Medical Stigma and Patients with Substance Abuse Disorders

It is tempting to think that people in the medical community, and especially physicians, are immune from bias and stigma. They are highly educated and well trained, and we might suspect that they treat all of their patients fairly and equally—after all, they are interested in disease and in treating disease, and that is where their attention is focused.

This is, unfortunately, far from the truth, especially when it comes to clinicians’ attitudes toward individuals with substance use disorders (SUDs). Our research has provided evidence that the attitudes of clinicians toward individuals diagnosed with SUDs may be worse than their attitudes toward individuals with other medical and mental health diagnoses (Avery, Han, Zerbo et al., 2017). In addition, these attitudes worsen over time—the further into their training that early career physicians progress, the worse their attitudes become.

Here are the five reasons we think this is the case (see Avery, Zerbo, & Ross, 2016).

1. The majority of clinical experiences tend to be with individuals with severe SUDs. Clinicians spend the most time working with severe cases, for the simple reason that these cases take the most time. This gives physicians the false impression that many individuals never recover—and it also lodges these difficult cases in physicians’ mind. When they think of patients with SUDs, they think of these cases.
2. Physicians often lack exposure to individuals in recovery. Once again, we see the positive side drop out: once an individual is in recovery, it is rare for him or her to discuss the recovery at any given clinical visit. Thus, clinicians often have little exposure to positive narratives of individuals who are doing well.
3. Physicians lack time and resources to care for individuals with SUDs. There is still a dearth of education on substance use disorders during medical training. Many physicians, especially those who do not specialize in psychiatry, never receive training on treating individuals with SUDs. This lack of knowledge shows up in treatment available. There is a lack of substance use providers and accessible treatments, and thus those physicians who do provide such treatment are often overworked and pressed for time.
4. There is a dearth of good role models and mentors. The “hidden curriculum” of medical education is learned early on in training, and the lesson often learned about individuals with SUDs from senior clinicians is a message of hopelessness. Better role models and more nuanced mentoring is needed if the next generation of physicians is going to be an ally in the fight against addiction.
5. Substance misuse is perceived as a moral failing. The disease model of addiction is taught in medical school and emphasizes that addiction is a chronic, relapsing brain disorder that, as with other disorders, is caused by multiple forces, including behavioral, environmental, and biological ones. Yet physicians often still frame addiction as a failure of personal and moral responsibility, and this frame is associated with worse attitudes towards individuals with SUDs.

There are many things we can do to improve these negative attitudes. Here are just a few:

1. Increase awareness of negative attitudes. We recently studied the impact of an online training module on residents’ attitudes toward people with SUDs (Avery, Knoepflmacher, Mauer et al., 2019). The module provided information on how clinicians’ attitudes toward individuals with SUDs are worse than their attitudes toward people with other medical and psychiatric conditions. It also explained why this is the case. Some physicians view substance use as a moral failing rather than a brain disease, and many physicians have had prior challenging personal and clinical experiences with individuals with SUDs. The module featured videos of individuals in recovery, and it contained interviews with family members of individuals with SUDs, who discussed their hopeful and challenging experiences with clinicians. From both research and impact perspectives, the video has been successful. It improved clinicians’ attitudes, and it has now been seen by more than 10,000 physicians around the United States (Avery, Knoepflmacher, Mauer et al., 2019).
2. Provide forums to discuss common attitudes. Clinicians need the time and space to reflect on their experiences with patients and some of the feelings and attitudes that result from their work. Doing this with other clinicians may be especially helpful. Without this safe and inclusive space, it is hard to recognize common attitudes and change.
3. Increase exposure to individuals in recovery. Clinicians should visit 12-step programs and also ask their patients in recovery about their journeys to recovery. There are many positive stories out there, but clinicians often overlook them.
4. Continue to increase and improve addiction treatment options. Especially in the era of the opioid epidemic, more and more resources and dedicated providers are needed. It is hard to treat SUDs alone, and we need to support clinicians in this work.
5. Intervene at all levels of professional development. From medical school to continuing education opportunities, all clinicians should receive training and feedback on addiction, stigma, and bias. Without it, the negative “hidden curriculum” relating to individuals with SUDs may continue to impact clinicians’ attitudes and behaviors.

While the negative attitudes that many members of the medical community hold toward individuals with SUDs is concerning, there is a lot that can be done, and it is our hope that change will happen.