Addressing the Stigma that Surrounds Addiction

nida-banner-science-of-abuse-and-addiction

From the Monthly Blog of Dr. Nora Volkow, Exec. Dir.
NATIONAL INSTITUTE ON DRUG ABUSE

Original Date April 22, 2020

Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. Healthcare already has effective tools including medications for opioid and alcohol use disorder that could prevent many of these deaths, but they are not being utilized widely enough, and many people who could benefit do not even seek them out. One important reason is the stigma that surrounds people with addiction.

Man sitting alone in streetlight at night

Stigma is a problem with health conditions ranging from cancer and HIV to many mental illnesses. Some gains have been made in reducing stigma around certain conditions; public education and widespread use of effective medications has demystified depression, for instance, making it somewhat less taboo now than it was in past generations. But little progress has been made in removing the stigma around substance use disorders. People with addiction continue to be blamed for their disease. Even though medicine long ago reached a consensus that addiction is a complex brain disorder with behavioral components, the public and even many in healthcare and the justice system continue to view it as a result of moral weakness and flawed character.

Stigma on the part of healthcare providers who tacitly see a patient’s drug or alcohol problem as their own fault leads to substandard care or even to rejecting individuals seeking treatment. People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff fearful of their behavior or assuming they are only seeking drugs. People with addiction internalize this stigma, feeling shame and refusing to seek treatment as a result.

In a Perspective published recently in The New England Journal of Medicine, Dr. Volkow tells the story about a man she met who was injecting heroin in his leg at a “shooting gallery”—a makeshift injection site—in San Juan, Puerto Rico, during a visit to that country several years ago. His leg was severely infected, and Dr. Volkow urged him to visit an emergency room—but he refused. He had been treated horribly on previous occasions, so preferred risking his life, or probable amputation, to the prospect of repeating his humiliation. This highlights a dimension of stigma that has been less remarked on in the literature and that is uniquely important for people with substance use disorders: Beyond just impeding the provision or seeking of care, stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.

Previously on her montly blog Dr. Volkow highlighted research by Marco Venniro at NIDA’s Intramural Research Program, showing that rodents dependent on heroin or methamphetamine still choose social interaction over drug self-administration, given a choice; but when the social choice is punished, the animals revert to the drug. It is a profound finding, very likely applicable to humans, since we are highly social beings. Some of us respond to social as well as physical punishments by turning to substances to alleviate our pain. The humiliating rejection experienced by people who are stigmatized for their drug use acts as a powerful social punishment, driving them to continue and perhaps intensify their drug-taking.

The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis. In addition to their greater risk through homelessness and drug use itself, the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.

Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Even people in healthcare, if they do not have training in caring for people with substance use disorders, may be at a loss as to how to interact with someone acting threateningly because of withdrawal or some drugs’ effects (e.g., PCP). It is crucial that people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants, be trained in caring compassionately and competently for people with substance use disorders. Treating patients with dignity and compassion is the first step.

There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised, and that medical care is often necessary to facilitate recovery as well as avert the worst outcomes like overdose. When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.

Find Help Near You

The following website 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.

You can also find help through Narcotics Anonymous at 844-335-2408.

Supporting Our Physicians in Addressing the Opioid Crisis

From the blog of Dr. Lora Volkow dated August 31, 2018

NIDA Banner Science of Abuse and Addiction

A recurring theme among addiction researchers and professionals is the so-called treatment gap: under-utilization of effective treatments that could make a serious dent in the opioid crisis and overdose epidemic. Ample evidence shows that when used according to guidelines, the agonist medications methadone and buprenorphine reduce overdose deaths, prevent the spread of diseases like HIV, and enable people to take back their lives. Evidence supporting the effectiveness of extended-release naltrexone is also growing; but whereas naltrexone, an opioid antagonist, can be prescribed by any provider, there are restrictions on who can prescribe methadone and buprenorphine.

Naltrexone Table of Facts.jpg

A series of editorials in the July 5, 2018 issue of the New England Journal of Medicine made a strong case for lessening these restrictions on opioid agonists and thereby widening access to treatment with these medications. For historical reasons, methadone can only be obtained in licensed opioid treatment programs, but experimental U.S. programs delivering it through primary care docs have been quite successful, as have other countries’ experiences doing the same thing. Although buprenorphine can be prescribed by primary care physicians, they must first take 8 hours of training and obtain a DEA waiver, and are then only allowed to treat a limited number of patients. Some physicians argue that these restrictions are out of proportion to the real risks of buprenorphine and should be lessened so more people can benefit from this medication.

stigma-word-cloud-concept-vector-260nw-719034481.jpg

Stigma contributes to reluctance to use evidence-supported treatment—both stigma against addicted individuals and stigma against agonist medications, due to the persistent myth that they just substitute a new addiction for an old. This idea reflects a poor understanding of dependence and addiction. Dependence is the body’s normal adaptive response to long-term exposure to a drug. Although people on maintenance treatment are dependent on their medication, so are patients with other chronic illnesses being managed medically, from diabetes to depression to pain to asthma. Addiction, in contrast, involves additional brain changes contributing to the loss of control that causes people to lose their most valued relationships and accomplishments. Opioid-dependent individuals do not get high on therapeutic doses of methadone or buprenorphine, but they are able to function without experiencing debilitating withdrawal symptoms and cravings while the imbalances in their brain circuits gradually normalize.

Treating patients with addiction may be uniquely complex and demanding for several reasons. Patients may have co-morbid medical conditions, including mental illness; thus they may need more time than doctors are reimbursed for by insurers. They may also have pain, and while pain management guidelines have changed to respond to the opioid crisis, those changes have not necessarily made a doctor’s job any easier, since there are currently no alternative medications to treat severe pain that are devoid of dangerous side effects.

Opiate Use Disorder Fact Sheet.png

Because of the complexity of Opioid Use Disorder (OUD), providers may find that it is not sufficient to simply dispense a new prescription after a quick consultation. These patients often need ancillary services provided by nurses or other treatment specialists; and in the absence of these extra layers of support, treatment is less likely to be successful, reinforcing physicians’ reluctance to treat these patients at all. In short, physicians are being blamed for causing the opioid epidemic, but thus far they have not been aided in becoming part of the solution.

Medical schools are starting to respond to the opioid crisis by increasing their training in both addiction and pain. For example, as part of its training in adolescent medicine, the University of Massachusetts Medical School has begun providing pediatric residents with the 8-hour training required to obtain a buprenorphine waiver—an idea that is winning increasingly wide support. Physicians in some emergency departments are also initiating overdose survivors on buprenorphine instead of just referring them to treatment. And through its NIDA MedPortal, NIDA provides access to science-based information and resources on OUD and pain to enable physicians to better address these conditions and their interactions, including easy-to-use screening tools to help physicians identify substance misuse or those at risk.

But if physicians are going to assume a bigger role in solving the opioid crisis, healthcare systems must also support them in delivering the kind of care and attention that patients need. Physicians need the tools to treat addiction effectively as well as the added resources (and time) for patients who need more than just a quick consultation and a prescription.

What Good Is Work? Is Government Assistance Biblical?

“Christians must revive a centuries-old view of humankind as made in the image of God, the eternal Craftsman, and of work as a source of fulfillment and blessing, not as a necessary drudgery to be undergone for the purpose of making money, but as a way of life in which the nature of man should find its proper exercise and delight, and so fulfill itself to the glory of God. That it should, in fact, be thought of as a creative activity undertaken for the love of the work itself; and that man, made in God’s image, should make things, as God makes them, for the sake of doing well a thing that is well worth doing.”
                                                                                                                                Dorothy L. Sayers

Public Assistance

I know from experience that lack of work almost always leads to complacency, stagnation, negativism, and laziness. It can eventually lead to serious financial woes, including insolvency and lack of preparedness for emergency. I suffered a back injury in 2004 while helping a gentleman “flip” houses for a living. I did a lot of concrete work, tear outs of old kitchens and bathrooms (oh, the cast iron tubs and old radiators!), and hanging drywall. I spent hours at a time on extension ladders painting the eves of houses. Due to my injury, and the subsequent collapse of discs in my lumbosacral spine, it became impossible to work in any capacity for several years. I subsequently began receiving welfare benefits, then, ultimately, social security disability benefits. Recently, I have been able to hold a part-time job or two while still collecting SSDI benefits.

A sense of guilt eventually set in, and I felt it necessary to return to the “world of the working,” which to me is akin to the world of the living. I am currently attending online classes at Colorado Christian University to finish my undergraduate degree in psychology, and will graduate next year. I have applied for admission to the master’s degree program in professional counseling at Lancaster Bible College (with a concentration in addictions). Classes begin September 2018. It is thrilling to me to be able to finally complete my education in psychology which I started at the University of Scranton in 1982. It is my intention to work as an addictions counselor until the day I can no longer make it out of my house and to the office.

It’s is sad to see the extent of “welfare as a way of life” in America today. Indeed, it often spans generations. There are so many factors that feed into this dilemma; too many to get into here. I think there are two ways we can help break that cycle. One is through an incentive-based public assistance program. We have to STOP allowing people to collect benefits while doing nothing whatsoever to improve their station in life. The other is to make college much more accessible to lower income families. According to the Pennsylvania Department of Human Services, approximately 25.3 percent of the Commonwealth’s population (one in four) receive some type of vital support, ranging from cash benefits and food stamps to medical assistance and low income home heating grants.

Welfare Benefits Pie Chart

In the matter of people who are incarcerated, it is paramount that we focus on vocational, psychological, spiritual, and educational programs and not merely on warehousing of criminals. In addition, we have to do something about the stigmatizing of felons, which is disenfranchising them from the workforce upon their release. Then there’s the nationwide opiate epidemic, mainly heroin, and our tendency to criminalize what is actually a brain disease. Yes, the individual makes a choice to get high, but the power of the morphine molecule is impossible to resist by sheer willpower, and the result is relapse and recidivism.

From a Theological Perspective

I read Courage & Calling by Gordon T. Smith for a class at Colorado Christian University. It’s available on Amazon.com by clicking here, and I highly recommend it. Gordon believes God calls us first to Himself, to know Him and follow Him, but also to a specific life purpose, a particular reason for being. This second calling or “vocation” has implications not only for our work or occupation, but also includes our gifts, our uniqueness, our life community, and what we do day-to-day. When we fulfill our specific vocation, we are living out the full implications of what it means to follow Jesus.

There seems to be this huge assumption in our social context today that work is bad (or, worse yet, something to be avoided) and leisure is good. Billions of dollars are spent every year on ways that help us relax or escape from the toils of work. God made man to work, and that work was to be meaningful. I believe God made mankind workers so that they could be co-creators with Him – not in the sense that they are creators of the Earth, but that their work was a part of God’s continual re-creation. Man is to be a steward over creation. Over all there is.

In Courage & Calling, Gordon says it is important to have a biblical theology of work. The witness of the Scriptures and of Christian spiritual heritage suggest that responsible human life includes stewardship of our capacities and opportunities. A biblical theology of vocation provides us with a critical and essential lens through which to view our lives and what it means to be stewards of our lives. So, we can ask not only “What good is work?” but “What is the good work I am called to do?” Living well, surely, is a matter of taking seriously the life that has been given us – the opportunities and challenges that are unique to us, to our lives, our circumstances. Taking our lives seriously means that we respond intentionally to these circumstances and the transitions of life. This is something I had no concept of, or capacity for, while in active addiction.

I had to come to understand three things. First, our lives are of inestimable value. Second, living our lives to the full is precisely what it means to be good stewards of our lives. Third, we live fully by living in a way that is deeply congruent with who we are. In the Scriptures there is a clear proclamation of what it means to have human identity – a person created by God, with worth and significance. It is also true that the field of psychology has enabled many to appreciate the full significance and weight of this scriptural insight. No lives are dispensable. No one can say that their life or work does not matter. Each person brings beauty, creativity and importance to the table.

Let’s Go To The Scriptures

The Bible has much to say about work, which in its different forms is mentioned more than 800 times. This is more frequently than all the words used to express worship, music, praise, and singing combined. The Bible begins with the announcement, “In the beginning God created…” It doesn’t say He sat majestic in the heavens. He created. He did something. He made something. He fashioned heaven and earth. The week of creation was a week of work. From the very beginning of the scriptures we are faced with the inescapable conclusion that God himself is a worker. It’s part of his character and nature.

Proverbs beautifully illustrates the work ethic. “Take a lesson from the ants you lazy bones. Learn from their ways and become wise! Though they have no prince or governor or ruler to make them work, they labor all summer, gathering food for the winter. But you, lazybones, how long will you sleep? When will you wake up?” (Proverbs 6:6-9, NLT)

In Genesis 2:15 we read, “The Lord God took the man and put him in the Garden of Eden to work it and take care of it.” (NIV) [Italics mine.] We were created by God to be stewards of His creation through our work. Work is actually a gift from God, and by it we employ useful skills to glorify Him and to help our neighbors. The Fall did not create work, but it did make in inevitable that work would sometimes be frustrating or seemingly meaningless. I believe Adam’s work in the garden can be seen as a metaphor for all work. In the story of Creation, we see God bringing order out of chaos. A gardener does the same thing by creatively using materials at his disposal. Adam was called by God to essentially rearrange the raw materials of a particular domain to draw out its potential for the benefit of everyone.

I believe our true calling evolves over time, and tends to emerge as we discover and hone our God-given talents into skills and useful competencies to be used for the glory of God and the service of our fellow man. Frederick Buechner said, “The place God calls you to is the place where your deep gladness and the world’s deep hunger meet.” Here’s the key: When it comes to work, there is no distinction between spiritual and temporal, sacred and secular. All human work, however lowly, is capable of glorifying God. Work is, quite simply, an act of praise. Colossians 3:17 says, “And whatever you do, whether in word or deed, do it all in the name of the Lord Jesus, giving thanks to God the Father through Him.” (NIV) Our work matters profoundly to God. We must be committed to the idea that we express our Christian discipleship through our employment, which is an important part of life. It is in this realm that we are called to stewardship.

Certainly, it can be argued that we will not have a meaningful life without work, but we cannot make our work the meaning of our life. As Christians, we must find our identity in Christ, not in our work. Yet, work is the major way we respond to God’s call in our life. It gives us the platform from which we can be salt and light in a tasteless and dark world. Interestingly, the idea of rest must also be in the picture. God rested from his labors on the seventh day, and so should we. Please know I’m not talking about a dogmatic observance of “the sabbath.” There are literally dozens of interpretations of sabbath from a religious perspective. In Courage & Calling, Gordon tells us the pursuit of diligence can sometimes become the burden of perfectionism, which is a burden to you and to those with whom you work. It can easily lead to a person feeling overworked and exhausted. Our only hope is to keep a balance.

This is only possible with a clearly defined pattern of sabbath renewal in our lives. The word sabbath comes from the Hebrew shabbat, which is derived from the verb shavat, meaning “to cease.” By regular sabbath rest, we are freed from seeing work as a burden; it is ultimately God’s work that is entrusted to us for six days a week, but we are not responsible for, nor should we feel the need to, feel the burden of carrying this work seven days a week. The sabbath gives us perspective. I will go so far as to say we should not call it a “day off,” because this does nothing more than define our day of rest negatively in terms of the absence of work. Sabbath actually builds a sense of rhythm into the whole of creation.

Closing Remarks

Work is a lifelong endeavor. Genesis 3:19 says, “By the sweat of your brow you will eat your food until you return to the ground, since from it you were taken; for dust you are and to dust you will return.” (NIV) It is important to realize that through the doctrine of work God changes culture, society, and the world. The entire world has fallen into a state of injustice and brokenness. Redemption is not just about helping individuals escape this world, or saving souls condemned to eternal spiritual death (although this is certainly the message of the Good News), it is about restoring the whole of creation. I can think of no better way to contribute to this goal than through fulfilling God’s call on our lives. We must integrate our faith and our work. It is critical that we perform our jobs with distinctiveness, excellence, and accountability.

You and I were designed by God to work. Work is not a curse that we must endure, it is the way we experience purpose, meaning and joy. It’s what we were created to do: work and produce. In fact, not working takes a greater toll on us in the long run. Our attitude toward work should be without parallel. Ecclesiastes 9:10 says, “Whatever your hands find to do, do it with all your might.” God wants us to work in a vocation that compliments the way we were designed to act. Ultimately, this means discovering our skills or talents and using them rather than burying them in the ground or hiding them away. As Paul wrote in Ephesians 2:10, “For we are God’s workmanship, created in Christ Jesus to do good works, which God prepared in advance for us to do.”

Opioid Use Disorders and Suicide

The following is a guest blog taken verbatim from the monthly blog post of Dr. Nora Volkow, director, National Institute of Drug Abuse published April 20, 2017.

“At a Congressional briefing on April 6, the President of the American Psychiatric Association, Dr. Maria Oquendo, presented startling data about the opioid overdose epidemic and the role suicide is playing in many of these deaths. I invited her to write a blog on this important topic. More research needs to be done on this hidden aspect of the crisis, including whether there may be a link between pain and suicide.” – Nora

In 2015, over 33,000 Americans died from opioids—either prescription drugs or heroin or, in many cases, more powerful synthetic opioids like Fentanyl. Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides. Let me share with you some chilling data from three recent studies that have investigated the issue.

20170311_woc097

In a study of nearly 5 million veterans recently published in Addiction, scientists reported that presence of a diagnosis of any substance use disorder and specifically diagnoses of opioid use disorders (OUD) led to increased risk of suicide for both males and females.  The risk for suicide death was over 2-fold for men with OUD.  For women, it was more than 8-fold.  Interestingly, when the researchers controlled the statistical analyses for other factors, including co-morbid psychiatric diagnoses, greater suicide risk for females with opioid use disorder remained quite elevated, still more than two times greater than that for unaffected women.  For men, it was 30 percent greater.  The researchers also calculated that the suicide rate among those with OUD was 86.9/100,000.  Compare that with already alarming rate of 14/100,000 in the general US population.

You may be tempted to think that these shocking findings about the effects of OUD on suicide risk are true for this very special population.  But that turns out not to be the case. 

Another US study, published last month in the Journal of Psychiatric Research, focused on 41,053 participants from the 2014 National Survey of Drug Use and Health.  This survey uses a sample specifically designed to be representative of the entire US population.  After controlling for overall health and psychiatric conditions, the researchers found that prescription opioid misuse was associated with anywhere between a 40 and 60 percent increased risk for suicidal ideation (thoughts of suicide).  Those reporting at least weekly opioid misuse were at much greater risk for suicide planning and attempts than those who used less often.  They were about 75 percent more likely to make plans for a suicide, and made suicide attempts at a rate 200 percent greater than those unaffected.

fig4test51414

Using a different strategy, a review of the literature in the journal Drug and Alcohol Dependence estimated standardized mortality ratios for suicide.  This is a way of comparing the risk of death in individuals with a given condition compared to individuals from the general population.  The researchers found that for people with OUD, the standardized mortality ratio was 1,351 and for injection drug use it was 1,373.  This means that compared to the general population, OUD and injection drug use are both associated with a more than 13-fold increased risk for suicide death. These are stunning numbers and should be a strong call to action.

Persons who suffer from OUD are highly stigmatized. They often talk about their experience that others view them as “not deserving” treatment or “not deserving” to be rescued if they overdose because they are perceived as a scourge on society.  The devastating impact of this brain disorder needs to be addressed.  People who could be productive members of society and contribute to their families, their communities, and the general economy deserve treatment and attention.

As a country, we desperately need to overcome stigmatizing attitudes and confront the problem. We need to understand what causes some individuals to become addicted when exposed to opioids and thus study the biological basis of the disease of opioid addiction. We desperately need to know what the best treatments are for a given individual, and for that too, we need research to identify biomarkers for treatment response. Given the fact that effective medications exist but are drastically underutilized, we need to overcome institutional and attitudinal barriers to these treatments and deliver them to the 24 million people who could benefit. It can prevent not only the suffering of addiction and the danger of unintentional overdose but also help prevent the tragic outcome of opioid-related suicide.

mountain-lake-931726__340