As an obstetrician-gynecologist and addiction-medicine provider, I work in the intersection of reproductive and behavioral health. This is a neglected terrain in both public health and patient care.
Consider the current focus on neonatal abstinence syndrome within the current opioid crisis: A great deal of attention is paid to the withdrawal symptoms of newborns, yet the “upstream” reproductive needs of women with opioid use disorder — specifically family planning — often go ignored. This is precisely why federal Title X funding, which supports affordable birth control and reproductive health care, is so important, as well as why a proposed gag rule that would limit the program’s services is so dangerous.
At its core, reproductive health is grounded in human rights — specifically the right to determine whether and when to have children. Modern contraceptive technologies developed over the past 50 years provide the means for the realization of this right, but inequities in access to reproductive health services abound. Unplanned birth rates differ by socio-economic status, primarily due to the fact that low-income women are less likely to use contraception and less likely to have an abortion once pregnant.
Title X is the nation’s only program focused on leveling this public health playing field. It was born from a campaign pledge made by Richard Nixon, who vowed to specifically address these inequities. "We can achieve the goal of providing adequate family planning services within the next five years to all those who want them but cannot afford them" Nixon said in the signing statement of this landmark legislation. In the half century since, the Title X funding stream has been essential to ensuring the reproductive liberty of low-income and/or underinsured Americans.
It is also an incredibly useful public health tool — especially in response to the opioid crisis.
Most pregnancies among women with opioid use disorder are unplanned. This is not to say that these women won’t love their children or parent as well or poorly as women with planned pregnancies; it is just to say that at the time that they learned they were pregnant, pregnancy was not what they had in mind as their immediate life plan. This disparity in unplanned pregnancies between women with and without a substance use disorder is directly related to the availability of family planning services — as a large percentage of women with substance abuse disorder report no contraceptive use and very few utilize highly effective methods such as implants or IUDs.
Title X has made possible innovative public health work, specifically the Baltimore Reproductive Health Initiative. In collaboration with the local health department and funded by the Abell Foundation, we integrated reproductive health services into substance use disorder treatment by establishing family planning clinics within two addiction treatment programs, one residential and one outpatient. We considered multiple different models, but in the end, the only viable and sustainable means of providing essential reproductive health care to women in addiction treatment was through the establishment of clinics under the Title X umbrella. To date, over 600 women with substance use disorder have received a contraceptive method of their choice through this program because of Title X.
There are other critical intersections between the opioid crisis and Title X, as well. Title X clinics are often the point of entry for care and often the only places where women and young people receive any preventive medicine services. Title X-funded health centers are therefore important sites for substance use assessment, and, as such, they enable early intervention to prevent the development of opioid misuse and addiction.
Another project I worked on in Baltimore integrated substance use screening into a family planning health center. We trained the staff on brief interventions to reduce unhealthy drug and alcohol use and created linkages between family planning and local addiction treatment clinics. Within that one center, we uncovered a large, previously unrecognized and unmet need for behavioral health: Over 20 percent of patients used an illicit substance, and over 40 percent reported excessive alcohol consumption. The Title X gag rule completely disregards opportunities like this to address reproductive health services and substance use, only to worsen existing gaps in care.
The opioid crisis reflects the failure of our fragmented health care system, specifically the absence of behavioral health integration. The continued segregation of addiction medicine and the massive gulf between reproductive and behavioral health hamstring our response.
A comprehensive response to the opioid crisis demands the thoughtful utilization of meaningful and evidence-based public health tools. This includes Title X. The proposed gag rule will widen disparities, erode personal liberty and worsen the opioid crisis.
Dr. Mishka Terplan (firstname.lastname@example.org) is a professor in obstetrics and gynecology and psychiatry, and associate director in addiction medicine at Virginia Commonwealth University.