Commentary on Rosen et al.: Attending to the unique needs of pregnant and parenting women at risk for overdose

Women experience unique determinants of overdose risk, including fears concerning child protective services involvement and child custody loss. When addressing the risk for opioid overdose, harm reduction services must account for the needs of pregnant and parenting people. Decades of research has examined the unique social, structural and policy drivers of drug-related harms among women who use drugs (WWUD). Much of this research has been concerned with the social dynamics of drug use and how women's intimate relationships influence harm through patterns of drug use initiation, control over drug use and sexual and injection-related risk for HIV and HCV acquisition [1-6]. Rosen et al. [7] bring this scholarship into the current era by addressing the nature of and reasons for solitary drug use (a risk factor for overdose death [8]) among WWUD. They identify three motivations for solitary drug use among women in their sample: (i) the need to alleviate opioid withdrawal symptoms, (ii) a desire to avoid anticipated and experienced substance use stigma and (iii) an attempt to reduce vulnerability to violence while intoxicated. An important additional consideration emerging in our research is the fear of child protective services (CPS) involvement among pregnant and parenting WWUD 1 and how that fear influences solitary drug use and other overdose risk factors. Some have argued that families are ground zero for the US drug war [9], and WWUD and their children (especially in communities of color) have been subjected to increased harms. In the United States, 53% of Black children will have CPS involvement by their 18th birthday [10], and parental substance use was a condition of removal for nearly 40% of all children placed in foster care in 2019 [11]. We have found that fear of CPS involvement weighs heavily upon women's decisions about when, where and with whom to use drugs. In our unpublished but forthcoming study on the acceptability of overdose prevention sites (a harm reduction strategy recommended by Rosen et al. to address the concerns in their study), women who had children living at home (or were care-givers to family members) found themselves in need of a safe space to use drugs that was both (i) outside the home and (ii) supervised in case of overdose. In the absence of such a site, some respondents describe using opioids alone, out of sight of children and other family members. Providing a supervised environment for parents while also reducing children's exposure to parental substance use and the trauma of a parent's overdose is a potential benefit of overdose prevention sites. We have also found that fear of CPS influences decisions to seek emergency medical assistance for an overdose by calling 911 [12]. It is well established that people who use drugs fear calling 911 because of the risk of law enforcement involvement [13] In our state, Nevada, where a 911 Good Samaritan Law protects 911 callers from some charges, involvement with CPS is not specifically protected under the law, leading to more risk to parenting women and heightened fear related to summoning help for overdose response. To our knowledge, this protection is not included in any state's 911 Good Samaritan Law. Similar to our findings in the later years of the HIV epidemic [6], in which we identified a host of competing priorities that challenged women's ability to negotiate HIV prevention behavior, Rosen et al.'s research [7] highlights issues that challenge women's ability to reduce their risk for fatal overdose. Harris et al. [14], too, recently found that women worry much more about their personal safety and care-giving responsibilities than the ‘inevitability’ of overdose. They conclude that gender-responsive harm reduction programming is needed to explicitly address women's concerns, including provision of child-care, women-only programs and women-focused mental health programming. We argue that other important additions to these gender-responsive approaches include explicit protections for pregnant and parenting people that keep parents safe from harm and guard against state surveillance that can result in family separation. None. L.L. is a staff member of the Washoe County Human Services Agency, in the CQI unit of Children's Services. Karla D. Wagner: Conceptualization; writing—original draft; writing—review and editing. Lisa Lee: Conceptualization; writing—original draft; writing—review and editing. None.