Expert forum: Why men and women experience opioids differently

  | September 20, 2016

Opioid addiction is an equal opportunity crisis, with a hold on more than 2 million men and women in the United States. But men and women often experience addiction — and the drive to seek treatment — in different ways.
A study of opioid prescribing patterns on the athenahealth network between January 2014 and June 2016 found differences between men and women when it comes to rates of dependence, dosages prescribed, and rates of seeking treatment for addiction.
athenaInsight asked three addiction experts to weigh in on the data, the path to dependence, and the road to treatment. Here are their comments, edited and condensed.
What the data shows: More men than women are diagnosed with opioid dependence
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David Rosenbloom, Ph.D., Professor of Public Health, Boston University School of Public Health: The experience of virtually all addictions is different for men and women. More men tend to be addicted to all of the substances of abuse than women. This episode of opioid epidemic is more male than female.
Jacob Kagan, M.D., Specialty Director of Behavioral Health, Atrius Health: The standard profile for women tends to be someone who's been introduced to opiate pain medications via a bona fide prescription, and then begins to misuse that prescription — as opposed to a male who skips that step, is introduced to opiates and immediately progresses to purchasing them illicitly.
Ellie Grossman, M.D., Instructor in Medicine, Harvard Medical School; Primary Care Lead for Behavioral Health Integration, Cambridge Health Alliance: Men are more likely to come in with some heavy labor-related injury that a prescriber might feel more sympathetic about. A woman may be more likely to come in with: “my back hurts, it always hurts,” without the classic work-related or motor vehicle-related pain episode.
Kagan: I cannot tell you how many times I've seen young men in their early twenties who have become addicted right from the first time they had a wisdom tooth extraction. The first time they took that pill, it really hit their brain chemistry and they developed a craving. The general profile of a female would be: They present with chronic pain. They're prescribed the medication. And then somewhere along the line, the medication tweaks that addiction piece and they begin to misuse the prescription.
What the data shows: Though prescribing guidelines for opioids aren't linked to patient weight, men are prescribed higher doses than women 0916_opioidgenderexpertforum_charts-01
Grossman: This is purely conjecture. But if two patients are both coming in saying, “Hey, doc, I'm on these meds but my pain's not well enough controlled,” I may be more likely to look at, say, a larger man and say, “Oh, yes, I can understand that 60 milligrams of oxycodone might not be enough for you. Let's go up a bit.” Whereas if a woman who's 20, 30, 40 pounds smaller said the same thing, I may be more likely to look at her and say, “You know, the dose of medicine you're on should really be enough for somebody like you.”
Rosenbloom: Maybe men seem to cry more about pain than women do.
Grossman: It used to be we were taught to make pain better. Make pain go away. Let's get your pain level to zero. But what's the easiest way to get your pain level to zero? Let me give you an opioid. And now what we're doing is acknowledging pain as a chronic illness, much like many other chronic illnesses we treat in primary care.
WATCH: Jacob Kagan, M.D., on one patient's experience

Kagan: I think we need to do better as physicians. When it becomes clear to the physician that an individual is misusing a prescription, they really need to offer treatment options. And what can happen [now] is, as soon as they recognize that there's an addiction, the prescription is cut off. And so at that point the [patient] is forced to then find opiates illicitly. We're now clear that there's a different disease model that's happening — addiction — and we should be offering treatment for that disease model. It doesn't happen as much as it should.
What the data shows: More men get prescriptions for drugs treating opioid withdrawal, but the rate of medical treatment is growing faster for women 0916_opioidgenderexpertforum_charts-03
Grossman: It is more common among my women patients to come in identifying as “I've got a problem with pain. My pain doctor, though, says maybe I should think about buprenorphine [a drug used to treat withdrawal symptoms].” Or they've had a couple of doctors cut them off from their pain pills, so now they're buying them from their friends. They know that's breaking the law and wasting their family's money and not good. But they still identify as: "I've got a problem with pain.”
Kagan: I'll see this slightly older female population entering treatment, having just disclosed to their husband, or maybe to their kids, that they're having this problem. That, on one hand, can be a very powerful motivator. At the same time, that's a huge, huge barrier. A very embarrassing, shameful thing that has now come out in the relationship, and sometimes can be a real obstacle to entering treatment.
Rosenbloom: Women may have additional incentives to seek treatment. In some states, they run the risk of losing their kids to the social services people if they have an addiction. Other women who are at the early stages of pregnancy or want to get pregnant are certainly advised to stop taking any substance. And as a practical matter, women are more likely to go to a doctor in the first place than men, particularly of that age group. And so they are more likely to encounter the health system.
WATCH: Ellie Grossman, M.D. on one patient's experience

Grossman: Men are more likely to enter treatment via the criminal justice system. That doesn't necessarily mean that's the way they will stay in treatment...[One] man I'm seeing, he's older, in his fifties. Didn't start with pills. Started with heroin decades ago, in his twenties. But able to function, hold down jobs, has a home. And then eventually, he realized he was getting older. He was foreseeing some health complications. Knowing that what's on the street is stronger and different than what used to be on the streets years ago. So he said, “You know, I'm just tired of this.” The line you hear among people who go to peer support meetings is: “I'm sick and tired of feeling sick and tired.” And he said some variation of that to me.
Kagan: I've developed this theory that The Lord of the Rings can be seen as a metaphor. The ring is addiction. When Frodo or Gollum takes on the ring, the ring begins to change that human being — or hobbit, in this instance — into a monster. It's really important that we think about addiction in those terms: that the addiction itself is not the person. The addiction is a disease that can make the person behave in a way that is really undesirable. As soon as you can separate the addiction from the human being, it immediately tends to lessen that stigma.
Rosenbloom: The messages to men and women are going to be fashioned, like all messages, [from] differing circumstances. But the message of recovery, the message of hope, the message that you can in fact lead a good life — that is important for both men and women.
Jackie Mow and Joanna Weiss contributed to this report.
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Expert forum: Why men and women experience opioids differently