The day her brother died, her mother passed away too. He was found next to the tools he used to prepare controlled substances. However, no details were provided about what caused her mother’s death. Nery, who asked to be identified by the name her mother affectionately called her, got a call on January 16, 2020, informing her that her mother had disappeared after learning her son was in critical condition. She never imagined that hours later, she would find her mother lifeless as well.

“It brings me more peace to think that she didn’t see him die… but I can’t say [if she witnessed that moment] because I have no information, and these are not things that are investigated,” Nery recounted over the phone.

Due to her mother’s history of substance abuse, Nery suspected she also died of an overdose, but she wasn’t sure. It wasn’t until she was contacted for this story, four years later, that Nery confirmed it. The Demographic Registry’s database, accessed by the Unidad Investigativa de Género (Gender Investigative Unit) — a partnership between Todas and the Centro de Periodismo Investigativo (CPI) — states: “Accidental death by poisoning and exposure to narcotics and psychodysleptics.”

Between 2013 and 2023, approximately 400 women died from overdoses, according to data from the Institute of Forensic Sciences (ICF, in Spanish). Although women make up a small percentage of overdose deaths, in the last decade, female deaths from this cause increased 4.7 times, compared to a 4.2 times increase among men. So, while deaths are rising for both genders, the increase in women’s overdose deaths has been proportionally faster.

Despite this, specific resources to help women with substance abuse are limited. Only three of eight rehabilitation shelters that serve women provide space for mothers with their children, two of which have age limits. Similarly, resources are nearly nonexistent for women who experience drug abuse alongside gender-based violence, as most shelters for victims of violence do not accept women unless they are stable in their addiction treatment.

The lack of transportation, limited availability of psychiatrists, and fear of intervention by the Department of the Family, in the case of mothers, add to the long list of circumstances that hinder the possibility of receiving treatment.

For Debora Upegui Hernández, who has been tracking overdose deaths for five years at the Gender Equity Observatory (OEG, in Spanish), this situation is alarming and cannot continue to be ignored.

“There is a crisis that is beginning, and if addressed promptly, it could be managed” to prevent and control it, she emphasized regarding the deaths that the OEG classifies as indirect femicide to draw attention to the increase and lack of specific resources for women.

To collect and classify its statistics, the OEG uses the Latin American protocol model for investigating violent deaths of women for gender reasons. This model classifies women’s overdose deaths as indirect femicides because it recognizes that women are in a state of vulnerability that men do not have, and although there is no direct culprit, the state could have taken action to prevent their deaths.

Upegui Hernández explained that although men also suffer overdoses, there are more resources for them, they do not face the stigma of being users as women do, they are not exposed to gender violence by other consumers in shelters, and the reasons that lead them to use controlled substances are different from those of women.

“Substance use among men is basically accepted. It may not be considered desirable, but it is understood that men have the freedom to do so… However, women are labeled as bad mothers. It’s as if they don’t have the right to seek pleasure in other ways because they are mothers, because they are daughters, because they must fulfill their assigned gender roles,” she said.

In October 2024, a dozen people were victims of overdoses in the town of Arecibo. At least two of them were women.

Limited Resources for Mothers

Nery remembers her mother, who was a secretary by profession, as a woman with goals who, when she was little, took her to the circus and the fair. “We had many beautiful experiences,” she recalled.

When Nery was between 17 and 20 years old, she and her brother, four years younger than her, constantly moved between relatives’ homes while their mother entered and exited rehabilitation centers. Later, Nery became independent and moved out on her own.

When women with substance addiction have children, seeking help becomes even more difficult. Vanessa Acevedo, coordinator of the assisted withdrawal program Compromiso de Vida, said they do not receive many mothers in their shelter because they fear the Department of the Family will take custody of their children.

“As mothers, we worry that our children will be taken away if we have problematic substance use, and that’s why women are very afraid to receive detox services,” Acevedo explained, adding that in community orientations, they try to lower that resistance to treatment among women.

Compromiso de Vida has 22 available beds, of which three are for women. Since they do not accept minors in their facilities, they coordinate with patients’ families to keep the minors during the 10-day treatment.

When contacting eight shelters that offer help to women with problematic substance use, only La Perla de Gran Precio; one of the Hogar Crea centers; and the Residence, Treatment for Adult Women of the Mental Health and Addiction Services Administration (ASSMCA, in Spanish) allow minors in their facilities. ASSMCA sets the limit for infants at “school age,” meaning children must be one year old or younger.

In the case of Hogar Crea, children must be between 0 and 4 years old, and at least one parent must be HIV positive to enter.

La Perla de Gran Precio does not offer rehabilitation treatments due to lack of economic resources, although they did so more than 10 years ago. According to its director and founder, Lissette Alonso, someone can start their treatment in the hospital and, once released, join the shelter. If they need outpatient procedures, such as methadone or psychological services, they can receive them at La Perla de Gran Precio.

“[Mothers] can have their children… we’ve had everything. We’ve had teenagers, mothers, and pregnant women,” Alonso said, then assured that among all the projects, they have approximately 60 beds for women. That number is the highest, as other projects have between eight and 22 beds for women.

In the case of transgender women, only Casa de la Providencia required gender affirmation surgery to be accepted into their facilities. Hospital Panamericano and Capestrano did not respond to interview requests from this media outlet.

Barriers for Mothers in Outpatient Treatment

The type of treatment a person receives will depend on their addiction. According to Vilmari Molina Roque, a social worker for Intercambios Puerto Rico, not all cases of substance addiction require a rehabilitation shelter. In some cases, such as opioids, people can get outpatient treatment with methadone or buprenorphine when they visit the center and go home the same day. If it’s crack, psychiatric assistance is needed.

But mothers receiving outpatient treatment also face obstacles, including lack of transportation, availability of psychiatrists, and lack of understanding from the Department of the Family, according to Molina Roque.

The social worker said she has had participants stable in their treatment from whom the Department of the Family attempted to take their children away because they had a history of controlled substance use.

“I saw that with participants who were stable and had children that, at some point, the Department removed due to substance use,” she said, but clarified that the situation with the agency improved, and with a suitable treatment plan, it is possible for mothers to stay in the rehabilitation process and have contact with their children.

She recalled the story of a young woman who was pregnant when she sought help for her addiction. She had told the social worker that she wanted to have contact with her daughter, and every time she was threatened with losing her, she became destabilized.

It was then that Molina Roque had to work together with the Department of the Family and the young woman so that, upon giving birth, the woman, who remained stable in treatment, could have contact with her daughter. Meanwhile, custody went to the baby’s father. “All this was achieved because I was there,” assured the social worker, who also urged professionals working with substance users to go the extra mile for their participants.

Similarly, she recalled that substance use is a chronic disease whose treatment takes time and must be addressed as such.

“I think there is a lot of ignorance. I think we are stigmatizing and judging our female substance users a lot because they are not allowed to spend time with their children if they are in treatment and stable,” she said about the times when minors are removed without first creating an adequate plan for their and their mother’s well-being.

The Gender Investigative Unit contacted the Department of the Family to ask about cases of mothers stable in treatment and the possibility of their children being removed. Family Secretary Ciení Rodríguez Troche said, through written statements, that removing minors is “an extreme measure” and is not taken unless there is no other alternative.

“Establishing that the Department of the Family attempts to remove minors just because mothers had a history of substance use is not only an erroneous argument but contrary to the current public policy of keeping families united. The removal of a minor from their home is an extreme measure that is only adopted when their safety is in danger and there are no viable alternatives to protect them within their family nucleus. In those cases, family resources are first evaluated at the time of placement,” she emphasized.

She also said there are situations where the woman appears to be stable in treatment, but when evaluated by a professional, “additional support is needed.” “In those cases, the service plan is modified, and additional support is offered,” Rodríguez Troche pointed out.

These limitations are compounded by the lack of transportation to reach centers where psychiatrists are willing to attend to them with fewer waiting hours. “An active and decompensated substance user, how are they going to wait so many hours?” Molina questioned.

It is estimated that the number of psychiatrists in Puerto Rico is between 200 and 250, meaning there is an average of one psychiatrist for every 2,000 people, said psychologist Johnny Rullán. The expert added that this figure prevents people from receiving personalized treatment of more than 15 minutes.

Victims of Violence Have Nowhere to Go

Mental health professionals play an essential role in treating controlled substance use, as many women turn to addiction due to childhood traumas, gender violence, and mental disorders. Others face these situations after starting substance abuse.

A study conducted by researchers at Ponce Health Sciences University in 2022 revealed that “gender violence can be one of the causes for starting substance use and, in turn, places women who use substances at greater vulnerability to receive violence.”

Nery remembers that her mother was in a domestic violence relationship after marrying at 16. In adulthood, she was diagnosed with schizophrenia and bipolar disorder. “She medicated with some medicines after a certain age, but in her youth, she medicated with drugs,” she said, noting that when she received social security, the woman was able to start treating her conditions.

The most recent study by the Homeless Count revealed that between 2010 and 2023, the number of homeless women increased from 10% to 26%. The main reason (37.1%) was gender violence, and the second, drug and alcohol use (34.1%). However, when women are in situations of domestic violence and are simultaneously abusing substances, their possibilities of getting help are limited.

This media outlet contacted six of the eight shelters for women victims of domestic violence in Puerto Rico. Only a spokesperson from the Casa Protegida de Mujeres y Niños said they would accept a woman with substance abuse in a situation of violence if she had a protection order and if approved by their coordinator. The rest responded that they do not have resources or cannot handle such cases if the person is not stable in treatment. Casa Protegida Julia de Burgos did not respond to this media outlet’s request.

“The few times I’ve had to say, ‘I have nothing to offer you’ have been to females,” said Molina Roque about those women who are in situations of gender violence, substance abuse, and homelessness.

She recalled one of her participants, active in crack use, whom she had to take to the emergency room once because she arrived beaten by the man she lived with. However, she couldn’t do more for her because, in circumstances like this, the person themselves must decide to start treatment for their addiction. “It’s been very difficult for me to work on that case,” she noted.

Collaboration Between Government Agencies is Just Beginning

Although it has been in operation since 2018, the Opioid and Substance Program of the Department of Health (DS, in Spanish) began last year to coordinate the collection of statistics between the agency, ASSMCA, and the ICF. This year, it began receiving statistics from the ICF, the manager of the DS Opioid Program, Dr. Riobel Palomino Gutiérrez, explained.

Although the data collection system shows the number of deaths with opioids present in their system, overdose death data is not yet available on the DS website because it is not updated. “Data meetings between ASSMCA and the Department of Health are being planned to determine how we will be updating that data,” said the official, who hopes this will happen before the end of the year.

Both agencies collect data related to overdose events from different sources and for different purposes.

While the DS focuses on statistics of overdose events that reach hospitals, ASSMCA obtains data from surveys on overdoses reversed with naloxone, commercially known as Narcan, as well as fatalities recorded by the ICF.

Palomino Gutiérrez said that last year, both agencies divided efforts to collect data that they will be sharing. He said the program aims to collect more statistics, provide funds to the ICF and community entities, and educate about opioids and other controlled substances.

According to Pedro Dedós Pérez, executive director of ASSMCA’s Mental Health and Addictions Observatory, “in the coming months,” both ASSMCA and the DS will have all available data on their respective pages.

“Conversations have already begun. The platforms are in programming, maintenance, and updates so that the systems can synchronize, and we can share the data,” he assured.

The ASSMCA Overdose Monitoring System was created in 2017, after the United States declared an opioid crisis, explained Dedós Pérez. This tool is part of a data repository known as the ASSMCA Observatory, among whose duties are to collect statistical information on fatal and reversed overdoses, suicides, calls to the First Psychosocial Aid line (PAS, in Spanish), and track opioids prescribed by pharmacies voluntarily, among others. This collection of statistics became a legal mandate in 2021.

However, the observatory’s page was not working, so the Overdose Monitoring System could not be accessed. Dedós Pérez attributed the issue to the lack of “maintenance” the page receives and expressed hope that it will be operational again by December 15.

New ICF Protocol and Health Strategy to Address the Problem

Due to the general increase in overdose deaths, mainly from fentanyl, the ICF implemented a new protocol three months ago that allows it to share its statistics with agencies in real-time, Director María Conte Miller said in a phone interview.

“A person we suspect died from an overdose is immediately given a rapid test. It’s a qualitative test, with a strip that turns a color indicating the substance,” Conte Miller explained. “That strip is entered into a digital platform so that other agencies can establish prevention plans, epidemiological surveillance, and interventions,” she noted.

Conte indicated that since 2020, the ICF has been working to expedite other toxicological tests that previously took longer due to problems in the Institute’s laboratory. At that time, they weren’t even looking to identify the presence of fentanyl. “Since 2020, we started looking for fentanyl as part of a routine. That’s why we’ve also been able to make more diagnoses. What was a perception, we’ve confirmed,” she recounted.

Conte explained that to determine the cause of death by overdose, forensic pathologists evaluate the correlation of autopsy findings and toxicological tests with the circumstances of the death.

She recounted that often, there is a witness to a death while the person was using substances, or the body is found with drugs in their possession. In other cases, a family member or acquaintance reports that the deceased fell into a deep sleep and did not wake up. The tests, which include urine, blood, and vitreous humor (the liquid found in the eyeball) samples, are analyzed in an ICF laboratory.

It takes an average of three months from the time the person dies until their relatives can be certain about the cause of death. Although the ICF automatically shares its data with other concerned agencies, there is no mechanism to automatically notify the relatives of a deceased person of the forensic pathologists’ conclusion. Conte confirmed that it depends on them contacting the ICF or getting the information, when ready, on the death certificate.

On October 11, the DS posted on its Facebook page that due to the multiple overdoses that occurred in Arecibo that month, it would distribute fentanyl detection kits and the overdose reversal medication, naloxone, commercially known as Narcan, to local entities and organizations.

The Department of Health’s Opioid and Substance Program provides Narcan and fentanyl reactive strips to organizations that request it by writing to [email protected].

Nery, whose mother and brother died from overdoses, would have liked to receive more education about methods to reverse overdoses like Narcan. “My concern is the lack of information about Narcan. If I had known they [her brother and mother] were using something like that, I would have had Narcan at home,” she emphasized.

Journalist Cristina del Mar Quiles contributed to this story