Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. Healthcare already has effective tools including medications for opioid and alcohol use disorder that could prevent many of these deaths, but they are not being utilized widely enough, and many people who could benefit do not even seek them out. One important reason is the stigma that surrounds people with addiction.
Stigma is a problem with health conditions ranging from cancer and HIV to many mental illnesses. Some gains have been made in reducing stigma around certain conditions; public education and widespread use of effective medications has demystified depression, for instance, making it somewhat less taboo now than it was in past generations. But little progress has been made in removing the stigma around substance use disorders. People with addiction continue to be blamed for their disease. Even though medicine long ago reached a consensus that addiction is a complex brain disorder with behavioral components, the public and even many in healthcare and the justice system continue to view it as a result of moral weakness and flawed character.
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.
In a Perspective I published recently in The New England Journal of Medicine, I tell the story about a man I met who was injecting heroin in his leg at a “shooting gallery”—a makeshift injection site—in San Juan, Puerto Rico, during a visit there several years ago. His leg was severely infected, and I urged him to visit an emergency room—but he refused. He had been treated horribly on previous occasions, so preferred risking his life, or probable amputation, to the prospect of repeating his humiliation.
This highlights a dimension of stigma that has been less remarked on in the literature and that is uniquely important for people with substance use disorders: Beyond just impeding the provision or seeking of care, stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.
Previously on this blog I highlighted research by Marco Venniro at NIDA’s Intramural Research Program, showing that rodents dependent on heroin or methamphetamine still choose social interaction over drug self-administration, given a choice; but when the social choice is punished, the animals revert to the drug. It is a profound finding, very likely applicable to humans, since we are highly social beings. Some of us respond to social as well as physical punishments by turning to substances to alleviate our pain. The humiliating rejection experienced by people who are stigmatized for their drug use acts as a powerful social punishment, driving them to continue and perhaps intensify their drug-taking.
The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis. In 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.
Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Even people in healthcare, if they do not have training in caring for people with substance use disorders, may be at a loss as to how to interact with someone acting threateningly because of withdrawal or some drugs’ effects (e.g., PCP). It is crucial that people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants, be trained in caring compassionately and competently for people with substance use disorders. Treating patients with dignity and compassion is the first step.
There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised, and that medical care is often necessary to facilitate recovery as well as avert the worst outcomes like overdose. When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.
See also - Words Matter - Terms to Use and Avoid When Talking About Addiction
Dr. Nora Volkow, Director
Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.
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Stigma of addiction
I understand the devastating effects that stigma has on someone suffering addiction. I myself have substance abuse issues and my step daughter committed suicide in 2013 at the age of 20 because she was so ashamed of her heroin addiction. It is great to see information about changing the way society views this condition finally being published publicly.
Dr. Volkow's Insight on Stigma
As always, Dr. Volkow does a wonderful job of highlighting the challenges individuals face when they seek help for substance use disorders. It is critically important that those of us in the healthcare field continue to advocate for our patients and combat stigma on a daily basis. Effective treatment is out there, but not enough people are able to or wiling to access it (in part because of stigma). We need to change that! Thanks again to Dr. Volkow for her outstanding leadership in this area.
Addiction is not a communicable disease- let's not pretend it is
Of course and resoundingly so, we should show impartial compassion toward anyone who is addicted to drugs or alcohol, medically treat their conditions, avoid the stigma and apply all we can for positive outcomes. Society needs to fully understand that there are conducive hereditary and environmental components that lead to addiction.
On the other hand, why can't we shame and stigmatize the widespread, popular drug culture that condones and promotes substance abuse to begin with? The lure and appeal to be a part of it, to be 'cool' so-to-speak, the 'sex appeal', while knowing the risks, is indeed a sign of flawed character and moral weakness. Celebrity lifestyles (sports, music, Hollywood) for instance are very often replete with illegal and addictive drugs. Yet much our society respects, adores, adulates and mimics them and their lifestyles as though they are doing nothing wrong. We basically have a 'behavioral disease' so-to-speak that also needs to be addressed.
Addiction is not some kind of 'communicable disease', so let's now act like it is and pretend nobody is to blame. Basically, our country played with fire, and now we are getting burned.
anti tumor properties of Cannabis
Please stop blocking research on the benefits of Cannabis. I shrank my terminal ovarian cancer on cannabis. After 4 years of fighting with 2 major surgeries, 12 rounds of Taxol, 6 rounds of Doxorubicin and 21 rounds of Carbo have no more options. I will not reach my 50th birthday. But Cannabis shrank my tumor. I am trying to cure/manage my cancer despite you. You have NO excuse, the first paper to show anti tumor effects was published back in 1973. Activists have been begging you for decades. And the pre-clinical data is pouring from labs around the world. If I die- I die from the stonewalling of science and the immoral DEA policy that suppress medicine. schedule1movie.com
I am very sorry to hear about
I am very sorry to hear about your cancer struggle. The NIH does not block research on possible therapeutic uses of cannabis and cannabinoid compounds for cancer or other illnesses. A summary of past and ongoing cannabis research in cancer is provided by the National Cancer Institute. NIDA is also leading the effort to facilitate cannabis research through establishment of a standard dose of THC for scientific study purposes. The lack of such a standard has impeded the science on this drug because the drug itself and the ways people use it are so widely varied. I wish you the best of luck with whatever course of treatment you pursue.
Stigma extends beyond patients
The stigma associated with TREATING OUD, while perhaps not as personal for patients, affects those who step up to support recovery and get viewed askance by distributors who are wary of regulatory consequences and a fear that regulators will shut them down for supplying MAT meds to pharmacies for chronic use. When pharmacies get rationed or cut off on their orders for MAT, the risk to patients is real. Pharmacies MUST adhere to best practices and be open to inspection or audit. Yet, we need an active dialogue around how to promote increased use of MAT rather than an environment of fear and suspicion.
Civil rights combats discrimination misidentified as stigma
This summer, we celebrate 30 years of the passage of the Americans with Disabilities Act (ADA). Over the years, much has changed for people with disabilities to improve equal access to employment, and state and local government and public accommodations such as health care, while very little has changed for people with addiction recovery in these same areas. Today, thousands of people in recovery are unaware of their civil rights under the law. The part of the ADA that addresses Alcohol Use Disorder (AUD) and Substance Use Disorder (SUD) is the most underutilized part of the law. Knowing one’s rights can have a transformative effect on how we treat and care for one another in this country. Civil rights are a guiding force in combating discrimination often misidentified as stigma for people with AUD and SUD. Turning people away from emergency rooms and health care treatment because a person is under the influence of alcohol or drugs is a violation of the ADA.
Based on 50yrs. of clinical experience in BHC here are some of my observations. Persons who experience addictions is widely seen as persons who exhibit very low Perceived Social Value (PSV) and perceive it as self-inflicted. And a # of primary care physicians are not sufficiently trained and thus reluctant to treat what they see as a high risk condition that is also illegal.
This is a significant hurdle to overcome.
A County of Lies!
I grew up here and my daughter is the third generation of women abused and neglected by this county as policy. Starting with being left alone as a child with a severely mentally ill mother; to being demonized and watching my child slice her arm on front of her father and losing my home trying to protect her and a $900 a MONTH share of cost because I WORKED! Unable to obtain detoxification services. This place has damaged us and not once has anyone even suggested trauma services....I am broke, devastated and my child...She is only 20 and already had a break. We are your mothers, children, a ROP Instructor and Mental Health Case Manager and I wouldn't believe it but my story is sadly not unique!
We are very sorry about what
We are very sorry about what you (and others) have experienced in in relation to addiction and mental illness. Both are extraordinarily difficult problems, and trauma is frequently a part it. There are recommendations and linkages to treatment provided by the National Institute of Mental Health: https://www.nimh.nih.gov/health/find-help/index.shtml and SAMHSA: https://www.samhsa.gov/find-treatment. In addition, several advocacy organization (NAMI and MHA) have local chapters to help you find support and services: https://www.nami.org/Home and https://www.mhanational.org/. Please don’t give up—people can recover their lives.
Coronavirus Lockdown Induced Day Drinking
I faced drug problems all my young life. I quit in November '16. On 4 May, when restrictions were lifted and wine shops reopened I started day drinking. Doctors were recommending drinking in moderation and people all over the world were drinking. I made me miserable. I have sought help from the local chapter of AA. I don't want to spend the rest of my life as an alcoholic. Brilliant blog.
Africans Needs Help
Please we the African need help regarding Addiction, drug and alcohol use is causing a lot of death in African more than poverty, mostly Nigeria and Ghana, and the government if not doing anything to help this. Please can the world come to out aid??
THE PROBLEM WITH OPIATE / ACETAMINOPHEN COMBINATION PRODUCTS
I am a retired Pharmacist from Lincoln, Nebraska.
I feel that the opioid/APAP combination should be removed from the market. I have appealed to the DEA, CDC and FDA with little to no response. The following is what I have sent to them.
Contributing risk factors for patients could be:
• Decreased weight and fatty tissues.
• Alcohol consumption, current and historic
• Decreased Liver Enzyme function
• Potential renal failure
• Comorbidities (hepatitis, alcoholism and gastroenteritis)
• Quantities of medication consumed, especially as a result of diversion.
The Acetaminophen alone may be a factor causing death in some drug abusers, due to the large number of pills being taken. If not the direct cause, it could be a factor contributing to the increases in opiate toxicity and/or death, by compromising the metabolic, plasma distribution and renal excretion of the opiate. The diversion of these meds can lead to a cascade of effects, that would not be at the same level of Risk if they were only to be allowed to be made of their individual ingredients and not in combination.
THESE ARE REASONS THAT I FEEL SUPPORT THE REMOVAL OF THESE PRODUCTS AS A COMBINATION FROM CIRCULATION IN THE MEDICAL COMMUNITY.
Dwayne Wilson R.P.
Determinism and destigmatization
"There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised..."
Indeed! Accepting that there is a full and complete causal story behind the genesis of someone's addiction and their addictive behavior - even their voluntary choices - can help to reduce stigma. An open access paper in Neuroethics, "Determinism and destigmatization: mitigating blame for addiction" argues as much in the context of the ongoing debate about the disease model. doi: 10.1007/s12152-020-09440-w
Thank you so much Dr. Nora for this article. And for understanding people like me. I'm currently on 11 months clean from alcohol, marijuana and crack cocaine addiction. I have struggled with substance abuse for 30 years. I'm am glad that I found subscribed to your blog to learn more about my illness.