Targeting each of the four types of opioid-​related stigma can bring health policy and social change

November 25/2019

By: Nicole Bodnar

U of T researchers have identified four types of opioid-related stigma that depend on a variety of factors, including the context of opioid use, the social identity and networks of the person who is consuming the opioid, and what type of opioid is being consumed, including prescribed opioids.  Each type requires targeted strategies to address the unique stigmas and reduce health inequities.

Prof Daniel Buchman

Professor Daniel Buchman

“We know that stigma is both a driver and consequence of the current overdose crisis, but opioid-related stigma is poorly understood,” said Daniel Buchman, senior author and Assistant Professor at the Dalla Lana School of Public Health.

North America is in the grips of an opioid-related overdose crisis, and stigma, discrimination, and prejudice are major contributors. Substance use in general is highly stigmatized, but stigma is a complex concept. Researchers say that there isn’t good evidence on the specific sources of opioid stigma, how it manifests in various contexts and its impact on affected groups.

Buchman worked with a research team to conduct a review of publications on opioid-related stigma that was published in the December 2019 edition of International Journal of Drug Policy. The team identified more than 8,500 papers of which 51 were analyzed. Four main themes emerged: interpersonal and structural stigma toward people accessing opioid agonist therapy (e.g., methadone, buprenorphine); stigma related to opioids for the treatment of chronic pain; stigma in health care settings; and self-stigma.

“Labels like addict, drug-seeker and junkie are barriers to accessing treatment and many people who use opioids internalize these labels and report feelings of self-blame, loathing, despair, shame and moral weakness,” said Melissa McCradden, first-author on the paper and Master of Health Science student at the University of Toronto Joint Centre for Bioethics.

Opioid-agonist therapy is the gold standard of treatment for an opioid use disorder, but researchers found that individuals receiving this treatment face stigma from multiple angles.

Factors include the context of opioid use, the social identity and the person who is consuming the opioid’s network, and what type of opioid is being consumed, including prescribed opioids.

For example, methadone’s association with heroin use stigmatizes the medication and the people who use it. The literature suggests that some physicians refuse to prescribe opioid agonist therapy out of fear of being stigmatized by their colleagues. Some patients who are prescribed opioids for cancer pain feel compelled to disclose their identity as a ‘cancer patient’ at the pharmacy in order to differentiate themselves from people on methadone and avoid barriers in accessing their medications.

Stigma in health care settings was another theme identified by the research team, both in the perception of physicians, nurses and pharmacists toward people who use opioids, as well as within health care’s bureaucratic systems. For example, excessive regulation, paperwork and requirements specific to prescribing opioids may intensify the stigma experienced people who use opioids.

“The literature suggests that some health-care professionals will make a distinction between patients with ‘legitimate’ pain who have ‘legitimate’ reasons for accessing opioids, and patients with ‘illegitimate’ pain who do not have legitimate reasons for accessing opioids,” said McCradden.

“This makes a harsh moral distinction between so-called ‘deserving’ and ‘undeserving’ patients. It entrenches stigma,” said McCradden.

Ultimately, researchers say that a paradigm shift is needed to address the structural forms of stigma — including social and economic determinants, laws, and public attitudes — in order to have an impact at the individual level.

“Stigma is considered a fundamental cause of population health inequalities and an independent social determinant of health,” said Buchman, who is also a Bioethicist at the University Health Network.

The social determinants of health are the conditions in which people live that are shaped by the distribution of money, power and resources. Social disadvantages — such as poverty, housing instability and discrimination — often occur simultaneously and can intensify stigma towards those who use opioids. This further marginalizes individuals, exacerbates health inequities and perpetuates stigma.

Buchman and McCradden say that evidence-based strategies to address stigma and its long-term impact on population health are critical to curb the overdose crisis. For example, ensuring people have barrier-free access (e.g. financial support and availability in pharmacies) to treatment and relaxing the social control factors (e.g. queuing for methadone treatment in clearly differentiated locations).

“The more familiar you are with a person, the less likely you are to stigmatize them, so there’s tremendous value in including and amplifying the voices of people who use opioids in health policy-making,” said Buchman.

“Humanizing people who use drugs and moving towards decriminalization of all drugs are key to a cultural shift in re-thinking substance use and redressing opioid-related stigma.”

The Canadian Centre on Substance Use and Addiction’s National Addictions Awareness Week is from November 25 to December 1, 2019 and the theme is Stigma Ends with Me. Click here to for resources to help spread the message and reduce stigma.