Opioid Addiction in Women Is Growing at Alarming Rates—What Accounts for the Increased Risk?

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Cassidy Webb was 17 when she got her wisdom teeth removed. As is common after a wisdom tooth extraction, she was prescribed hydrocodone—the generic form of Vicodin—to help her manage the pain. But for Cassidy, it was the spark that ignited an opioid addiction. "I fell in love with it immediately," she says. "It helped me slow down and relax."

Taking opioids for even three consecutive days significantly increases the likelihood of chronic use, according to the CDC. And that was true for Cassidy. After her prescription ran out, she complained to her doctor that her teeth hurt and got a refill. And when that ran out, she spent the next year buying pain meds illegally. "I went off to college and I started doctor shopping. I found a doctor who would give me pain medications every month," she says. "I would just tell him I had bronchitis." She ultimately started selling weed to have the money to buy opioids illegally—including heroin, which she had started injecting less than two years after getting her wisdom teeth removed.

"All my money went to drugs," Webb says. She had started college with a full-ride scholarship to study chemistry, but all her attention went to fueling her addiction. "I kept using for two years and it reached a point where I had lost the will to live," she says.

She eventually decided to intentionally overdose. "I told myself that if I did wake up, I would get help," she says.

Fortunately, Webb did indeed wake up, in the hospital, and decided to leave her home state of Arkansas and go to an in-patient treatment facility in Florida to deal with her addiction. She says that the withdrawal was miserable (she had shakes, cold sweats, and vomiting for several days straight), but the worst part was the mental aspect. "I just wanted to continue to get high," she says.

"I found a doctor who would give me pain medications every month. I would just tell him I had bronchitis."

Now, she's been sober for over a year and works for Recovery Local, a non-profit that provides resources to people struggling with drug and alcohol abuse. "There’s a stigma around addiction and everyone wants to know if it’s a choice or if it’s a disease," Cassidy says. "And I would say, if I had a choice, I would have never stuck a needle in my arm. That mental obsession was so strong."

Webb's experience is far from uncommon, especially for a woman her age. Americans now have a one in 96 chance of dying from an opioid overdose, surpassing the likelihood of death caused by a motor vehicle crash for the first time ever, according to the National Safety Council. A 2018 report released by Plan Against Pain (a consumer education platform funded by Pacira Pharmaceuticals) surveyed nearly 90,000 women ages 18 to 64 who were prescribed opioids following surgery. And the demographic found to be most at risk of developing an addiction, according to the report? Millennial women. Persistent opioid use among women aged 18 to 34 spiked 17 percent from 2016 to 2017 while use among all other age and gender groups declined. The report also found that women who were prescribed opioids after surgery were 40 percent more likely than men to become "newly persistent" users—defined as individuals who were still getting an opioid prescription 90 to 180 days after surgery.

Men may seem like the face of the opioid crisis, says Samantha Arsenault, the director of national treatment quality initiatives for Shatterproof, an addiction awareness non-profit. "Men do use illegal drugs at higher rates than women and their opioid overdose rate is higher than women," she says. But a 2017 white paper released by the Substance Abuse and Mental Health Services Administration revealed that the rate of women dying from a prescription opioid overdose grew nearly 500 percent between 1999 and 2015. That's over twice as much as that of men, which rose 218 percent during the same period. (For context, the CDC estimates that 219,000 Americans have died from prescription opioid overdoses between 1999 and 2017).

So that raises the question: What's making women turn to prescription painkillers in such growing numbers?

chronic pain opioids
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Women have unique risk factors for opioid addiction

Opioids work by binding to receptors in your body to block feelings of pain. They also prompt your body to release dopamine, which creates a relaxed, euphoric feeling. They're prescribed for certain conditions (post-surgery care, cancer, traumatic injuries) because they're effective at dealing with moderate and severe pain. But if abused or taken for long periods of time, your body develops a tolerance, meaning you need a higher dose in order to feel the same pain-relieving effects. You also develop additional pain receptors, says Paul Thomas, MD, author of The Addiction Spectrum, potentially becoming more sensitive to certain kinds of pain—and making it even harder to wean yourself off the drug.

Even taking opioids for a short period of time can be risky, because it can take as few as seven to 10 days for the body to become dependent, says Kevin Gilliland, PsyD, a licensed clinical psychologist and the executive director of Innovation360, an outpatient counseling service that works with people struggling with substance abuse. And for women, it might take even less time to develop an addiction. There is some evidence that women can become more dependent on opioids more quickly than men, likely due to physiological differences (metabolism, body fat composition, and hormonal shifts) that make them more susceptible to addiction.

It can take seven to 10 days to become addicted to opioids. For women, it might even take less time.

These reasons (the scary tolerance build-up, increased pain receptors, and women's increased propensity for opioid addiction) make it particularly worrisome that opioids are often prescribed to treat chronic pain—and indeed, experts agree the practice is one of the biggest drivers of opioid addiction in women. According to the CDC, 20 percent of US adults (a whopping 50 million people) suffer from chronic pain—persistent pain that lasts for months or years, often the result of an old injury or a disease like arthritis or fibromyalgia—and women are more likely to suffer from chronic pain than men. "Because of that, women make up a greater proportion of total prescription opioid use," says Arsenault, "and women are prescribed opioids at higher doses and for longer periods of times than men."

And then, of course, there are the surgeries that only people with uteruses get—like c-sections, hysterectomies, and uterine fibroid surgeries that result in serious pain where opioids are needed but often over-prescribed. One 2017 study found that women are given twice as many opioids after a hysterectomy than they actually need. On average, patients were given 40 pills when they only used about 18. Having a bottle still half-full of Oxy makes it more tempting to take them, even when an over-the-counter painkiller like Tylenol will do. 

opioids mental health
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Where mental health comes in

And it's not just physical health conditions that are putting women at a disproportionate risk of opioid addiction. "Women are twice as likely to suffer from depression and two to three times higher in terms of their rates of anxiety," Arsenault says.

The connection might not seem immediately clear—after all, people aren't prescribed opioids to treat depression. But the numbers don't lie: The 16 percent of Americans who have mental health disorders receive over half of all opioids prescribed in the United States, according to a 2017 study released by Kaiser Health News. The researchers estimate that among the 38.6 million Americans with mental health disorders, 18.7 percent (7.2 million) use prescription opioids.

However, the reason why there's a link between opioid abuse and mental illness isn't completely clear. Dr. Gilliland says that sometimes people who have mood disorders turn to pain meds off-label to manage their mood. A person's depression could also be the result of their physical pain (30 to 50 percent of people with chronic pain also suffer from depression). There's also evidence that taking opioids can make you feel depressed, regardless of pain levels. It's essentially a chicken-or-the-egg type situation, but the association is there.

So, what's the solution?

All of this can sound pretty overwhelming (and downright terrifying), but here's the encouraging part: You have more power than you think. If becoming dependent on pain medications is something that concerns you—or if you're in recovery—all the experts interviewed for this article say it's important to have an open conversation with your doctors about it from the get-go. For example, you might not think it's worth mentioning to your dentist or doctor that you have a history of struggling with depression, but that information could prompt them to take another route when it comes to pain management. "I know a dentist who performs a lot of surgeries and he uses Tylenol and Advil instead of opiates," Dr. Gilliland says.

Arsenault says many doctors don't ask about mental health or a history of past opioid abuse when prescribing, so it's important to bring it up yourself. Webb holds herself accountable by bringing someone from her recovery group with her to any doctor appointments where a pain medication might be prescribed. "That way, if I don't bring it up myself, I know they will," she says.

"Our culture is to just take a pill and there are a lot of alternatives to pain management that are really effective." —Kevin Gilliland, PsyD

Dr. Thomas says that if you don't have a history of addiction, you should also talk to your doctor about how you can be mindful when taking your medications. He says it's important to gauge your own pain threshold (judging whether you really need the Vicodin or whether your OTC painkiller will cut it) and to not take prescription pain killers for more than a couple days if possible. "You can also talk to your health-care provider about other alternative methods to pain medication" to see if they may be a fit for your scenario, he says. "Many people choose to turn to meditation, acupuncture, herbal support, or other holistic practices for treatment instead for both acute pain and for ongoing chronic pain."

Arsenault also recommends exploring alternatives to painkillers first, especially when it comes to chronic pain, although she acknowledges that it's often easier to get a prescription filled than it is to take time off of work for physical therapy. But she staunchly believes that it is a safer and more effective way to treat chronic pain. Drs. Thomas and Gilliland concur. "Our culture is to just take a pill and there are a lot of alternatives to pain management that are really effective," Dr. Gilliland says. "The US over-consumes pain medications compared to other countries."

This is where the health-care industry needs to be changed, says Arsenault. "Insurance coverage to manage pain should be increased for those therapies to make sure people are not financially pushed in the direction of taking an opioid instead of these alternatives," she says. She also says workplaces should be more understanding when it comes to taking time off to attend PT, acupuncture, or other appointments. "Our whole culture really needs to shift on a greater scale," she says.

All the experts maintain that pain medication is not inherently bad; there are times when it's the fastest and most effective method for treatment. "If you have acute pain, opioids are great for that. But they are not effective for long-term pain treatment," Dr. Gilliland says. "If you have legitimate acute pain, it's okay to take pain medication, but the problem is we aren't told how to take them responsibly, [explained] the dangers, or are even asked, 'Hey, have you ever struggled with mood or anxiety issues?' All they ask about is pain, and that's some of what we have to change."

This piece was originally published on January 10, 2019. It was updated on January 15, 2019.

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