Women with opioid use disorder and who are also involved with the criminal legal system face unique challenges and stigmas that may keep them from seeking substance use treatment and harm reduction tools that could prevent overdose deaths, according to new research led by a team from Penn State. Harm reduction strategies are evidence-based practices to engage people who use drugs and provide them with tools and information to reduce the risk of overdose. These practices can play a critical role in addressing the overdose crisis in the United States, especially when tailored to address women’s needs.

Through in-depth interviews with women with opioid use disorder and professionals who work with them, the researchers identified recommendations for more effective drug treatment programs. Recommendations include increasing the accessibility of harm reduction tools, expanding harm reduction education and shifting away from “abstinence only” paradigms within substance use treatment programs.

They published their findings in the journal Psychology of Addictive Behavior.

“Improving engagement in overdose prevention and harm reduction practices is one challenge that must be addressed to mitigate the impacts of the U.S. overdose crisis,” said Eric Harrison, graduate student in the human development and family studies program at Penn State and lead author of the paper. “Finding ways to teach women with opioid use disorder about harm reduction, more effectively distribute harm reduction tools to them and reduce stigma among providers and professionals is essential to reduce overdose risk for women with opioid use disorder.”

According to the Centers for Disease Control and Prevention, nearly 108,000 people died from drug overdoses in 2022, 76% of which involved an opioid. However, there is limited research that examines the risk factors for overdose particularly among women who may face different challenges compared to men.

“Women who use drugs are heavily stigmatized because many are also mothers. This stigma may prohibit women from seeking harm reduction programs and substance use treatment,” said Abenaa Jones, the Ann Atherton Hertzler Early Career Professor in Health and Human Development, assistant professor of human development and family studies and senior author of the paper.

Women who use drugs and are involved in the criminal legal system are in a particularly vulnerable state, the researchers said. Not only do they face a high chance of overdose immediately following release but involvement in the criminal legal system also imposes longer-term challenges to recovery.

“These stigmas and barriers can make it hard to attain the forms of ‘recovery capital’ that are so needed to sustain recovery,” said Kristina Brant, assistant professor of rural sociology and co-author of the study. “Finding unique ways to support this group facing so many intersecting vulnerabilities is essential to promoting well-being.”

Researchers conducted in-depth interviews with 20 women with an opioid-use disorder and history of criminal justice involvement, 12 substance use disorder treatment professionals and 10 criminal justice professional who have worked with women with opioid use disorder, all of whom were based in Pennsylvania.

The interviews explored the women’s personal experience with overdose, their use or knowledge of overdose prevention techniques and barriers faced when accessing or using those techniques or the professionals’ experience working with women with opioid use disorder. In these conversations, the researchers also parsed the challenges that pregnant people and mothers face when seeking treatment. They detailed those findings in a paper published earlier this year.

From these interviews, they also found that there’s a lack of knowledge about harm reduction practices. Women may not be aware of tools like naloxone — or Narcan, a medication that can reverse overdose from opioids — and fentanyl testing strips, where to access them and how to use them, which severely limits their usefulness in preventing overdose. In some cases, this could be attributed to low communication between substance use treatment professionals and clients or insufficient aftercare support following an overdose. Without proper tools or knowledge, women may turn to strategies that may be ineffective or even harmful.

“Harm reduction tools like Narcan are more common today, but we need to consider the implications of effectively getting Narcan into everyone’s hands. Even with Narcan available over the counter, there are still people who may never purchase it,” Harrison said, explaining that stigma may prevent the purchase, especially for women who fear possible legal or child custody repercussions. “Increasing accessibility and expanding education around naloxone and other harm reduction tools, especially to individuals not directly connected to substance use, is an important consideration.”

The findings also highlight important differences in perspective between women with opioid use disorder and the professionals who work with them, the researchers said. While both groups noted a heightened vulnerability to overdose because of a drug supply increasingly contaminated with substances like fentanyl and xylazine, some of the professionals drew on a narrative that people put themselves at risk by seeking out more potent substances and weren’t concerned about overdosing.

“The women never put this blame on themselves or others who use drugs, instead telling us about the dangers of a toxic drug supply and lack of access to tolls that can help assess drug type, like fentanyl testing strips, and help people make decisions about how to reduce risk,” Brant said.

In order to prevent opioid overdose, the researchers said there needs to be increased access to naloxone and other harm reduction tools, expanded harm reduction education and a shift away from “abstinence only” paradigms within substance use treatment programs.

“Some people may not seek help because they don’t want to pursue total abstinence,” Harrison said. “We need more open discussions about overdose prevention and harm reduction and more socially accepted options to help save lives by meeting people where they are without bias or judgment.”

The study’s findings will inform the design of a comprehensive intervention for women with opioid-use disorder and involved in the criminal legal system. The program integrates substance use treatment with peer support, overdose response training, access to overdose reversal drugs, and assistance with transportation, childcare and housing. Half of the women will be randomly selected to participate in a trauma support group.

“These components are rarely offered in tandem with substance use treatment. This research is assessing if having this comprehensive program is linked with better substance use and social outcomes,” Jones said.

Other Penn State authors on the paper include Emma Skogseth and Sienna Strong-Jones, graduate students in human development and family studies. Carl Latkin, vice chair, department of health, behavior and society at Johns Hopkins University also contributed to the paper.

Funding from the National Institute on Drug Abuse and the Social Science Research Institute at Penn State supported this work.