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Addressing Stigma in Addiction Medicine

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As an addiction medicine specialist, I am all too aware of the importance of addressing the stigma that our patients with addiction face. 

A study among PCPs showed that negative attitudes toward people with prescription-related opioid use disorder were prevalent, even though the majority believed that treatment could be effective. Dr. Nora Volkow, the director of the National Institute on Drug Abuse writes that while visiting a makeshift “heroin shooting gallery” in Puerto Rico, she encouraged a man to go to the ER for treatment for what appeared to be an abscess on his leg. The man responded that he was frightened of returning to the hospital, since he was treated so badly when he had previously sought medical care. For this patient and many others like him, past stigma prevented the pursuit of care for both an addiction and a medical condition. 

The idea that addiction is a moral failing as opposed to a disease of the brain that can be treated contributes significantly to the stigma. While people with substance use disorders often resort to behaviors such as lying and stealing to feed their addictions, it is important to understand that these actions are consequences of changes that have occurred in their brains, for which they need treatment. 

According to Dr. Volkow, more research is needed on overcoming stigma against people with addiction — but even without this research, we know that compassion and respect are essential. 

Our patients aren’t the only ones affected; the stigma also extends to those of us who work in the specialty. When I first announced that I was about to start a position as the medical director of a methadone clinic, a family member asked, “Why would you want to do that?” 

The negative impact of stigma is compounded by inadequate training and exposure: In a recent New York Times newsletter, German Lopez writes that, in addition to stigmatizing attitudes, other reasons doctors give for refusing care to people with substance use disorders include their own lack of training in addiction medicine and lack of access to specialists who have that training. 

In addition to the attitudes listed above, assumptions are often made about why those of us working in addiction medicine went into the specialty. Though having had a personal experience with addiction is common among addiction specialists, it is not a requirement. When I started seeing patients at an in-patient treatment facility in order to get the experience needed to make me eligible for board certification, I encountered the assumption that physicians in the specialty have personal experience with addictions first-hand. I was seeing a patient that happened to be a physician. While I was taking her history, she referred to the organization that provides support for physicians with addictions by an acronym that I was unfamiliar with at the time. When I asked what it meant, she was surprised and responded, “You aren’t in recovery? If you were in recovery, you would know.” 

For my colleagues who are in recovery, self-disclosure can be a double-edged sword. A colleague of mine told me about a time when a patient assumed he (the physician) couldn’t relate to the patient’s experience because he didn’t know what it was like to have an addiction. When my colleague disclosed that he actually did have the experience and was in recovery, the same patient immediately changed his tune and said, “I don’t want to be treated by an addict!” 

Internalized stigma can also affect our own behaviors. When I was working at the methadone clinic, all too aware of the stigma associated with such facilities, I felt like I needed to prominently display my stethoscope as I walked from the parking lot to the building so I wouldn’t be mistaken for a patient. 

More importantly, stigma can prevent physicians from seeking treatment for their own addictions or other mental health conditions. Questions about past mental health conditions posed by licensing bodies and malpractice insurance companies discourage people from seeking care when needed. If our patients are entitled to their privacy when it comes to their mental health history, shouldn’t we have the same protections? I recently came across a video in which a physician was sharing the fact that he takes medications for his mental health condition, and he wanted people to know that it was OK to be on psychiatric medications. At the beginning of the video, he stated that he had been warned that sharing such information publicly could be detrimental to his career. This speaks to the extent of stigma surrounding mental health conditions, including addiction. We wouldn’t discourage our patients from getting help for their mental health problems, so why should we discourage each other from doing so? 

As health care professionals, we should all be aware of our own biases and do our best to avoid perpetuating stigma in any form, whether it is directed against our patients, our colleagues, or our own selves. Awareness of stigma in all its ramifications is the first step toward its elimination, and we should all play our part in this process. 

How do you work to combat stigma toward patients with substance use disorders in your own clinic? Share your experiences and strategies in the comments below.

Dr. Olapeju Simoyan is the medical director of New Directions Treatment Services and a full professor in the department of psychiatry at Drexel University College of Medicine. She has received several awards, most recently the Arnold Gold Foundation’s National Humanism in Medicine Award for exceptional leadership in placing human interests, values, and dignity at the heart of every health care connection, and Pro-Health International’s Award of Excellence in Humanitarian Services. Dr. Simoyan has combined her interests in writing and photography in several books, including The Amazing World of Butterflies, Living Foolproof, and most recently, Transformation and Recovery, a workbook for patients with addictions and other behavioral disorders. Dr. Simoyan strongly believes in the need to transform education and health care, with a focus on creativity, problem solving and integration of the arts and sciences. She is a 2022–2023 Doximity Op-Med Fellow.

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