Mishka Terplan, MD, MPH, FACOG, DFASAM

Dr. Terplan is Professor of Obstetrics and Gynecology and Psychiatry and Associate Director of Addiction Medicine at Virginia Commonwealth University. He is dual board-certified in obstetrics and gynecology and in addiction medicine, and a Distinguished Fellow of the American Society of Addiction Medicine.

Substance misuse and addiction are important domains of health, illness, and wellness that relate to numerous other physical conditions. Assessment of patients for substance use disorder should be a part of routine medical care across all medical specialties. Obstetricians and gynecologists are already treating women with substance use disorder, even if they are not recognizing it. Failure to identify and address substance misuse and substance use disorder compromises the care these women receive from their providers.

One way in which providers can improve their ability to provide patient care is to obtain certification in addiction medicine. Addiction medicine was recognized as an American Board of Medical Specialties (ABMS) subspecialty in 2016, and the first-ever addiction medicine certification examination was held in the fall of 2017. Registration for the 2019 Fall examination closes July 1, 2019 (Late Registration ends July 16), and will open in Spring 2020 for the Fall 2020 examination.

Women and Substance Use Disorders

The opioid crisis has brought greater attention to the relationship between gender and addiction. Women bear a disproportionate behavioral health burden. They are more likely than men to report a major depressive episode, anxiety disorder, post-traumatic stress or other psychiatric illness [1], have a higher prevalence of childhood emotional or sexual abuse and are more likely to experience gender-based violence. [2, 3] Furthermore, because women are more likely to report pain than men they are more likely to receive prescription opioid or other psychotherapeutic medications than men. [4, 5] This results in a greater prevalence of longer term opioid medication use. [6] Among women, overdose deaths from prescription opioids increased more than 400% from 1999 to 2010, compared with 237% among men. [7] Heroin overdose deaths among women have tripled in the last few years. [8]

Gender differences in substance use and addiction are not isolated to opioids and have been described for all substances. Compared with men, women start to have alcohol-related problems sooner and at lower levels of alcohol consumption. [9] Given the reproductive capacity of women, specific issues emerge at the intersection of substance use and pregnancy, issues for which the obstetrician/gynecologist is clinically oriented to address. For example, the prevalence of fetal alcohol syndrome (FAS) is increasing in the United States. In 1996, the Institute of Medicine estimated it to be between 0.5 and 3 cases per 1,000 births, whereas more recent reports indicate a prevalence of 2 to 7 cases per 1,000. [10]

As the primary medical field focused on the care of women, obstetrics and gynecology should be at the forefront of providing services to women with addiction. Without the voices of individuals who understand women’s health in general, and reproductive health in particular, it is likely that women with addiction will not receive appropriate care. The addiction treatment workforce should reflect the diversity of medical practices and patients within the population.

The Treatment Gap

Treatment outcomes for addiction are similar to other chronic health conditions. [11] However, there are gaps in both addiction screening and assessment as well as treatment capacity.

In 2017, an estimated 20.7 million Americans needed treatment for SUD, but only 4 million reported receiving any form of treatment or ancillary services. [12] Similarly, data from 2012 indicated that although 2.3 million Americans aged 12 years or older suffered from opioid use disorder, there was only enough treatment capacity to serve 1.4 million people. That leaves a gap in capacity of nearly 1 million people. [13]

In the United States, only 2.2% of physicians have obtained the Drug Enforcement Agency (DEA) waiver required to prescribe buprenorphine, and more than 30 million people live in counties that do not have any providers of medication assisted treatment. [14] The bulk of these patients live in rural counties, where mental and behavioral health professionals are also scarce, leaving people in many regions without treatment options for opioid use disorder (OUD).[15]

Increasing the number of addiction medicine specialists is necessary to reduce the addiction treatment gap, elevate the quality of addiction care available, and decrease the stigma associated with this disease.

Knowledge About Substance Use Disorders Can Improve Practice Efficiency

There are perceived barriers to addiction medicine integration into obstetrics and gynecology practice. For example, providers might be concerned that by taking care of one patient with an addiction, a flood of patients with substance use disorder will overwhelm their practice. Alternatively, they may be concerned about the time needed to address addiction issues, time that will slow down their busy practice. These are legitimate concerns, however, in reality we are already taking care of these patients; it is just that often, we are not taking care of them very well.

Nonadherence, with medication or clinic visits, is a common frustration with any medical practice and is related to physician burnout.[16] Undiagnosed and/or untreated addiction is associated with patient nonadherence including with contraception.[17] Integration of behavioral health services has been shown to improve health outcomes, including birth outcomes.[18, 19] Hence, contrary to common assumptions regarding patients with addiction, the inclusion of behavioral health in general, and addiction assessment and treatment in particular, not only provides holistic care to patients, but actually will improve clinic flow and provider efficiency.

Professional Benefits of Subspecialty Certification

One pathway to excellence in provision of care for people with addiction is to obtain certification in addiction medicine. Many professional opportunities arise from obtaining dual certification in obstetrics and gynecology and addiction medicine that can benefit providers at any stage in their careers.

Providers who are already actively working in the field of addiction would benefit from obtaining this certification because it is a way of being recognized as an expert. If you are doing the work, you should get the recognition for it.

For providers who are in established practices but not working specifically on addiction issues yet, the many benefits of certification include setting yourself apart as an expert who is equipped to treat the whole patient. In addition, there are numerous opportunities to participate in public health and influence public policy.

Finally, for those just now entering the medical profession who are considering a specialty in women’s health, because of the large, unmet need for dual experts in this field, there are numerous academic and public health opportunities available at the local, state, and federal levels.

Significant policy work has been accomplished over the past year to increase the number of physicians who treat patients with OUD. The growth in the number of addiction specialists is invaluable in making these policy changes as effective as possible.

Providing direct patient care, addiction specialists also provide leadership in training and mentoring across the treatment spectrum.

Benefits of Obtaining Addiction Medicine Certification Now

Through 2021, physicians who have a primary ABMS board certification (including current addiction medicine specialists with a primary ABMS board certification) may apply to take the examination to become or continue to be an addiction medicine specialist. After 2021, a one-year fellowship will be required to become an addiction medicine specialist.

For all providers, certification can be an important step in providing the best patient care possible. In my clinical experience, taking care of women with addiction is incredibly humbling and satisfying. They are really a wonderful population to work with. I urge you to consider certification in addiction medicine as a path to providing better, more holistic care to your patients.

References

1.         Substance Abuse and Mental Health Services Administration, Receipt of services for substance use and mental health issues among adults: results from the 2016 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR2-2016/NSDUH-DR-FFR2-2016.htm. September 2017. Accessed May 14, 2018.

2.         Felitti, V.J., et al., Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med, 1998. 14(4): p. 245-58.

3.         Russo, N.F. and A. Pirlott, Gender-based violence: concepts, methods, and findings. Ann N Y Acad Sci, 2006. 1087: p. 178-205.

4.         Anthony, M., et al., Gender and age differences in medications dispensed from a national chain drugstore. J Womens Health (Larchmt), 2008. 17(5): p. 735-43.

5.         Substance Abuse and Mental Health Services Administration, Prescription drug use and misuse in the United States: results from the 2015 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm. September 2016. Accessed May 14, 2018

6.         Terplan M. Women and the opioid crisis: historical context and public health solutions. Fertil Steril, 2017. 108(2): p. 195-99.

7.         Centers for Disease Control and Prevention, Prescription painkiller overdoses: a growing epidemic, especially among women. https://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html. Updated March 23, 2017. Accessed May 14, 2018.

8.         Hedegaard H, Chen LH, Warner M, Drug poisoning deaths involving heroin: United States, 2000–2013. NCHS data brief, no 190. Hyattsville, MD: National Center for Health Statistics. 2015. https://www.cdc.gov/nchs/data/databriefs/db190.pdf. Accessed May 14, 2018.

9.         National Institutes of Health, Alcohol: a women's health issue. NIH Publication No. 154956. https://pubs.niaaa.nih.gov/publications/brochurewomen/Woman_English.pdf. Updated 2015. Accessed May 14, 2018.

10.       National Institute on Alcohol Abuse and Alcoholism, Alcohol facts and statistics. https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics. Updated June 2017. Accessed May 14, 2018.

11.       McLellan, A.T., et al., Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA, 2000. 284(13): p. 1689-95.

12.       Substance Abuse and Mental Health Services Administration. “Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health”. Retrieved from https://www. samhsa.gov/data/

13.       Jones, C.M., et al., National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health, 2015. 105(8): p. e55-63.

14.       Rosenblatt, R.A., et al., Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med, 2015. 13(1): p. 23-6.

15.       Ellis, A.R., et al., County-level estimates of mental health professional supply in the United States. Psychiatr Serv, 2009. 60(10): p. 1315-22.

16.       Rosenstein, A.H., Physician dissatisfaction, stress, and burnout, and their impact on patient care, in Distracted Doctoring: Returning to Patient-Centered Care in the Digital Age, P. Papadakos and S. Bertman, Editors. 2017, Springer International Publishing: New York, NY. p. 121-142.

17.       Griffith, G., et al., Prescription contraception use and adherence by women with substance use disorders. Addiction, 2017. 112(9): p. 1638-1646.

18.       Druss, B.G., et al., Integrated medical care for patients with serious psychiatric illness: a randomized trial. Arch Gen Psychiatry, 2001. 58(9): p. 861-8.

19.       Goler, N.C., et al., Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. J Perinatol, 2008. 28(9): p. 597-603.

Acknowledgements

The idea of this manuscript was developed with the American Society of Addiction Medicine (ASAM). ASAM enlisted the services of Beverly A. Caley JD, of Caley-Reidenbach Consulting LLP to assist me with some of the drafting and editing of the manuscript. Ms. Caley (http://www.crcmedcom.com/bev-caley) received payment from ASAM for these services. I received no compensation from ASAM.