided for RH Willing to provide/refer Significant barriers exist Providers Recognize importance of RH Barriers to RH stigma, preoccupation with use, CPS, cost, access Interested in integration Patients Unmet RH needs Barriers to RH stigma, preoccupation with use, CPS, cost, access Interested in Integration

45 Discussion Integration of Services Interest and willingness from stakeholders Need to address infrastructure, cost, and other barriers Importance of Family Motherhood and addiction Role of CPS Policy implications

46 Discussion Does this research resonate with your clinical work? What do you think you can do in your treatment program?

47 Discussion Share a time when a patient s substance use treatment and reproductive healthcare came together.

48 Discussion How do you feel about integrating reproductive health care into your treatment program?

49 Questions?

50 Interested in working with us? Our patient survey data collection is ongoing ANONYMOUS survey of opioid using women in treatment, ages All participants receive $20 for time and effort Survey is completed on computer tablets, a member of our research team will come directly to your facility location to administer surveys on agreed upon day/time If you think your substance use treatment program or facility is interested in getting involved, please contact me by phone or . Roxanne Harfmann, Study Coordinator harfmann@med.umich.edu Phone: (989)

51 Results Facility Characteristics Primary Focus n % Substance Use Mental Health Mix of Mental Health/Substance Use General Health Other Organization Private, for-profit Private, non-profit State gov't Local/county gov't Tribal gov't Federal gov't Other Payment for Services n % No payment accepted Cash or self-payment Medicare Medicaid Federal military insurance Private health insurance Federal/state/local funding Other Religious Affiliation Opioid Treatment Program