Stigma and the Opioid Epidemic

BY YASHEEN GAO

When Victoria, a young woman from San Antonio, went to her doctor, she thought back pain was the extent of her medical problems. Her doctor prescribed  Vicodin® to cope with the pain1. Victoria realized Vicodin could be addictive, but she never imagined that fact would impact her. That was something that happened to other people. But Victoria did become addicted, fast. Her doctor quickly cut her off of the medication, which meant that she was now dealing with back pain and an addiction– without help.1 As a result, she experiences heavy withdrawal and begins using heroin-  causing her to lose her job, damage relationships with family and friends, and lose status as a valued member of her community1

Heroin users preparing their morning “hit”.
Source: Sam Creighton for the Daily Mail.

Max, a young man was similarly prescribed Vicodin® when he hurt his back2. Instead of taking the two pills twice a day as prescribed, he took a few more and began to enjoy how the pills made him feel2. He quickly became dependent on the highly addictive drug. He went to different doctors to get pills, sometimes lying about his pain to get prescriptions. A local pharmacist became  suspicious of the  number of prescriptions she filled for   Vicodin® for Max, and began denying them.o 2. These are stories of isolation, shame, and stigma. There are few happy endings. Sadly, Victoria and Max’s stories reflect  common narratives of victims of the  Opioid epidemic– a deeply stigmatized issue which is compounded by the marginalization of those affected.

The Opioid epidemic is a serious public health crisis that has been particularly compounded by stigma. Opioids are the  driving force behind drug overdose, which is now the leading cause of accidental death in United States3. In 2015, there were 20,101 overdose deaths related to prescription pain relievers and 12,990 heroin overdose deaths3. This reflects a dramatic increase in the past few decades as there have been over four times as many more overdose deaths from 1999 to 20083. Much of this morbidity can be attributed to the severe stigma surrounding opioid addiction, which negatively impacts treatment, access, and utilization. Thus, 80% of opioid addicted patients are unable to receive the treatment they need to recover from their addictions4. Furthermore, studies have shown that as morbidity increases from opioid addiction, public discourse scrutinizes physicians who prescribe  Opioids, which in turn causes physicians to prescribe fewer pain medications5. Though fewer prescriptions seems helpful on the surface, the lack of access to pain relievers has led opioids users to resort to dangerous recreational drugs such as heroin, which has seen a large increase in usage rates in recent years6. The shame and subsequent neglect of opioid addiction in social, political, and clinical worlds on the backdrop of a worsening epidemic  demands a rethinking of addiction from  negativity and stigma to acceptance and rehabilitation.

The United States’ Opioid Epidemic is worsening. Pictured are the overdose deaths involving opioids per county in 2015.
Source: Center for Disease Control.

Stigma is both deep-rooted and long-standing. Defined as a set of negative beliefs towards a person of group of people, stigma has been condemned as a fundamental  cause of discrimination and injustice by the World Health Organization8. Like many forms of injustice, stigma finds its way “under the skin”. Stigma is a fundamental cause of health outcomes, which means that stigma makes people sicker and sometimes kills people. Not only that, stigma disrupts social networks of those affected by stigmatized conditions like addiction. For example, stigma causes reduction in self-esteem and disputes among family members8. In the scope of opioid addiction, addicts are given pejorative  labels like “junkies”, “crackheads”. This shaming comes from both external sources like news media, and internal sources like family and friends. Furthermore, the National Institute on Drug Abuse’s survey on drug use has indicated that between 94% and 99% of adults in the United States disapprove of heroin use,. Even frequent users of ecstasy and other drugs shame those who use  heroin9. The social stigma surrounding opioid users makes it increasingly difficult for them to seek much needed help and care. Stigmatization  makes it difficult for opioid users to recover from addiction, which implicates public health officials to create multi-level stigma reduction measures.. 

One level of stigma reduction intervention is the clinical setting, where physicians can provide inferior care to addicted patients because they too view them as immoral or lesser. In article from AMA wire, Dr. Patrice A. Harris, the chair of the AMA Task Force to Reduce Opioid Abuse, stated that “Unfortunately, we still have a lot of people who think that people who have substance use disorders have character flaws, or that having an addiction is a moral failing. What makes the problem worse is the lack of care that healthcare professionals tend to provide towards opioid users.” 4 Although some may claim that physicians are helping the opioid epidemic by refusing to prescribe pills, this action must be coupled with an awareness that opioid users should get treatment for addiction rather than being neglected altogether. Moreover, it is evident several years into this epidemic that patronization by physicians is not enough to curb addictive behaviors. Thus, doctors stigmatize their own patients, reducing utilization and effectiveness of care. 

Prescription pain-relievers are a huge issue in the opioid epidemic.
Source: Fran Kritz, Addiction.com.

For the physician, treating addiction patients implicates them morally and legally.5. Opioid prescriptions are increasingly legislated in state and federal governments. . On the one hand, physicians are obligated to provide pain relief for individuals who need it. On the other hand, there is a significant risk to prescribing pain relievers as patients can become addicted, which in turn implicates the prescribing physician in iatrogenic harm. Possible consequences for physicians include risk of under prescription and over prescription, overdose liability, and third-party liability. When physicians under-prescribe pain medication, they may face loss of licensure and monetary consequences. However, over prescription can have criminal consequences. Between 2004 and March 31, 2016, over 240 criminal cases have involved convicted physicians10. In one such case, a physician was found guilty in a Court in Pennsylvania for continually prescribing controlled substances to individuals that were dependent on drugs10. He was sentenced to fourteen years in prison, followed by twenty years of probation as well as being ordered to pay a $30,000 fine10. Physicians are also liable to be sued or to be legally responsible for overdoses and other issues related to pain relievers that they may have prescribed. They may also be liable for the dangerous or illegal behavior that may have resulted from their prescription of pain relievers, even though they may have not participated in the violent behavior themselves10. For instance, a physician in Nevada was convicted of one count of second degree murder for prescribing controlled substances to young adults without a medical reason10. As a result, several young adults overdosed and died10. The physician was sentenced to serve ten years to life in prison10. These past examples have clearly indicated that physicians can face serious consequences regarding the prescription of pain relievers. These serious consequences cause doctors to prescribe Opioids less often, which sometimes means that people who need pain relief cannot get treatment and those who seek medical Opioids for addiction will find unsafe sources. . Thus, physicians must turn towards constructive treatment of addiction patients, rather than  than disengaging from the issue to avoid personal liability.

A few suitable methods of treatment and preventative changes have already been proposed by medical professionals. These methods have been centered on improving the physician-patient stigma that has existed for so long.  Prescription drug monitoring programs (PDMP) have been created to inform physicians about whether a patient has received opioid prescriptions in and out of the state and updates them when controlled substances are dispensed4. Furthermore, they can help to identify the need for special counsel or other treatment for an opioid use disorder4. Simpler interventions such as adapting a more forthright approach towards physician-patient interaction and medication-driven treatment for substance approach have helped to reduce stigma and provide more access to care in the healthcare system for opioid users4. A study showed that heroin deaths decreased by 37% with the introduction of Buprenorphine, a medication for addiction12. Along with medication, behavioral therapy, known as Medication Assisted Treatment (MAT), provide a “whole patient” approach that has also been shown to be an effective treatment for opioid addiction12,13. MAT has been shown to decrease opioid use and deaths as well as criminal activity12,13. More innovative approaches have been researched as well, including developing a vaccine that would prevent opioids from reaching the brain11. These solutions are centered on giving physicians better tools that encourage them to interact and connect with patients addicted to opioids. Hopefully, these tools will help reduce the issue of stigma in the medical community in a positive and healthy way. 

Heroin dose deaths are decreasing as a result of MAT and medication.
Source: National Institute on Drug Abuse. drugabuse.org.

As the Opioid crisis has spread, stigma has deepened. This public health crisis will no doubt require sober policy-making and fundamental social change. Stigma is not just an unfortunate side effect of an otherwise-serious disease. Stigma makes people sicker. Sometimes, stigma kills people. Stigma keeps people from accessing treatment, keeps doctors from providing the best care, and keeps families from supporting loved ones through addiction. Even though PMMPs and different approaches to treatment have lessened stigma in doctor-patient relationships, many providers and patients are unable to access these types of treatments. If one thing is clear, it is that this crisis will persist unless serious efforts are made to mitigate the harmful effects of stigma.

Yasheen Gao is a first-year in Pauli Murray College study Molecular, Cellular, and Developmental Biology. Yasheen is from Atlanta, Georgia. Contact her at yasheen.gao@yale.edu.

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References:

  1. Stoeltje, M. Caught in the opioid snare. The San Antonio News. Retrieved from http://www.expressnews.com/news/local/article/Caught-in-the-opioid-snare-12290762.php.
  2. Pain medicine addiction: “All I wanted was more of the drug.” National Institute on Drug Abuse. Retrieved from https://easyread.drugabuse.gov/content/pain-medicine-addiction-all-i-wanted-was-more-drug.
  3. American Society of Addiction Medicine. Opioid Addiction 2016 Facts and Figures. Asam.org. Retrieved from https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf.
  4. Parks, T (2016). Physicians key to cutting stigma opioid addiction. AMA Wire. Retreived from 

.

  1. Dineen, K (2017). Between a rock and a hard place: can physicians prescribe opioids to treat pain adequately while avoiding legal sanction? Am J Law Med. 42 (1): 7-52.
  2. Rudd, R.A., Seth, P., David, F., Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths-United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 65 (5051): 1445-1452. 
  3. Stigma and discrimination. World Health Organization. Retrieved from http://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/priority-areas/stigma-and-discrimination.
  4. Johnston, L.D., O’Malley, P.M., Bachman, J.G., Schulenberg, J.E., Miech, R.A. Monitoring the Future National Survey Results on Drug Use 1975-2014. National Institute on Drug Abuse at the National Institute of Health. Retrieved from http://www.monitoringthefuture.org/pubs/monographs/mtf-vol2_2014.pdf
  5. Kosten, T.R., George, T.P. (2002). The Neurobiology of Opioid Dependence: Implications for Treatment. Addiction Science & Clinical Practice. 1(1): 13-20. 
  6. Cases Against Doctors (2016). U.S. Department of Justice DEA, ed. U.S. Department of Justice, Drug Enforcement Administration. Retrieved from https://www.deadiversion.usdoj.gov/crim_admin_actions/doctors_criminal_cases.pdf.
  7. National Institute on Drug Abuse (2016). Effective Treatments for Opioid Addiction. Drugabuse.gov. Retrieved from https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction.
  8. Schwartz, R.P., Gryczynski J., O’Grady, K.E., Sharfstein, J.M., Warren G., Olsen Y., Mitchell, S.G., Jaffe, J.H. (2009). Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health, 103(5):917-22.
  9. Mattick, R.P., Breen, C., Kimber, J., Davioli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, (3).

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