Let s Clean Up the Dirty Talk: How Stigma Impacts Prevention and Treatment of Substance Use Disorders Jennifer Michaels, MD, FASAM Medical Director, Brien Center Attending Psychiatrist, Berkshire Medical Center Assistant Professor, University of Massachusetts Medical School
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What is Stigma? Mark or brand placed on Greek slaves, separates from free men Socially discrediting attribute, behavior or reputation that classifies the individual in undesirable, rejected stereotype *Goffman, 1963
Knowledge Ignorance Attitude Prejudice Behaviors Discrimination
Types of Stigma Self Social Structural
STIGMA EVOLVES
Stigma Synergy Social problems Poverty Criminality Stigmatized health conditions HIV Hepatitis C Mental Illness Substance Use Disorder
Consequences of Stigma Blame Shame Secrecy Isolation Exclusion
Negative Impact of Stigma Housing Employment Relationships Mental Health Physical Health Access Outcome Recovery
Stigma World Health Organization 18 most stigmatized conditions 14 different countries Drug addiction- #1 - most stigmatized Alcoholism- 4 th most stigmatized Room et al 2001
25 20 NUMBER IN MILLIONS OF PEOPLE WHO NEED TREATMENT FOR SUBSTANCE USE DISORDER VS. NUMBER WHO SEEK TREATMENT STIGMA ONE OF THE 15 LEAD REASONS 10 PEOPLE DO NOT 5 0 SUFFER SUD SEEK TREATMENT NEED TREATMENT SEEK TREATMENT 2012 NATIONAL Survey on Drug Use and Health, SAMHSA
Economic Cost to Society ($ billions) 700 600 500 400 300 200 100 0 CHRONIC PAIN SUBSTANCE USE DISORDER DIABETES OBESITY SMOKING HEART DISEASE Bouchery et al. (2011), CDC (2012), US Department of Justice (2011), Medical Expenditure Panel Survey
Prevention Early Intervention Treatment
OUR STIGMA-INFORMED FUNDING Office of National Drug Control Policy
Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets Of every dollar that federal and state governments spent on substance use and addiction, 95.6 cents went to paying for the wreckage; only 1.9 cents went to prevention and treatment, 0.4 cents to research, 1.4 cents to taxation or regulation and 0.7 cents to interdiction CASA: National Center on Addiction and Substance Abuse Published 2009
Stigma and Negative Stereotypes Allocation of health-care expenditures Public policy Social action
Is it their fault? Can they control it? Social threat? Treat? Punish?
What should we do with Mr. Williams? Mr. Williams has Mr. Williams is a a substance substance abuser disorder and is attending a treatment program through and is attending a treatment program through the court. As the court. As part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He part of the program Mr. Williams is required to remain abstinent from alcohol and other drugs. He has been has been doing extremely well, until one month ago, when he was found to have two positive urine toxicology doing extremely well, until one month ago, when he was found to have two positive urine toxicology screens screens which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the which revealed drug use and a breathalyzer reading which revealed alcohol consumption. Within the past past month there was a further urine toxicology screen revealing drug use. Mr. Williams has had a substance use disorder for the past six years. He now awaits his appointment with the judge to month there was a further urine toxicology screen revealing drug use. Mr. Williams has been a substance abuser for the past six years. He now awaits his appointment with the judge to determine his determine status. his status. J Kelly, C Westeroff, S Dow, 2009, 2010
Substance User Substance Use Disorder Punish Blame Threat Willful Misconduct Exonerate Genetic Disease Treatment
Comparison of Substance Abuser and Substance Use Disorder
Stigmatizing Terminology DIABETES Person with Diabetes Elevated glucose Treatment Insulin requiring SUBSTANCE USE DISORDER User Abuser Junkie Addict Dirty Clean War on Drugs Substituting one drug for another
Words Matter AVOID Addict, Abuser, Junkie Abuse Clean, Dirty INSTEAD Person in active addiction, with SUD, experiencing drug/alcohol problem, patient Misuse, harmful, risky, hazardous use Negative, positive, substance free
Words Matter AVOID INSTEAD Habit Person with substance use or misuse disorder, disease, active addiction Replacement or Substitution Treatment, Medication, MAT User Person who misuses, who engages in risky use of substances
Stigma in Healthcare: Attitudes and Consequences Assess health professionals attitudes towards patients with substance use disorders Examine consequences on healthcare delivery for these patients Boekel, Brouwers, Weeghel, Garretsen, 2012 Literature review n=28
Results Negative attitudes about patients with SUDs Violence, manipulation, poor motivation Patient with active SUD Most Stigmatized Lack training, education, support and skills regarding SUDs Negative attitudes had negative impact on engagement, outcome > contact with people who use IV drugs had more positive attitudes
Journal of Clinical Neuroscience, 2009
Pain, Blame and Stigma 26 Participants watched 96 3.5 second video clips of patients Witnessed expressions of pain from viral ear infection Informed patients Healthy HIV due to transfusion HIV due to drugs Decety, Echols, Correll, The Blame Game, Journal of cognitive Neuroscience, 2010, n=22, 32 trials/condition
Perception of Pain & Report of Personal Distress Mean and SDs of video evaluations for (A) composite pain ratings (z score) and (B) composite emotions rating (z score)
Blame and Pain Ratings
Right Interior Insula Anterior Midcingulate Cortex Periaqueductal Gray Mirror neurons and empathy pain
Overcoming Stigma
ADDICTION IS A BRAIN DISEASE
Addiction is a Chronic Disease Most obtain sustained recovery
Cause and Control: What is Addiction? Addiction is a disease of the brain characterized by impaired control over a reward-seeking behavior from which harm ensues
EFFECTIVENESS OF INTERVENTIONS TO REDUCE STIGMA People with substance use disorders (self-stigma) Acceptance and Commitment Therapy (ACT), remove needle track marks, skills training, vocational counseling General public (social stigma) Educational factsheets, positive profile stories, motivational interviewing Professional groups (structural stigma) Medical Students: Structured education, direct contact with people with SUDs Police Officers and Counselors: Crisis Intervention Team, Multi-cultural training, ACT Livingston, Milne, Fang, Amari, Addiction, 2012, n=13
12/13 studies demonstrated positive effect on stigma outcome measures
Person-first language Evidence-based treatment for chronic disease Survivor Engagement Avoid slang and idioms Addiction-free, use, misuse, remission Broyles, Binswanger, Jenkins, et al, 2014, Kelly 2015
Anti-Stigma Toolkit: A Guide to Reducing Addiction-Related Stigma Addiction Technology Transfer Center Network, SAMHSA Engage in effective stigma prevention efforts Stigma free language, letters to the editor, community action group, community campaigns, etc. National Alliance for Advocates for Buprenorphine Treatment (NAABT)
Familiarity (Marijuana) 1. My school provides services/treatments for individuals addicted to marijuana. YES NO 2. I have observed, in passing, a person I believe may have been addicted to marijuana. YES NO 3. I have observed a person addicted to marijuana on a frequent basis YES NO 4. I have worked with a person who was addicted to marijuana. YES NO 5. A friend of the family is addicted to marijuana. YES NO 6. I have a relative who is/was addicted to marijuana. YES NO 7. I have lived with a person addicted to marijuana. YES NO 76 Familiarity (Heroin) 1. My school provides services/treatments for individuals addicted to heroin. YES NO 2. I have observed, in passing, a person I believe may have been addicted to heroin. YES NO 3. I have observed a person addicted to heroin on a frequent basis. YES NO 4. I have worked with a person who was addicted to heroin. YES NO 5. A friend of the family is addicted to heroin. YES NO 6. I have a relative who is/was addicted to heroin. YES NO 7. I have lived with a person addicted to heroin. YES NO 77
Appendix B Perceived Dangerousness Scales Perceived Dangerousness (Alcohol) 1. One important thing about people addicted to alcohol is that you can t tell what they will do from one minute to the next. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 2. If I know a person has been addicted to alcohol, I will be less likely to trust him. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 3. Although some individuals addicted to alcohol may seem alright, it is dangerous to forget for a moment that they are mentally ill. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 4. If a group of individuals formerly addicted to alcohol lived nearby, I would not allow my children to go to the movie theater alone. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 5. The main purpose of alcohol addiction treatment programs should be to protect the public from individuals that are addicted to alcohol. 1 2 3 4 5 6 Strongly Disagree Strongly Agree Perceived Dangerousness (Marijuana)
Familiarity Scales Familiarity (Alcohol) 1. My school provides services/treatments for individuals addicted to alcohol. YES NO 2. I have observed, in passing, a person I believe may have been addicted to alcohol. YES NO 3. I have observed a person addicted to alcohol on a frequent basis YES NO 4. I have worked with a person who was addicted to alcohol. YES NO 5. A friend of the family is addicted to alcohol. YES NO 6. I have a relative who is/was addicted to alcohol. YES NO 7. I have lived with a person addicted to alcohol. YES NO
1. One important thing about people addicted to marijuana is that you can t tell what they will do from one minute to the next. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 2. If I know a person has been addicted to marijuana, I will be less likely to trust him. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 3. Although some individuals addicted to marijuana may seem alright, it is dangerous to forget for a moment that they are mentally ill. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 78 4. If a group of individuals formerly addicted to marijuana lived nearby, I would not allow my children to go to the movie theater alone. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 5. The main purpose of marijuana addiction treatment programs should be to protect the public from individuals that are addicted to marijuana. 1 2 3 4 5 6 Strongly Disagree Strongly Agree Perceived Dangerousness (Heroin) 1. One important thing about people addicted to heroin is that you can t tell what they will do from one minute to the next. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 2. If I know a person has been addicted to heroin, I will be less likely to trust him. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 3. Although some individuals addicted to heroin may seem alright, it is dangerous to forget for a moment that they are mentally ill. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 4. If a group of individuals formerly addicted to heroin lived nearby, I would not allow my children to go to the movie theater alone. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 5. The main purpose of heroin addiction treatment programs should be to protect the public from individuals that are addicted to heroin. 1 2 3 4 5 6 Strongly Disagree Strongly Agree 79 Appendix C Fear Scales Fear (Alcohol) 1. Persons addicted to alcohol terrify me. 1 2 3 4 5 6 7 8 9 10 not at all very much 2. How scared of a person addicted to alcohol would you feel? 1 2 3 4 5 6 7 8 9 10 not at all very much 3. How frightened of a person addicted to alcohol would you feel? 1 2 3 4 5 6 7 8 9 10 not at all very much Fear (Marijuana) 1. Persons addicted to marijuana terrify me. 1 2 3 4 5 6 7 8 9 10 not at all very much 2. How scared of a person addicted to marijuana would you feel? 1 2 3 4 5 6 7 8 9 10 not at all very much 3. How frightened of a person addicted to marijuana would you feel? 1 2 3 4 5 6 7 8 9 10 not at all very much Fear (Heroin) 1. Persons addicted to heroin terrify me. 1 2 3 4 5 6 7 8 9 10 not at all very much 2. How scared of a person addicted to heroin would you feel? 1 2 3 4 5 6 7 8 9 10 not at all very much