Stigma and Substance Use Disorders

 

 

 

I’ve been thinking a lot about stigma lately.

Recently I was asked to do a short presentation about stigma against people with substance use disorders. I thought I could put something together easily to satisfy the intended audience.

But as I created power point slides with all the usual stuff, I dug a little deeper. I thought about how everyone in my intended audience probably already agrees that stigma is bad. What would I be telling them? Everyone was opposed to stigma, right?

But then I thought, if that is so, then why is there stigma? Or perhaps there’s only stigma in people who don’t have knowledge about the nature of substance use disorders. Perhaps the problem is lack of education, and after hearing facts, people won’t support stigma against those with substance use disorder.

I did internet searches about stigma in general and stigma specific to substance use disorders.

I went down some interesting rabbit holes, as one can easily do on the internet. I came across web pages that reminded me of something I’d read about ten years ago, by a physician, that was pro-stigma. I found it on my bookshelf and re-read it.

It was a peculiar chapter in a book about substance use disorder treatment, titled, “Addiction Treatment: Science and Policy for the Twenty-first Century,” edited by Henningfield et al. Just as I recalled, there was a chapter in that book that stood out from all the others, titled, “In Praise of Stigma,” by Dr. Sally Satel.

I’ll try to summarize her viewpoints without the sarcasm that begs to be included. In that chapter, Dr. Satel says stigma against substance use, and people that use substances, is a good thing because stigma discourages deviant behavior and has a civilizing effect on society. She says it’s a normal and necessary part of society. She views the behavior of people with substance use disorders as irresponsible and says it’s bad policy to “cleanse the addict’s image.”

She feels stigma encourages people to get help for substance use disorders, and that eliminating stigma will not make it more likely for people to get help for substance use disorders.

She says people who relapse back to drug use repeatedly is “…a behavior almost always under one’s control…”

Aha, I thought. That’s the key to understanding her point of view. She believes people with substance use disorders have at least some degree of control over their drug use. However, loss of control over substance use is one of the hallmark criteria for the diagnosis of substance use disorder.

It is confusing. Some people who use substances heavily can stop on their own, if given a good enough reason. Most Addiction Medicine experts don’t feel those people meet criteria for diagnosis of substance use disorder. But those are the people Dr. Satel is thinking of, and she fails to make a distinction between those two very different people. Of course, her conclusions are different from most of the rest of the field. She’s talking about apples and the rest of us are talking about oranges.

Her ideas may have some validity for people in the early stages of drug use. Just like the “Just say no” campaign of the 1980’s, early intervention can prevent formation of substance use disorder. But they are of little use when addressing substance use disorder.

To further complicate things, sometimes people with substance use disorders can partially control their substance use, or control it for a short time. Or they may have full control over one drug for a time, but no control over another drug. That’s confusing, and is why friends and family of a person with substance use disorder can become frustrated and puzzled by the behavior of the affected person.

It’s not as confusing when we think about other chronic medical problems. Nearly all have behavioral components, just like substance use disorders, and often we see the same partial/total loss of control over these behavioral aspects.

For example, a diabetic may be able to refrain from eating sweets on most days, but occasionally, perhaps on a stressful day, may eat several servings of sweets. Such a person usually faces less judgment from others, probably because so many of us have tried and failed to control our eating, and commiserate.

But imagine how much harder it is to control use of a substance that produces more intense feelings of pleasure – using substances that stimulate the pleasure centers of the brain much more intensely than eating or not exercising.

We can talk about whether stigma is deserved or not, but what about its effects? Does stigma make it more likely that people will enter treatment for substance use disorders? No, according to the limited studies done on this issue.

Studies of stigma towards people with mental illnesses show it results in unemployment, housing problems, impaired social functioning, lowered self-efficacy, and lowered self -esteem. One study (Joy et al., JAMA, 10/18/16) showed that people with mental health diagnoses are less likely to get appropriate medical care when they go to an emergency department for care for health problems.

Pregnant women with substance use disorders face the most intense stigma. They encounter harsh judgment from friends, family, law enforcement, and even medical care providers. The ultimate stigmatization is criminalization, and around half of the U.S. states have laws that say drug use during pregnancy is child abuse.

The trouble is, it’s harder for pregnant women to get treatment for substance use disorders. Pregnant women using drugs make doctors nervous. Either medical providers lack confidence in their ability to treat substance use disorder in women, or they are anxious about their legal responsibilities to report drug use during pregnancy.

Tennessee provides the best example of the harm that laws can do. In 2014, Tennessee passed the Fetal Assault Law, which said drug use during pregnancy was a crime. Over the two years this law was in effect, around thirty women were charged, almost all were poor and/or minority race. Some of the women who were charged had tried, multiple times, to access substance use disorder treatment, but were turned away. Only two of Tennessee’s one-hundred and seventh-seven treatment programs (at that time) provided pre-natal care and allowed children to stay with expecting moms, so there were few places for women to go when they did ask for help.

At the end of the two years, fewer women sought treatment for substance use disorder, and the law was allowed to sunset in July of 2016. Criminalizing drug use during pregnancy did not push women toward treatment, but away from it, out of fear they would face criminal charges if they sought health care during pregnancy.

It is interesting that Tennessee’s law covered illegal drugs, and not nicotine or alcohol. Ironically, we have more data about the harms caused by both legal drugs than about the illegal drugs.

Alcohol consumption during pregnancy is the number one cause of developmental disabilities and birth defects in the U.S. If the motive for Tennessee’s law was fetal protection, they might have included alcohol. But they didn’t; some drugs have more stigma against them than others, and some drug users have more stigma against them than others.

Thinking about stigma for my small presentation got me thinking about my own tendencies to stigmatize. I wish I could say that I don’t ever look down on other people for who they are or what they do, but that’s not true. I’m better than I used to be, and sometimes have enough insight to know what I’m doing and adjust my thinking, but the tendency towards judgmentalism is still with me.

When I stigmatize, I’m usually feeling fear – fear of people who behave differently than me. Stigmatization gives me the false sense that I’m superior to a certain group, that I’m protected from the judgment that they deserve. Stigmatization can be used to oppress certain people, or suppress a certain point of view. These motivations are not healthy. They damage the people I stigmatize, but they mostly damage me. It turns me into someone I don’t like, and that doesn’t feel good at all.

When I read Toni Morrison’s book “Paradise,” years ago, it helped me see why we stigmatize and scapegoat. That book, for me, vividly illustrated the human tendency to stigmatize and the tremendous damage it does to all concerned.

I wish all of us could resist the tendency to stigmatize, not only against people with substance use disorders, but against all groups. I pray at this difficult time in our history, we will resist the temptation to reject and stigmatize groups with whom we don’t agree. To use a quote from twelve step fellowships: “as long as the ties that bind us together are stronger than those that would tear us apart, all will be well.”

Indeed.

 

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6 responses to this post.

  1. Posted by Obsteve on July 16, 2018 at 1:18 am

    Great post. Do you have a lit citation to back up the assertion that most addiction docs don’t consider a person to give up drugs thru some strong motivator, don’t meet criteria for SUD?
    I happen to completely agree with you and have been saying that for a few years but would like to have something to support my assertion

    Reply

    • no, it’s just that they wouldn’t meet DSM 5 criteria without loss of control, or at least would have mild disease.
      You must be careful when asking patients if they’ve quit using opioids – if they are pregnant or have some other major consequence for telling the truth if they are still using (jail, shame, etc), you may not get an accurate history.

      Reply

  2. Posted by Trudy on July 16, 2018 at 1:36 am

    Thank you for another thoughtful post. I will pick up and read the Toni Morrison book tomorrow.

    Reply

  3. Posted by Scott on July 16, 2018 at 1:11 pm

    I don’t agree with Dr. Satel’s view at all. This statement made the hairs stand up on the back of my neck:

    “Dr. Satel says stigma against substance use, and people that use substances, is a good thing because stigma discourages deviant behavior and has a civilizing effect on society.”

    She has “determined” that substance use is a deviant behaviour, which is a very modern viewpoint (and purely an opinion). This opinion is also (sadly) derived from a basis of discrimination and misinformation.

    I’m sure people used a very similar argument about homosexuality in the not too distant past (and some probably still do). I’m sure we can all see the damage this stigma has caused the homosexual community.

    Drug use has and will always be normal human behaviour. We see evidence of it going back as far as we see evidence of human civilisation.

    Addiction and abuse deviates from normal human behaviour. That said, the % of people that will suffer from drug or alcohol abuse at some point during their lifetime shows that it is a very common deviation.

    Stigmatising the sufferers just relegates them to the fringes of society. I took a lot longer to ask for help due to the stigma associated with my use. Even today, 7 months clean, if work found out I’d get fired.

    Addicts need warmth and understanding to bring thm into treatment amd help them to begin their reintegration into society.

    Reply

  4. Posted by David Faber MD on July 17, 2018 at 2:10 pm

    Always find your comments thoughtful and well-written. Especially appreciate your treatment perspectives. I’m an Alabama-transplanted NC boy in a rural, solo practice so it helps a bunch to hear what others are doing.

    Reply

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