Dennis J. Hand

Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review.

AIM To systematically review the literature on contraceptive use by women with opioid and other substance use disorders in order to estimate overall contraceptive use and to examine method choice given the alarmingly high rate of unintended pregnancy in this population. METHOD Pubmed (1948-2014) and PsycINFO (1806-2014) databases were searched for peer-reviewed journal articles using a systematic search strategy. Only articles published in English and reporting contraceptive use within samples of women with opioid and other substance use disorders were eligible for inclusion. RESULTS Out of 580 abstracts reviewed, 105 articles were given a full-text review, and 24 studies met the inclusion criteria. The majority (51%) of women in these studies reported using opioids, with much smaller percentages reporting alcohol and cocaine use. Across studies, contraceptive prevalence ranged widely, from 6%-77%, with a median of 55%. Results from a small subset of studies (N=6) suggest that women with opioid and other substance use disorders used contraception less often than non-drug-using comparison populations (56% vs. 81%, respectively). Regarding method choice, condoms were the most prevalent method, accounting for a median of 62% of contraceptives used, while use of more effective methods, especially implants and intrauterine devices (IUDs), was far less prevalent 8%. CONCLUSIONS Women with opioid and other substance use disorders have an unmet need for contraception, especially for the most effective methods. Offering contraception services in conjunction with substance use treatment and promoting use of more effective methods could help meet this need and reduce unintended pregnancy in this population.

Examining delay discounting of condom-protected sex among opioid-dependent women and non-drug-using control women

BACKGROUND Opioid-dependent (OD) women tend to engage in unprotected sex with high-risk partners, placing themselves at elevated risk for sexually transmitted HIV infection. This behavior generally persists after completion of interventions that increase sexual HIV risk reduction knowledge and skills, suggesting that decision-making biases may influence HIV transmission among OD women. METHODS The primary aim of this report is to examine delay discounting of condom-protected sex among OD women and non-drug-using control women using the novel Sexual Discounting Task (SDT; Johnson and Bruner, 2012). Data were collected from 27 OD women and 33 non-drug-using control women using the SDT, a monetary discounting task, and the Barratt impulsiveness scale (BIS-11). RESULTS OD women discounted the value of delayed condom-protected sex more steeply than controls for hypothetical sexual partners in the two sets of paired partner conditions examined. Overall, women discounted condom protected sex more steeply for partners they perceived as being lowest STI risk vs. those they perceived as being highest risk. Steeper discounting of condom-protected sex was significantly associated with higher scores on the BIS-11, but not with discounting of money. CONCLUSIONS Delay discounting of condom-protected sex differs between OD women and non-drug-using women, is sensitive to perceived partner risk, and is correlated with a self-report measure of impulsivity, the BIS-11. The effect of delay on sexual decision-making is a critical but underappreciated dimension of HIV risk among women, and the SDT appears to be a promising measure of this domain. Further investigation of these relationships is warranted.

E-cigarette use among women of reproductive age: Impulsivity, cigarette smoking status, and other risk factors

INTRODUCTION The study aim was to examine impulsivity and other risk factors for e-cigarette use among women of reproductive age comparing current daily cigarette smokers to never cigarette smokers. Women of reproductive age are of special interest because of the additional risk that tobacco and nicotine use represents should they become pregnant. METHOD Survey data were collected anonymously online using Amazon Mechanical Turk in 2014. Participants were 800 women ages 24-44years from the US. Half (n=400) reported current, daily smoking and half (n=400) reported smoking <100 cigarettes lifetime. Participants completed questionnaires regarding sociodemographics, tobacco/nicotine use, and impulsivity (i.e., delay discounting & Barratt Impulsiveness Scale). Predictors of smoking and e-cigarette use were examined using logistic regression. RESULTS Daily cigarette smoking was associated with greater impulsivity, lower education, past illegal drug use, and White race/ethnicity. E-cigarette use in the overall sample was associated with being a cigarette smoker and greater education. E-cigarette use among current smokers was associated with increased nicotine dependence and quitting smoking; among never smokers it was associated with greater impulsivity and illegal drug use. E-cigarette use was associated with hookah use, and for never smokers only with use of cigars and other nicotine products. CONCLUSIONS E-cigarette use among women of reproductive age varies by smoking status, with use among current smokers reflecting attempts to quit smoking whereas among non-smokers use may be a marker of a more impulsive repertoire that includes greater use of alternative tobacco products and illegal drugs.

Improving medicaid health incentives programs: Lessons from substance abuse treatment research

This commentary addresses the efforts of Medicaid programs in several US states to employ financial incentives to increase healthy behavior among their beneficiaries. While these Medicaid incentive programs have been successful at boosting rates of less effortful behaviors, like semiannual dental visits, they have fallen short in promoting more complex behaviors, like smoking cessation, drug abstinence, and weight management. Incentives have been extensively studied as a treatment for substance use disorders for over 20years, with good success. We identify two variables shown by meta-analysis to moderate the efficacy of incentive interventions in substance abuse treatment, the immediacy of incentive delivery and size (or magnitude) of the incentive, that are lacking in current Medicaid incentive program. We also offer some guidance on how these moderating variables could be addressed within Medicaid programs. This is a critical time for such analysis, as more than 10 states are employing incentives in their Medicaid programs, and some are currently reevaluating their incentive strategies.

Using behavioral economic theory to increase use of effective contraceptives among opioid-maintained women at risk of unintended pregnancy

OBJECTIVE An unsettling aspect of the US opioid epidemic is the high rate of in utero exposure, especially since most of these pregnancies are unintended, due in part to low rates of effective contraceptive use among opioid-using women. This study tested an intervention informed by behavioral economic theory and aimed at promoting effective contraceptive use among opioid-maintained women at risk of unintended pregnancy in the Burlington, VT, area between 2011 and 2013. METHODS Thirty-one women were assigned (initial 5 consecutively, subsequent 26 randomly) to either usual care or an experimental intervention. Participants in usual care received condoms, a dose of emergency contraception, and referral to local providers. Participants in the experimental condition received usual care plus the World Health Organizations contraception initiation protocol, including free prescription contraceptives, and financial incentives for attending 13 follow-up visits over 6months to help manage side effects and other issues. RESULTS Significantly more women in the experimental vs. usual care control conditions initiated prescription contraceptive use (100% vs. 29%) and reported prescription contraceptive use at 1-month (63% vs. 13%), 3-month (88% vs. 20%), and 6-month (94% vs. 13%) assessments. None of the experimental condition participants became pregnant during the 6-month protocol vs. three women (20%) in the control condition. CONCLUSIONS These results provide the first experimental evidence supporting the efficacy of an intervention for increasing prescription contraceptive use among opioid-maintained women at risk of unintended pregnancy.