Joanne is a 34-year-old female veteran with longstanding heroin use who presents for prenatal care in the late first trimester. Several years ago, Joanne became homeless and was sexually assaulted. Subsequent to this event, she decided to sleep nightly in a garbage dumpster to increase her sense of security. Several months later when the dumpster was emptied into a garbage collection truck, Joanne’s arm was severely injured in the truck’s compactor.
With medication-assisted treatment for opioid-use disorder, Joanne is eventually able to stop using heroin in her second trimester as evidenced by repeated negative urine drug screens. She goes on to have a full-term vaginal delivery complicated by a second-degree perineal tear. Shortly thereafter staff members from child protective services arrive after being contacted by a nurse who has read “opioid-use disorder” in Joanne’s medical record but who is otherwise unfamiliar with Joanne’s case. It takes a few hours for Joanne’s current treatment status to be clarified. However, for the rest of her hospital stay Joanne is emotionally distressed and so kept under constant surveillance of the area near the pediatric intensive care unit.
Pregnant women who have histories of trauma and opioid use frequently present to the medical setting with unique biopsychosocial needs. Social stigmatization related to both trauma and addiction can also present a major barrier to improved health outcomes. In recent decades, identification of gender-linked trauma has become recognized as an important component in the integrated and interdisciplinary care of women with addiction . This chapter provides an overview of current prevalence, screening and assessment approaches, and effective clinical practices for gender-linked trauma and posttraumatic stress disorder (PTSD) as they relate to pregnant women with opioid-use disorder.
Examples of trauma that disproportionately affect women include childhood sexual abuse, intimate partner violence, sexual trauma occurring in the context of military service, and traumatic childbirth. A potential consequence of gender-linked trauma PTSD is a mental health disorder that can arise from trauma related to a single event, a series of repeated or resultant events, or a chronic condition. Trauma meeting diagnostic criteria for PTSD requires exposure to actual or threatened death, serious injury, or sexual violence, and is inclusive of such events whether they are experienced directly or indirectly. PTSD is also defined by four cluster symptoms: intrusive reexperiencing of the event, avoidance of stimuli associated with the event, persistent negative alterations in cognition and mood, and alterations in arousal and reactivity .
|Intrusive reexperiencing||Avoidance||Cognition and mood||Arousal and reactivity|
Figure 5.1 Sample cluster symptoms of PTSD in the perinatal period
PTSD is a disorder that disproportionately affects women. Prevalence estimates of lifetime PTSD from large national surveys consistently indicate that PTSD is more common in women than men in the general population [3, 4]. It has been postulated that higher lifetime prevalence of PTSD in women may partially relate to gender differences in hormonal responses to stress as well as to higher lifetime rates of sexual trauma among women as compared to men. Traumatic injury during pregnancy is most commonly associated with motor vehicle crashes and intimate partner violence but suicide, homicide, falls, burns, accidental poisoning, penetrating trauma, and toxic exposure also contribute to injury during pregnancy .
In both pregnant and postpartum women, a history of such stressful or traumatic life events has been found to be significantly associated with higher risk of comorbid psychiatric disorders . Current research suggests that PTSD is higher in the perinatal population and that higher rates of detachment, loss of interest, anger and irritability, trouble sleeping, and nightmares occur in this population . Pregnant women with a diagnosis of PTSD have also been found to have higher risk for perinatal complications such as ectopic pregnancy, spontaneous abortion, hyperemesis, preterm contractions, excessive fetal growth , and preterm birth . Additionally, anticipatory anxiety and lived experiences related to pregnancy, labor, and childrearing have also been suggested as potential causal pathways for trauma-related symptoms. In women with low partner support and unplanned pregnancy, higher prevalence rates of PTSD have been found in the postpartum period . Maternal PTSD during pregnancy and associated changes in stress hormones may also have as yet unknown potential epigenetic and developmental consequences in regards to outcomes in offspring .
When opioid-use disorder intersects with trauma exposure, a woman’s ability to protect herself, access support, negotiate safe sex practices, or avoid sharing drug-use equipment may be limited. A bidirectional relationship between substance use and trauma has been qualitatively described in the literature as continuing during the course of pregnancy . Past-year prevalence of PTSD in women has been found to be significantly associated with both nonmedical opioid-use and opioid-use disorder , and female gender has been found to be a risk factor for traumatic event reexposure among injection drug users . Pregnancy or the presence of other children in the home may promote maintenance of an abusive relationship with a drug-using partner for emotional or financial reasons. Trauma sequelae such as physical injury or pain may lead to exposure to prescribed or illicit opiates, and child abuse potential may also increase [15, 16]. Current studies from multiple disciplinary fields suggest that gendered experiences of trauma and substance use disorder may be linked to interrelated biomedical, environmental, health systems, and sexual/reproductive factors. These intersecting areas of research are summarized in Figure 5.2.
Figure 5.2 Intersecting domains of current research: gender, trauma, and opioid-use disorder
However, while a paradigm shift toward transdisciplinarity and integration has increasingly evolved in the field of research , trauma-specific services for women with substance use disorders remain limited in the addiction services sector . This finding presents an opportunity for the broader medical community to adopt services that are trauma-informed. By definition, trauma-informed care indirectly acknowledges the impact of trauma at the individual and societal levels and focuses on the general engagement and support of women with trauma histories. Training resources and self-assessment tools for organizations that wish to become trauma-informed can be found in the public domain .
A trauma-informed approach promotes awareness and recognition of trauma-related symptoms. Research suggests that in clinical interactions with pregnant women, treatment providers often do not elicit histories of trauma-related symptoms or PTSD [20, 21]. It is unclear whether this relates to limited appointment time, lack of training, or fears that exploring the trauma may precipitate increased substance use. However, it appears that trauma-related symptoms can be concomitantly identified and addressed with substance use disorders without precipitating adverse events . Additionally, as trauma-related symptoms such as sleep disturbance can overlap with other mental health disorders or be a product of pregnancy itself, trauma screening may prevent wasteful errors in diagnosis and treatment planning. For example, trauma self-report questionnaires can be administered in the relative privacy of a waiting room setting and may serve as an effective catalyst to the clinical interview. The number of items, completion times, and psychometric properties of many such screening tools are available to health professionals for comparative review [23, 24].
A trauma-informed lens may also be utilized when reviewing the general medical history. Frequent emergency department visits, injuries inconsistent with the stated history, missed appointments, late initiation of prenatal care, multiple unplanned pregnancies, or medication nonadherence may relate to gender-linked trauma. Additionally, among reproductive-aged women, a diagnosis of PTSD can also be significantly associated with chronic pain, gastrointestinal, and gynecologic problems . Women with a history of PTSD or PTSD and depression have also been found more likely to experience sexual dysfunction, genital pain, dyspareunia, menstrual abnormalities, and reproductive difficulties . It may be important to discern if such trauma-related somatic symptoms may have historically been managed or masked with clinically prescribed opiates or benzodiazepines in addition to illicit drugs. PTSD has been found to correlate with prescription of opiates in pregnancy , and evidence suggests that benzodiazepines are now increasingly prescribed to women with PTSD as compared to their male peers .
As the gynecologic exam or childbirth itself may trigger feelings of fear or embarrassment among women with trauma histories and PTSD , preparatory discussion regarding exam procedures can elicit ways to reduce the patient’s anticipated stress. A variety of potentially useful modification techniques in the context of a trauma history have been described [30, 31]. However some techniques, such as the administration of benzodiazepines prior to anticipated stressors in nonemergency settings, may be contraindicated for multiple reasons in those who are pregnant and have substance use disorder. In addition to the risks detailed in Chapter 4, benzodiazepines may also potentially precipitate or worsen trauma-related dissociation.
If the completed clinical assessment reveals that further mental health evaluation or treatment may be beneficial, the provider can review the assessment results with the patient. If referral to treatment is declined, it may be useful to explore the reasons or barriers related to this decision. However, ongoing education and reevaluation of symptoms at future visits can be offered and continued in lieu of treatment. Discreet referral to community-based or online resources may also provide alternative sources of support to a patient reluctant to engage with mental health services. This trauma-informed approach can also be adopted in circumstances where integrated or specialty mental health care is not accessible.
Regardless of whether or not a woman chooses to engage in direct trauma-specific services, it can be useful to understand whether labor or childbirth may also be perceived as a source of anticipatory fear or anxiety [32–35], and plan accordingly. A preemptive and collaborative discussion regarding the management of possible complications such as intense pain, prolonged labor, perineal tear, hemorrhage, and cesarean section can maximize a woman’s sense of autonomy and control.
For pregnant women who desire mental health treatment but wish to avoid psychotropic medication, cognitive behavioral therapy can be therapeutic for this population , is likely safe in pregnancy [37, 38], and can be integrated successfully into primary care settings . One form of cognitive behavioral therapy that seeks to address both trauma and substance use symptoms is Seeking Safety , which can be delivered in individual or in group formats. Seeking Safety may effectively reduce substance use symptoms in those women who are heavy substance users at baseline, and may also reduce HIV risk behaviors in substance-abusing women who engage more frequently in high-risk sexual activities at baseline . Women whose PTSD symptoms respond to Seeking Safety may also be more likely to experience more global improvement in other mental health domains . A number of other promising treatment programs for trauma-related and substance use symptoms have been developed in recent years , but future study is needed to determine if these programs produce outcomes for women that are superior to standard community treatments.
For those pregnant women with moderate to severe trauma-related symptoms who wish to try psychotropic medication, first it is important to ask if there is future plan to breastfeed. Choosing an initial medication that minimizes infant drug exposure may help encourage a woman’s adherence to a prescribed psychotropic medication during pregnancy and lactation. Furthermore, while there is little data to guide the clinician in the use of these medications in treating trauma-related symptoms during pregnancy, a general approach can be extrapolated from observational studies of other related mental health and sleep disorders, as described in Chapter 4. Selective serotonin reuptake inhibitors (SSRIs) are commonly used during pregnancy for other disorders, with comparatively few adverse effects and little overdose potential, and are considered first-line treatments for PTSD in the context of substance use . However, paroxetine, which has been linked to congenital anomalies, is an exception to the above guidance and consensus suggests avoidance of this drug during pregnancy in favor of other SSRIs . Comparatively, typical adjunctive treatments for PTSD in the general population such as antipsychotics and prazosin have significantly less data supporting their effectiveness in PTSD and their safety in pregnancy.
In summary, women experience significant vulnerability to trauma-related mental illnesses such as PTSD throughout the lifespan. For women of reproductive age, unique causal pathways of trauma can include aspects of pregnancy, labor, and childbirth. Additionally, women in this age group are concurrently entering into military roles and other traditionally male-dominated arenas where there is additional risk of trauma exposure. Potential opportunities for collaborative research include the need to better understand how women’s experiences of trauma intersect with opioid-use disorder, and the need to improve treatment outcomes related not just to mental health, but also to physical and reproductive health.