Stigma of Addiction

 

Stigma and Addiction

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What is stigma?

Stigma is a discrimination against an identifiable group of people, a place, or a nation. Stigma about people with SUD might include inaccurate or unfounded thoughts like they are dangerous, incapable of managing treatment, or at fault for their condition.

Where does stigma come from?

For people with an SUD, stigma may stem from antiquated and inaccurate beliefs that addiction is a moral failing, instead of what we know it to be—a chronic, treatable disease from which patients can recover and continue to lead healthy lives.

How does stigma affect people with SUD?

• Feeling stigmatized can reduce the willingness of individuals with SUD to seek treatment.1,2
• Stigmatizing views of people with SUD are common; this stereotyping can lead others to feel pity, fear, anger, and a desire for social distance from people with an SUD.2
• Stigmatizing language can negatively influence health care provider perceptions of people with SUD, which can impact the care they provide.3

How can we change stigmatizing behavior?

• When talking to people with SUD, their loved ones, and your colleagues, use non-stigmatizing language that reflects an accurate, science-based understanding of SUD and is consistent with your professional role.
• Because clinicians are typically the first points of contact for a person with an SUD, health professionals should “take all steps necessary to reduce the potential for stigma and negative bias.”3 Take the first step by learning the terms to avoid and use.
• Use person-first language and let individuals choose how they are described.4 Person-first language maintains the integrity of individuals as whole human beings—by removing language that equates people to their condition or has negative connotations.5 For example, “person with a substance use disorder” has a neutral tone and distinguishes the person from his or her diagnosis.6

What else should I keep in mind?

It is recommended that “substance use” be used to describe all substances, including alcohol and other drugs, and that clinicians refer to severity specifiers (e.g., mild, moderate, severe) to indicate the severity of the SUD. This language also supports documentation of accurate clinical assessment and development of effective treatment plans.7 When talking about treatment plans with people with SUD and their loved ones, be sure to use evidence-based language instead of referring to treatment as an intervention. 

HOW PREVALENT IS ADDICTION STIGMA?

We live in a society where millions of Americans are dependent on drugs or alcohol and only a small percentage receive treatment at a facility. In fact, the 2014 National Survey on Drug Use and Health found that 21.5 Americans age 12 and older had a substance use disorder in the previous year; however, sadly only 2.5 million received the specialized treatment they needed.

Stigma affects all of us – and nearly everyone has felt stigmatized or has stigmatized others at some point in their lives. In a study done by Johns Hopkins Bloomberg School of Public Health, the general public was more likely to have negative attitudes towards those dealing with drug addiction than those who were dealing with mental illness. Additionally, researchers found that people don’t generally support insurance, housing, and employment policies that benefited people who were dependent on drugs (JHU, 2014).

A PICTURE OF STIGMA

Becoming dependent on drugs can happen to anyone. It’s important to keep in mind that we can all do a better job of decreasing stigma around drug use.These responses help illustrate the importance of remaining kind, compassionate, and human. The image below includes quotes from some of the respondents.

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HOW STIGMA HURTS

Stigma can negatively impact a number of areas, including:

• Willingness to attend treatment and access to healthcare.
• Harm reduction.
• Self-esteem and mental health.

IMPACT ON TREATMENT

Unfortunately, people who experience stigma regarding their drug use are less likely to seek treatment, and this results in economic, social, and medical costs. In the United States, costs associated with untreated addiction (including those related to healthcare, criminal justice, and lost productivity) amounted to a whopping $510 billion (Harwood, 2000).

Perceived stigma in hospitals or doctors’ offices can discourage people from accessing needed healthcare services. Having a trusted primary care doctor is associated with maintaining well-being and a good quality of life. However, studies have found that some healthcare providers feel uncomfortable when working with people who are dependent on drugs. In a study of nurses’ attitudes towards patients, the majority of nurses held negative views about people who used drugs (Howard & Chung, 2000). In another study of nurses in the UK, most of the nurses had a stigma against injection drug users (Monks, Topping, & Newell, 2013). When health providers carry a stigma towards people with drug dependencies, it can affect their willingness to assess or treat the patient for substance abuse, how they approach him or her, and it may prevent addicted individuals from seeking healthcare altogether.

In order to better support people with substance use disorders, the Affordable Care Act (ACA) includes benefits for addiction treatment. People who have Medicaid or purchase plans through the health exchanges are eligible for treatment services, including psychotherapy and counseling. Plans vary, and some have limits on the number of days or visits covered, how much of the deductible and copayment will be covered, and whether or not you need authorization for treatment. Despite these limits, more Americans have access to care than they did before. Due to social factors such as stigma, however, whether or not they gain access to treatment still remains a major public health issue.

The problem of access to treatment even extends into the criminal justice system. A study conducted by The National Center on Addiction and Substance Abuse (CASA) found that of the 2.3 million people incarcerated in the United States, more than 65% of them met the criteria for a substance abuse disorder, yet only 11% of those people received treatment (CASA, 2010).

IMPACT ON HARM REDUCTION

Unfortunately, stigma can affect the public’s perception of evidence-based harm reduction strategies. Harm reduction refers to public health interventions like:

• Needle exchanges.
• Substitution therapies.
• Safe drug consumption rooms that are designed to decrease the risk associated with drug use (e.g., infected needles).

Due to widespread stigma about those who use drugs and who suffer from addiction, however, these interventions are not usually supported by the public and believed by some to facilitate and encourage drug use – despite evidence demonstrating that they actually decrease drug use (Logan & Marlatt, 2010).

SOCIAL AND MENTAL IMPACT

Perceived stigma can cause major harm to people in their social lives. The chronic stress of discrimination may affect the mental and social health of individuals who use drugs. People who use drugs can feel pushed to the outskirts of society and may lose touch with their community and family and experience profound loneliness and isolation.

When a person does not have social ties or a person to talk to, they are less likely to reach out for healthcare or treatment. They are also more likely to be depressed and may hide their drug use from health care providers to avoid stigma and drug shaming. The mental health consequences of isolation can fuel even more drug use, leading to further isolation, and ultimately a vicious cycle that is hard to be break out of.

Perceived stigma can also be internalized. People who use drugs can view themselves as deviants; this can severely impact their self-esteem and self-worth. Historically, a dependence on drugs has been viewed as immoral or the result of a lack of self-control. These views contribute to stigma and present barriers to people accessing necessary treatment.

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FIGHTING BACK AGAINST STIGMA

People report perceived stigma from healthcare providers, loved ones, and the general public. No matter the situation, no one likes to feel judged or devalued. In order to encourage people to reach out for help and get on the path to recovery, it is important to reduce the stigma surrounding their situation. Educational programs and modeling of non-stigmatizing behavior can help people provide nonjudgmental, empathic support.

Effective ways for individuals to help reduce stigma include:

• Offering compassionate support.
• Displaying kindness to people in vulnerable situations.
• Listening while withholding judgment.
• Seeing a person for who they are, not what drugs they use.
• Doing your research; learning about drug dependency and how it works.
• Treating people with drug dependency with dignity and respect.
• Avoiding hurtful labels.
• Replacing negative attitudes with evidence-based facts.
• Speaking up when you see someone mistreated because of their drug use.
• Sharing your own stories of stigma.

FIGHTING STIGMA THROUGH NEXT-GENERATION PSAS

Some public service announcements (PSAs) that moved passed the stigmatizing announcements of years ago (think: “this is your brain on drugs”). The contest looked to find a new inspiring message for those suffering with the disease to feel supported, encouraged and motivated to step on the path to seek treatment for their addiction. The Judge’s Choice winner is shown below:

More Than An Addict, filmed and produced by Tori Utley

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Terms to avoid, terms to use, and why

Consider using these recommended terms to reduce stigma and negative bias when talking about addiction.

Instead of…	Use...	Because...
Addict User Substance or drug abuser Junkie   Alcoholic Drunk   Former addict Reformed addict	Person with substance use disorder8 Person with opioid use disorder (OUD) or person with opioid addiction [when substance in use is opioids] Patient   Person with alcohol use disorder Person who misuses alcohol/engages in unhealthy/hazardous alcohol use   Person in recovery or long-term recovery Person who previously used drugs	Person-first language. The change shows that a person “has” a problem, rather than “is” the problem.7 The terms avoid eliciting negative associations, punitive attitudes, and individual blame.7
Habit	Substance use disorder Drug addiction	Inaccurately implies that a person is choosing to use substances or can choose to stop.6 “Habit” may undermine the seriousness of the disease.
Abuse	For illicit drugs: Use For prescription medications: Misuse Used other than prescribed	The term “abuse” was found to have a high association with negative judgments and punishment.9 Legitimate use of prescription medications is limited to their use as prescribed by the person to whom they are prescribed.  Consumption outside these parameters is misuse.
Opioid substitution replacement therapy Medication-assisted treatment (MAT)	Opioid agonist therapy Pharmacotherapy Addiction medication Medication for a substance use disorder Medication for opioid use disorder (MOUD)	It is a misconception that medications merely “substitute” one drug or “one addiction” for another.6 The term MAT implies that medication should have a supplemental or temporary role in treatment. Using “MOUD” aligns with the way other psychiatric medications are understood (e.g., antidepressants, antipsychotics), as critical tools that are central to a patient’s treatment plan.
Clean	For toxicology screen results: Testing negative For non-toxicology purposes: Being in remission or recovery Abstinent from drugs Not drinking or taking drugs Not currently or actively using drugs	Use clinically accurate, non-stigmatizing terminology the same way it would be used for other medical conditions.10 Set an example with your own language when treating patients who might use stigmatizing slang. Use of such terms may evoke negative and punitive implicit cognitions.7
Dirty	For toxicology screen results: Testing positive For non-toxicology purposes: Person who uses drugs	Use clinically accurate, non-stigmatizing terminology the same way it would be used for other medical conditions.9 May decrease patients’ sense of hope and self-efficacy for change.7
Addicted baby	Baby born to mother who used drugs while pregnant Baby with signs of withdrawal from prenatal drug exposure Baby with neonatal opioid withdrawal/neonatal abstinence syndrome Newborn exposed to substances	Babies cannot be born with addiction because addiction is a behavioral disorder—they are simply born manifesting a withdrawal syndrome. Use clinically accurate, non-stigmatizing terminology the same way it would be used for other medical conditions.10 Using person-first language can reduce stigma.

In Healthcare:

• Stigma on the part of healthcare providers who tacitly see a patient’s drug or alcohol problem as their own fault leads to substandard care or even to rejecting individuals seeking treatment. 
• People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff fearful of their behavior or assuming they are only seeking drugs. 
• People with addiction internalize this stigma, feeling shame and refusing to seek treatment as a result.
• stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.

COVID

• The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis addition to their greater risk through homelessness and drug use itself, the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. 
• And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.

Decreasing stigma

• Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. 

•  When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.