Publisher’s Note: Despite the current buzz about the expansion of opioid-agonist treatment, stigma continues to prevail. This is the first in a series of four articles exploring the causes and consequences of stigma in opioid addiction, and offering suggestions from experts on ways to minimize its effects.
Epithets—junkie, crackhead, stoner—they’re only words, but they’re “dismissive and disdainful,” and “a relic of a bygone era” when many considered opioid addiction a type of “moral failing” and a “source of shame.”
That’s the hard-hitting assessment published by the American Medical Association Task Force to Reduce Opioid Abuse—a group comprising more than two dozen physicians’ organizations plus other specialty and medical societies.
The Task Force article—“Patients With Addiction Need Treatment—Not Stigma”—appeared December 15 in the American Society of Addiction Magazine, an official publication of the American Society of Addiction Medicine (ASAM).
Patients Don’t “Abuse”
In a printed response to the article, Richard Saitz, MD, MPH, FACP, DFASAM, lightly admonished the Task Force for the irony inherent in including “abuse,” an outdated, “inaccurate and pejorative” term, in the title of the Task Force itself. He suggested ASAM follow its own guidance by using appropriate terminology; as a start, replacing the word “abuse” with “opioid use disorder,” or a similar term.
(Dr. Saitz, whose editorials we discuss in a separate stigma article in this issue of Addiction Treatment Forum, is the newly appointed senior editor of the Journal of Addiction Medicine.)
It’s fair to mention that the Task Force does use terms other than “abuse” in the body of its article. And Dr. Saitz notes that “of course national and state agencies still have ‘abuse’ in their name” (presumably because it’s difficult to change longstanding names). In fact, Dr. Saitz currently chairs a committee for the National Institute on Alcohol Abuse (italics added) and Alcoholism. As he acknowledges, “abuse” in the Task Force name remains from a time when inaccurate language was considered okay, because everyone knew what it meant.
But it’s clear now that such language is harmful; it is not okay.
Stigma Associated With Methadone Treatment
The Task Force article provides an extensive list of resources under the first heading, “Reducing the Stigma of Substance Abuse Disorder” (there’s that word “abuse” again!). Among the resources, “Negative Stigma of Methadone” defines stigma as rejection or disgrace, which many patients expect if they seek methadone treatment. Anticipating stigma prevents some people from starting methadone treatment, others from benefiting fully from it.
Stigma can cause friends, family, and others to look down on patients who choose methadone treatment. Some patients feel they must hide their participation in methadone programs; some who participate have trouble being socially accepted—even by other patients with addiction. The article notes that negative attitudes about methadone exist even in most 12-step programs.
Many aspects of stigma are based on misunderstanding. Rather than accepting methadone treatment as the legitimate medical treatment it is, some see it as substituting one addiction for another. Methadone is administered only in special clinics, away from other health care facilities, perhaps perpetuating the idea that addiction is a moral failing, rather than an illness. It’s no surprise that many patients feel they must keep secret their methadone treatment.
Words That Stigmatize
Some people in the addiction treatment field who would not deliberately use stigmatizing words do so from lack of awareness. We still see “substitution therapy” or “replacement therapy” in recent articles, suggesting that methadone or buprenorphine can “substitute” for an illicit drug.
Others point out that “substitution” and “replacement” suggest that treatment medications are equal to street drugs. The National Alliance of Advocates for Buprenorphine Treatment (NAABT) considers both terms stigmatizing, because they suggest “a lateral move from illegal addiction to legal addiction.” According to NAABT, the terms also ignore the fact that successful treatment stops, rather than replaces, dangerous, uncontrollable, compulsive behavior—“the essence of addiction.”
The table below, based on comments in a JAMA article, offers a few additional examples.
Implications of Words That Cause Stigma
|Urine Test Results||Urine is termed “clean” or “dirty,” rather than “positive,” “expected,” “negative,” or “unexpected”||The test result is “positive” or “dirty” if an unexpected substance, such as an illicit opioid, is identified|
|Evaluation of OUD Patients||Patients are considered “clean” if in recovery or if managing their symptoms||Patients showing symptoms are considered “dirty”|
|Dosage Decreases of Methadone or Buprenorphine||Tapering often is called “detoxification”||Methadone and buprenorphine are toxic (poisonous)|
|Treatment That Doesn’t Involve Medication||Treatment often is considered “drug-free,” or patients “abstinent,” only if patients are not taking any medication||A person cannot be drug-free if taking methadone or buprenorphine|
Reducing Stigma: Task Force Recommendations
So, how to reduce stigma, and ultimately eliminate it? The AMA Task Force suggests specific actions:
- Change the conversation about what it means to have addiction. Increase access to evidence-based treatment; in particular, support expanded use of naloxone. “People with addiction deserve to be treated like any other patient with a medical disease, and physicians are helping the nation understand how to do this.” The Task Force encourages increased education and training for MAT.
- Continue to use prescription drug monitoring programs (PDMPs) to identify doctor shoppers, but use the programs also to identify patients who need counseling and treatment for a drug use disorder.
- Improve preventive measures: intervene early if teenagers start using alcohol or marijuana; store opioid medications safely, under lock, out of children’s reach; dispose of unused medications safely; and screen all patients for co-existing psychiatric disorders, and provide treatment for patients who need it.
Also: pregnant women shouldn’t have limits placed on access to opioids for pain relief, and shouldn’t be prosecuted, incarcerated, or coerced to withdraw from treatment. Nor should Medicaid patients and patients who have failed previous treatment for addiction have limits placed on MAT.
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AMA Task Force to Reduce Opioid Abuse. Patients With Addiction Need Treatment—Not Stigma. American Society of Addiction Magazine. December 15, 2015.
The National Alliance of Advocates for Buprenorphine Treatment. The Words We Use Matter: Reducing Stigma Through Language. NAABT.org.
https://www.naabt.org/documents/NAABT_Language.pdf. Accessed January 17, 2016.
Negative Stigma of Methadone. http://pcssmat.org/opioid-resources/barriers-to-treatment/. Accessed January 17, 2016.
Olson Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. April 9, 2014;311(14):1393-1394.