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Two months ago, Justice called the front desk of the North Carolina hotel she was living in and said, shakily, “I have a baby in my arms.”

It was her baby, and she had just given birth in the hotel bathroom.

Soon, the paramedics burst into her room. They asked if she had used any substances in the past 24 hours. It was painful to admit, she says, but for her baby’s sake, she told them she had. Immediately, they made a mark on their forms and removed her daughter from her arms. Then, they loaded her into an ambulance and her daughter into a second one.

“It’s hard enough having to be honest and admit you’re using substances,” says Justice, a 28-year-old working in the hospitality industry who asked to be identified by her first name to speak candidly about substance use. “I’m already judging myself worse than anyone else could, and just by saying it, you’re being vulnerable. And then it felt like nobody cared.”

Justice had been trying to get someone to listen for months.

She had been calling every treatment within driving distance since the day she found out she was pregnant, desperate to get help with her substance-use disorder. Program after program told her they didn’t accept pregnant women or didn’t have any available beds; or, they asked her to jump through bureaucratic hoops so onerous they felt impossible, she says. Justice also had a 5-year-old daughter who would need child care while she got treatment, a service that was almost unheard of.

The further along she got in her pregnancy, the more panicked she became.

“I got a point where I was so frustrated I just wanted to give up,” she says. As her due date approached, she estimates that her name was on three to four waitlists and that she was leaving voice mails every day at whatever numbers she could find for treatment centers.

“One thing that used to blow my mind is that they would say, ‘If it’s not an emergency then we won’t take you.’ What qualified as an emergency?” Justice asks.

“If I’m pregnant and I’m using then I’m not on a stretcher dying, but what could come of it? I wasn’t qualified as an emergency because nobody was right there dying in front of them.”

Justice’s desperate wait wasn’t unusual. In 2015, it was estimated that nearly 22 million — or one in 12 — Americans needed substance use treatment. But just under 11 percent actually received it. The United States has long lacked quality and accessible treatment centers; as the opioid crisis has surged, the gap has only widened. And for women like Justice, the barriers are even greater.

That’s because the opioid crisis — and drug use more broadly — has been dominated by men. But as women close social and professional gender gaps, they’re also increasingly abusing drugs and alcohol. Heroin deaths among women are increasing more than twice as quickly as those among men. When it comes to prescription opioid overdose deaths, those among women increased by 471 percent and among men by 218 percent between 1999 and 2015. Many female drug users are pregnant; the number of women with opioid use disorder at delivery more than quadrupled during that time.

The reasons for these high numbers are complex. Part of it is that there were more men using drugs to begin with. There is also evidence, however, that women progress from first drug use to dependence more quickly and that they’re more likely to abuse multiple substances at once — such as mixing binge-drinking with prescription pills — which puts them at a higher risk of overdosing. Women are also more likely to experience chronic pain, which means that they constitute 65 percent of opioid prescriptions. Sexism and implicit bias affect female drug users, too: One study found that women are three times less likely than men to receive lifesaving naloxone from emergency responders after an opioid overdose.

According to experts, one of the most pernicious reasons — and perhaps the most tractable — is that most treatment programs weren’t designed for women.

“We’re still basing things off of a male-focused treatment system, a more male-centered approach to substance use disorder,” says Hendrée Jones, executive director of the University of North Carolina’s Horizons Program in Chapel Hill, N.C., one of the few programs that provide residential treatment for pregnant and parenting women and their children. It’s also where Justice finally managed to get treatment, shortly after her daughter was born.

Nationwide, only 13 percent of both outpatient and residential treatment facilities and 7 percent of hospital inpatient treatment facilities had programs specifically for pregnant and postpartum women. Many programs do not admit pregnant women at all, and very few provide child care. In Alabama, for example, there is only one program that provides specialized treatment for pregnant women and women with children that accepts women regardless of their ability to pay.

“Unfortunately, the perception is still that women are more difficult, that they’re harder to treat,” says Jones.

In many ways, women are indeed harder to treat — but only because a gnarled web of laws, stigma and sexism that make it close to impossible for women like Justice to get the treatment they need.

Criminalizing mothers

“I experienced barriers at every turn, at every level, to get treatment — any way you can think of it, I faced it,” says Amy, a 32-year-old who is now receiving treatment at Horizons and asked to be identified by her first name as she goes through recovery.

In the months leading up to giving birth, Amy was desperate for help. But at 28 weeks pregnant, she feared getting it would mean losing her son — and maybe even landing in jail.

At the time, she lived in South Carolina, where a 1997 Supreme Court ruling found that a viable fetus is considered a person and that “maternal acts endangering or likely to endanger the life, comfort, or health of a viable fetus” — including substance use during pregnancy — constitute criminal child abuse.

“That’s what stopped me from seeking treatment,” she says.

While laws vary, 23 states and Washington, D.C., consider using substance use during pregnancy child abuse. Some states require women to be tested if health-care providers suspect it; many more require them to report it to the state. A few states (Minnesota, South Dakota and Wisconsin) even consider it grounds for involuntary commitment to a mental-health unit.

Amnesty International research on the subject found that criminalization laws often deter women like Amy not just from going into treatment, but even for getting prenatal care.

“Addiction is a chronic disease, it’s a medical condition that needs to be treated,” says Doris Titus-Glover, an assistant professor at the University of Maryland School of Nursing who researches pregnancy and opioid use disorder. “If a diabetic binges on sugar, we don’t tell them that we’re going to withhold their insulin. Why don’t we treat these women like they have a chronic disease?”

When Amy finally found a South Carolina treatment center that catered specifically to women and pregnant women, she was relieved. Shortly after completing her intake forms, however, she says they informed her that not only had they reported her to the Department of Social Services, but they had also called her licensing board, which put her profession as a clinical counselor at risk.

“Now I’m scared: Did I make it worse by trying to get help?” Amy remembers thinking at the time.

Fearing prosecution, Amy fled to North Carolina. She was rejected or waitlisted at another four treatment center before she got into Horizons, she says.

For many women, it doesn’t turn out that way. Between 2011 and 2017, the number of infants entering the foster care system increased by almost 10,000. At least half of foster care placements for infants in the United States are associated with parental substance use. In West Virginia, the state with the highest rate of newborns diagnosed with opioid withdrawal after birth, 4.1 percent of infants are now placed into foster care.

Spiraling stigma

For many women, this criminalization is a codification of the crippling stigma female drug users report facing.

Christine Grella, director of the Integrated Substance Abuse Programs at the University of California at Los Angeles, puts it like this: “Their behavior is just more deviant. We see that absolutely with alcohol, it’s just not as deviant for men. When they have alcohol problems and exhibit behavior that goes along with it, it’s less aberrant — they’re actually celebrated in some parts. For women, the stigma is profound.”

During Abbi Cushing’s prenatal care, she says her doctor advised her to get an abortion: In addition to a complicated pregnancy, the doctor told her she just really wasn’t equipped to be a mother.

“They treated me like I wasn’t intelligent, like I didn’t know anything; they didn’t treat me with respect,” Cushing, 41, says. “They had me scared: I didn’t know if I could be a mom.”

The advice didn’t help Cushing’s own doubts: With unpaid months of rent piling up, she was facing homelessness. She had also been kicked out of her methadone program, which utilized a medication to treat opioid use disorder, and couldn’t find a treatment program that would accept pregnant women.

Cushing still isn’t sure why she was removed from the methadone program. But to her, it felt resonant with the way a lot of providers treated her: like she wasn’t capable of making decisions for herself, she says.

Titus-Glover’s research found that women who use methadone during pregnancy face stigma and negative attitudes despite the fact that it’s a recommended treatment for pregnant women with opioid use disorder.

“The stigmatization is a huge barrier, and the attitudes that we as nurses sometimes project on these women does not help their recovery,” she says.

“They feel the shame of using while they’re pregnant, they feel the shame of not knowing whether they’re competent to care for their child and the attitude they get from clinic or hospital staff makes them feel like less of a person.”

While many women are able to stop using substances during pregnancy, 80 percent of women relapse postpartum, making methadone an important medication for pregnant women to manage their condition. Despite this, there are still widespread perceptions that using methadone (or buprenorphine, another treatment) is just replacing one substance for another. Subsequently, insurance companies can be reluctant to cover it and some health-care providers reluctant to prescribe it.

In addition to the stigma, getting and staying in methadone programs can be complicated. Medicaid doesn’t cover methadone in all states, and in many places, women often lose free or subsidized treatment after they give birth — which is part of what makes the postpartum period so risky for overdose. Moreover, a limited number of providers are certified to prescribe treatment.

While Cushing was eventually able to get back into her methadone program, adhering to it meant driving to a methadone clinic at the same time every day, even when her daughter was hospitalized for weeks due to complications after her birth.

Paths to treatment

It has been over 10 years since her pregnancy, and things have changed a lot for Cushing; she’s been in recovery since she gave birth to her daughter. Today, she works as a recovery coach supervisor at the Recover Project, a peer recovery center in Greenfield, Mass., that helps women who are in the position she once was.

“It’s sad that all these years later, they’re still stigmatizing women,” she says. “It doesn’t have to be so hard, we can support women.”

It’s work that pays off, according to Cushing: She says that at least in Greenfield, women face a lot less stigma than she did — even if it remains a different story in many other parts of the state.

In her research, Titus-Glover has found that peer support programs like Cushing’s can be hugely helpful in getting women past the myriad barriers they face to treatment. Titus-Glover is also working on training health-care providers to reduce negative attitudes toward women and to treat addiction like a medical diagnosis, rather than a moral failing.

Well-rounded treatment is also incredibly important for women, experts say, given that female drug users are more likely to have a history of trauma, sexual assault and mental-health struggles than male users. The lifetime prevalence of drug use disorders is four times higher for women with a history of sexual assault and 5.7 times higher for women with a history of childhood abuse. One study of female alcoholics show that 57.9 percent have major depression.

And, given how many female drug users are the primary caretakers for children or are pregnant, obstetric services and child care are critical, according to experts.

“Giving the opportunity for the mothers and the children as a family unit to heal is something that we’ve seen be very successful with reductions in child protective service involvement as well as with rates of unemployment and health-birth outcomes,” says Jones, the Horizons Program director.

So too, says Jones, is using a non-punitive approach to treatment:

“They’ve often lost everything; there would be nothing more to take away from them.”

The good news is that research on the unique challenges women with substance abuse disorder face is beginning to increase, and consequently, so are treatment options. As part of an $86 million grant to Columbia University’s School of Social Work from the National Institute on Drug Abuse aimed to reduce opioid deaths in New York, for example, Nabila El-Bassel will continue her research on female drug users, the high rates of intimate partner violence they face, and how treatment programs designed for and run by men often don’t work for them.

And in Massachusetts, the EMPOWER program at Baystate Franklin Medical Center works with pregnant women with opioid use disorder by providing peer support, midwives, mental health care and helping women to navigate conversations with social workers. The program received a $1 million federal grant this year to expand the program to the vulnerable year after women give birth, when many relapse. In Philadelphia, Public Health Management Corporation runs two treatment programs designed for women and their children, one for outpatient care called CHANCES and another residential program called Interim House West.

These programs are still few and far between. But for the women who do receive this kind of care, treatment designed for them is a revelation.

Justice is living at Horizons with her two daughters; her infant is just over two months old now. Horizons, which serves around 35 women at a time, allows her to access medically assisted treatment, obstetrics care, housing and mental health care.

“Now I get to be with people who have gone through what I’ve gone through, and we can share the fact that change is possible,” she says.

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