New York Society of Addiction Medicine

Clinical Considerations for Contraception in People Who Use Drugs

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Clinical Considerations for Contraception in People Who Use Drugs

written by Dolly Patel, MD
Primary Care and Social Internal Medicine PGY-3
Montefiore Medical Center

There is a critical unmet need in providing contraception care to reproductive aged individuals with substance use disorders (SUDs). This group has lower rates of contraception use and higher rates of unintended pregnancy than the general population1. Although these individuals face the same structural barriers (i.e. cost, transportation) to accessing care as other vulnerable populations, they also experience unique challenges related to their substance use2,3. For example, individuals who use substances experience higher rates of interpersonal violence (IPV) and sexual trauma4. Furthermore, they may have chronic medical conditions (i.e. alcohol associated liver disease, chronic viral hepatitis) related to their substance use that could impact which method of contraception is best for them5.

It is imperative that providers delivering SUD care understand how to provide compassionate, comprehensive contraception care while recognizing the impact of stigmatization and reproductive coercion on patients with SUDs. To address this, we readapted the Reproductive Health Access Project’s “Your Birth Control Fact Sheet” to include columns on substance use considerations and contraindications as well as interpersonal violence considerations. We hope providers find this tool helpful in discussing contraception with their patients. View the readapted fact sheet here.

Please see the case below that includes a framework on how to approach contraception counseling and apply the tool for a patient with unhealthy alcohol use.

Sample Case
A 33-year-old female with no significant medical history presents to SUD Bridge clinic. She last engaged in care more than 5 years ago. She has consumed 1/2 pint of hard liquor daily for the past 6 years since her newborn’s passing. She has never experienced withdrawal symptoms, but has not tried to decrease her alcohol use. She has been able to work and manage her daily responsibilities. As part of her sexual history, the patient is asked about her current relationships. She is currently sexually active with 1 new male partner and does not use any form of contraception. She feels safe in this relationship.  

Step 1: Seek permission to discuss substance use
After thanking her for sharing, permission is sought to further discuss her alcohol use, and she consents. Grief is a trigger for her and alcohol numbs painful memories, helping her cope with her loss. She was subsequently offered talk therapy, which she was curious about but not yet ready to engage in.  

Step 2: Apply motivational interviewing
Motivational interviewing is utilized to gauge her interest in cutting down on alcohol. She is pre-contemplative, not yet ready to cut down but understands that her consumption is unhealthy.  

Step 3: Ask open-ended questions about family planning and contraception (i.e what are your thoughts about pregnancy? what are your thoughts or concerns about contraception?)
Using open-ended questions, the patient is asked about future plans for pregnancy. She states that she would like to be pregnant again one day but is not sure when. When asked about her thoughts on contraception, she expresses ambivalence. Her ambivalence is explored, and she notes that she has only been offered hormonal options, which she is not interested in.   

Step 4: Apply shared decision making for next steps
At the end of the visit, the patient is agreeable to assess her liver function with lab work. She is counseled to stop drinking immediately if she were to learn that she is pregnant and prescribed prenatal vitamins.

In this case, the patient is uncertain about pregnancy and is not interested in hormonal contraception. Thus, the table can be used to discuss the Copper IUD. There are no substance use considerations and considerations for alcohol use disorder or risky alcohol use. Had the patient screened positive for IPV, then the possibility of insertion and/or removal being re-traumatizing could be discussed. Levonorgestrel (Plan B) or ulipristal (Ella) can also be discussed and prescribed if the patient is interested.

 

 

References

  1. Shafique, S., Umer, A., Innes, K. E., Rudisill, T. M., Fang, W., & Cottrell, L. (2022). Preconception substance use and risk of unintended pregnancy: pregnancy risk assessment monitoring system 2016–17. Journal of addiction medicine, 16(3), 278-285.\
  2. Drescher-Burke, K. (2014). Contraceptive risk-taking among substance-using women. Qualitative Social Work, 13(5), 636-653.
  3. Black KI, Day CA. Improving Access to Long-Acting Contraceptive Methods and Reducing Unplanned Pregnancy among Women with Substance Use Disorders. Substance Abuse: Research and Treatment. 2016;10s1.
  4. Pallatino C, Chang JC, Krans EE. The Intersection of Intimate Partner Violence and Substance use among Women with Opioid use Disorder. Substance Abuse. 2021;42(2):197-204.
  5. WHO provider brief on hormonal contraception and liver disease. Kapp, Nathalie. Contraception, Volume 80, Issue 4, 325 – 326