According to Nora Volkow, MD, head of the National Institute on Drug Abuse, shame, and stigma, far too often fuel addiction and obstruct the treatment. However, substituting judgment with compassion has the potential to save lives.
Science has provided a great deal of information on addiction. We now know that changes in brain networks required for self-regulation cause some people’s substance use to become compulsive, despite their best efforts to reduce or quit using. We are also learning more about the genetic, developmental, and environmental factors that contribute to drug experimentation and the brain alterations that underpin addiction.
Data from a large longitudinal study of adolescents funded by the National Institute on Drug Abuse in collaboration with other National Institutes of Health entities, for example, have given insights into the negative effects of adversity and poverty on the developing brain, which include neurobiological changes that increase the likelihood of drug use and addiction.
On the plus side, preventative research indicates that delivering tailored interventions to low-income families or those without social supports can avoid – or even reverse – these neurological alterations. Furthermore, decades of research on brain signaling systems have shown that addiction is reversible and recovery is possible even after it has taken hold.
Unfortunately, stigma restricts the accessibility of our tools and the impact of this knowledge.
Medicine, policy, and communities are all plagued by stigma.
Because addiction was not recognized as a medical disease for many years, medical schools provided little or no training in screening for or treating substance use problems until recently. Even now, when medical systems provide therapy, it may be restricted or insufficient. According to National Academies of Sciences, Engineering, and Medicine research, fewer than half of dedicated addiction treatment programs supply medications, which amounts to a denial of appropriate medical care.
Insurers are frequently hesitant to cover addiction therapy, including opioid use disorder drugs, and coverage is limited when it is provided. Due to insufficient coverage, many people who require these life-saving treatments are unable to obtain them. Stigma also limits pharmaceutical use in most correctional settings, despite the fact that at least half of all incarcerated people in the United States have a substance use disorder, generally an opioid use disorder.
[Stigma] leads to the unfortunate truth that in 2019, less than 13% of people with an illicit drug use disorder received any treatment for their addiction.
Furthermore, many communities refuse to provide harm-reduction measures such as syringe services programs and the overdose medicine naloxone due to a moralistic – and scientifically false – assumption that doing so encourages illegal drug use.
Even when therapies and other support systems are available, individuals who are addicted may not seek them out because they are afraid of the judgments of others around them and the discrimination, they frequently face in the health care system. Patients are frequently hesitant to confess their substance abuse to their doctors.
This contributes to the tragic reality that in 2019, fewer than 13% of individuals with an illicit drug use disorder received any treatment for their addiction, and only 18% of people with an opioid use disorder obtained one of the three safe, effective, and potentially lifesaving medications that could aid their recovery. The proportion of those suffering from alcoholism who received medication is significantly lower to 3%.
Government policies, particularly criminal justice reform, can reflect – and add to – stigma. When we penalize people who use drugs due to addiction, we imply that their usage is a defect in their character rather than a medical issue. And by incarcerating addicts, we reduce their access to treatment and intensify the personal and societal repercussions of their substance use. Furthermore, drug laws are unfairly used against Black people and communities, contributing to socioeconomic and health inequities.
The stigma of illegality has an impact on the treatment of addicts. Some treatment programs, for example, exclude patients for positive urine tests, as if relapse were not merely a known indication of the condition and a clinical signal to change the treatment method, but a rather actual crime.
Addiction medicine prescribers are regulated and subjected to strict constraints that do not apply to other prescriptions – or even the same meds in different contexts, such as prescribing buprenorphine for pain. Such oversight implicitly implies that these treatments and the individuals who receive them are suspicious.
The negative impacts of stigma extend well beyond hindering care and care-seeking. Internalized stigma, as well as painful social and emotional impacts such as rejection, loneliness, and shame, promote drug use in order to alleviate one’s suffering, creating a vicious cycle.
Stigma is not eliminated just by educating people about the science of an illness. It is necessary, in part, to facilitate contact between a stigmatized group and the larger community. Empathy and compassion can begin to replace judgment and fear if individuals with substance use disorders can express their stories.
To do this, combating stigma must be a major component of our public health initiatives. If we are to end the present addiction and overdose catastrophe, we must prioritize stigma reduction alongside the development and implementation of novel prevention and treatment measures.
To influence public perceptions toward addiction and people living with the disease, we require a large-scale social intervention. Aside from assuring adequate training and resources to assist individuals with substance use disorders, we must seriously evaluate policies – not just laws, but regulations and practices in health care and other settings – that promote perceiving substance use as wrongdoing. Moreover, we must make it safe for patients and families to address addiction and remove the stigma that impedes therapy.