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 Treatment” (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 neonatal abstinence syndrome (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 SUDs 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.