White Paper: Opioid Use, Misuse, 

and Overdose in Women

This paper was prepared for the U.S. Department of Health and Human Services Office on Women’s Health 

with contract support from NORC at the University of Chicago. 

December 2016
Table of Contents

Executive Summary............................................................................................................................3

Introduction ......................................................................................................................................4

What Does the Opioid Epidemic Mean for Women? ...............................................................................5

Why Was it Critical That This Group Convene? ........................................................................................5

What Does the HHS Opioid Initiative Mean for Women?.....................................................................6

Improving Opioid Prescribing Practices for Women.................................................................................6

Increasing Use of Naloxone for Women................................................................................................. 10

Expanding Use of Medication-Assisted Treatment for Women .............................................................10

Exploring Issues in Prevention: Research and Promising Practices.....................................................12

Biological Pathways to Substance Use Disorder.....................................................................................12

Social Pathways to Substance Use Disorder — Adverse Childhood and Adult Experiences..................13

Social Determinants and Demographics................................................................................................. 14

Geography ............................................................................................................................... 14

Race, Ethnicity, and Socioeconomic Status ............................................................................. 16

Chronic Pain and Pain Management.......................................................................................................17

Alternative Approaches to Opioid Pain Management............................................................. 18

Women as Family Caregivers and Parents..............................................................................................18

Adolescents.............................................................................................................................................20

Older Adults............................................................................................................................................20

Recently Incarcerated Women ...............................................................................................................21

Exploring Issues in Treatment: Research and Promising Practices......................................................21

Unique Needs to Women in Treatment..................................................................................................21

Women as Caregivers and the Impact on Treatment.............................................................................22

Women, Treatment, and the Justice System..........................................................................................22

Child-Friendly and Family-Friendly Treatment Options..........................................................................23

Health Insurance Coverage Issues for Women in Treatment................................................................. 23

Training ...................................................................................................................................................24

Opportunities for Research and Evaluation.......................................................................................25

Approaches and Opportunities for Moving Forward..........................................................................26

Appendix: HHS Work in Support of the Secretary’s Initiative .............................................................27

Centers for Medicare & Medicaid Services (CMS)..................................................................................27

Medicare, ................................................................................................................................ 27

Medicaid.................................................................................................................................. 27

Centers for Disease Control and Prevention (CDC).................................................................................27

Food and Drug Administration (FDA)......................................................................................................28

Health Resources and Services Administration (HRSA) ..........................................................................29
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HRSA/Bureau of Primary Health Care ..................................................................................... 29

HRSA//Federal Office of Rural Health Policy ........................................................................... 29

HRSA/Bureau of Health Workforce ......................................................................................... 30

National Institutes of Health (NIH) .........................................................................................................30

Improved Opioid Prescribing Practices to Reduce Opioid Use Disorders and Overdose: ........ 30

Expanded Use of Naloxone to Treat Opioid Overdose: ........................................................... 31

Expanded Use of MAT to Reduce Opioid Use Disorders and Overdose:.................................. 31

Substance Abuse and Mental Health Services Administration (SAMHSA) .............................................31

Resources........................................................................................................................................33

HHS Resources........................................................................................................................................33

AHRQ Resources...................................................................................................................... 33

ASPE Resources........................................................................................................................ 33

CDC Resources......................................................................................................................... 33

FDA Resources......................................................................................................................... 33

NIH Resources.......................................................................................................................... 33

ODPHP Resources.................................................................................................................... 34

OHAIDP Resources................................................................................................................... 34

SAMHSA Resources.................................................................................................................. 34

Other HHS Resources............................................................................................................... 35

Other Federal Resources.........................................................................................................................35

DOJ Resources ......................................................................................................................... 35

ONDCP/White House Resources.............................................................................................. 35

Other Resources......................................................................................................................................35

References.......................................................................................................................................37
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Executive Summary

This report was developed as part of an initiative supported by the U.S. Department of Health and 

Human Services (HHS) Office on Women’s Health (OWH) to examine the prevention, treatment, and 

recovery issues for women who misuse, have use disorders, and/or overdose on opioids. The White 

Paper was developed with the goal of ensuring that all stakeholders attending a September 2016 HHS 

OWH national meeting started from a shared level of understanding of how the unique aspects of the 

opioid epidemic impact women across age, race, geography, and income levels. To develop this report, 

we conducted a review of the literature focused on topics around opioid use disorders and women, as 

well as consulted with subject matter experts within and outside HHS.

Opioid use disorder is increasing at alarming rates for both men and women in the United States. While 

the epidemic is being addressed at many different levels, much still needs to be done. The prevalence of 

prescription opioid and heroin use among women is substantial. Between 1999 and 2010, overdose 

deaths from prescription pain killers increased more than 400% among women, compared to an 

increase of 237% among men; between 2002 and 2013, heroin use among women increased 100% 

compared to an increase of 50% among men. 1, 2 At the same time, the differences in how it impacts 

women and men are often not very well understood. This paper explores what is currently known about 

the opioid epidemic and describes promising practices for addressing opioid use disorder prevention 

and treatment for women, as well as identifies areas that are less well understood and may warrant 

further study. There is emerging knowledge about the many factors that affect a woman’s path to opioid 

misuse and opioid use disorder, including biological and social influences, past experiences, geography, 

and demographic characteristics, but more needs to be learned about each aspect of this path. As we 

move forward to address the opioid epidemic generally and its impact on women specifically, we must 

evaluate the impact of multiple interventions considering the unique aspects of women across age, race, 

and socioeconomic spectrums. 
Page 4 

Introduction

This White Paper was developed to serve as a starting point for a September 2016 national meeting 

hosted by the U.S. Department of Health and Human Services (HHS) Office on Women’s Health (OWH) 

to examine prevention, treatment, and recovery issues for women who misuse, have use disorders, 

and/or overdose on opioids. This effort builds on the HHS Opioid Initiative aimed at reducing 

prescription opioid and heroin related overdose, death, and dependence.

3

 

Opioids are a class of drugs used to reduce pain. They are often prescribed to treat moderate to severe 

pain, despite their potential for serious risks and side effects. Common opioids include oxycodone 

(OxyContin), hydrocodone (Vicodin), morphine, and methadone. Fentanyl is a synthetic opioid pain 

reliever that is typically prescribed for severe pain, such as advanced cancer; however, the availability 

and use of illegally made and distributed fentanyl is on the rise. Heroin is an illegal opioid, use of which 

has increased across the U.S. among both men and women, most age groups, and all income levels. 

Opioid use has been deemed an “epidemic” in the U.S., as deaths from drug overdose have never been 

higher and the majority of drug-related deaths involve opioids (more than six out of ten in 2014)4

. This

White Paper was originally developed with the goal of ensuring that all meeting stakeholders started

from a shared level of understanding of how the unique aspects of this epidemic impact women across 

age, race, geography, and income. Through that meeting and other activities, OWH is exploring the 

opioid epidemic through the lens of the specific needs of women with the overall mission to: 

• Foster a national conversation on best practices to prevent, diagnose and treat opioid-related 

hazards and death among women in the U.S.; 

• Bridge gaps between researchers and public health practitioners by creating platforms to share 

best practices, promising approaches, and priority questions;

• Consolidate what is already known about opioid use and hazards of opioid-related harms 

specific to women or that are more pronounced among women, as well as the research on 

prevention, diagnosis and treatment of opioid use disorder (OUD) among women; and,

• Explore options for federal, state, and local governments, health insurers, law enforcement, and 

clinicians to address this epidemic of death, disability, and dependence among women. 

To develop this report, we conducted a review of the literature focused on topics around OUDs and 

women, as well as consulted with subject matter experts within and outside HHS. This report begins by 

providing an overview of the opioid epidemic and what it means for women, followed by a description 

of the Secretary’s Initiative and how it specifically relates to women. Issues of prevention and treatment 

are then explored, all with the lens of the unique or pronounced needs of women. We conclude with a 

resource section with links to key information. 
Page 5 

What Does the Opioid Epidemic Mean for Women? 

There is growing recognition that the United States is facing an epidemic due to an increase in opioid 

misuse, use disorders, and overdose, and that disparities exist between men and women with regard to 

both prescription opioid and heroin use. Although between 1999 and 2014 men were more likely than 

women to die of opioid overdoses, the gap in mortality has been closing.

5 Between 1999 and 2010, 

overdose deaths from prescription pain killers increased more than 400% among women, compared to 

an increase of 237% among men.6

 Although nonmedical use of prescription opioids among women has 

generally been decreasing since then,

7 heroin use among women has been increasing, and increasing 

faster among women than among men.8, 9 For example, between 2002 and 2013, heroin use among 

women increased 100% compared to an increase of 50% among men.10

The picture of substance use is different for women compared to men. According to the Centers for 

Disease Control and Prevention (CDC), women are more likely to experience chronic pain and use 

prescription opioid pain medications for longer periods and in higher doses than men.11 Women tend to 

use substances differently than men, sometimes using a smaller amount of drugs for a shorter amount 

of time before they become dependent.

12 For example, a national multisite effectiveness trial suggests 

that women who use opioids not only progress to dependence more quickly than men, but also

experience more cravings than men.13 Psychological and emotional distress have also been identified as 

risk factors for hazardous prescription opioid use among women, but not among men.

14 Many people 

with a substance use disorder may transition to injection drug use; thereby putting themselves at risk 

for viral hepatitis and HIV. Notably, new cases of hepatitis C among women increased more than 260% 

from 2010 to 2014,15 likely increasing the risk of perinatal hepatitis C transmission to their infants.16

Finally, women who are caregivers may face additional barriers to treatment for substance use disorders 

(SUDs), such as lack of childcare.17 

Why Was it Critical That This Group Convene? 

The HHS OWH convened experts and stakeholders to examine issues associated with the opioid 

epidemic through the lens of women’s health. The September 2016 national meeting benefited from 

recent work by federal agencies and other organizations. The meeting provided an opportunity to foster 

a national conversation about best practices in OUD prevention and treatment for women, and 

supported a vigorous collaboration among researchers, public health practitioners, clinicians, policy 

makers, women with lived experience, and others to bring this epidemic to an end. This White Paper 

summarizes what is already known about opioid use and its hazards for women and briefly reviews the 

evidence base for prevention, diagnosis and treatment among women.
Page 6 

What Does the HHS Opioid Initiative Mean for Women?

On March 26, 2015, HHS Secretary Sylvia M. Burwell announced a department-wide initiative focused on 

combatting the opioid epidemic.18 The HHS Opioid Initiative focuses on three priority areas: 

• “Opioid prescribing practices to reduce opioid use disorders and overdose,

• The expanded use of naloxone, used to treat opioid overdoses,

• Expanded use of Medication-assisted Treatment (MAT) to reduce opioid use disorders and 

overdose.”19

In this section, we explore each of the priority areas of the HHS Opioid Initiative from the perspective of 

women and women’s health. 

Improving Opioid Prescribing Practices for Women 

Over the last fifteen years, prescription opioids have been increasingly prescribed to treat acute and 

chronic pain; they have also been increasingly misused and implicated in drug overdose deaths. After a 

sharp increase in the number of opioid prescription filled in the U.S. during the first decade of the 

twenty-first century, opioid prescribing and deaths began to level out around 2012, though each remain 

high (see Exhibit 1).

20, 21, 22, 23, 24 In fact, at least half of all U.S. opioid overdose deaths involve a 

prescription opioid.25 

Exhibit 1: Opioid Sales, Admissions for Opioid Treatment, and 

Deaths Due to Opioid Overdose in the U.S, 1999–2013
Page 7 

The prevalence of prescription opioid use among women is substantial, and the hazards of opioid use 

are similarly great. A 2015 CDC Morbidity and Mortality Weekly Report (MMWR) article found that 

between 2008 and 2012, more than one quarter of privately insured women ages 18-44 and more than 

one third of women of the same ages enrolled in Medicaid filled a prescription for an opioid 

medication.26 The Substance Abuse and Mental Health Services Administration’s (SAMHSA) 2015 

National Survey on Drug Use and Health reported that 4% of females ages 12 and older misused 

prescription pain relievers in the last year.

27 A 2013 Vital Signs report from CDC indicated that “every 3 

minutes, a woman goes to the emergency room for prescription painkiller misuse.” Although more men 

die from drug overdoses than women, the percentage increase in deaths seen between 1999 and 2010 

was greater among women: deaths from opioid pain relievers increased five-fold during that time for 

women versus 3.6 times for men.28 

The March 2016 CDC Guideline for Prescribing Opioids for Chronic Pain summarizes the research 

literature about the benefits and risks associated with prescription opioids, and provides an evidencebased guide for clinicians and patients in shared decision-making about the use of these medications 

(see Exhibit 2) for chronic pain management.29 The CDC prescribing guideline states: “long-term opioid 

use has uncertain [pain management] benefits but known, serious risks.”30

The Guideline acknowledges that prevention, assessment, and treatment of chronic pain are challenges 

for health care providers. The Guideline also reports that patients within certain groups, including 

women, can be at risk for inadequate pain treatment and that patients can experience persistent pain 

that is not well controlled. There are clinical, psychological, and social consequences associated with 

chronic pain – including limitations in complex activities, lost work productivity, reduced quality of life, 

and stigma – that emphasize the importance of appropriate and compassionate patient care. The CDC 

Guideline recommends patients receive appropriate pain treatment based on a careful consideration of 

the benefits and risks of treatment options.31 

Ultimately, although the CDC Guideline focuses specifically on opioids and chronic pain, acute and 

postoperative pain are also important to consider. In fact, Recommendation 6 of the CDC Guideline 

notes that long-term opioid use often begins with treatment of acute pain, stating specifically “When 

opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediaterelease opioids and should prescribe no greater quantity than needed for the expected duration of pain 

severe enough to require opioids. Three days or less will often be sufficient; more than seven days will 

rarely be needed.”32 Some states, including Ohio and Arizona, have developed state specific opioid 

prescribing guidelines for acute pain.33, 34, 35 The Arizona prescribing guidelines include an appendix that 

specifically focuses on considerations of opioid use during pregnancy and among women of childbearing 

age.36 
Page 8 

Exhibit 2: CDC recommendations for prescribing opioids for chronic pain outside of active 

cancer, palliative, and end-of-life care

Determining When to Initiate or Continue Opioids for Chronic Pain

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should 

consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the 

patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic 

therapy, as appropriate.

2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including 

realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh 

risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function 

that outweighs risks to patient safety.

3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic 

benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of 

extended-release/long-acting (ER/LA) opioids.

5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when 

prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing 

dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or 

carefully justify a decision to titrate dosage to ≥90 MME/day.

6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians 

should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than 

needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; 

more than seven days will rarely be needed.

7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic 

pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 

months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize 

other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

Assessing Risk and Addressing Harms of Opioid Use

8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioidrelated harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including 

considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history 

of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug 

monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous 

combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid 

therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to 

every 3 months.

10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and 

consider urine drug testing at least annually to assess for prescribed medications as well as other controlled 

prescription drugs and illicit drugs.

11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with 

buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

* All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care) except 

recommendation 10 (designated category B, with individual decision making required); see full guideline for evidence ratings.
Page 9 

In February 2016, the American Pain Society released a clinical practice guideline similar to the CDC 

Guideline, but focused on post-surgical pain management.37, 38 The American Pain Society’s post-surgical 

guideline includes recommendations to limit use of opioids to manage post-operative pain. The 

guideline also discusses the need for education aimed at correcting misperceptions including “that 

opioids are always required for postoperative pain, or that opioid use inevitably leads to addiction.”39

Although the recommendations do not focus specifically on women, they do include guidance around 

opioid use following cesarean sections, as well as a discussion of the need to educate parents and 

caregivers about issues around post-operative pain management for children, such as assessing pain and 

concern about OUD. 

The Surgeon General also recently launched a national campaign called “Turn the Tide Rx” which 

encourages improved prescribing practices and acknowledges the role of clinicians in addressing the 

opioid epidemic. The campaign seeks to “educate and mobilize prescribers to take immediate action to 

stem the opioid epidemic, provide patients with information to protect themselves and their families 

from opioid misuse and overdose, learn from communities around the country that are finding creative 

ways to tackle the epidemic, and change the cultural perceptions about addiction so that it is not seen 

as a moral failing but a chronic illness.”40 The website, TurnTheTideRx.org, informs providers about 

different treatment options, including a pain treatment toolbox, as well as an educational section for 

patients that discusses different types of opioids and risks associated with their use. The Turn the Tide 

Rx campaign has the potential to improve opioid prescribing practices in general, including for women. 

Prescription Drug Monitoring Programs (PDMPs) are also showing promise as a strategy to improve 

prescribing practices. PDMPs, which are statewide electronic databases that track the dispensing of 

certain controlled substances including prescription opioids to patients, can help prescribers and 

pharmacists identify patients who are at risk for substance use disorders. Evidence suggests that PDMPs

are also effective as clinical support tools and aid in public health surveillance. PDMPs appear to be 

effective in changing prescriber behavior and reducing the number of patients who visit multiple 

providers seeking the same or similar drugs.

41,42,43 Although 49 states currently have established PDMPs, 

not all are mandatory, and uptake is much lower in states where use is voluntary.44 In July 2016, the 

Indian Health Service (IHS) issued a new PDMP policy for all providers who prescribe opioids and who 

work in IHS federally operated facilities. The policy requires providers to check state PDMPs “prior to 

prescribing and dispensing opioids for pain treatment longer than seven days and periodically 

throughout chronic pain treatment.”45 In October 2016, the Department of Veterans Affairs established 

a new policy requiring Veterans Health Administration providers “to query State Prescription Drug 

Monitoring Programs (PDMPs) to support safe and effective prescribing of controlled substances.”46 A 

number of states have similar policies requiring providers to check PDMPs prior to prescribing certain 

medications.47
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Increasing Use of Naloxone for Women

Naloxone is a medication called an “opioid antagonist” used to reverse the physical effects of opioid 

overdose. Specifically, naloxone is administered during an opioid overdose to reverse life-threatening 

depression of the central nervous system and respiratory system, restoring normal breathing for the 

person experiencing the overdose. Naloxone is a prescription medication with no potential for either 

physical or psychological dependence. Although traditionally administered by emergency response or 

hospital personnel, naloxone can be administered by Good Samaritans or minimally trained bystanders, 

such as family and peer networks, which makes it a valuable resource in reversing the epidemic of 

opioid overdose deaths. Good Samaritan and Naloxone Access laws, including laws allowing standing 

orders for naloxone in community pharmacies in many states and tribes, and strong support by HHS for 

its use, are making naloxone more available.48 However, women may not be benefiting as much as they 

could from the expanding availability of naloxone. A 2016 study found that men were nearly three times 

more likely than women to receive naloxone in Emergency Medical Services (EMS) opioid overdose 

resuscitation efforts.49 Reasons for this lower use among women are not well understood. In 2014 and 

late 2015, the Food and Drug Administration (FDA) approved an auto-injector version and a nasal spray 

version of naloxone, respectively. Prior to that, naloxone had previously only been available in less 

consumer-friendly formats, such as with an atomizer device that could spray injectable naloxone into 

the nose. With multiple formulations now available, increased availability and usage will hopefully 

follow for both men and women. Given the trends in increased heroin use among women, increased 

availability and usage of naloxone may soon be that much more critical to prevent death from overdose 

among women. 

Expanding Use of Medication-Assisted Treatment for Women

Medication-assisted treatment (MAT) is “the use of medications with counseling and behavioral 

therapies to treat substance use disorders and prevent opioid overdose.”50 There are currently three 

FDA-approved drugs used for medication-assisted treatment of OUDs (methadone, buprenorphine, and 

naltrexone), each with different advantages and disadvantages, as well as different uses and effects. 

Each medication also has different requirements around how they can be prescribed; not all of these 

medications are indicated for use by pregnant women. Methadone can only be provided by an opioid 

treatment program (OTP). OTPs are closely regulated, certified, and accredited through SAMHSA.

51, 52

Naltrexone, which can be delivered as a daily oral dose or as a long-acting injection, can be provided by 

any physician or other health care provider operating within their scope of practice. Buprenorphine and 

the combination medication buprenorphine and naloxone can be provided by an OTP, but can also be 

provided by physicians who have received a minimum of eight hours of training on the medication in 

addition to having received a waiver from the Drug Enforcement Administration. In their first year, 

certified providers may only treat 30 patients at a time with buprenorphine, followed by up to 100 

patients in subsequent years after submitting an additional notification. A final rule published in July 

2016 increased the patient limits to 275 patients at a given time for certain qualified physicians. 
Page 11 

Limitations on the number of patients a provider can treat at one time are designed to ensure that each 

patient receives high-quality care, appropriate behavioral health services, care coordination, care 

continuity during emergencies, and that risk of diversion is minimized.53 Additionally, the 

Comprehensive Addiction and Recovery Act of 2016 includes a provision that, for the first time, allows 

physician assistants and nurse practitioners to prescribe buprenorphine.54 

The evidence of the effectiveness of MAT is overwhelmingly positive.55, 56, 57 However, despite a 2015 

Practice Guideline from the American Society of Addiction Medicine that focuses on the use of 

medications in the treatment of substance use disorder involving opioid use (ASAM National Practice 

Guideline), and a recommendation within the CDC prescribing Guideline that clinicians offer or facilitate

MAT for patients with OUD58, MAT remains underutilized. Only 20% of adults with an OUD get the 

treatment they need each year, with cost and access reported as a primary barrier.

59 Many substance 

use treatment programs are reluctant to offer opioid dependent patients MAT. Stigma and negative 

attitudes towards MAT (based on the misconception that buprenorphine or methadone “substitute a 

new dependence for an old one”)

60 persist among clinic staff and administrators. This leads to 

insufficient dosing or limitations on the duration of use of these medications (when they are used at all), 

which often results in treatment failure and the perception that the drugs are ineffective, further 

reinforcing the negative attitudes toward their use.61 

Another barrier to care is insurance coverage. Private insurance policies are inconsistent in their 

coverage of MAT, the duration of treatment they will cover, number of episodes of treatment, or 

requirements that patients “fail” (meaning relapse) first before MAT is approved.62 The Mental Health 

Parity and Addiction Equity Act (MHPAEA) does require that those insurance plans that cover SUD offer 

coverage for services that are no more restrictive than the coverage for medical and surgical conditions. 

However, MHPAEA does not require insurance plans to offer coverage for SUD in general, nor does it 

require coverage for specific treatments or services for SUDs.63 In addition, according to a 2013 report, 

only 28 states currently cover all three FDA-approved medications under Medicaid, and requirements to 

obtain these medications vary from state to state.64 Medicaid state pharmacy programs must cover 

buprenorphine, buprenorphine naloxone combination products, and naltrexone products; however, 

state Medicaid programs may require prior authorization, step therapy, or fail preferred medication first 

policies. 

The comprehensive nature of MAT, when implemented as recommended, lends itself well to addressing 

the many physiological, psychological, and psychosocial factors facing women with OUD. For example, 

individual, group, and family therapy may help address psychosocial complications associated with 

family dynamics or guilt over the adverse effects of OUD on the family.65 To increase the use of MAT for 

women services need to be both comprehensive and woman-focused, and barriers, such as concerns 

about what will happen to a woman’s children if she seeks treatment, need to be addressed. SAMHSA 
Page 12 

has issued guidance about the types of services that should be included in comprehensive MAT for 

women, such as: 

• “Special groups to address problems of pregnant women who are opioid addicted

• Available treatments for women addicted to opioids, including pharmacotherapies

• Education and discussion groups on parenting and childcare

• Special groups and services for children and other family members

• Couples counseling

• Case management and assistance in locating safe, affordable housing.”66

In future sections, we explore these and other elements of the opioid epidemic and their specific effect 

on women. 

Exploring Issues in Prevention: Research and Promising 

Practices

Many factors may affect a woman’s diagnosis of OUD, including biological and social influences, past 

experiences, geography, and demographic characteristics. In this section, we explore some of these 

issues as they relate to the prevention of opioid misuse and use disorder in women.

Biological Pathways to Substance Use Disorder 

Women’s path to substance use is complicated, and relatively little empirical information is available 

regarding biological pathways in women. The biological differences between men and women in 

substance use are better understood with regard to nicotine and alcohol than for opioids. For instance, 

women metabolize nicotine faster than men, which may be related to why women generally do not 

respond as well as men to nicotine replacement therapies. With alcohol, evidence shows that women 

often become intoxicated after fewer drinks and in a shorter amount of time than men. Higher blood 

alcohol concentrations, smaller amounts of water in the body due to proportion of body fat, and 

differing levels of sex hormones may all play a role in how women metabolize alcohol and other 

substances.

67, 68 In addition, evidence shows that women develop heart and nerve damage and cirrhosis 

after fewer years of heavy drinking than men, as well as experience more lung damage than male 

smokers.

69, 70 These physiological sex differences may also put women at a higher risk for medical 

problems associated with substance use disorders.71 

Women may also become physically dependent on opioid pain medication more quickly than men, a 

phenomenon known as “telescoping.” Telescoping refers to the progression of time from first use of an 

addictive substance to physical dependence on that substance.

72 Women tend to use substances 

differently than men, sometimes using a smaller amount of drugs for a shorter amount of time before 
Page 13 

they become dependent.

73 These differences in use and basic physiological differences (e.g., body fat 

percentages, metabolic rate, and hormonal fluctuations)between the sexes are what likely leads to 

telescoping.

74 The telescoping phenomenon supports the need for both screening and early intervention 

among women in order to impede the progression of opioid use to the realization of opioid-related 

harms. 

In addition to dependence, some research has shown that women also may be more sensitive to 

cravings. For example, one study demonstrated that women are more sensitive to cue-induced cravings

for cocaine.

75, 76 Another study examining cigarette smoking found women’s smoking was more 

intensely influenced by craving than by mood, with the converse being true for men.

77 A study 

specifically examining opioids found cravings were significantly higher among women than among 

men.

78

Social Pathways to Substance Use Disorder — Adverse Childhood and Adult 

Experiences

Relationships and family history can also play a critical role in women’s introduction to substance use. 

Women are more likely to initiate hazardous drug use in the context of some type of intimate partner 

relationship, particularly after introduction of the substance by a boyfriend or spouse.

79 While women 

are likely to be introduced to substances by an intimate partner, men are more likely to be introduced to 

substances by a peer.

80 

Additionally, psychological and emotional distress have been identified as risk factors for prescription 

opioid nonmedical use among women, but not in men.

81 For example, victims of violence and/or sexual 

abuse are at an increased risk for adverse outcomes from substance use.

82 Research indicates that 

opioid use disorders are associated with intimate partner violence victimization, particularly among 

women, and that women may also be particularly susceptible to such violence when under the influence 

of opioids.83 

A history of traumatic childhood events, such as physical or sexual abuse and domestic violence, has also 

been associated with the initiation of substance use among women.

84 Research has shown that physical 

and sexual trauma followed by post-traumatic stress disorder (PTSD) is more common in drug-misusing

women than in men seeking treatment.

85

Studies have repeatedly found that rates of both childhood and adult sexual abuse are higher among 

women than among men86 and that this abuse is correlated with substance use disorders. A research 

review by Najavits et al. found that a lifetime history of trauma was found in 55% to 99% of women who 

misused substances, compared with rates of 36% to 51% in the general population.

87 Compared to men, 

a higher proportion of women with substance use disorders have histories of trauma, including sexual 

and/or physical abuse. Often this abuse was perpetrated by people the women knew and trusted.88 
Page 14 

Adverse childhood experiences are limited not only to physical and sexual abuse, but may also include 

other forms of trauma including emotional abuse, neglect, substance use disorders among family 

members, mental illness in the home, separation/divorce of parents, an incarcerated household 

member, or having a mother who was treated violently.

89 The CDC’s Adverse Childhood Experiences 

Study has demonstrated a strong relationship between adverse childhood experiences and a variety of 

negative health outcomes including smoking, alcohol use, and harmful drug use.

90 

Women are also more likely than men to have co-occurring mental and substance use disorders. For 

women, anxiety disorders and major depression have been associated with substance use disorders and 

are typically the most common co-occurring diagnoses. In addition to depression and anxiety, studies 

have identified common comorbidities to also include PTSD, eating disorders, and agoraphobia with or 

without panic attacks.

91, 92

Women typically report they use substances more often to cope with negative emotions.

93 Research has 

demonstrated that trauma followed by PTSD tends to be more commonly seen in drug-misusing women 

than men who are seeking treatment.

94 Therefore, health care and other service providers should be

aware of and understand trauma theory, and how to provide or refer to trauma-informed services for

their clients.

95 In addition, prevention strategies to eliminate exposure to trauma in childhood and 

adulthood should be considered an important part of a comprehensive approach to substance use 

disorders.

Social Determinants and Demographics

Factors such as geography, race/ethnicity and socioeconomic status are also determinants for rates of 

opioid use and misuse in U.S. women. Although these factors are often generally correlated with rates 

of opioid use and misuse, some differences appear to exist between genders. Understanding trends can 

help target prevention programming, treatment efforts and monitoring efforts. 

Geography

Opioid prescribing rates vary widely across the U.S. When controlling for gender, rates are generally 

highest in Appalachia, along with counties in Southern and Western states.96 CDC analysis of geographic 

region data from private insurance claims illustrated similar trends for women, finding opioid 

prescription rates were highest among 15-44 year old women in the South and were lowest in the 

Northeast. Death rates from drug overdose for women are more pronounced in rural areas in the South 

and Midwest. Geographic differences are also apparent for prescription opioid dispensing during 

pregnancy as illustrated in Exhibit 3.97 Rates of opioid use during pregnancy are highest in the Rocky
Page 15 

Mountains. Similar to the trends for death rates from drug overdose for women, dispensing to pregnant 

women is also high (20-30%) in the Midwest, South, and northern New England. Discussed later in the 

“Women as Family Caregivers and Parents” section, opioid use during pregnancy is particularly risky as it 

potentially affects not only the woman, but also her child. Access to prescription opioids, overdose 

deaths, and other factors may also indicate that a community or state is at risk for infectious disease 

outbreaks. For example, CDC identified 220 vulnerable counties in the U.S. at risk for outbreaks of HIV 

and hepatitis C among people who inject drugs.98

 

Reasons for geographic differences cannot be explained by differences in health of the population as 

there is no significant evidence to show that women in specific regions have more pain-related issues 

than others. Instead the differences may be accounted for by a lack of consensus of when it is 

appropriate to prescribe opioid pain relievers. As CDC Director, Dr. Tom Frieden, stated in 2014, "We're 

Exhibit 3. Regional variation in the rates of prescription opioid dispensing during pregnancy, 

Medicaid 2000-2007

*Note: States in white were excluded from the study due to incomplete data.

Source: Desai et al. “Increase in Prescription Opioid Use During Pregnancy Among Medicaid-Enrolled Women.” Available at 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020039/
Page 16 

not seeing consistent, effective, appropriate prescribing of opioid pain medication across the Nation, 

and this is a problem because of the deaths that result.”99 Inconsistent and inappropriate prescribing is 

resulting in higher prescription rates and overdoses in some regions compared to others. Therefore, all 

states, especially those with high prescription rates, need to reexamine the way opioids are prescribed. 

In an effort to improve appropriate prescribing of opioid pain medication, some states are seeing 

success in instituting PDMPs to track a patient’s prescriptions and identify potential prescription 

problems, such as multiple doctors prescribing opioid pain medications to the same patient.100 Many 

states throughout the South now have PDMPs, which may help to address the high rates of opioid 

prescriptions and death from overdose among women in that region. North Carolina’s PDMP, for 

example, mandates monitoring patients’ prescription history at OTP intake and at least every six 

months. Any discovered undisclosed prescriptions will result in patients having to sign a release of 

information (ROI) form allowing their treatment status to be communicated to their prescribers in order 

to coordinate care. The ROI is a requirement to remain in treatment.101 Because patients are aware their 

prescription data will be checked, they may be more likely to disclose, but the evidence of the impact of 

this model is not yet determined. 

Race, Ethnicity, and Socioeconomic Status

Racial and ethnic background can also be determinants in substance use disorder development. Though 

Americans in general are living longer, death rates are increasing for white, non-Hispanic women. Death 

rates for white, non-Hispanic women age 15 to 54 between 2005 and 2013 for accidental poisoning, a 

category that includes drug overdoses (largely comprised of prescription drugs), increased 121% 

compared to 80% for men.102, 103 Though men are more likely to die from a drug overdose, the rate at 

which women, especially white women, are closing that gap is alarming. The increase in death rates for 

white American women has coincided with a shift towards prescribing opioids for more types of chronic 

pain rather than purely acute pain and cancer treatments, as was the case in the late 1980s to mid1990’s. There is little epidemiological evidence as to why death rates among white women have 

increased while other racial groups have decreased. Further, white women, specifically the middle class, 

are more likely to be treated for chronic pain compared to minority women, including increasing 

prescription of opioids.104Research has shown that prescriber bias may contribute to the disparity in 

prescribing rates, with minorities being less likely to be prescribed opioids.105 For Medicaid beneficiaries, 

CDC researchers found opioid prescriptions were nearly one and a half times higher among white, nonHispanic women age 15-44 as compared to non-Hispanic black or Hispanic women.

106

As noted previously, the increased risk of adverse childhood experiences and violence into adulthood 

may contribute to increased substance misuse and the need for drug prevention and treatment 

programs that address the unique needs of these populations. American Indian/Alaska Native and black, 

non-Hispanic women are more likely than women of other racial and ethnic groups to be victims of rape, 
Page 17 

physical violence, and stalking by an intimate partner during their lifetime107 and American Indian or 

Alaska Native women have the highest risk of dying from a prescription painkiller overdose.108

 

In addition, women with substance use disorders are more likely to have lower incomes, be 

unemployed, and have less education compared to women without substance use disorders.

109

Generally, socioeconomically disadvantaged minority drug users experience a disproportionate number 

of overall health consequences from harmful drug use.

110 One reason for such trends can be traced to 

differences in treatment and access to care for minorities. Opioid treatment among women is generally 

low. One study found that although there was not a significant difference between males and females in 

rates of seeking treatment for OUD, treatment-seeking rates are low when compared to mental health 

disorders and other substance use disorders.111 However, one study did show that treatment was even 

more unlikely for those of lower socioeconomic status and for those women who were recently 

incarcerated. The National Academy of Medicine also noted health care, legal and regulatory systems 

vary across socioeconomic status providing disparities that may account for the racial-ethnic disparities 

for substance use treatment in the U.S.112

Chronic Pain and Pain Management

The 2012 National Health Interview Survey (NHIS) reported that approximately 25 million adults in the 

United States have daily pain and that adults who reported having severe pain also had worse health, 

used more health care, and reported more disability than those reporting less severe pain. When pain is 

chronic and continuous, people can experience emotional responses including anxiety and depression

which can lead to more pain.113 Of adults who report daily pain, the NHIS found an association between 

pain severity and gender, as women are more likely than men to report any pain.114 Epidemiologic and 

clinical findings support these findings and also demonstrate women are at increased risk for chronic 

pain and some evidence suggests that women may experience more severe clinical pain.

115 While the 

sex/gender differences in chronic pain are not clearly understood, possible explanations include 

biological and psychosocial mechanisms. Some studies have shown a link between sex hormones and 

pain sensitivity, including changes in pain perception across the menstrual cycle.

116, 117

In addition to being at increased risk for chronic pain, women are also more likely to be prescribed 

prescription opioids, be given higher doses of opioid pain medication, and use them for a longer 

duration of time than men.118 Research suggests women may also be more likely to use prescription 

opioids to self-medicate for other problems including anxiety or stress.

119 Childhood abuse has also been 

linked to chronic pain later in life; individuals who have reported a history of abuse early on in life also 

are more likely to experience chronic pain.

120

In 2010, the National Institutes of Health (NIH) contracted with the Institute of Medicine (IOM) to 

undertake a study and make recommendations “to increase the recognition of pain as a significant 

public health problem in the United States”. The report called for a cultural transformation in pain 
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prevention, care, education, and research. In response to the report, the HHS Assistant Secretary for 

Health directed the Interagency Pain Research Coordinating Committee to oversee creation of a 

National Pain Strategy (NPS). The objectives of the NPS are to decrease the prevalence of pain across its 

continuum from acute to high-impact chronic pain and its associated morbidity and disability across the 

lifespan. The NPS addresses the public health significance of opioid use and misuse, and notes that 

public health concerns related to the misuse or diversion of prescription opioid pain medications and 

risk for dependence and overdose with long-term opioid prescribing need to be considered during the 

development of policies and programs related to pain management. The NPS further notes that 

programs to curb inappropriate prescribing practices and prescription opioid abuse should be balanced 

with the use of and access to these drugs for appropriate and quality pain management.

121 

Alternative Approaches to Opioid Pain Management

The first recommendation in the CDC Guideline discusses how nonpharmacological therapies, including 

physical therapy and exercise therapy, are preferred for chronic pain.122 The Guideline notes evidence 

that both physical and exercise therapy can reduce chronic pain, noting high-quality evidence of exercise 

therapy for knee,123 hip,124 and low back pain.

125 The Guideline also discusses psychological therapies

combined with exercise as a strategy that can reduce long-term pain. 

SAMHSA’s “Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders” also 

discusses nonpharmacological therapies for managing chronic pain, including: therapeutic exercise, 

physical therapy, cognitive-behavioral therapy, and complementary and alternative medicine. There is 

some evidence that exercise can help manage various types of pain as well as reduce anxiety and 

depression, which as previously noted, women cite as reasons for using opioids.

126 Some studies have 

shown that cognitive-behavioral therapy can help patients manage and reduce pain, often while 

addressing the depression and anxiety that often accompany chronic pain.

127, 128, 129Alternative and 

complementary strategies for pain management are also discussed throughout a number of the 

objectives of the National Pain Strategy, particularly as an element of comprehensive and patientcentered pain management.130

Women as Family Caregivers and Parents

According to the Family Caregiver Alliance’s National Center on Caregiving, approximately 66% of 

caregivers are women.131 Increased levels of stress and depression can be common among women who 

are in caregiving roles, whether they are caring for children, parents, family members, friends, or other 

loved ones. The role women often play in society as caregivers means they tend to define themselves 

based on the relationships in their lives. Therefore, women are more likely to seek out and stay in 

treatment longer if they are able to maintain their caregiving role while in treatment, and either stay 

within the same treatment services or retain relationships with treatment providers throughout the 

provision of services.

132
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Becoming pregnant can also have an effect on women’s substance-misusing behaviors. Oftentimes, 

women will stop using harmful substances during pregnancy, only to begin hazardous substance use 

shortly after birth.

133 SAMHSA’s “Substance Abuse Treatment: Addressing the Specific Needs of 

Women” refers to this as the “double edged sword” in treatment planning.

134 Pregnancy can serve as a 

key moment to address harmful substance use in a woman’s life; however any progress made toward 

recovery may not have lasting effects if pregnancy is the only reason for abstaining. 

SAMHSA’s “Advancing the Care of Pregnant and Parenting Women with Opioid Use Disorder and Their 

Infants: A Foundation for Clinical Guidance” reports that from 2000 to 2009, prenatal maternal opioid 

use increased from 1.19 to 5.63 per 1,000 hospital births per year.135 Opioid misuse during pregnancy is 

especially risky as it not only impacts the health of the woman but also can impact that of her unborn 

child.136 For example, studies have found that use of codeine in the first-trimester of pregnancy is 

correlated with congenital heart defects.

137, 138, 139, 140, 141 Prenatal exposure to oxycodone, 

propoxyphene or meperidine have also been shown to increase the risk of birth defects.

142, 143 Chronic 

untreated heroin use is associated with an increased risk of fetal growth restriction, placental abruption, 

fetal death, preterm labor, and intrapartum passage of meconium.

144 Further, pregnant women with 

opioid use disorders often seek prenatal care late in their pregnancy and their infants experience poor 

weight gain and poor birth outcomes.145

Opioid use puts the neonate at risk of neonatal abstinence syndrome (NAS) – hyperactivity of the central 

and autonomic nervous system. SAMHSA’s “Advancing the Care of Pregnant and Parenting Women with 

Opioid Use Disorder and Their Infants: A Foundation for Clinical Guidance” reports a nearly twofold 

increase in the incidence of NAS from 2009 to 2012. Further, a 2015 study found the rate of neonatal 

intensive care unit admissions with NAS from 2004 through 2013, increased from 7 cases per 1000 

admissions to 27 cases per 1000 admissions.

146 Infants with NAS may have uncoordinated sucking 

reflexes that can lead to poor feeding, irritability, and high-pitched cries. Infants born to mothers who 

misused opioids during pregnancy must be monitored and treated accordingly. The recommended 

treatment for pregnant women with an OUD is methadone or buprenorphine assisted therapy to 

prevent complications with withdrawal. These treatments improve pregnancy outcomes and can 

potentially reduce the risky behavior in the mother, and while they still confer some risk of NAS, the risk 

is less severe than it would be in the absence of treatment.147, 148 Infants exposed to methadone can 

experience withdrawal as early as 72 hours from birth. Those exposed to buprenorphine can experience 

NAS within 12-48 hours of birth. Additionally, injection drug use is a risk factor for viral hepatitis and 

HIV. These infectious diseases can be passed from a mother to her baby. Notably, an increasing 

proportion of people who inject drugs and become infected with hepatitis C are young women of 

reproductive age. CDC recommends all pregnant women get screened for hepatitis B and HIV.149, 150

Pregnant women with risk factors for hepatitis C – such as current injection drug use or having a history 

of injection drug use – should also be screened.151 Women with risk factors for hepatitis B should be 

vaccinated. 
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Adolescents

In 2015, 3.9% (n=969,000) of adolescents age 12 to 17 misused pain relievers in the last year. More than 

half of those adolescents who misused pain relievers in the last year are female (n=518,000). Further, 

122,000 of adolescents age 12 to 17 had a prescription pain reliever substance use disorder in the last 

year.152 The rates for prescribing opioids to adolescents age 15 to 19 nearly doubled from 6.4% to 11.2% 

between 1994 and 2007.153 Though doctors typically have the ability to prescribe medication as they see 

fit, the FDA’s approval in 2015 of OxyContin for adolescents ages 11 through 16 years with “pain severe 

enough to require daily, around-the-clock, long-term opioid treatment for which alternative treatment 

options are inadequate” has offered guidance to help pediatricians to prescribe opioid pain medications 

safely.154 However, most adolescents who misuse prescription pain relievers get them from a friend or 

relative (54.2% for free and 16.6% taken/bought). Only a small percentage of those who use these pain 

relievers obtain a prescription from a medical professional (18.1%).155, 156 Teens may misuse opioids to 

experience the euphoria and high; lessen the feelings of anxiety, stress and physical pain; and/or use 

them in response to peer pressure.157 The primary reasons teens listed for using opioids rather than 

other drugs are that they are easy to get from their parents’ medicine cabinets, are easily available, are 

not illegal drugs, and/or can be claimed as their own prescription if caught.158 Because adolescents’ 

brains are not fully developed, exposure to opioids puts them at risk for misuse; there is evidence that 

the use of these drugs in adolescence can evolve into OUD in adulthood. A University of Michigan study 

found people who have taken prescription opioids for legitimate medical purposes during high school 

have a greater risk of opioid misuse by the age of 23.

159 Youth who misuse prescription medications are 

also more likely to report other drug use.

160 

Looking at adolescent use by gender, girls age 12-17 years are more likely than boys in that age group to 

use all psychotherapeutics including pain relievers for nonmedical reasons. Moreover, of the 

nonmedical users of prescription drugs, girls in this age range are more likely to become dependent. This 

gender difference is not the same for all age groups, however. For individuals age 18 years and older, as 

previously stated, males are more likely than females to misuse prescription drugs.161 Little research has 

been done to account for why girls age 12-17 years display such a unique trend towards nonmedical use

compared to their male counterparts and compared to other age groups. However, as noted previously, 

women are more likely than men to have co-occurring disorders. Data show, for example, that girls in 

this age group are more likely to experience other disorders such as eating disorders (over half of 

teenage girls use unhealthy weight control behaviors and those who diet are 12 times more likely to 

binge).162 The rate of such co-occurring disorders may account for the increased rate of nonmedical use.

Older Adults

Some 40-50% of adults age 65 and older report the presence of a chronic pain disorder.

163

Approximately one-third of all prescription drugs in the U.S. are used by individuals in this age range. 

Women age 65 years and older have a higher percentage of long-term use of prescription drugs than 

women below 65 years and of men in all age groups 18 years and older.

164 Specifically, among patients 
Page 21 

65 and older, 19% of men and 23% of women take at least five prescription drugs.

165 In addition, the use 

of opioids may be associated with a range of side effects including constipation, nausea, and dizziness. 

The use of opioids is also known to increase the risk of falls in this population.166 Health professionals 

may treat patients for falls, however, rather than exploring the underlying cause of the falls such as 

OUD. Health professionals need to explore the possibility of opioid use as they assess the reasons for an 

older adult’s fall. In general, OUD often goes unrecognized and untreated in this age group and research 

on treatment of substance use disorders for this population is limited.167 

Recently Incarcerated Women

In 2014, 1,508,600 individuals were sentenced to more than one year in state and federal facilities. Of 

those, 109,200 were women.168 According to data from the U.S. Department of Justice, approximately 

half of state and federal prisoners meet the DSM-IV criteria for substance use disorders.169 Though the 

need for safe and effective detoxification or continuing medication-assisted treatment for opioid use 

disorders is appropriate for these individuals, studies have found that these types of services are 

infrequently available. The majority of jails report that they do not provide medications for opioid 

detoxification and those that do often do not use evidence-based practices.

170 Failure to provide safe 

and effective detoxification, treatment and counseling for incarcerated individual’s dependence on

heroin also puts them at high risk for HIV and viral hepatitis transmission through unsafe injection in 

prisons and possible loss of tolerance after detoxification that could result in fatal overdoses, and 

recidivism upon release.

171 

Incarcerated women have additional risk when entering jails and prisons with substance use disorders. 

At any given time, approximately 6% to 10% of incarcerated women are pregnant; many of these 

women first learn they are pregnant when they enter into a correctional facility.

172 For these women, as 

discussed previously, it is especially important that they receive medication-assisted treatment and 

counseling.173 

Exploring Issues in Treatment: Research and Promising 

Practices

Unique Needs to Women in Treatment

In general, there tends to be a lack of substance use disorder treatment to meet overall demand, 

particularly in rural areas, and this is particularly true for opioid use disorders.

174, 175, 176, 177 Looking at 

treatment for both men and women, approximately 96% of states, including the District of Columbia, 

have opioid use or dependent rates higher than their treatment capacity rates.178 Many states are also 

already operating at significant capacity; 38 states (77.6%) have at least 75% of their OTPs operating at 

80% capacity.179 According to SAMHSA’s 2014 National Survey of Substance Abuse Treatment Services 
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(N-SSATS), 44% of treatment programs provided special programs or groups for adult women and only 

20% offered programs or groups for pregnant or postpartum women.

180 Analysis of data from over 

50,000 participants in the National Survey on Drug Use and Health found that among prescription opioid 

users, men reported significantly higher rates of treatment utilization (11% lifetime, 5% past year) as 

compared to women (6% lifetime, 3% past year).

181 The reasons are not well understood, although the 

N-SSATS research suggests a lack of services for women may play a role. When women do enter 

treatment for substance use disorder, they typically present with medical, behavioral, psychological, and 

social problems that are generally more severe than for men, suggesting a need for gender-specific 

treatment approaches.182 

Women as Caregivers and the Impact on Treatment

Many women who are in caregiving roles often will not seek treatment or do not complete treatment 

because they are unable to manage their caregiving responsibilities and participate in treatment 

programs at the same time. Women with children may also fear that their children will be removed from 

their custody. In addition, the responsibilities of caregiving in addition to undergoing treatment can 

become overwhelming for some women. Successful treatment programs may need to consider 

providing increased supports to address this barrier.

183 

Treatment options and levels of care are not sex or gender specific and both men and women require a 

variety of treatment services along the continuum of care. However, women who are in caregiving roles 

require additional consideration as to what types of services best fit their needs. When caring for 

children, women who are allowed to stay with their children in treatment, such as programs that include 

residential care, are more inclined not only to enter into treatment, but to participate and stay in the 

program, and even to maintain abstinence.

184 

Women, Treatment, and the Justice System

In many states, pregnant women or women with children can be reported to child protective services 

for using illicit drugs, leading to loss of child custody. Involvement with the child welfare system plays a 

critical role in a woman’s decision to seek care, because admitting to a substance use disorder may lead 

to involvement with the criminal justice system and potential loss of custody. The 2011 National Drug 

Control Strategy has acknowledged the importance of women not having to choose between seeking 

treatment and caring for their children.

185 

The Office of National Drug Control Policy has encouraged sentencing alternatives to incarceration, 

expanding family-based treatment programs, and treatment interventions that are trauma-informed.

186

Drug courts are one sentencing alternative that has shown strong evidence in reducing drug-related 

recidivism.

187 Drug courts provide offenders with substance use disorders an alternative to jail by 

providing intense supervision, drug testing and treatment. These new approaches may be helpful in 

addressing women’s needs.
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Child-Friendly and Family-Friendly Treatment Options

Many of the existing, traditional residential drug treatment programs do not allow children to be 

present. As a result, parenting women may feel torn between seeking the needed treatment and caring 

for children.

Approximately 70% of women entering substance use treatment services have children.

188 Children of 

one or more parent or caregiver with substance use disorder are at increased risk of developmental, 

behavioral, and emotional difficulties. Therefore, early intervention is important for women seeking 

treatment and, as appropriate, for their children and family members. The SHIELDS for Families

programs based in Los Angeles, CA have successfully incorporated children into treatment, incorporating

youth programs and child development centers into many of their programs. For example, their Exodus 

program is the only family-centered treatment program in the country that allows entire families to live 

in individual apartments within the treatment environment. The SHIELDS’ Exodus program consistently

reports program completion rates of 80% and family reunification rates of over 90%.189

A family-centered treatment model looks at the role of the family in the treatment of women with 

substance use disorders. In addition to clinical treatment, this model includes a continuum of familybased clinical and community support services that address many factors for women and their families 

such as: substance misuse, mental health; physical health; developmental health; and social, economic, 

and environmental needs. Because women place high values on their relationships and families, 

treatment should focus on promoting and supporting healthy attachment and relationships between 

parents and children and on women’s relationships with others. Family-centered treatment helps not 

only the woman dealing with adverse outcomes of drug use, but with her family and their needs. 

Health Insurance Coverage Issues for Women in Treatment

As noted above, public and private coverage for treatment may serve as barriers to access. In an effort 

to encourage state adoption of appropriate treatment options, in July 2014, the Director of the Center 

for Medicaid and CHIP Services within CMS issued a joint Informational Bulletin with the Director of CDC 

and the Administrator of SAMHSA as well as the directors of the National Institute on Drug Abuse and 

the National Institute on Alcohol Abuse and Alcoholism190 to highlight the use of MAT. CMS also issued a 

brief in January 2015191 to emphasize that states have the flexibility to tailor programs—within defined 

requirements and subject to federal approval—to meet the needs of their beneficiaries and local 

providers. More recently, in a January 2016 guidance on “Best Practices for Addressing Prescription 

Opioid Overdoses, Misuse and Addiction,” CMS encouraged states to “assess their Medicaid benefits 

coverage, delivery systems, payment mechanisms and provider networks for substance use disorder 

services to ensure that effective treatments are available to beneficiaries when medically appropriate.” 

CMS also supports the Medicaid Innovation Accelerator Program (IAP), which provides states with 

expert resources, coaching opportunities, and program support to accelerate policy, program, and 
Page 24 

payment reforms appropriate for a robust SUD system. The goal of the IAP initiative is to help 

participating states to better identify individuals with SUD, enhance provider capacity to effectively treat 

individuals with SUD, and expand coverage for promising and evidence-based SUD services, such as 

MAT.

192

Although Medicaid is encouraging state efforts to prevent and treat opioid use disorders, limitations and 

requirements for Medicaid reimbursement may serve as real or perceived barriers to treatment. One 

example of such a barrier is the lifetime limitation for buprenorphine-naloxone required by some states. 

This limitation offers a challenge for payers because OUD is chronic and therefore, places individuals at 

risk for relapse when their Medicaid-covered treatment limit is up.193 A number of states also require 

evidence that patients are receiving behavioral therapy with their medications; however, care needs to 

be taken that documentation does not become burdensome and turn into a barrier to accessing 

medications.194 Similarly, only 28 states cover all three FDA-approved substance use disorder treatment

medications under Medicaid. Many private health plans also exclude coverage of methadone 

maintenance treatment altogether, even though it is demonstrated to be the most effective treatment 

option for many people with an OUD.195 

Insurance coverage can be challenging with respect to non-pharmaceutical pain management, as well. 

Because there is limited evidence of effectiveness of some alternative treatments such as yoga, 

chiropractic and osteopathic manipulation, meditation, or massage therapy, Medicaid and private 

insurance plans may not cover such treatments making these methods expensive for individuals 

choosing to use them. Some states and private insurers, however, are moving towards coverage of 

alternative treatments. In July 2016, Oregon’s Medicaid program, for example, began covering

acupuncture, chiropractic and osteopathic manipulation, and cognitive behavioral therapy for patients 

with chronic back pain if these treatments are appropriate upon initial evaluation.196 

Training

HHS is actively working to stem the overprescribing of opioids through providing prescribers with access 

to the tools and education they need to make informed decisions. In particular, HHS has developed a 

number of activities that support opioid prescriber education.197 The Surgeon General’s Turn the Tide Rx 

campaign includes a pain treatment toolbox for prescribers, as well as other educational resources for 

prescribers.198 SAMHSA funding has also been used to create continuing medical education courses on 

prescribing opioids for chronic pain developed by local and state health organizations across the 

country. These courses offer training on practice management, legal and regulatory issues, opioid 

pharmacology, and strategies for managing challenging patient situations.199 With respect to training 

around acute pain prescribing, some states have developed provider training to correspond with their 

acute pain prescribing guidelines. In June 2016, for instance, prescribers in Ohio were asked to complete 

an online training program around their new acute pain opioid prescribing guidelines.200 Beginning in fall 

2016, over 60 medical schools started requiring students to take some type of prescriber education 
Page 25 

based on the CDC Guideline.201 Similarly, almost 200 nursing schools and more than 50 pharmacy 

schools have committed to requiring prescriber training in their educational programs. Beginning in fall 

2016, participating schools of nursing will require advanced practice registered nursing students to take 

some form of prescriber education in line with the CDC guideline by the time they graduate. Colleges 

and schools of pharmacy will also provide education in their curricula on overdose interventions and 

how to counsel patients on appropriate use of naloxone.202 

In addition, CDC is offering a suite of tools and resources to ensure distillation of the information within 

the CDC Guideline into practical and implementable tools to assist providers. For example, CDC has 

developed a clinical decision making checklist as well as a webinar series to provide a training 

opportunity for clinicians to learn about the recommendations within the Guideline and how they can 

be implemented within practice.

Opportunities for Research and Evaluation

While this paper explores what is known about the opioid epidemic and describes promising practices 

towards addressing opioid prevention and treatment among women, it also identifies numerous areas 

that are less well understood and can serve as a platform for further research and evaluation. There is 

emerging knowledge about the many factors that affect a woman’s diagnosis of OUD, including 

biological and social influences, past experiences, geography, and demographic characteristics, but more 

needs to be learned about each aspect of this path. As more is learned about the factors of opioid 

misuse that are specific to women, evidence-based successful strategies aimed towards prevention and 

treatment for women can be evaluated and shared across the numerous stakeholders who have an 

opportunity to prevent and treat this deadly epidemic. As noted in the introduction, this paper and the 

September 2016 HHS OWH meeting provide an opportunity to bridge knowledge and gaps among 

researchers, public health practitioners, and other stakeholders by creating opportunities to share best

practices and promising approaches and identify areas for further research and evaluation.

Potential key areas for further exploration include:

• Assessing the biological and environmental differences related to physical dependence and risk 

of death from prescription opioids among women.

• Supporting health services research and evaluation to further explore differences in motivations 

for treatment utilization and barriers to seeking treatment for substance use disorders.

• Supporting health services research and evaluation on access and health insurance coverage for 

pharmacologic treatment of opioid use among women.

• Conducting health services research and evaluation on how external factors and social 

determinants may serve as barriers to implementation of treatment programs, and to women’s 

access to such programs. 
Page 26 

• Studying approaches to best train providers to help prevent and treat OUD, and assess for 

related health outcomes such as HIV, viral hepatitis, and overdose risk.

Approaches and Opportunities for Moving Forward

Hazardous and deadly opioid misuse, including prescription opioids and heroin, is increasing at alarming 

rates for both men and women in the United States. While the epidemic is being addressed at many 

different levels, much still needs to be done, including special efforts designed to address the unique 

needs of women. As discussed above, the prevalence of prescription opioid use among women is 

substantial, and the hazards of opioid use are similarly great. Even in areas where differences are

apparent between sexes, such as women progressing more quickly to use disorders than men, very little 

is understood about why those differences occur. As we collectively move forward to address the opioid 

epidemic generally and its impact on women specifically, it will be very important to systematically 

evaluate the impact of each intervention while considering the unique aspects of women across age, 

race, and socioeconomic spectrums. 

 As we have discussed, there are many more questions than answers when it comes to understanding 

the unique aspects of women and hazardous opioid use. Ultimately, the opioid epidemic will not be 

addressed through a one-size fits all approach and we must consider how the epidemic is impacting 

women differentially. 
Page 27

Appendix: HHS Work in Support of the Secretary’s Initiative

Many HHS agencies have taken multiple concrete steps this year to support the Secretary’s targeted 

initiative aimed at reducing prescription opioid and heroin related overdose, death and dependence. 

Examples include:

Centers for Medicare & Medicaid Services (CMS)

Medicare203, 204

In July 2016, CMS issued a proposal to remove the Pain Management dimension of the Hospital 

Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of the 

Hospital Value Based Purchasing Program. The proposed rule, which was finalized in November 2016, 

removes HCAHPS survey pain management questions from hospital payment scoring calculations. These 

changes were implemented in response to clinicians who reported feeling pressure to overprescribe 

opioids because scores on the HCAHPS survey pain management questions are tied to Medicare 

payments to hospitals. Under the CMS final rule, hospitals will continue to use the questions in patient 

surveys, but the responses will not affect the level of payment hospitals receive.

Medicaid205

In January 2016, the Center for Medicaid and CHIP Services issued an Informational Bulletin on “Best 

Practices for Addressing Prescription Opioid Overdoses, Misuse and Addiction” to highlight emerging 

Medicaid strategies for preventing opioid-related harms. Medicaid programs can encourage the use of 

safer, effective alternatives to opioid pain medications—in particular, alternatives to methadone 

prescribed for pain relief—by working collaboratively with other state agencies to educate Medicaid 

providers about opioid prescribing and dispensing practices. Medicaid programs can consider pharmacy 

benefit management strategies such as reassessing preferred drug list placement, introducing clinical 

criteria, prior authorization, step therapy, quantity limits, and implementing drug utilization review 

processes. 

Centers for Disease Control and Prevention (CDC)206

In March 2016, CDC issued new provider recommendations for prescribing opioid medications for

chronic pain, excluding cancer, palliative, and end-of-life care. CDC also released materials to assist 

physicians with implementing the recommendations including a fact sheet, checklist, and posters, and 

online trainings for which continuing education credits are available.

207

The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 are is designed to help

primary care providers improve patient care for chronic pain. The principles recommend:
Page 28 

• Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative care and 

end-of-life care.

• Clinicians should establish treatment goals with patients, and include a plan for discontinuation 

of opioid therapy if risks outweigh benefits.

• Clinicians should discuss the risks and benefits of opioid therapy with patients prior to 

treatment, and revisit possible harms and benefits not less than every three months.

• When starting opioid therapy, clinicians should prescribe immediate-release opioids instead of 

extended-release (or long acting) opioids.

• When opioids are used, the lowest possible effective dosage should be prescribed to reduce 

risks of OUD and overdose.

• Clinicians should review patients’ history of controlled substance use and consult PDMPs to 

determine risk for overdose.

• Clinicians should use drug testing to identify other prescribed medications as well as illicit or 

undisclosed drugs.

• Clinicians should avoid prescribing opioid pain medications and benzodiazepines at the same 

time when possible.

• Clinicians should offer or make arrangements for evidence-based treatment with medicationassisted treatment for patients with OUD. 

Food and Drug Administration (FDA)208

In February 2016, FDA announced the agency will:

• Re-examine the risk-benefit paradigm for opioids and ensure the agency considers their wider 

public health effects

• Convene an expert advisory committee before approving any new drug application for an opioid 

that does not have abuse-deterrent properties;

• Assemble and consult with the Pediatric Advisory Committee regarding a framework for 

pediatric opioid labeling before any new labeling is approved; 

• Develop changes to immediate-release opioid labeling, including additional warnings and safety 

information that incorporate elements similar to the extended-release/long-acting (ER/LA) 

opioid analgesics labeling that is currently required;

• Update Risk Evaluation and Mitigation Strategy requirements for opioids after considering 

advisory committee recommendations and review of existing requirements;

• Expand access to, and encourage the development of, abuse-deterrent formulations of opioid 

products;

• Improve access to naloxone and medication-assisted treatment options for patients with opioid 

use disorders; and

• Support better pain management options, including alternative treatments.
Page 29 

• Seek guidance from outside experts in the fields of pain management and drug abuse including 

the National Academies of Sciences, Engineering, and Medicine, which has been asked to help 

develop a framework for opioid review, approval and monitoring that balances individual need 

for pain control with considerations of the broader public health consequences of opioid misuse 

and abuse.

• Convene independent advisory committees composed of physicians and other experts when 

considering any new opioid drugs for approval that do not contain abuse-deterrent properties. 

• Convene a meeting of the Pediatric Advisory Committee to make recommendations regarding a 

framework for pediatric opioid labeling and use of opioid pain medications in the pediatric 

population.

• Strengthening the requirements for drug companies to generate post market data on the longterm impact of using extended release/long acting opioids to create comprehensive data in the 

field of pain medicine and treatments for OUD. The data will further the understanding of the 

known serious risks of opioid misuse, overdose and death.

Health Resources and Services Administration (HRSA)

HRSA/Bureau of Primary Health Care209

In March 2016, HRSA awarded $94 million to 271 health centers in 45 states, the District of Columbia, 

and Puerto Rico to improve and expand the delivery of substance abuse services in health centers, with 

a specific focus on treatment of opioid use disorders in underserved populations. These awards will 

increase the number of patients screened for substance use disorders and connected to treatment, 

increase the number of patients with access to MAT for opioid use and other substance use disorder 

treatment, and provide training and educational resources to help health professionals make informed 

prescribing decisions. This investment is expected to help awardees hire approximately 800 providers to 

treat nearly 124,000 new patients.

HRSA//Federal Office of Rural Health Policy210

In September 2015, HRSA announced the award of $1.8 million to support rural communities in reducing 

morbidity and mortality related to opioid overdoses. The Rural Opioid Overdose Reversal Grant Program 

supported the purchase and placement of naloxone and training for its use by licensed healthcare 

professionals and emergency responders in rural areas. The pilot program supported local partnerships 

to coordinate care including local emergency responders, health facilities, academic organizations, fire 

departments, law enforcement, and other non-profit or for-profit entities involved in the prevention and 

treatment of opioid overdoses. The partnerships collaborated to increase the availability and use of 

naloxone in rural communities with emphasis on the importance of referring those with an opioid use 

disorder to an appropriate substance use disorder treatment center. Each of the 18 recipients, 

representing 13 states, were awarded $100,000. 
Page 30 

HRSA/Bureau of Health Workforce

HRSA awards grants to academic institutions to increase the number of behavioral health providers in 

medically underserved areas, which will increase access to substance use treatment. For example, as 

part of the President’s Now Is The Time initiative, HRSA is partnering with SAMHSA to expand the 

behavioral health workforce by supporting clinical training for behavioral health professionals. This 

activity, the Behavioral Health Workforce Education and Training Program, awarded $44.5 million in 

2016. Additionally, the Graduate Psychology Education (GPE) Program supports academic programs to 

prepare psychologists to provide behavioral health care, including substance abuse prevention and 

treatment services to underserved and/or rural populations. For 2016, GPE distributed $7.9 million in 

awards.

National Institutes of Health (NIH)

NIH supports a robust portfolio of research and other programs that align with the three priority areas 

of the Secretary’s Opioid Initiative as described below. 

Improved Opioid Prescribing Practices to Reduce Opioid Use Disorders and Overdose:

Improved Pain Treatment

• The NIH Pain Consortium was established to enhance pain research and promote collaboration 

among researchers across the many NIH Institutes and Centers that have programs and 

activities addressing pain. The Consortium, along with its federal partners on the Interagency 

Pain Research Coordinating Committee, developed the National Pain Strategy, which was 

released on March 18, 2016 and outlines actions for improving pain care in America.

• NIH is funding the development of the first open-access, no-cost, clinically based, retrospective 

and prospective chronic pain data registry. The registry will identify pain-management 

interventions that are most effective for specific patient types with chronic pain.

• NIH funds a broad range of research grants in this area, including grants to support the basic 

science of pain, as well as development of analgesics with non-opioid mechanisms and reduced 

misuse potential, development non-pharmacological pain treatments (including nerve 

stimulation, surgical interventions, behavioral and psychosocial interventions), and novel 

technologies and pain treatment delivery devices. 

Prescriber Education 

• As of October 2015 a total of 113,631 clinicians were certified in the accredited CME/CE 

courses Managing Pain Patients Who Abuse Prescription Drugs and Safe Prescribing for Pain.

(Accreditation has now expired.) Developed by the National Institute on Drug Abuse (NIDA), this 

NIDAMED initiative is currently working to develop a CME/CE course on Adolescent Substance 

Use for general healthcare providers that will include modules on prescription opioid misuse.

• On September 18, 2015, the NIH Pain Consortium established a new Physician Centers of 

Excellence in Pain Education (CoEPEs). The initiative selected 11 CoEPEs to develop and 

disseminate pain curricula and improve medical education on the treatment and management 
Page 31 

of pain while minimizing the abuse of opioid medications, an area that current medical training 

under-emphasizes.

Expanded Use of Naloxone to Treat Opioid Overdose:

• In 2013 NIDA partnered with Adapt Pharma/Lightlake Therapeutics, Inc (a partner of Adapt 

Pharma Limited) to develop an intranasal formulation of the drug naloxone to reverse opioid 

overdose. This user-friendly formulation, NARCAN® Nasal Spray, achieves therapeutic blood 

levels of naloxone via a quick spray into the nasal passages, and can be used by first-responders, 

family, friends and bystanders to save lives. Approved by the FDA on November 18, 2015, it 

became commercially available on February 25, 2016. 

• NIDA-funded research suggests primary healthcare providers have limited knowledge about 

naloxone and misplaced concerns about its misuse and safety which are barriers to its adoption 

and distribution. 

• NIDA supported research is evaluating naloxone distribution across a range of health care 

settings and populations. 

Expanded Use of MAT to Reduce Opioid Use Disorders and Overdose:

• NIDA supported the development of Probuphine through its partnership with Titan/Braeburn 

Pharmaceuticals. This implantable formulation of buprenorphine provides six months of 

continuous medication for patients stabilized on buprenorphine, eliminating the need for daily 

dosing. Probuphine was approved by the FDA on May 26, 2016.

• NIDA supports a broad portfolio of research on the basic science of OUDs, and on novel 

treatments ranging from brain stimulation to heroin vaccines. 

• NIDA’s Clinical Trials Network (CTN) is developing evidence-based clinical decision support for 

the management of OUDs in general healthcare settings, as well as supporting research on MAT. 

NIH is also supporting research and collaboration relevant to the effects of the opioid epidemic on 

special populations. NIH convened a scientific workshop in April 2016 focused on “Opioid Use in 

Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes”, and is partnering with the 

Appalachian Regional Commission to provide one-year planning research grants to address increased 

opioid injection drug use in Appalachia. 

Substance Abuse and Mental Health Services Administration (SAMHSA)211

In May 2016, SAMHSA accepted applications for Targeted Capacity Expansion: Medication Assisted 

Treatment-Prescription Drug Opioid Addiction grants totaling up to $33 million over three years. This 

program is designed to provide funding to 27 states identified as having an increase of 25% or more in 

admissions for OUDs in recent years (2007-2012). The purpose of the grants are to enhance/expand 

their treatment service systems to increase capacity and provide accessible, effective, comprehensive, 
Page 32 

coordinated care, and evidence-based medication assisted treatment (MAT) and recovery support 

services to individuals with OUDs seeking or receiving MAT. The goal of the funding is to: 

• increase the number of individuals receiving MAT services with pharmacotherapies approved by 

the FDA for the treatment of OUDs;

• increase the number of individuals receiving integrated care; 

• decrease illicit opioid drug use at six-month follow-up; and 

• decrease the use of prescription opioids in a non-prescribed manner at six-month follow-up.

SAMHSA expects up to $11 million will be available each year to provide up to 11 grants of up to $1 

million each for states using a certified Electronic Health Record (EHR) system or planning to certify their 

currently non-certified EHR system. States not using a certified EHR system or not planning to certify 

their EHR system can receive up to $950,000 a year.

In July 2016, SAMHSA also finalized a rule to increase access to buprenorphine to allow a greater 

number of individuals to be treated for OUD.212 Under the new rules, practitioners with an active waiver 

can treat up to 100 patients for 1 year; that can be increased to 275 patients with additional 

credentialing.
Page 33 

Resources

HHS Resources

AHRQ Resources

• The Effectiveness and Risks of Long Term Opioid Treatment of Chronic Pain

• An HCUP Statistical Brief on Hospital Inpatient Utilization Related to Opioid Overuse Among 

Adults, 1993-2012

• Infographic: Opioid Overuse on the Rise; More Widespread Across U.S. 

• Medication-Assisted Treatment Models of Care for Opioid Use Disorder in Primary Care Settings

• Supporting HHS’s Opioid Initiative

ASPE Resources

• ASPE Issue Brief: Opioid Abuse in the U.S. and HHS Actions to Address Opioid-Drug Related 

Overdoses and Deaths

CDC Resources

• Common Elements in Guidelines for Prescribing Opioids for Chronic Pain

• CDC Guideline for Prescribing Opioids for Chronic Pain

• July 2013 Vital Signs: Prescription Painkiller Overdoses

• Fact Sheet: Hepatitis C and Injection Drug Use

• Hepatitis Risk Assessment 

• Viral Hepatitis and Young Persons Who Inject Prescription Opioids and Heroin

• HIV and Injection Drug Use in the United States

FDA Resources

• Opioid Medications

• General Principles for Evaluating the Abuse Deterrence of Generic Solid Opioid Drug Products. 

(Draft Guidance).

• Fact Sheet – FDA Opioids Action Plan

• A Proactive Response to Prescription Opioid Abuse 

NIH Resources

• Prescription Drug Abuse: Opioids

• Drugs of Abuse: Opioids

• NIDAMED: Medical & Health Professionals

• Substance Use in Women
Page 34 

• Review Article Outlines Strategies To Reduce Opioid Abuse Risk

• Drug Facts: Substance Use in Women

• Probuphine: A Game-Changer in Fighting Opioid Dependence

• NIH Pain Consortium 

• NIH Centers of Excellence in Pain Education (CoEPEs)

• National Pain Strategy

ODPHP Resources

• National Action Plan for Adverse Drug Event Prevention

OHAIDP Resources

• AIDS.gov: Substance Abuse Issues 

• Viral Hepatitis

• Technical Consultation: Hepatitis C Virus in Young Persons Who Inject Drugs 

SAMHSA Resources

• Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs: A 

Treatment Improvement Protocol. (TIP 43) 

• Quick Guide for Clinicians Based on TIP 43: Medication-Assisted Treatment for Opioid Addiction 

in Opioid Treatment Programs. 

• Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: A 

Treatment Improvement Protocol. (TIP 40) 

• Quick Guide for Clinicians Based on TIP 40: Clinical Guidelines for the Use of Buprenorphine in 

the Treatment of Opioid Addiction. 

• Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: 

A Brief Guide. 

• Substance Abuse Treatment: Addressing the Specific Needs of Women: A Treatment 

Improvement Protocol (TIP 51). 

• A Treatment Improvement Protocol: Managing Chronic Pain in Adults with or in Recovery from 

Substance Use Disorders (TIP 54). 

• Medication-Assisted Treatment for Opioid Addiction. Fast Facts for Families and Friends.

• Methadone Treatment for Pregnant Women

• Alcohol, Tobacco, and Other Drugs: Opioids

• A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders: 

Practice and Policy Considerations for Child Welfare, Collaborating Medical, and Service 

Providers

• Buprenorphine Training for Physicians

• Women, Children & Families: Training and Technical Assistance
Page 35 

Other HHS Resources

• Fact Sheet: Medication Treatment for Opioid Use Disorders: Increasing the Buprenorphine 

Patient Limit

• Medication Assisted Treatment for Opioid Use Disorders

• Opioids: The Prescription Drug & Heroin Overdose Epidemic

• The Surgeon General’s Call to End the Opioids Crisis: Treatment Options for Physicians and 

Patients 

• U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing 

Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, 

DC: HHS, November 2016

Other Federal Resources

DOJ Resources

• 2015 National Drug Threat Assessment Summary

ONDCP/White House Resources

• 2014 National Drug Control Strategy

• Women, Girls, Families, and Substance Abuse

• Substance Abuse and Maternal and Child Health

• Women and Treatment

• Women Research and Resources

• Office of the National Drug Control Policy at the White House

Other Resources

• NASHP Site Highlighting State Laws to Combat Opioid Crisis

• UN Women Policy Brief: A Gender Perspective on the Impact of Drug Use, the Drug Trade, and 

Drug Control Regimes

• National Commission on Correctional Health Care: Women's Health Care in Correctional Settings

• Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) Educational 

Training 

• ASTHO Prescription Drug Misuse and Abuse: Neonatal Abstinence Syndrome 

• ASTHO State Action to Prevent and Treat Prescription Drug Abuse 

• National Center on Substance Abuse and Child Welfare

• ASAM Opioid Addiction 2016 Facts & Figures

• ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction 

Involving Opioid Use
Page 36 

• ASAM Committee Opinion: Opioid Abuse, Dependence, and Addiction in Pregnancy
Page 37 

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