Young, urban and poor women in Puerto Rico are highly vulnerable to substance dependency and suffer most in the opioid crisis. Limited government data invisibilizes their experiences.

Damaly Gonzalez
@damalywrites

Michelle Perez
@michiperezart

Tina Vasquez
@thetinavasquez

Before OxyContin hit the U.S. mainland market, the drug’s creator, Purdue Pharma, owned by the infamous Sackler family, tested the painkiller in Puerto Rico in 1989. The test subjects were 90 Puerto Rican women who consented to participate in the clinical trials while hospitalized and recovering from abdominal and gynecological surgery.

The larger story of OxyContin — its highly addictive qualities, the communities decimated by opioids and the endless stream of lawsuits related to the drug — is far better known than the pre-history involving the Puerto Rican women who were used to bring OxyContin to market. The 1989 clinical trials were only possible because of the colonial status of Puerto Rico and the racist, patriarchal and classist system it finds itself in, which has long contributed to broader conditions on the island, including current rates of opioid use disorder (OUD).

The Oxy trial wasn't the first time the bodies of women in Puerto Rico were exploited under colonial rule. A 1930s sterilization program that spanned four decades — well into the 1970s — was, in part, an effort by the U.S. government to improve the economy by eliminating what was seen as an unfit class of people. In the mid-1950s, women in Puerto Rico were also infamously recruited for and coerced into birth control pill clinical trials.

Under colonialism, the bodies of women in Puerto Rico are subject to cycles of abuse and discard. Little is known how they fare in the end because the colonial government they live under has historically failed to maintain records or collect and analyze data regarding outcomes.

As of 2020, Puerto Rico is home to 28,000 people who inject drugs, a statistic that is also linked to nearly half of the island’s HIV/AIDS cases and its status as having one of the most hepatitis C virus-vulnerable populations in the U.S. When it comes to Puerto Rico’s opioid crisis, the effects on women are ignored and neglected. Studies dedicated to the subject are relatively new and only just beginning to be conducted. More broadly, it remains difficult to estimate the true scale of the problem in Puerto Rico due to the lack of local governmental overdose surveillance. Local advocacy groups and researchers agree that additional monitoring efforts are needed to better address the opioid epidemic in Puerto Rico.

‘Puerto Rico could be showcasing many more strategies, tactics and ways to approach drug use that could be much more humane (and) patient-centered.’

The lack of research and study isn’t a coincidence; it is an intentional effort by the U.S. and Puerto Rican governments to keep the public in the dark. Colonized bodies are not important, unless they need to be used. Without accurate data on the opioid crisis and its specific impact on women, advocates like Yorelys Rivera Amador say Puerto Rico is ill-equipped to address the overlapping public health crises that stem from opioid dependency or meet the specific needs of women who use drugs, including those who are pregnant, unhoused, living with HIV/AIDS or who engage in sex work.

Rivera Amador is the executive director of Iniciativa Comunitaria, a nonprofit in Puerto Rico focused on health and rehabilitation services. Rivera Amador relayed a recent interaction she had while performing outreach with her organization as an example of the kinds of multifaceted services women need. A 34-year-old woman approached her in need of a syphilis test. She was a sex worker and an intravenous drug user in an abusive relationship. Rivera Amador said that while such circumstances are not uncommon for women she encounters, the government makes little effort to understand or respond to the specific needs of women in Puerto Rico who use drugs.

“One of the things that I find most shocking is that sometimes data is brought from the United States (to Puerto Rico), and it's interpreted as if substance users behave the same here,” Rivera Amador said.

Rafael Torruella, the executive director of the harm reduction NGO Intercambios, intercambios in the town of Fajardo, echoed Rivera Amador’s frustration.

“Puerto Rico could be showcasing many more strategies, tactics and ways to approach drug use that could be much more humane (and) patient-centered,” Torruella said. “The reason why we're not doing it is because at its core, we don't care about people who use drugs at the governmental level.”

palabra contacted the Puerto Rico Department of Health with questions about the type of opioid use information the agency tracks, and whether the agency has any plans to conduct research or perform outreach to the growing number of women in Puerto Rico who inject drugs. An official with the agency said they did not have authorization to discuss these issues with the media.

Understanding the intersectional inequities of women in Puerto Rico affected by the opioid crisis is crucial because the issues that commonly lead women to use drugs — poverty, child abuse and sexual and domestic violence — are also in dire need of attention. Traditionally, women in Puerto Rico are their families’ caregivers. When they experience substance dependency, not only do they face stigma, but also a systemic lack of care that causes ripple effects in their families and communities. With few places to turn for help or understanding, the ramifications of their drug use are particularly dire.

*Illustration by Michelle Perez for palabra*

The State of Women in Puerto Rico

Drugs such as heroin are commonly used by injection in Puerto Rico. However, without more extensive government data, we don’t have a full statistical picture of each gender’s usage patterns. Most existing research is focused on men in Puerto Rico who use drugs. Advocates say it’s becoming more common to see women with opioid use disorder.

Torruella’s organization has encountered women with opioid use disorder accessing services, but he noted that the organization is likely only seeing a fraction of the women in need. There’s still a lot of “patriarchal” stigma these women face, Torruella said — including the belief that the street is for men and women should be at home.

“Many times, women fall into the hands of their male partners, so men tend to be the ones using more and then introducing that to women partners,” Torruella explained.

Given the limited information available about opioid prescribing practices in Puerto Rico, researchers set out to identify opioid distribution trends from 1999 to 2013. Their findings warned that if opioid distribution on the island continued to increase, Puerto Rico would soon face a crisis.

Eight years before OxyContin was approved in 1995, a 1987 study of 912 Puerto Rican men and women ages 17 to 68 found that 4.8% of women surveyed had a history of using drugs and 0.4% were dependent and lifetime users of drugs that included cocaine and heroin. A 2002 study in Puerto Rico of 4,332 men and women ages 15 to 64 found that women’s lifetime use of opiates was 2.2%. For cocaine, lifetime use was 2.3% and 0.8% for heroin. While the sample size was larger than the 1987 study, it’s clear that drug use among women was on the rise.

One of the most comprehensive overviews of women’s drug use in Puerto Rico doesn’t come by way of a quantitative study, but rather a doctoral dissertation published in 2007. While it doesn’t provide statistical data, the study outlined the conditions that informed women’s drug use, much of which is arguably a consequence of more than 500 years of colonialism.

The 15 women drug users who informed the study are referred to by the author as a “hidden population.” The women were between the ages of 18 and 35, and 10 of them were mothers who shared a collective history of dysfunctional family dynamics that included domestic violence, sexual abuse, and verbal abuse. Some of the women were raised by too-lenient grandparents or had parents or other family members who used drugs or alcohol. The majority came from low-income households where the unstable and unsafe communities where they lived increased their risk of becoming substance dependent. Many of the women were introduced to drugs by their friends or intimate partners.

‘We suffer from the lack of updated data.’

For many women who use opioids, their status as mothers who bear the bulk of responsibility for their children worsens the ramifications they experience from drug use. One of the 2007 study’s participants, Jessenia, said her drug use affected the duties she was able to carry out as a parent. Another woman, Mara, described how women are penalized more severely for their drug use.

“A man can be completely messed up, but they won’t take away his kids, like they will a mother,” Mara said. “(T)hey don’t have the same difficult journey, the same problems that a mother has when (the authorities) are going to take away her kids.”

Mónica, another woman from Puerto Rico who participated in the study, also detailed how women who use drugs suffer much more than their male counterparts.

“A man leaves the house — he’s gone and that’s that, he has nothing more to do with anything, he doesn’t care about anything,” Mónica said. “But a woman loses her children, loses the house, loses her dignity. Because a woman will get to the point where she sells herself… when you sell yourself, you lose everything, your self-esteem — a woman is a disaster when she hits bottom.”

Nearly two decades after the publication of the dissertation, Rivera Amador says these same conditions persist for women drug users in Puerto Rico. While each woman’s story is different, she says, the commonalities are clear: Many have a history of familial or intimate partner violence — and this violence shaped their lives.

“In the home, when they were minors, they lived a cycle of violence and abuse and they ran away from that home, fleeing from the violence and they ended up on the streets,” Rivera Amador said.

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A lack of empirical data relegates Rivera Amador’s insights to anecdotes, a major hurdle to addressing the needs of the very women rendered invisible. “We suffer from the lack of updated data,” Rivera Amador acknowledged, noting that when writing proposals for the federal government, she’s forced to cite data that in some cases is more than a decade old.

The COVID pandemic renewed interest in filling “considerable” gaps in knowledge regarding the needs of vulnerable populations, including drug users in Puerto Rico. Using data from 2020-2022 gathered by the Puerto Rico Administration of Mental Health and Anti-Addiction Services, a subdivision of the Public Health Department, researchers identified opioid use and overdose patterns in Puerto Rico, finding that there was a marked increase in the number of women dying from overdoses. COVID-19 also appeared to escalate the opioid crisis on the island. The study of 1,310 men and women found that women’s overdose rates increased from 6.5% in 2020 to 10.8% in 2021. The age group that saw the most overdoses collectively were 35 to 44, followed by 25 to 34. Most resided in the towns of Vega Baja, Caguas and San Juan.

According to researchers, Puerto Rico’s vulnerability to natural disasters only worsens adverse (and deeply complicated) political and socioeconomic conditions on the island, coalescing to form an exceptionally unstable public health environment.

“We (Puerto Rico) have been through earthquakes, pandemics, hurricanes, (an) economic situation, (a) political situation, wars, mental health. So, human beings sometimes resort to methods that are not the best — and a lot of people go to fentanyl, opioids, heroin, all those elements,” explained Dr. Grisel Burgos-Barreto, one of the principals of the opioid overdose study and an assistant professor in the Clinical Skills and Community Engagement Department and researcher at San Juan Bautista School of Medicine.

Rivera Amador says she has encountered more regular use of fentanyl over the last decade or so. Fentanyl appears to have arrived large-scale in Puerto Rico just prior to Hurricane Maria. In 2017, there were reportedly more than 600 overdoses related to fentanyl in Puerto Rico and 60 reported deaths, compared to 208 overdoses in 2016. Just like on the U.S. mainland, drug dealers in Puerto Rico replace heroin with fentanyl because it is cheaper, easier to transport, and more profitable than heroin.

Rivera Amador said that among the populations her organization helps, all test positive for fentanyl — and some aren’t even aware they’ve consumed the drug.

“Sometimes the participants indicate that they don't consume it, but when they are subjected to the doping test, it turns out to be positive,” Rivera Amador said. “There are some that do know that they are consuming it. All of the heroin, cocaine, everything is adulterated with fentanyl.”

Young, Urban and Poor

Urban and poor women in Puerto Rico are suffering today from an additional unique form of oppression: the opioid crisis. Due to their socio-economic status and a lack of robust treatment systems that take into account the specific needs of women, the same conditions have persisted for women drug users on the island for decades.

The limited data that exists regarding drug use in Puerto Rico confirms that men use drugs and overdose in far greater numbers. But the lack of research on young women leaves significant gaps in data that is desperately needed, in large part because of the unique ways drug use permeates their lives and has the potential to impact future generations.

According to Dr. Burgos-Barreto’s study, it’s adults ages 35 to 44, followed by adults ages 25 to 34, who experience substance dependency at the highest rates in Puerto Rico. The professor said these are people who would otherwise be at their most productive times of life. Instead, they are stuck in patterns of drug use.

Arguably, women’s progress is particularly stunted by opioid use disorder, in part because they become dependent more quickly. Women are prone to develop dependence on opioids, leading to health effects that include disruption to their menstrual cycles and damage to their reproductive and cardiovascular systems. And because many women who develop opioid use disorder are already economically disadvantaged, they are more likely to do sex work, for example, or remain in abusive relationships because they are dependent on their partner for financial resources and access to drugs. The patriarchal and colonial system of Puerto Rico that reinforces machista culture and keeps people economically disenfranchised also contributes to the distinct marginalization women face.

One 2018 study of 90 Puerto Rican women who inject drugs found a direct correlation between sexual violence and substance use. The women, who ranged in age from 23 to 63, were recruited from treatment centers to participate in the study between July 2013 and February 2014 — a timeline that also roughly marked the beginning of the third wave of the opioid crisis.

A majority of the women lived in the San Juan metropolitan area, were unemployed, and earned less than $1,000 a month. More than a quarter began to inject drugs between the ages of 16 and 20, illustrating that young, urban and poor women in Puerto Rico were most vulnerable to substance dependency. The most frequent drug used by the women was heroin mixed with other unknown drugs. The second most common drug was cocaine, followed by ketamine, crack, dissociative anesthetics, prescription stimulants, sedatives and alcohol.

‘The knowledge is on the island, the resources are there for the services. Sadly, because of bureaucracy and the colonialism that we live in, the services are fragmented and that help is diluted and does not arrive in the appropriate way.’

“Living on the streets begins with the problematic use of substances,” Rivera Amador said, noting that poverty and education are also factors. Among the women she’s encountered, it’s not uncommon to drop out of school and, because they are then ineligible for many jobs, turn to sex work. The 2018 study of 90 women who use drugs also found that 56% of them experienced sexual assault.

While the total number of women in Puerto Rico who are dependent on heroin, opioids or fentanyl is unknown, what’s clear is that more resources and options for care are desperately needed by women. Their steady rise as lifetime users and survivors of overdose shows us that. Without these interventions, already marginalized young, urban, and poor women in Puerto Rico will continue to suffer and the cycle will replicate itself across generations.

But solutions under colonial rule can be hard to come by.

Torruella proposes decriminalizing drug users, regulating soft drugs such as cannabis and psychedelics, and scaling up harm reduction services while also applying harm reduction principles to drug treatment services.

Rivera Amador suggests making services for drug treatment more accessible by limiting requirements and bureaucracy. The services available are also in desperate need of overhaul. Rather than the constant cycle of penalization women drug users experience, Rivera Amador said family therapy and counseling should be integrated into current services, along with mechanisms for women to regain custody of their children.

According to Dr. Burgos-Barreto, the best way to make these kinds of policies a reality is to conduct more research focused specifically on women drug users, allowing them to have a voice in shaping the services they need while also allowing researchers to work with the government to establish public policies. According to experts, new research must also prioritize data collection on risk factors, drug use patterns, and treatment barriers women in Puerto Rico face.

Change doesn’t happen overnight — especially in Puerto Rico, where resources are lacking, political and socioeconomic conditions are complex and the colonial government women drug users live under appears unmotivated to address the opioid crisis. But all hope is not lost, according to Rivera Amador.

“I am a woman who believes in possibilities and every day I think that it is possible to develop new services for women,” Rivera Amador said. “The knowledge is on the island, the resources are there for the services. Sadly, because of bureaucracy and the colonialism that we live in, the services are fragmented and that help is diluted and does not arrive in the appropriate way, but I think it is possible (to overcome this).”

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Women in Puerto Rico Bear Unique Burdens in the Opioid Crisis