Excerpts from Addressing Opioid Use Disorder Among LGTBQ Populations
Opioid use disorder has reached an alarming rate in the United States. As a population disproportionately affected by substance use disorders (SUDs), the lesbian, gay, bisexual, transgender and queer (LGBTQ) community has not been spared from the opioid epidemic. According to the 2015 National Survey on Drug Use and Health, LGB men and women across all age brackets were significantly more likely to have misused prescription pain relievers in the last year compared to heterosexual adults (Figure 1), and had almost three times greater risk of opioid use disorder compared to heterosexual adults.1 Although little is known about opioid use among transgender people, the few studies that do exist have found an elevated prevalence of illicit drug use in this population.
Minority Stress and Opioid Use
The higher prevalence of SUDs, including opioid use disorder, among LGBTQ people can best be understood within the framework of minority stress. Starting at a young age, LGBTQ people live with everyday discrimination, marginalization, and victimization based on their sexual and gender minority statuses. The stress caused by such high levels of external stigma can disrupt an individual’s psychological processes, such as the ability to cope adaptively, regulate emotions, and achieve positive interpersonal relationships. External stigma can become internalized, leading to identity concealment, self-hate, feelings of worthlessness, and fear of rejection. To escape or mute these challenging emotions, some LGBTQ people turn to opioids and other substances that provide a sense of euphoria or relief. These behavioral coping mechanisms can lead to worse mental and physical health outcomes, such as physiologic dependence and addiction; depression and other mental health disorders; and HIV and other sexually- and intravenously-transmitted infectious diseases.
LGBTQ youth in particular may turn to opioid use to cope with stigma-related stressors. One study found that sexual minority youth are more likely to initiate opioid misuse early in life compared to sexual majority peers. Other studies have found associations between stress and higher opioid use among young men who have sex with men (MSM), and specifically Black MSM. A large survey of transgender Americans found that 35% of those who experienced school-related harassment or assault reported using substances to deal with the mistreatment.
Medical Opioid Use in LGBTQ Populations
In medical settings, LGBTQ people are exposed to opioids at disproportionate rates as well. According to recent Massachusetts Behavioral Risk Factor Surveillance System (BRFSS) data, 58% of sexual and gender minority respondents between 35-44 years of age report ever being prescribed an opiate by a medical professional, compared with just 35% of their sexual and gender majority counterparts. Certain clinical situations place LGBTQ people at increased risk of opioid exposure in medical settings. For example, though not all transgender people pursue surgical methods for gender affirmation, recent data from the American Society of Plastic Surgeons suggest that gender affirmation surgery is on the rise. As opioid therapy is by far the most common form of post-surgical pain management, and opioid dependence is correlated with frequency of opioid exposure, each of these procedures places transgender patients at increased risk of developing opioid dependence. Additionally, both transgender people and older people living with HIV have increased prevalence of chronic pain, and up to one-fifth report taking an opioid-based pain medication. Taken together, these clinical situations suggest that certain subpopulations of the LGBTQ community are at increased risk of developing opioid use disorder and signal the need for special care in prescribing opioids in these and other LGBTQ populations.
Opioid Use and Sexual Risk
Substance use is known to mediate the relationship between life stress and sexual risk, and opioid use in particular has the potential to increase HIV risk via sexual and injection drug behaviors. For example, non-medical opioid use among MSM was associated with increased risk of condomless sexual intercourse, increased number of sexual partners, and sharing syringes. Additionally, opioid use may compromise obtaining and giving sexual consent. It may also specifically place transgender people at risk of acquiring HIV via other needle sharing for hormone therapy, though little is known about the complex interplay of these risks. Furthermore, treatment for opioid use disorder has been shown to be associated with a reduction in certain high-risk sexual and injection-drug behaviors and an increase in condom use, bolstering the case for addressing opioid use disorder in LGBTQ populations.
Best Practices for Addressing Opioid Use Disorder among LGBTQ People
As with all patients suffering from an opioid use disorder, medication assisted therapy (MAT), in combination with counseling and behavioral health interventions, is the mainstay of treatment for LGBTQ people with opioid use disorder. However, given the multifactorial nature of opioid use in LGBTQ people and the complex medical needs of this population, certain concerns and considerations may arise during the course of opioid use disorder treatment. For example, how will treatment affect adherence to hormone therapy for transgender patients, to antiretroviral therapy (ART) for sexual and gender minority people living with HIV, and to pre-exposure prophylaxis (PrEP) for those at risk of acquiring HIV? How might MAT, such as buprenorphine and methadone, interact with hormone therapy, ART, and PrEP in these patients, and what are patients’ beliefs about potential medication interactions that could impact their treatment adherence? What models of behavioral health interventions will be most efficacious for LGBTQ populations, and what adaptations should be made? Here we provide a framework and resources for addressing some of these pressing concerns.
Opioid Use Disorder Treatment and Medication Interactions
Opioid agonists, including treatments such as methadone and buprenorphine, have known interactions with certain ART medications, particularly efavirenz, and with hormone-modulating medications, such as spironolactone. Known or perceived interactions between these and other medications may deter some patients and providers from initiating potentially life-saving treatment for opioid use disorder; we strongly caution against this fear. Co-prescription of these medications is safe and feasible with appropriate monitoring and follow up. Though a full discussion of these medication interactions is outside the scope of this clinical brief, resources for prescribers are available. Of note, buprenorphine is thought to be safer and have fewer drug-drug interactions than methadone or other opioids.
The co-occurrence of SUDs, including opioid use disorder, with posttraumatic stress disorder (PTSD) is common in the general population. Having an SUD is associated with increased treatment costs, decreased treatment adherence, and worse physical and mental health outcomes for those with PTSD. Posttraumatic stress can occur as a result of an identifiable traumatic incident (such as sexual violence, assault, other hate crimes, etc.) but is also believed to occur after chronic, insidious minority stress, which many LGBTQ people experience throughout their lives. Though substance use is a common avoidance strategy for posttraumatic stress, treatment for SUDs that also targets trauma and stress in an integrated fashion has proven acceptable and efficacious in community addiction treatment programs.
The Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Trauma-Informed Care offers excellent resources for organizations on best practices for providing trauma-informed care for SUD treatment, which can be broadly applied to LGBTQ people with opioid use disorder. According to SAMHSA, a trauma-informed service organization:
• Realizes widespread impact of trauma and understands potential paths for recovery
• Recognizes signs and symptoms of trauma in clients, staff, and others involved with the system • Responds by fully integrating knowledge about trauma into policies, procedures, and practices • Seeks to actively promote a sense of safety and resist re-traumatization.
Several evidence-informed treatments designed to improve posttraumatic stress symptoms are emerging, including models for people living with HIV. Trauma-informed approaches to opioid use disorder among LGBTQ people should incorporate the following:
- Development of a trauma-sensitive practice environment, including:o training for clinical and administrative staff to ensure a sense of safety in all staff interactions with patients.
- Identification of trauma and its mediators, including:o screening patients for trauma history, particularly populations with a higher risk of prior trauma and intimate partner violence,o screening for sequelae of posttraumatic stress, including poor adherence to treatment and high-risk behaviors, among others.
- Education for patients about the connection between trauma and its negative behavioral and physical health outcomes.
- Linkage to suitable resources and referrals for more specialized treatment as needed.Tools are available from the SAMHSA Center for Trauma-Informed Care to assist health centers and other healthcare organizations in adapting these approaches. However, implementation of these strategies to target the effects of trauma on health has been limited and inconsistent. Importantly, the framework of trauma-informed care has recently gained more national traction with increasing concerns about consequences of posttraumatic stress among veterans, presenting more opportunities for synergistic efforts by health centers.