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Best practice №37

Provide health care providers with stigma education/resources

by Lauren Caton

Last updated March 12th, 2020

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Overview

Treatment of SUD is often eclipsed by the misperception that SUD is a personal weakness or a willful choice. Whether or not these misconceptions are consciously employed, they can have a dramatic impact on patient outcomes and adherence to treatment during recovery. Stigma can be experienced across several domains: self, social, and structural stigma. This toolkit focuses on structural stigma oriented toward health care professionals and systems-based approaches.

Providers who interact with OUD/SUD patients often cite them as their most challenging patients due to expectations of cooperation, aggression, demands, and low rates of treatment completion. It is therefore not uncommon for health professionals who interact with these patients to show unconscious bias whether or not they explicitly report negative attitudes. Stigma can come from staff interactions at all contact points and through materials provided in clinical settings.

Why we are recommending this best practice

Several studies have shown that perceived discrimination and stigma from providers has a significant impact on treatment completion by increasing the likelihood of dropout and decreasing retention. Whether or not adoption of stigmatizing beliefs is conscious, evidence shows that health professionals not trained to interact with patients with substance use disorders may avoid or shorten appointment visits or express less empathy to these patients. This may reduce quality of care and decrease patient retention. 

Strategies for implementation

Perform a language audit of all internal (EHR, protocols) and external (brochures, educational pamphlets) materials.
Designate a staff member to review all materials distributed or posted in the clinic regarding OUD/SUD to address any stigma-perpetuating language. An analysis of materials should identify the following terminology, and materials should be updated accordingly:  

  • Diagnosis - In alignment with DSM - 5, replace older categories of substance “abuse”, “drug habit”, and “dependence” with a single classification of “substance use disorder” (SUD) or “opioid use disorder”. Use clinically accurate terminology which reflects the treatable, clinical, and chronic nature of SUD and moves away from choice-based terminology. 

  • Person-first language – Discussing substance use should follow the accepted standard for discussing people with disabilities and/or chronic medical conditions. Replace “abuse”, “abuser”, “addict”, “druggie”, “alcoholic” with “person with SUD” or “person experiencing” with “person struggling.”

  • Testing and Toxicology – Replace “clean” and “dirty” urine drug screens with “positive” and “negative” or “expected” vs. “unexpected” and use “consistent with prescribed medications.” “Person in Recovery” focuses on the process and acknowledges the consistent management of symptoms and stable conditions. 

  • Medications – Avoid using “replacement” and “substitution” therapy. Preferred are “medication assisted therapy” (MAT), “pharmacotherapy for …”, and specifically “medications for OUD” (MOUD) or “medications for SUD”. Additionally, once an individual is receiving MAT, “medically indicated tapering” or “decreasing of dosage” (from buprenorphine or methadone) conveys that the medications might be noxious toxins leaving the body and should also therefore be replaced.   

  • Maternal and Newborn - Although not commonly employed in medical literature or materials, use of the language “crack baby,” “opioid baby,” or “drug-addicted baby” should be replaced with NAS, for opioid or heroin exposure, and prenatal cocaine exposure, or colloquially “in utero exposure to [substance] …”.


Individual identification of stigma 
Provide opportunities for individual identification of stigma:

  • Formally through Implicit Associations Test– Mental Health, a test for unconscious bias in relation to mental health

  • Informally through Stigma Self-Assessments


Addressing stigma: healing stigma through training and intervention
Broad education campaigns oriented toward changing public perception have been found to have limited impact on changing attitudes about opioid use disorder. However, targeted intervention with staff, medical personnel, and trainees has been shown to reduce stigmatizing language and behaviors. Contact-based interventions where individuals with SUD can humanize patients has been shown to significantly reduce stigmatizing ideology compared to education alone. When training is not immediately available, the Woll Healing Approach is recommended and has a self-directed workbook.  Their approach addresses beliefs and accountability in order to heal the potential trauma and effects of working with OUD and SUD populations. Several training opportunities are available to educate medical professionals and staff, some more informal than others. Potential training opportunities are listed below in order of feasibility and scale:  
 
  • Informal staff and patient-facing personnel (including health professional) intervention: 
    • Focus on inadvertent ways personnel may be perpetuating stigma
    • Explore the perceptions personnel may hold towards the SUD population
    • Facilitate discussion on how to adopt alternative language

  • Empathy training or defined stigma curricula: 
    • Many regional Addiction Technology Transfer Centers have access to CME and CEU credit for completion of their curricula: 
      • Addiction Technology Transfer Centers Network Center: https://attcnetwork.org/centers/global-attc/training-and-events-calendar
      • Pacific Addiction Technology Transfer Centers: https://attcnetwork.org/centers/global-attc/training-and-events-calendar 
      • California Health care Foundation: https://www.chcf.org/topic/opioid-safety/ 
      • Acceptance and Commitment Training (ACT), a cognitive-based approach incorporating flexibility and mindfulness, has shown to significantly increase positive attitudes toward people with substance use disorders and decrease negative thoughts toward SUD clients among SUD providers. 

  • Medical trainee education:
    • Integrate stigma training in medical curricula. An upstream approach is shown to be among the most effective.
    • Trainee education can be effective in combating stigma by integrating understanding and efficacy into medical residency programming, with particularly positive outcomes for work with pregnant women. Self-reflection techniques and training rotations in specialized prenatal clinics has been shown to significantly increase the comfort level of working with this population and reduce negative ideology.
    • Many clinics and hospitals interact with or supervise clinical trainees.  Integrating, introducing, or providing stigma reduction trainings to medical residents, fellows, and post-docs may be an effective tool. 

Resources

References

  • Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach. Drug Alcohol Rev. 2010;29(5):491-7. doi: 10.1111/j.1465-3362.2010.00173.
  • Boekel LCV, Brouwers EP, Weeghel JV, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence. 2013;131(1-2):23-35. doi:10.1016/j.drugalcdep.2013.02.018.
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013.
  • Brener L, Hippel WV, Kippax S, Preacher KJ. The Role of Physician and Nurse Attitudes in the Health Care of Injecting Drug Users. Substance Use & Misuse. 2010;45(7-8):1007-1018. doi:10.3109/10826081003659543.
  • Mclaughlin DF, Mckenna H, Leslie JC. The perceptions and aspirations illicit drug users hold toward health care staff and the care they receive. Journal of Psychiatric and Mental Health Nursing. 2000;7(5):435-441. doi:10.1046/j.1365-2850.2000.00329.
  • Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. Journal of Personality and Social Psychology. 2009;97(1):17-41. doi:10.1037/a0015575.
  • Hayes SC, Bissett R, Roget N, et al. The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy. 2004;35(4):821-835. doi:10.1016/s0005-7894(04)80022-4.
  • Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction. 2011;107(1):39-50. doi:10.1111/j.1360-0443.2011.03601.
  • Ramirez-Cacho WA, Strickland L, Beraun C, Meng C, Rayburn WF. Medical students’ attitudes toward pregnant women with substance use disorders. American Journal of Obstetrics and Gynecology. 2007;196(1). doi:10.1016/j.ajog.2006.06.092.

Lauren Caton

MPH

Lauren Caton, MPH is a Clinical Research Coordinator at the Center for Behavioral Health Services and Implementation Research (CBHSIR) in the Department of Psychiatry & Behavioral Sciences at Stanford University School of Medicine. Her projects at CBHSIR focus on the implementation and sustainment of medication-assisted treatment for opioid use disorders.