The Impact of Stigma on People with Substance Use Disorders

The #QuitStigmaNow campaign was launched in 13 countries worldwide and reached 3 million people approximately through the media and social networks – photo: Shutterstock

On 26^th June 2018, Dianova launched a campaign to raise awareness of the physical and psychological consequences of stigma among people facing substance use disorders (SUD). The #QuitStigmaNow campaign aimed to highlight how people with SUD can be stigmatized and discriminated against in a number of specific settings – in the media, in health services and at the workplace – and to introduce a number of recommendations to help bring addiction stigma to an end. The campaign was launched in 13 countries worldwide and reached 3 million people approximately through the media and social networks.

This declaration focuses on the issue of addiction stigma and discrimination in health services and what can be done to prevent it. We urge international organizations dealing with drug policy, human rights and health as well as Member States of the United Nations to take appropriate measures to effectively #QuitStigmaNow.

People facing SUD must face a highly stigmatizing (1) moral judgment from society, particularly those using illicit drugs. They experience stigmatizing or discriminatory attitudes on a daily basis and a study by World Health Organization has found addiction to illicit drugs to be the most stigmatizing condition (2). Experiences resulting from stigma can be highly distressing for people who often feel shame, guilt, anger, rejection and a sense of worthlessness that in turn can trigger further substance use and other risky behaviours.

Stigma can negatively impact people’s willingness to attend treatment and their access to healthcare. In addition, they may experience mental health difficulties and experiences of profound loneliness and isolation – photo: Shutterstock

It should primarily be emphasized that the consequences of addiction stigma can be devastating, and all the more so as they target vulnerable people, especially women or people having physical or mental disabilities.  People with SUD can be stigmatized and discriminated against in a wide variety of situations and places, however, the high levels of ostracism, stigma and self-stigma (3) that people report having experienced in healthcare services are especially upsetting since they originate from the very people whose mission is to help.

Some examples of stigma associated with addiction treatment or health services:

People fail to seek treatment, in part because of their concern that they will be labelled an “addict”. As a result, people tend to hide their addiction problem, thus reducing their chances of receiving the treatment they need.

Many health professionals are not trained in addiction treatment. As a result, people with SUD do not receive adequate treatment. Many doctors do not recognize addiction as a treatable condition and encourage patients to seek help outside of the medical community. Doctors should recognize addictive behaviour as part of their purview and utilize scientifically validated approaches and practices.

Health professionals sometimes view their work with people with SUD as having lower status than that with other categories of patients (4). Finally, in mental health practices, persons with substance misuse problems can routinely be discharged from treatment when their substance misuse is revealed.

Healthcare services can be below quality standards. A meta-analysis of 28 studies (5) assessed the attitudes of health professionals towards patients with SUD. The analysis revealed widespread negative attitudes that contribute to a substandard quality of care. Among other elements:

• Health professionals generally have a negative attitude towards patients with SUD;
• These patients are seen as manipulators, potentially violent and lacking in motivation, a misrepresentation that hinders the provision of health care;
• Professionals lack the education, training or adequate structures that could enable efficient work with these patients;
• Negative attitudes of health professionals contribute to a reduced sense of empowerment in patients, thus hindering their chances of successful treatment;
• Professionals are less involved in delivering health care and more inclined to adopt a task-based approach, which results in less empathy and personal commitment on their part.

Recommendations to healthcare providers

Respect for human rights is essential to help people recover. These rights include, among others: the right to respect and dignity for every individual, the prohibition of inhuman or degrading treatment, and equitable access to quality health care.

Reception and treatment services for substance use disorders should be welcoming and non-stigmatizing. The sector’s practice values should include non-discrimination, respect and dignity, compassion, non-judgement, empowerment, person-centred practices, strength-based practices, holistic care, accessibility, flexibility and responsiveness. These practices should be selected from a set of science-based approaches.

General Practitioners

General practitioners are often reluctant to treat patients with SUD; most consider that they are difficult or problematic patients (only 10% to 20% of them are) and they  also fail to consider addiction as a chronic pathology. This situation results in a decrease of addiction treatment opportunities by general practitioners – even though they are a privileged gateway to healthcare – and unequal accessibility depending on the region. In the case of opioid addiction, for example, few general practitioners agree to prescribe substitution treatment.

Proposals to improve addiction treatment services

• Implement a public, free of charge, and comprehensive network of services that equally embraces the physical, psychological and social aspects of substance abuse and addiction;
• Improve and adapt the training of general practitioners in addiction medicine and promote continuing education;
• Strengthen the role of general practitioners as a first resort to the treatment of addictive disorders; Promote treatment by general practitioners, as the main gateway to the health care system;
• Build a coordinated and articulated health care pathway with the various health and social systems;
• Develop specific methods of care adapted to the needs of women;
• Reinforce the patients’ rights to receive treatment and care as would any patient with a different condition.

Perceived stigma can also be internalized. People who use drugs can view themselves as deviants; this can severely impact their self-esteem and self-worth – photo: Shutterstock

Front-line Services

Front-line health services are often the first point of contact for people experiencing problematic alcohol and other drug use, and the quality of the interactions between the staff and an individual is critical to supporting them in their recovery and for enabling access to a wide range of services across the continuum of care. Adequate health care services should be based on:

• Quality of the service provision (including the absence of stigma and discrimination);
• Quality of the service environment;
• Quality of the referral process;
• Ability of a person using a service to report their experience back to a dedicated agency to support ongoing service improvement;
• Implementation of training programmes to promote a better understanding of stigma and its consequences, change individual attitudes and behaviours and positively influence the organizational culture.

Specialized Services

Addiction treatment should be organized in a network including outpatient services, hospital-based detox facilities, day centres, therapeutic communities and other residential programmes, dual-pathology programmes, supervised housing services, reintegration programmes, etc. All of them must work in close cooperation in order to better meet the needs of beneficiaries and their families and help reduce stigma and discrimination. More specifically, these services should:

• Provide adequate information, advice and support to those concerned, their families and significant others;
• Ensure that people directly or indirectly affected by substance use fully understand the nature, purpose and functioning of local resources;
• Appropriately involve individuals, their families and significant others in all phases of the treatment process and support them in the navigation of the addiction treatment system;
• Build or enhance patients’ ability to understand and manage issues related to their well-being and health;
• Improve the resilience, confidence and self-esteem of the patients, their families and significant others;
• Support, inform, convey hope, optimism and education in the management of substance use issues and harm reduction to patients, their significant others and the wider community;
• Work towards increasing social awareness about addictive disorders through social dialogue and pedagogy to help break with such ideas as the association between addiction and violence, criminality, lack or morality and lack of will to recover.

This statement was submitted prior to the sixty-second session of the United Nations Commission on Narcotic drugs, held from 14 to 22 March, 2018. The English language version of the document is available for download on the UNODC website.

References:

1. Stigma is especially widespread among people experiencing problematic alcohol or other drug use.
2. Mentioned in: Stigma, social inequality and alcohol and drug use (2008) – Robin Room et al. Online access, 16 June, 2018
3. An investigation of stigma in individuals receiving treatment for substance abuse (2007) Luoma JB, Twohig MP, Waltz T, Hayes SC, Roget N, Padilla M, Fisher G. Online access, 16 June, 2018
4. Staff regard towards working with substance users: a European multi-centre study (2011) Gilchrist G1, Moskalewicz J, Slezakova S, Okruhlica L, Torrens M, Vajd R, Baldacchino A. Online access 16 June, 2018
5. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review (2013) – Leonieke C. van Boekel Evelien P.M.Brouwers Jaap van Weeghel Henk F.L. Garretsen. Online access 16 June, 2018