Stigma is used to describe the negative way we think about, feel and act towards someone who is different from us. Who and what we stigmatize knows no bounds. We talk about ‘stigma’ in situations of being diagnosed as mentally ill, or having HIV, or being addicted to pain killers or alcohol. But what is meant by ‘stigma’ in these situations is rarely articulated.
For example, despite extensive efforts to reduce stigma about seeking mental health services among military personnel, a Government Accountability Office review of these efforts found that little guidance was provided to Department of Defense officials and health care providers for how to recognize stigma in everyday behaviors, treatment services or personnel policies. For the healthcare and business sectors outside the military, there is little evidence that the situation is any better.
This shadow world of stigma needs to be brought into the sunlight to effectively address our nation’s opioid crisis.
When I talk with consumers, patients being treated for chronic pain, the health care providers who prescribe pain medications, and the professionals who design and implement programs to address the opioid crisis, the same questions come up.
Is it stigma when:
- someone feels shame that they may be addicted to their pain medications and needs help?
- people blame us for “choosing” to become or stay addicted to opioids?
- friends and relatives counsel a patient to not tell anyone about their addiction?
- providers worry that they will lose patients if they begin to offer medication-assisted treatment for opioid addiction?
- a person in treatment for their opioid addiction is denied an apartment to rent or passed over for a job promotion because the landlord or employer has found out about their ‘problem?’
The answer to these questions, as you might expect, are the same – “Yes.”
A social or public stigma starts as we develop stereotypes of people addicted to opioids, without a home, or recently released from prison. We ascribe negative attributes to whole categories of people, believing, for example, that people who use opioids are dangerous, immoral, of certain social or demographic backgrounds, or criminals.
On top of this we layer emotional reactions to the stereotype such as fear, disgust and judgments such as that they are to blame for their situation. This accumulation of beliefs, attitudes and judgments then leads to behaviors such as excluding them from social circles, avoiding contact with them, and depriving them of social and career opportunities.
Often overlooked are other facets of stigma, the ones that are in the shadows, that can be subtler and more damaging. There is the stigma that the person feels about themselves in reaction to the social stigma they perceive. They may have low self-esteem and feel untrustworthy, irresponsible, dangerous, and a misfit. Such self-stigma is often found to be a major barrier to people seeking help for their addiction and can undermine their recovery.
A third type of stigma affects the family, friends and caregivers of someone who is addicted to opioids – the concern of what will happen if people find out that they associate with an addict. Will they still stop in to see how the family is doing? Offer to help? Think less of them professionally? This ‘courtesy stigma’ can not only affect how much support a family member or provider gives to someone addicted to opioids, but not wanting to embarrass the family can lead someone who is addicted to try and keep it a secret.
Deepest in the shadows is the way stigma that gets expressed, overtly or covertly, in policies and programs to deal with the opioid crisis. Whether we are trying to bring more people into treatment, insure that opioid reversal drugs are available and used in the case of an overdose, or expand addiction treatment and recovery services in the community, so-called structural stigma may be the number one problem we face. Structural stigma consolidates and sustains stigma through the cultural norms, institutional practices and policies that constrain the opportunities and wellbeing of people addicted to opioids and provide a reinforcing context for stigma when practiced by individuals.
These structural manifestations of stigma might be seen in housing or employment discrimination, punitive responses to women who are addicted to opioids during their pregnancy, and uneven or non-existent access to care for those addicted. For example, in a project to expand access to opioid overdose reversal drugs in rural communities, stigma not only prevented people struggling with their addiction from seeking support from friends and family, but it also prevented health care providers from integrating treatment into their facilities out of fear of being labeled as a clinic for addicts.
How can we identify and reduce stigma when addressing the opioid crisis?
The research tells us we need to look for signs of stigma in the way we think, feel and act. We must challenge ourselves and others when we think of all people being addicted to opioids as being the same and to blame them for their own troubles, incompetent in managing their own lives, having a moral failure, and with little chance of recovery. Simply shifting from talking about “addicts” to “a person with an addiction” is one place to start. Moving beyond blaming people for perceived moral or personal shortcomings to people who have a chronic disease that can be treated is another step in that direction.
We must examine how our feelings about someone addicted to opioids need to rise above anger, fear, pity or shame. More importantly, we must recognize and counteract how we or others act on these thoughts and feelings by denying people who are addicted to opioids the services they may need or discriminating against them in various ways. How do we provide them with resources and opportunities to seek, use and sustain services that can help them overcome their addiction?
With the additional resources provided by the SUPPORT for Patients and Communities Act, efforts will intensify and expand to reduce the supply and use of prescription and illicit opioids, expand access to effective and affordable treatment and recovery services for people who become addicted, increase the availability of opioid overdose reversal drugs, and increase people’s awareness, concern and knowledge about the opioids and how the epidemic affects them and their community.
But unless we address the shadow of stigma that looms over these responses to the crisis, we will likely fall short.
Will it be possible for someone addicted to opioids to admit it and feel relief and a sense of hope that they can successfully overcome it? That their family, people around them, and health care providers will rally to their aid and support without fear of being ostracized by their peers? That they can use addiction treatment and recovery services without fear of the possible impact on their family, education and job prospects, or finances? That people will still treat them as a human being first – and not an ‘addict?’
When we can see these things happening, the shadow of stigma will begin to recede and combatting the opioid crisis will be more effective.