Addressing Stigmas That Hinder Addiction Treatment and Recovery
If you accept the expectations of others, especially negative ones, then you never will change the outcome.—Michael Jordan
The United States is experiencing an unprecedented substance use crisis (1). Substance use disorders are defined in DSM-5-TR as the presence of pathological patterns of behavior that are associated with the use of any substance that falls into one of the 10 recognized classes. These behaviors include impaired control of use; unsuccessful efforts to decrease or discontinue use; spending a great deal of time obtaining, using, and recovering from use; frequent cravings for the desired substance; impaired social functioning; and risky use practices (2).
The 2022 National Survey on Drug Use and Health reported that an estimated 48.7 million people ages 12 or older (17.3%) in the United States had a substance use disorder in the past year, including 29.5 million who had an alcohol use disorder, 27.2 million who had a drug use disorder, and 8.0 million who had both an alcohol use disorder and a drug use disorder. Only 26% of those individuals received any treatment for their substance use disorder. Of the more than 40.4 million people who needed but did not receive treatment for an illicit drug or alcohol use disorder in the previous year, only 1.8 million felt (or admitted) that they needed treatment (3). Estimates indicate that 100,105 people died as the result of preventable drug overdoses in 2022—an increase of 797% since 1999. Of the approximately 100,000 drug overdose deaths, 77,603 were from opioids (4).
The U.S. health and mental health care systems are clearly unprepared for this inundation of patients who require prevention, early intervention, and treatment services for substance use disorders. There are only 1,883 physicians nationwide who are certified in addiction medicine, with an additional 1,288 physicians who specialize in addiction psychiatry (5). Given the paucity of specialists, and the enormous scope of the problem, all health and mental health providers are in a crucial position to identify, treat, and refer individuals with substance use disorders—from those with emerging dependence to those with seriously impairing use. At least 30% of adults with mental health conditions have a co-occurring substance use disorder (6). This disorder is frequently unidentified because professionals often fail to screen adequately for substance use disorders. A 2018 study by Mark and Meinhofer (7) found that 80% of patients who have co-occurring mental and substance use disorders receive only psychiatric treatment and no concurrent substance use treatment. They reported that 8.7% of psychiatric office visits involved a substance use disorder diagnosis, 2.2% involved a prescription for opioid use disorder, and 0.5% involved a prescription for alcohol use disorder. This suggests that psychiatrists are diagnosing and treating less than half of patients in their care who have a co-occurring substance use disorder (7).
Clinical Vignette
Bill is a 35-year-old man who presented to the emergency department with lethargy and difficulty rousing. He is married and has two young children. He is a successful attorney at a well-respected law firm in town.
Bill was an athlete in high school—on the track and basketball teams. After a knee injury in his junior year of high school, he took up cycling. Like most things in his life, when he started cycling, he went into the sport wholeheartedly and competitively. He excelled at both mountain biking and road cycling. In fact, he received a full-ride athletic scholarship to Western Colorado University, which had a competitive cycling team. At the national championships in road cycling, their team placed first, and in the individual competition, Bill placed second. After considering a career in competitive cycling, Bill opted to attend law school. He continued to cycle alone and with club teams in the area and averaged 250 miles weekly.
Bill married his high school sweetheart after law school, joined a prestigious law firm in town, and was considered a rising star. Bill had a few cycling accidents along the way. One car hit him and drove off, which resulted in a serious concussion. At age 32, Bill sustained his most painful injury. He was on a long, solo bike ride, cruising up and down the hills, and achieving a personal record for speed. As he barreled down a hill, a deer darted in front of him and collided with his bicycle. Bill was flung into the air and landed on his shoulder. He sustained a clavicle fracture, a shoulder ligament tear, injury to his axial nerve, 18 rib fractures, and two punctured lungs. His pain was excruciating. After a night in the emergency department, surgery for his clavicle fracture, and another night in the hospital for recovery, he was discharged with plans for orthopedic and neurology follow-up.
The oxycodone that was prescribed temporarily blunted his pain. For the first time in his life, Bill, who considered himself to have a high pain tolerance, felt that he could not tolerate the excruciating pain. He quickly depleted his oxycodone. He visited an urgent care center and a few more pain pills were prescribed. He tried marijuana edibles and achieved some relief. Bill continued to have chronic and throbbing pain despite physical therapy. Dealing with his pain and inactivity took an increasing toll on Bill’s mental health. He experienced a major depressive episode. Cycling had previously improved his mood, but he required opioids to manage the pain in order to resume cycling. A friend suggested a physician who was known to prescribe pain pills more liberally. Bill pushed himself to get back to his former cycling condition, but he required more and more opioids to get the same relief. He began to buy medication through illegal means. As his substance use became more expensive, he resorted to fentanyl to manage the pain.
Bill began to miss work due to sedation. He failed to get an important legal brief completed by a deadline. The senior partners, who had been discussing making him a partner in the firm, began to question his competence. Bill began to drink heavily as well. Bill’s shame and self-loathing increased, and he contemplated suicide. With his wife’s urging, he agreed to see a psychiatrist for his depression. He was too humiliated to admit to using drugs. A selective serotonin reuptake inhibitor was prescribed, and it was recommended that Bill join Alcoholics Anonymous for his excessive alcohol intake.
When Bill’s wife had difficulty waking him for work one morning, she called 911 and he was rushed to the hospital. Naloxone was administered as standard procedure, and he soon was easily roused. It was then that he was diagnosed as having opioid use disorder.
Barriers to Substance Use Treatment
There are multiple barriers to treatment access for individuals who are experiencing substance use disorders. Cost, availability, wait times, a lack of diversity, and proximity to care all represent significant obstacles for those who are seeking care (8). Another barrier to effective treatment is the stigma that is associated with addictions (9). Stigma is defined as the negative social attitude that is attached to a characteristic of an individual that may be regarded as a mental, physical, or social deficiency. Stigma implies social disapproval and can unfairly lead to discrimination against and exclusion of the individual (10). As described in the following text, four types of stigmas may be experienced by individuals with substance use disorders (11).
Public stigma includes the negative attitudes and fears of society more broadly toward persons with addictions. Barry and colleagues (12) found that Americans hold more negative attitudes toward persons with drug addiction than toward persons with mental illness. Public stigma isolates individuals with addictions from family, friends, and other support systems.
Structural stigma includes policies and health practices that exclude individuals with addictions from opportunities and resources (11). A 2013 study by van Boekel (13) found that health professionals often report a negative attitude toward patients with substance use disorders. They tend to perceive patients with substance use disorders as more violent, manipulative, and less motivated for treatment than individuals with other mental and general medical health disorders. Health care professionals were found to treat patients with substance use disorders with less empathy and personal engagement (13). Patients who perceive stigma in care settings have been found to have worse treatment outcomes overall (9).
Stigma against medications for opioid use disorder occurs when medications with proven effectiveness are characterized as “trading one addiction for another.” Despite U.S. Food and Drug Administration approval, these medications are under-prescribed, underutilized, overly restricted, and often not covered by insurance. Some recovery settings disparage the use of any medications, which furthers the stigma regarding the use of medications such as buprenorphine in the treatment of opioid use disorder.
Perhaps the most insidious stigma, however, is self-stigma, which is when the negative stereotypes about addictions are internalized and erode self-esteem and hope (11).
Concerns about stigma may deter some individuals from excessive substance use. However, once an individual is on the path to addiction, stigma contributes to more chronic and disabling substance use disorder (9). The National Center on Health, Behavioral Health, and Safety (11) identified seven ways that stigma contributes to addiction: 1) increasing shame and isolation from family, friends, and community; 2) preventing individuals from seeking help; 3) limiting treatment availability; 4) enabling health insurance companies to limit the amount of substance use treatment that is covered; 5) pushing individuals toward treatment that is not evidence-based; 6) treating persons with addiction as criminals; and 7) creating social and structural barriers to recovery, such as difficulty getting and keeping a job and staying employed. White Americans receive treatment more easily and quickly than do Black or Hispanic Americans. Black and Hispanic Americans experience broader stigmas, which tend to compound the stigma associated with addiction (11).
Many psychiatrists and general practitioners shy away from treating patients with co-occurring disorders—those with psychiatric disorders and substance use disorders (7). Lack of adequate training, the complex needs of patients, not having a team of experts to provide the comprehensive services required, and lack of adequate reimbursement for care are all deterrents (13). Physicians are not immune to stereotypes. Implicitly held stigma toward those with addictions is another factor that dissuades psychiatrists and other physicians from treating patients with substance use disorders. Careful self-reflection is required to identify biases that may hinder optimal empathy and care. It takes bravery and determination for individuals with a substance use disorder to overcome obstacles to access treatment and face the risk of feeling devalued. Stigma has deterred many patients from seeking mental health care, but this stigma is lessening. Addressing the substance use epidemic requires a concerted effort to destigmatize these disorders by treating clinicians, policy makers, the public, and those who are experiencing substance use disorders.
With so many obstacles to treatment access, engaging the patient who is experiencing a substance use disorder is essential to assisting in recovery. The following tips can help with rapport building and treatment engagement of patients with substance use disorders (14–17):
1.
Self-reflection: Reflect on biases that you may hold regarding substance use disorders. Addressing those biases within oneself provides a more accepting state of mind for optimizing the care provided. Mentalization or imagining the inner experience of a patient who is experiencing addiction also enhances empathy.
2.
Create a welcoming environment: This includes a smile from a friendly receptionist, kind and respectful health and mental health professionals, and verbal and nonverbal communication that conveys that the patient is welcome.
3.
Ample time: Set the appointment schedule for initial evaluations to be of sufficient time to allow for rapport building and sensitive information gathering.
4.
Preferred language: Conduct the interview in the patient’s dominant language whenever possible.
5.
“People-first” language: Use language such as “person with a substance use disorder” instead of “drug addict.”
6.
Medically accurate language: Use medically accurate language to destigmatize the disorder and empower patients to confront their addiction with dignity.
7.
Ask for permission: Start with open-ended questions and active listening to get to know the person and help them feel comfortable in sharing. Ask for permission to ask more specific or personal questions and give the patient the option to not answer if they feel uncomfortable. Seeking permission can help you create a safe, nonjudgmental space, and encourage open communication.
8.
Be aware of body language: Maintain an open and active-listening posture to foster trust.
9.
Normalize the conversation: Reassure patients that their experience is shared by others. Destigmatize substance use disorders by clarifying that they are common, yet complex medical diseases for which there are effective treatments.
10.
Motivational interviewing: Use motivational interviewing techniques to assist the patient in identifying their personal reasons for change and sobriety.
11.
Goals and barriers: Ask about the patient’s goals, what recovery means to them, and the life they imagine if they are sober. Ask what barriers might limit their ability to stay in treatment.
12.
Acceptance: Demonstrate acceptance through understanding and encouragement.
13.
Acknowledge struggles and courage: It takes courage for individuals to admit to having a substance use disorder and to face the potential for rejection and criticism. Acknowledge this.
14.
Commitment: Ask the patient to commit to attending at least four follow-up sessions.
15.
Provide choices: Help each patient to become informed of possible treatment options and the pros and cons of each (as well as pros and cons of no treatment).
16.
Shared decision making: Involve the patient in their treatment plan through shared decision making. Jointly signing a treatment plan is one way of demonstrating this agreement.
17.
Honesty and transparency: Provide education and explain your rationale for the treatment you are recommending.
18.
Medication-assisted treatment: Recommend medication-assisted treatment whenever appropriate as an effective and evidence-based treatment.
19.
Co-occurring disorders: Assess for and address co-occurring psychiatric disorders. Substance use disorders and psychiatric disorders often reinforce each other.
References
1.
Opioid Crisis. Rockville, MD, United States Health Resources and Services Administration, 2023. https://www.hrsa.gov/opioids#:∼:text=The%20Nation%20is%20in%20the,critical%20to%20fighting%20this%20epidemic. Accessed Jun 6, 2024
2.
Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision. Washington, DC, American Psychiatric Association, 2022. https://doi.org/10.1176/appi.books.9780890425787
3.
2022 National Survey on Drug Use and Health (NSDUH) Releases. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2023. https://www.samhsa.gov/data/release/2022-national-survey-drug-use-and-health-nsduh-releases. Accessed Jun 6, 2024
4.
Drug Overdoses. Itasca, IL, National Safety Council Injury Facts, n.d. https://injuryfacts.nsc.org/home-and-community/safety-topics/drugoverdoses/data-details/#:∼:text=Preliminary%202022%2C%20estimates%20indicate%20that,%2C%20homicide%2C%20and%20undetermined%20intents. Accessed Jun 6, 2024
5.
Scutti S: 21 million Americans suffer from addiction. Just 3,000 physicians are specially trained to treat them. Washington, DC, American Board of Medical Specialties News, 2019. https://www.aamc.org/news/21-million-americans-suffer-addiction-just-3000-physicians-are-specially-trained-treat-them#:∼:text=Just%201%2C883%20physicians%20nationwide%20are,of%20Medical%20Specialties%20(ABMS). Accessed Jun 6, 2024
6.
Key Substance Use and Mental Health Indicators in the United States: Results From the 2022 National Survey on Drug Use and Health (HHS Pub no PEP23-07-01-006, NSDUH Series H-58). Rockville, MD, Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 2023. https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report
7.
Mark TL, Meinhofer A: The extent to which psychiatrists diagnose and treat substance use disorders. Psychiatr Serv 2018; 69:250
8.
2022 Access to Care Survey Results. Prepared by the Harris Poll. Washington, DC, National Council for Mental Wellbeing, 2022. https://www.thenationalcouncil.org/wp-content/uploads/2022/05/2022-Access-To-Care-Survey-Results.pdf. Accessed Jun 6, 2024
9.
Crapanzano KA, Hammarlund R, Ahmad B, et al: The association between perceived stigma and substance use disorder treatment outcomes: a review. Subst Abuse Rehabil 2018; 10:1–12
10.
Stigma. Washington, DC, American Psychological Association, 2018. https://dictionary.apa.org/stigma. Accessed Jun 6, 2024
11.
Understanding Substance Use Stigma. Washington, DC, National Center on Health, Behavioral Health, and Safety, 2021. https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/understanding-substance-use-stigma.pdf. Accessed Jun 2, 2024
12.
Barry CL, McGinty EE, Pescosolido BA, et al: Stigma, discrimination, treatment effectiveness, and policy: public views about drug addiction and mental illness. Psychiatr Serv 2014; 65:1269–1272
13.
van Boekel LC, Brouwers EP, van Weeghel J, et al: Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend 2013; 131:23–35
14.
Engaging Patients in Opioid Use Disorder Treatment. Rockville, MD, Agency for Healthcare Research and Quality, 2024. https://integrationacademy.ahrq.gov/products/playbooks/opioid-use-disorder/implement-mat-for-oud/engaging-patients-oud-treatment. Accessed Jun 2, 2024
15.
A Movement to End Addiction Stigma. Addressing Opioid Use Disorder Stigma: The Missing Piece of Our Nation’s Strategy to Confront the Opioid Epidemic. Norwalk, CT, Shatterproof, 2024. https://www.shatterproof.org/our-work/ending-addiction-stigma/understanding-addiction-stigma. Accessed Jun 5, 2024
16.
How to Talk With Patients About Substance Use Disorder: 11 Tips. Chicago, IL, Gateway Foundation, 2024. https://www.gatewayfoundation.org/addiction-blog/how-to-talk-with-patients-about-substabce-abuse/. Accessed Jun 6, 2024
17.
Parks T: How to talk about substance use disorders with your patients. Chicago, IL, American Medical Association, 2016. https://www.ama-assn.org/delivering-care/overdose-epidemic/how-talk-about-substance-use-disorders-your-patients. Accessed Jun 6, 2024
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Published in print: Fall 2024
Published online: 15 October 2024
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Dr. Stubbe reports no financial relationships with commercial interests.
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