The stigma that stifles caregiving

Robert Ashford, MSW, appears to have a promising future on paper: He's a PhD student in health policy and a graduate research assistant at the University of the Sciences in Philadelphia's Substance Use Disorders Institute

12/21/20223 min read

In actuality, he has had to overcome numerous challenges and continues to do so. Ashford has suffered housing discrimination and difficulties to attending and affording his education as a person in recovery from a drug use illness since 2013.

"I draw on my lived experience with a substance use disorder and the discrimination and bigotry I've faced over the previous six years in all of my research and advocacy work," he says.

Stereotypes of people with opioid use disorder are at the basis of these and other discriminatory actions. This group is frequently stereotyped as criminals, lousy employees, and morally bankrupt. Biased attitudes not only promote discriminatory treatment of substance users, but they can also impair health-seeking activities (Brener, L., Drug and Alcohol Review, Vol. 29, No. 5, 2010).

"Even if they have the same level of addiction severity, people who feel stigmatized are less likely to seek treatment," says John Kelly, PhD, the founder and director of the Recovery Research Institute at Massachusetts General Hospital in Boston and an associate professor of addiction medicine at Harvard Medical School. "If they feel stigmatized and ashamed, they're also more likely to drop out of treatment."

Psychologists are examining stigmas across various populations, getting involved with policy activities, and teaching the public about addiction as part of a larger campaign to convey destigmatizing messages. "There are around 22 million people in recovery for substance use disorders in the United States, but because of the high level of stigma, you may not even realize that your colleague or neighbor is one of them," Ashford adds. "We shouldn't have to live in a society where people are afraid to reveal their addiction histories."

Language, stigma, and identity

Substance abuse has a long-standing stigma attached to it. Illness's even ingrained in the terminology we use to describe it, which is frequently medically incorrect and can cause more harm than benefit (see How to talk about addition).

The terms "drug abuse" and "drug abuser," for example, have an implied connotation with physical, sexual, or emotional abuse.

"This creates the impression that persons with addiction are purposefully and maliciously abusing substances while, in reality, they have lost control over their usage," says David Eddie, PhD, clinical psychologist and research scientist at Massachusetts General Hospital's Recovery Research Institute.

Kelly discovered in a study that physicians and clinical psychologists who were exposed to the term "substance abuser" in a scenario were more likely than those who were exposed to the phrase "having a substance use problem" to blame a hypothetical patient for his or her condition. Clinicians in the first group were also more likely to believe that punishment rather than treatment was warranted (International Journal of Drug Policy, Vol. 21, No. 3, 2010).

"Words matter—the words we use frame how clinicians, health professionals, and society at large view a problem," says Howard Koh, MD, MPH, a professor at Harvard's T.H. Chan School of Public Health and former assistant secretary for health at the US Department of Health and Human Services. "If we don't carefully choose our words, we perpetuate bias, confuse comprehension, and end up alienating the individuals we're trying to help."

Michael Botticelli, head of the White House Office of National Drug Control Policy under the Obama administration, initiated modifications in language use at the federal level as a result of Kelly's and others' studies. The International Society of Addiction Journal Editors agreed in 2015 to eliminate the terms "abuse" and "abuser" from addiction journals all around the world, and the Associated Press suggested in 2017 that journalists use non-stigmatizing language when reporting on substance use disorders.

Other studies have looked at how addiction stereotypes combine with ethnic, gender, and other prejudices to effect various groups in different ways. For example, Kimberly Goodyear, PhD, and colleagues performed a countrywide survey of over 2,600 people, utilizing vignettes to gauge stigmatizing sentiments, and discovered that males and those who began using opioids that were not prescribed by their doctors were rated more adversely (Drug and Alcohol Dependence, Vol. 185, 2018).

Even among the rehabilitation community, there is stigma. People who use safe injection sites or pharmaceuticals like methadone and buprenorphine in their therapy are seen as not being truly sober by others in recovery, according to Kelly, despite the fact that such therapies greatly minimize overdoses and cravings and raise the odds of remission.

What psychologists may do to assist

Studies also suggest that, while not totally true, the public's perception of addiction may be more complicated than previously considered. According to Ashford and his colleagues' survey of 1,300 community college students and administrators, many Americans believe that addiction is both a disease and a moral failing (Substance Use & Misuse, in review). "We need to learn more about how people think about this problem so we can produce health message that reduces stigma while also supporting evidence-based approaches," adds Ashford.

Psychologists can continue to research and apply medically accurate vocabulary to describe opioid use disorder in the future. They can also encourage health-care workers, lawmakers, journalists, law-enforcement officials, and anyone involved in the opioid problem to use nonstigmatizing language.

Kelly believes that more comprehensive teaching about the genetic and neurological roots of addiction in medical schools and psychology PhD programs will improve compassion, minimize blame, and diminish discriminatory attitudes among health-care workers. For example, studies reveal that genetics contribute for nearly half of an individual's addiction risk, while chronic opioid use causes detectable changes in brain activity and structure.