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With surprising speed, prescription opioids have become our greatest challenge in drug policy — not to mention an issue in the presidential election. An estimated 10 million Americans take prescription opioid medications for nonmedical reasons. Deaths from prescription opioid medications have quadrupled since 1999. Both Hillary Clinton and Donald Trump have felt compelled to make the issue part of their campaigns.
Prescription opioid misuse among pregnant women poses especially difficult issues given the complex medical challenges of addiction treatment and pain management during pregnancy, the possibility of harm to the developing fetus, and the unique legal and ethical sensitivities arising in any potentially coercive intervention involving pregnant women. The prevalence of such disorders among pregnant women appears to have also increased by roughly a factor of four since 1999.
The plight of pregnant women struggling with addiction elicits widespread compassion and, sometimes, support for policies such as expanded access to addiction treatment. Yet the sight of pregnant women misusing intoxicating substances and media reports of newborns experiencing symptoms of acute opioid withdrawal elicit harsher reactions, too. And those reactions may increase support for policies such as criminal charges or child abuse referrals. Health experts worry that such policies drive may drive pregnant women away from health care providers or lead them to conceal their drug use from their doctors.
The search for interventions that reduce stigma
Public health practitioners have long sought ways to reduce the stigma directed at pregnant women experiencing opioid disorders. One approach has been to publicize brain scans and other scientific information in order to frame addiction as a chronic condition — a legitimate disease, not a moral failing. Another is to present stories that highlight poverty and other poignant life struggles faced by these women.
Neither approach seems to have moved public opinion appreciably in the direction of evidence-informed interventions. One might assume that depicting pregnant women as caught in the grip of a brain-altering chronic disease or stuck in broader pathologies of their life circumstances might make voters less angry at these women. But these same depictions may also intensify the psychological distance many Americans feel toward such people.
That perceived distance might even make voters more receptive to coercive interventions. Suppose we learn that a pregnant woman’s debilitating Oxycodone habit reflects the altered brain chemistry of addiction or reflects other pathologies rooted in her difficult life circumstances. This knowledge might lead us to pity her. It’s not obvious that it would make us any less willing to infringe on her autonomy during pregnancy, or to trust her any more with the responsibility of raising a new baby.
A recent study, however, both highlights the challenges facing advocates for addicted women and identifies an intervention that actually changes people’s minds: It makes them less punitive.
Put another way, it leads people to transfer some of the natural empathy they have for well-off pregnant opioid addicts to poorer addicts.
In a randomized web experiment, Alene Kennedy-Hendricks, Emma McGinty, and Colleen Barry of the Johns Hopkins Bloomberg School of Public Health recruited 1,620 statistically representative US adults online.
The researchers then divided these participants into six groups. Researchers asked a control group about their attitudes toward various policy issues — whether they would support prosecuting pregnant drug users, for example. In contrast, the diverse treatment groups were presented with different vignettes about addicted pregnant women in varied economic circumstances who faced barriers to getting help.
Some were described as successfully completing treatment; in other vignettes, treatment outcomes were not specifically discussed. After reading the vignettes, participants in each treatment arm got the same questions as the control group. (The work appears in the current Journal of Health Politics, Policy, and Law, which I help edit.)
People are more likely to object to employers refusing to hire a well-off person with a pain pill problem
The researchers’ most chastening findings reflect the obvious class overhang in any discussion of the opioid epidemic. When respondents were presented with accounts of a woman of high socioeconomic status (SES) running into trouble with pain pills, they were notably less likely than the control group to support punitive criminal justice and health care policies toward pregnant opioid users. The high-SES woman was described as a regional manager of a restaurant chain who holds an MBA, a new homeowner, and as experiencing a first pregnancy in her early 30s.
When the stories depicted this woman, respondents were less likely to say they wouldn’t work closely with a colleague addicted to opioid pain medication. They were also less likely to say that companies and landlords are justified in denying employment or housing on the basis of these disorders.
Researchers found the opposite reaction when they presented a vignette involving a pregnant woman who ran into precisely the same addiction problems but who was in her early 20s, a high school dropout, by implication unmarried, and living in a government-subsidized apartment. In virtually every category, respondents who learned about that woman endorsed more punitive policies and expressed greater anger and disgust toward pregnant addicted women than was observed in the control group.
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These biases are especially concerning when we consider the strong class overtones attached to opioids, sometimes called "hillbilly heroin."
When you explain the barriers opioid addicts face in seeking treatment, empathy rises
Such findings are depressing, if not entirely surprising. But there was also a bright side to the paper. In another part of the study, respondents provided more compassionate responses when presented with the barriers facing low-income pregnant women who seek addiction treatment. One group was told that "Michelle’s" doctor told her that Oxycontin could cause trouble for her pregnancy, and therefore she should begin methadone treatment. But there was a waiting list at the closest clinic, so she was forced to try one two hours away.
She didn’t have a car, felt bad about imposing on friends, and taxis were too expensive. "Traveling four hours round-trip on the days she was able to find a ride became exhausting and began to create problems for Michelle at work," continued the narrative. "Her manager became angry when she was repeatedly late for shifts and threatened to let her go. Michelle missed days of treatments and began using OxyContin again. She felt guilty and ashamed."
Respondents presented with this tale were notably less willing to support punitive policies such as requirements for health providers to report pregnant opioid users to child welfare authorities. When barriers to treatment were concretely described, respondents were also more willing to require Medicaid to cover such treatment.
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Similar but weaker effects were observed when respondents were presented with "treatment success" vignettes indicating that "Michelle" had successfully completed treatment and hadn’t used narcotic prescription pain medication in the past two years. (These vignettes did not include all the details about the challenges.)
Americans hold complex and ambivalent views regarding pregnant women with addiction disorders. That human mixture of compassion and anger leads us to support apparently contradictory policies, depending how the issue is framed.
This data suggests that voters are most likely to reject punitive attitudes and interventions when they recognize pregnant women struggling with addiction as functional and appealing in other aspects of their lives, and when voters see some basis for realistic, evidence-based optimism that treatment actually works.
Attitudes are still too dependent on seeing opioid addicts as "people like us"
That’s good news. Yet I confess that reading this paper was a bittersweet experience. I began working in public health 25 years ago, when the intertwined HIV and crack epidemics were peaking. Most Americans emphatically did not regard low-income, LGBTQ, and minority citizens at the epicenters of these crises as recognizably similar to themselves. Reflecting that sense of distance, our nation failed to protect people who injected drugs and faced the most immediate HIV risk. We imposed heavily coercive policies on the predominantly-minority population of pregnant women who used crack.
Compared with these earlier epidemics, today’s prescription opioid crisis is less respectful of the usual economic and racial-ethnic boundaries. Not coincidentally, our current response is decidedly more inclusive, bipartisan, and humane.
Kennedy-Hendricks, McGinty, and Barry’s important experiment suggests ways to expand that zone of inclusiveness a little bit further. Given the checkered history of drug-abuse policy, that’s no small thing.
Harold Pollack is the Helen Ross Professor of Social Service Administration at the University of Chicago.
The Big Idea is Vox’s home for smart, often scholarly excursions into the most important issues and ideas in politics, science, and culture — typically written by outside contributors. If you have an idea for a piece, pitch us at thebigidea@vox.com.
