From the Blog of Dr. Nora Volkow, Executive Director
Original Date November 8, 2021

Dr. Nora Volkow reviewing the NIDA Website

Far too often, shame and stigma fuel addiction and prevent treatment, argues Nora Volkow, MD, director of the National Institute on Drug Abuse. But replacing judgment with compassion can save lives.

Science has shed much light on addiction. We now understand that changes in brain networks needed for self-regulation cause substance use to become compulsive in some individuals — despite their best efforts to decrease or stop use. We are also gaining an understanding of the genetic, developmental, and environmental factors that cause susceptibility to drug experimentation and to the brain changes underlying addiction. For instance, data from a large longitudinal study of adolescents funded by the National Institute on Drug Abuse in close partnership with other National Institutes of Health entities have provided insights into the adverse effects of poverty and adversity on the developing brain, including neurobiological changes that make drug use and addiction more likely.  

On the positive side, prevention research shows that providing targeted interventions to families with low incomes or lacking social supports can avert — or even reverse — these neurobiological changes. What’s more, decades of research on brain signaling systems have demonstrated that even once addiction takes hold, it is still reversible and recovery is achievable. Unfortunately, stigma limits the impact of this knowledge and the reach of our tools.

The Role of Stigma

Stigma pervades medicine, policy, and communities. Medical schools until recently offered little or no training in screening for or treating substance use disorders because, for many years, addiction was not seen as a medical problem. Even now, when medical systems offer treatment, it may be limited or inadequate. Among dedicated addiction treatment programs, fewer than half offer medications, which is tantamount to denial of appropriate, according to a National Academies of Sciences, Engineering, and Medicine report.

Insurers are often reluctant to cover addiction treatment, including medications for opioid use disorder, and coverage is limited when it is provided. Inadequate coverage puts these life-saving treatments out of reach for many people who need them. Stigma also prevents the use of medications in most justice settings—even though at least half of incarcerated individuals in the United States have a substance use disorder, often an opioid use disorder. What’s more, many communities fail to provide harm-reduction measures, such as syringe services programs and the overdose medication naloxone, out of a moralistic—as well as factually incorrect—belief that those measures encourage illegal drug use.

Even when treatments and other supports are available, people with addiction may not seek them, fearing the judgments of those around them and the discrimination they routinely experience in the health care system. Patients are often hesitant to disclose their substance use to their physicians. This contributes to the tragic reality that fewer than 13% of people with an illicit drug use disorder received any treatment for their addiction in 2019 and just 18% of people with opioid use disorder received one of the three safe, effective, and potentially lifesaving medications that could facilitate their recovery. The proportion of people with alcohol addiction who received medications is even lower: 3%.

Government policies, including criminal justice measures, often reflect — and contribute to — stigma. When we penalize people who use drugs because of an addiction, we suggest that their use is a character flaw rather than a medical condition. And when we incarcerate addicted individuals, we decrease their access to treatment and exacerbate the personal and societal consequences of their substance use. What’s more, drug laws are disproportionately leveraged against Black people and Black communities, driving societal and health disparities. The aura of illegality affects the treatment of people with addiction. For example, some treatment programs expel patients for positive urine samples, as if relapse were not simply a known symptom of the disorder and a clinical signal to adjust the treatment approach but instead actual wrongdoing.

Help and Healing

Stigma’s damaging effects go well beyond impeding care and care-seeking. Painful social and emotional effects like rejection, isolation, and shame—internalized stigma—drive drug-taking to alleviate one’s suffering, leading to a vicious cycle. It was internalized stigma that led my grandfather to end his life. Research supports the lesson I learned firsthand in my own family—that stigma is not alleviated solely by educating people on the science of a disease. Partly, it requires facilitating contact between a stigmatized group and the wider community. If people with substance use disorders can share their experiences, then empathy and compassion can begin to replace judgment and fear. For that to happen, addressing stigma must be a central prong of our public health efforts. If we’re going to end the current addiction and overdose crisis, we must treat combating stigma as no less important than developing and implementing new prevention and treatment tools.

We need a large-scale social intervention to change public attitudes toward addiction and people who have the disease. Besides ensuring proper training and the resources needed to help patients with substance use disorders, we need to seriously reconsider policies — not only laws but regulations and practices in health care and other settings — that promote viewing substance use as wrongdoing. And we must make it safe for patients and families to discuss addiction and remove the shame that interferes with its treatment.

Find Help Near You

The following can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. A step by step guide on what to do to help yourself, a friend or a family member on the Treatment page.

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