“Epidemic.” “National emergency.” “Crisis.” According to a New York Times article in January of this year, opioids killed more than 33,000 Americans in 2015. So calling it an “epidemic” or “crisis” is no exaggeration.
Women, particularly women in midlife, are disproportionately affected by the opioid crisis. According to the Centers for Disease Control, adults 40 and over are more likely to use prescription opioids than younger adults, and women use prescription opioids more than men. That puts women in midlife directly in the bullseye. Let's dive into the crisis of prescription drugs for menopause.
Because addiction, and particularly opioid addiction, destroys so many lives and is at such a crisis point in the US and other countries, we decided to seek out an expert to help us understand why women are particularly vulnerable and how we can keep ourselves safe.
We met Dr. Suzanne Gilberg-Lenz at the annual meeting for the North American Menopause Society earlier this year. Dr. Suzanne is an ob/gyn in private practice in Beverly Hills, California. After completing her medical degree at the University of Southern California School of Medicine, she did her residency in obstetrics and gynecology at Cedars Sinai Medical Center. She is also a Clinical Ayurvedic Specialist and is board certified in Integrative and Holistic medicine.
We asked her several questions about opioids, addiction, and women in midlife. Here’s what we learned:
According to Dr. Suzanne, very little attention was paid to women’s experience with substance abuse at all – opioid or other – until about a decade ago, so our information is still lacking. But, says Dr. Suzanne, we do know that …
Additional research on women, and particularly women in midlife, is needed to determine exactly how women respond to medications, so doctors can prescribe appropriately.
The benzodiazepine class of medications (Ativan, Xanax, Valium, Klonopin) are often prescribed for midlife mood disorders such as anxiety and sleep disorders that can increase substantially during perimenopause and menopause, says Dr. Suzanne. However, the BZs are very habit-forming and should be taken with caution.
Other red flags are pain pills that are prescribed chronically and not by a pain management doctor. If, says Dr. Suzanne, you keep getting more Vicodin for your period cramps every month or well after the postoperative period has past (1-6 weeks for gynecological surgery), you’re at risk for abuse.
Fentanyl is incredibly potent and has been implicated in overdose when not taken under a doctor’s supervision. It is “orders of magnitude more potent than heroin,” Dr. Suzanne tells us, so abuse can result in overdose or death.
Combinations of sleeping aids like Ambien plus painkillers or BZs plus painkillers can be deadly because the drugs can interact, changing the metabolic rate of the user. When combined levels get toxic, it can result in respiratory depression – basically the brainstem stops getting the message to “keep breathing, no matter what.” This is how overdoses kill people.
When it comes to women, midlife, and opioids, we’ve created a bit of a perfect storm here in the US: impatient patients with unrealistic expectations, doctors needing to meet patient quotas, the furor over HRT, and the persistent dismissal of women’s bodies and issues in modern medicine.
Patients are trained to believe a pill can and should provide instant relief. According to Dr. Suzanne, some of the overprescribing we’re seeing is patient-driven. Medicine has become so effective at treating symptoms that we’re all trained to believe that, as patients, instant gratification is possible, and we should never have to tolerate anything unpleasant or out of our control.
Doctors are undertrained and overtaxed. The blame isn’t all on patients: many doctors lack training in pain management and the massive abuse potential of many pain meds, Dr. Suzanne says. “When I was in training 20ish years ago, the talk was all about why it was wrong to withhold pain management. But we didn’t completely understand the potential for abuse if these drugs were sold on the street or used in large quantities over long periods of time. Because chronic use leads to decreased pain thresholds and increased tolerance for the meds, use can create a vicious cycle where the meds create a need for more and more and work less and less well.”
Doctors, particularly those employed in large systems, are under considerable time pressure and “productivity” measures (volume of patients seen). Many may simply not have the time necessary to devote to addressing substance use and abuse. Some may, unwittingly, be contributing to the crisis by taking the simpler, more “efficient” path of writing another prescription instead of referring a woman to other resources for treatment. Or, possibly, those alternative resources don’t exist in their area.
Concern over HRT made matters worse for women in midlife. The 2002 study by the Women’s Health Initiative (WHI) left many women and doctors afraid to use hormone replacement therapy (HRT) because of possible links to breast cancer. That, says Dr. Suzanne, “created a gap in menopause treatment options that perhaps other medications filled inappropriately.” As a 2016 article in The Cut put it, “ Many doctors hit the brakes on HRT after that study and their patients ‘white-knuckled’ their way through menopausal side effects…. Some women may have sought out alcohol, anxiety meds, and painkillers to cope.”
But more important, says Dr. Suzanne, there’s systematic and covert dismissal of women’s needs in medicine. It’s built in – women’s health is not studied as thoroughly as men’s. Many clinical and other trials do not include women, leading to a lack of critical information (see question one above). “We don’t have data on women’s experiences, impacts, treatments, etc. Women’s complaints are often dismissed, and the nuance required to understand midlife women in pain in general is not in many doctors’ training or wheelhouse.”
Women tend to be smaller, we metabolize differently. Plus, age, hormones and menopause symptoms can create other issues and vulnerabilities. We know all that, she says; we just don’t know the mechanisms behind those issues and vulnerabilities. But we need to.
With all the concerns over addiction and overdose, it’s understandable that many women are reluctant to take opioids when prescribed. But, says Dr. Suzanne, there are legitimate uses for these drugs, such as for short-term post-operative pain management; we just have to take care to use them correctly.
These drugs are sometimes – appropriately – prescribed for chronic, recurring, uncontrollable pain (think of the cycles of pain of endometriosis, for example). If you get such a prescription, or are given opioids for any reason other than short-term pain management, make sure you’re fully informed. Ask:
You shouldn’t be afraid to take medication you need. Just be cautious of taking medication you don’t need. Eliminating pain entirely with opioids may not be possible or safe, so discuss with your doctor what your limits are and what else you can do to get relief.
More recent research – or at least the reporting on it – seems to be saying that HRT carries no additional risk for women under 60. However, as Dr. Suzanne says, that would appear to indicate that it’s unsafe for women over 60, which is not the case. The new research does demonstrate that the WHI study resulted in some faulty and confusing ideas about the safety of HRT. While more data on long-term use is needed, women should not be afraid to explore HRT as a viable treatment option for menopause relief.
Dr. Suzanne advises that anyone who suspects she may have developed an addiction talk with a trusted friend or family member – don’t keep secrets or be ashamed! And of course, speak with your doctor or therapist right away and ask for help or referrals. You can find information on the Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Society of Addiction Medicine (ASAM) websites. “12-step meetings have been saving lives one day at a time for 82 years and are everywhere,” Dr. Suzanne reminds us. One warning: discontinuation of opioids should be medically supervised. Quitting “cold turkey” can be dangerous.
Even if we’re not in need of pain medication or concerned about addiction, there are things we can do to have a positive impact on the opioid crisis. Become your own best advocate in your health management, says Dr. Suzanne. Get informed, talk with your doctor, ask questions and don’t stop until you get answers. Engage in conversations with other women. Push for better, safer, more sophisticated options for relief from pain (and menopause symptoms!). Advocate for restrained use of these medications, better training for doctors and other medical professionals, and addiction support and treatment – not punishment and incarceration.
If the opioid crisis has touched your life, and you want to share, please do. You can leave a comment below (anonymously, if you prefer), or on Gennev’s Facebook page, or in our closed Facebook group, Midlife & Menopause Solutions.
Find out what else we learned at the North American Menopause Society event in “News from NAMS: learnings from a menopause conference.”