“It was dehumanizing,” Slade Skaggs told us about how health care providers treated him when he turned to them for help with his substance use disorder. “They made me feel like I was drug-seeking and that I was not deserving of their time or care.”
Fortunately, he finally got the help he needed and is now in recovery, serving as a peer-support specialist for others with substance use disorders.
Stigma — society’s negative attitudes and behaviors towards individuals because of their substance use disorders — propagated by people working in health care causes feelings of shame, limits access to care, and ultimately contributes to vicious cycles of addiction. This is particularly true for people living with opioid use disorder.
In the setting of Covid-19 and physical distancing, it is more important than ever to dismantle such stigma and develop effective continuums of care for vulnerable patients, including those with substance use disorders. In fact, economic uncertainty, social isolation, and burdened health care delivery systems contributed to a 42% increase in overdoses in the U.S. in May alone — the sharpest increase since 2016. Now is the time to improve attitudes toward and knowledge about substance use disorders among health care providers.
Historically, the medical community has not been supportive when treating people with substance use disorders. Stigmatizing patients with opioid use disorder deepens prejudicial feelings among health care providers such as fear, anger, or disgust. Such emotions result in discriminatory clinical care. A Massachusetts survey found that 24% of emergency, family, and internal medicine providers believed that their practices would attract undesirable patients if they treated individuals with opioid use disorder.
Also worrisome is the lack of faith physicians have toward using medication to treat opioid use disorder. Many do not think that treating this disorder with medication is any more effective than treatment without it, despite ample evidence that buprenorphine and methadone are highly effective and save lives. The belief that these medications do not work is built on a foundation of bias, not science.
Stigma from the provider community isn’t surprising. There are meaningful gaps — including limited quality measurement related to outcomes for people with substance use disorder, poor reimbursement practices for treating people with substance use disorders, and inadequate education of clinicians about how to best care for people struggling with addiction — that get in the way of the community coming to terms with the importance of treating individuals with substance use disorder with the highest quality medical care accompanied by genuine respect and compassion.
The Massachusetts study we mentioned earlier also showed that only 1 in 4 respondents who went to graduate medical school or social work school had received addiction-related training during medical education, a startling statistic relative to other chronic diseases.
Stigmatizing perceptions directed toward people with opioid use disorder actually increase during time spent in formal medical education, revealing the “hidden curriculum” of negative bias towards individuals with this condition. Stigmatizing language commonly used in medical records, such as “drug abuser,” influences the attitudes and prescribing behaviors of physicians, nurses, and other health care providers.
The impact of stigma on access to quality care and patient outcomes is significant. Because of the attitudes of health care professionals, people with opioid use disorder may defer seeking care for infections or other medical conditions until they are serious or life-threatening. Once they seek treatment, individuals are likely to downplay their substance use history out of fear that revealing it will affect the quality of the care they receive.
Clinicians must be educated and empowered to use patient-first and recovery-centered language, and to apply evidence-based medicine to their practice.
The first step is to widely share best practices that are likely to reduce the amount of stigma and bias experienced by people with opioid use disorder. There are simple things clinicians can do, such as replacing “drug addict” with “person with a substance use disorder” in conversations and in medical records, that have been shown to shape people’s perceptions and attitudes. One study conducted with more than 500 trained mental health and addiction clinicians found that those asked to read a patient vignette with the term “an individual with substance use disorder” were less likely than those who read vignettes containing the term “substance abuser” to say the patient was personally responsible for his or her illness and punitive action should be taken.
This should start in every U.S. health care organization today. “Every time a doctor talks to me in a way that allows them to look me in the eye and not be a paper on a clipboard, they’re reducing harm because all of a sudden I don’t feel shame,” says Skaggs in an interview we filmed with him. “I feel like I’m being treated as a human being worth loving.”
Beyond language, organizations should look closely at practices that may, purposely or inadvertently, result in discrimination toward patients with substance use disorders. Health care organizations must actively engage clinicians in professional development about substance use disorders and stigma; ensure that medications for opioid use disorder such as buprenorphine and methadone are part of the formulary and no barriers exist to initiating or continuing these lifesaving treatments; and support and advocate for institutional, state, and federal policy that allows for substance use disorders to be cared for as chronic medical conditions similar to diabetes or hypertension. Such systems improvements must be done within a health equity framework.
Another component of reducing stigma associated with substance use disorders is creating easily accessible tools to teach the basics around stigma reduction, such as the Reducing Stigma Educational Tools (ReSET) program we recently released. It features videos of Skaggs and other people with lived experiences related to substance use and stigma from the medical community. The two modules include pragmatic steps that any medical professional or health care trainee can take to improve care for this vulnerable group of patients. Shatterproof, the national nonprofit organization dedicated to transforming addiction treatment that one of us (M.S.) works for, recently launched a nationwide initiative to combat stigma.
Every organization has a role to play in controlling addiction, and this is especially true for the health care community.
There is no time to waste. The Covid-19 pandemic has not only made treatment and recovery support more difficult to access, but it is also intensifying the existing fear, uncertainty, and lack of social connection and cohesion that those with substance addictions already feel. The first, necessary, and immediate step to propelling solutions forward is looking inward at ourselves and our organizations to end stigma.
Richard Bottner is a certified physician assistant and an affiliate faculty member in the Department of Internal Medicine at Dell Medical School at The University of Texas at Austin. Christopher Moriates is a hospital medicine physician and assistant dean for health care value at Dell Medical School. Matthew Stefanko is the director of the National Stigma Initiative for Shatterproof.
Though your article focuses on opioid use disorder, much of what you say applies to patients with cancer who smoke cigarettes. As a Tobacco Treatment Specialist at a cancer center, I can tell you that many patients say, “I have quit every drug in the book and I haven’t drunk alcohol for 20 years, but I just can’t kick tobacco. It’s the most difficult drug of all to quit.” They, too, mention fearing and experiencing stigma in health care setting settings. About 70% of smokers in the US want to quit completely, according to surveys. Patients who smoke usually do not want more information, they want help and support to quit.
If the problem is starting in the education system then we need to reorganize the education system and hire teachers who really do care about these issues and people who have addictions. I myself have struggled with an addiction to cigarettes and was stigmatized by the system for no good reason in a big way. I don’t believe it has to do with my smoking habit that I was stigmatized. I tend to think it has to do with the fact that I am smarter, more experienced and more mature than these people who are in social work in the system around here. They did gang up on me big time. We need great people to work in the system and help us with our issues, not drive us insane and make muck of us because they are so incompetent and poorly behaved themselves.
Why doesn’t Congress mandate that all physicians that have a DEA Number that permits them to prescribe controlled substances also require these same physicians to complete training on diagnosing and treating substance use disorders. At the minimum, these physicians should be trained to prescribe buprenorphine for opioid dependence.
Airline pilots are trained how to take-off AND land their aircraft. Physicians should be trained how to prescribe opioids AND how to treat opioid dependence. Currently too many opioid prescribers abandon their opioid patients and permit them to ‘crash.’
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