Addiction Medicine Made Easy | Fighting back against addiction

Stigma Kills Patients. How We Can Fight Back.

• Casey Grover, MD, FACEP, FASAM

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In this episode, we are tackling stigma. Specifically stigma against patients by healthcare providers. 

Stigma against patients struggling with addiction is a significant barrier to effective healthcare treatment, leading to profound consequences, including increased harm and even death. The episode highlights the definition of stigma, its impacts on patient behavior, and actionable strategies to reduce it within the healthcare system. 

We discuss:
• Definitions and types of stigma 
• The harmful effects of stigma on quality of life 
• The link between stigma and higher mortality rates 
• Patient responses to stigma in healthcare settings 
• Personal stories highlighting the real impact of stigma 
• Effective strategies for reducing stigma in healthcare 
• Importance of using person-first language and educational outreach

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years, I worked in the emergency department seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. Today, we are going to be talking about stigma. This is a huge topic that affects all of medicine, but it affects patients with addiction, in my opinion, more than those with any other disease. We're going to talk about what stigma is, how it affects patients and what we, both as people in general and as healthcare providers, can do to reduce stigma. I work as the medical director for a residential drug and alcohol treatment program and I do education for my colleagues each month, and this is the topic that we talked about this month. One clarification I reference a hospital called CHOMP in the lecture. It's the hospital where I work in Monterey and, if you've been a podcast listener for a while, I have covered this topic before. We did a nearly one hour long episode on this back in 2021. This episode is an updated and abbreviated version of that episode. Let's dig in. Okay, well, we will get started. This is a fairly emotional lecture. This comes from Chomp.

Speaker 1:

I was asked to speak about stigma by healthcare providers against patients and what that does, and we'll get started. So what is stigma? I'm going to read what's on the screen here An attribute considered to be undesirable and unpleasant by society and which differentiates the stigmatized person from the other members of the community that he or she should belong to. So essentially, it's something about a person that makes them a member of an out group, and we'll dig into this more. There's various types of stigma In healthcare and, in general, we think about various types of stigma.

Speaker 1:

The first type is enacted stigma. This is where and I'm going to focus on healthcare providers, but this is where a healthcare provider directly acts in a particular way that is meant to confer judgment. The second type is perceived stigma, which is where a person feels stigma from their healthcare provider, but it wasn't meant as such. It might be something that's taken out of context. It's also something a lot of our patients with addiction really struggle with, because they've often been treated so badly, so many times, that they come to expect stigma. And the third type of stigma that we're going to talk about here is self-stigma, which is where patients develop stigmatizing views about themselves. They judge themselves, and when I was learning with this topic, I wanted to make it more concrete. So let's imagine I have depression and you're my healthcare provider. Enacted stigma would be where you judge me or discriminate against me because I have depression. Again, that's enacted stigma. Perceived stigma is I believe that my healthcare providers treat me differently or judge me or discriminate against me because of my depression. And self-stigma would be is that I feel badly about myself because of my depression. And now that we've gotten a little definition as to what stigma is, my next question is does stigma harm patients? And I think we all know that answer is yes, but the question is to what extent?

Speaker 1:

This was a study I found that looked at when people with mental health and addiction experience enacted stigma from their healthcare providers, and this is looking very high level. What are the greater trends in their lives? And, as you can see, when patients with mental health conditions experience enacted stigma, they are more likely to be unemployed, unhoused and have difficulty with social interactions. And, for our population, when patients with addiction experience enacted stigma, they are less likely to seek treatment in a timely fashion, they're more likely to have low self-esteem. Or, said another way, they're more likely to have self-stigma and they overall report a lower quality of life. So the very highest level enacted stigma absolutely harms patients and these are some specific ways it affects them. Now I knew that stigma harmed patients but I didn't realize it had a mortality difference, meaning people die earlier when they experience stigma.

Speaker 1:

This is a study looking at structural stigma in sexual minorities and I'll talk about what those terms mean. Structural stigma is really not between people, it's more societal level conditions that make it harder for members of a stigmatized population to function in society. An example would be for people who are of a non-traditional gender identity, male and female bathrooms makes it hard for them to use the restroom. That's an example of structural stigma. Or, you know, for tax reasons, marriage being defined as between only a man and a woman that's an example of structural stigma for non-traditional couples. So this was a study looking at people that were sexual minorities in a particular community, and a sexual minority would be somebody who has a different sexual orientation than the general population. So let's say the community is predominantly heterosexual, homosexual or bisexual would be a sexual minority. So this was a study that said if you're a sexual minority and you live in a community where there is lots of stigma against you and your identity, versus low amounts of stigma, what's the mortality difference? So, in other words, how does experiencing stigma about who you love, how does it, affect your lifespan? And this number every time I read it, just amazes me. If you were a sexual minority in a high stigma community, your lifespan was 12 years shorter than if you were in a community where you did not experience a lot of stigma. That is an incredible number of years that are lost because of stigma.

Speaker 1:

It turns out, as you can imagine, that stigma casts a very wide net. It affects all sorts of conditions mental health, diabetes, obesity, addiction. There's a very large number of conditions that experience stigma. And this was a study looking at weight stigma in people who are overweight and obese. And what they did in this study is they looked at 14,000 roughly adults and they looked at weight stigma. So they took people who were overweight and they basically assessed did they experience stigma about their weight or did they not experience very much stigma about their weight? And then they corrected for all the other variables. So there were equal rates of diabetes, equal rates of heart disease, equal rates of high blood pressure. The only difference between the two populations is one group identified as experiencing a lot of stigma about their weight and the other did not, and the mortality difference between the two groups during the study period was 60%. People who experienced stigma about their weight were 60% more likely to die a premature death during the study period as compared to those who did not experience stigma. I don't know a lot of conditions that have such an incredible difference in mortality. One can argue that the treatment to reduce the risk of premature death in people who are overweight or obese is to just not judge them. Based on this study, experiencing stigma was associated with a higher rate of premature death, and the authors actually tried to look at this to say well, why does this happen? And it was thought to be due to chronic stress, which led to chronic inflammation and higher levels of stress hormones.

Speaker 1:

So we've talked about what stigma is. We've talked about how it hurts our patients and their quality of life, as well as their ability to even stay alive. What do patients do when they experience stigma when they're trying to receive healthcare? There are four basic ways patients respond. The first is to hide it secrecy. The second would be to actually educate and push back a little bit and say well, it's actually not quite that simple. Let me explain. The third would be to actually calling people out for their stigma and trying to change how people perceive the stigmatized condition. And then people even just sometimes just avoid healthcare altogether, which we'll talk about Now.

Speaker 1:

Secrecy is the most common. Almost three quarters of people who experience stigma about a healthcare condition that they have will hide it from their healthcare providers, and you can imagine, if you have to lie about what you have, it weighs on you. So secrecy about stigmatizing conditions is associated with lower self-esteem, higher perceived stigma. In other words, you're more likely to feel like you're being stigmatized and then also this goes along with lower self-esteem you're more likely to have higher levels of self-stigma. Now, this one is the one that hurts me the most. This is where people refuse to go to the hospital. The name of this study is strategies used by people who inject drugs to avoid stigma in healthcare settings.

Speaker 1:

This is a quote from someone that they interviewed in the paper Quote. When it comes down to it, a lot of the times that I need to get medical attention. I put it off and put it off, and put it off because I don't want to face the embarrassment that they make me feel and that's not fair, it's not. End quote. So this is a patient named Stacy who talked about just not seeking medical care because she didn't want to be judged. And this is where it gets really emotional for me. This is Mike. If anyone knew him, I apologize if this is triggering, but in my humble opinion, mike died of stigma.

Speaker 1:

Mike was working at a syringe exchange. He had an addiction to opioids and he was actively injecting and he worked with myself and Dr Reb Close. Most of you know her. She's on the board for Sun Street, she's one of the local addiction doctors and she happens to be married to me and we worked with Mike regularly. He was helping people at the syringe exchange, trying to get treatment and help, and we'd ask him like hey, mike, you ready for Suboxone? Nah, not yet. Okay, let me know when you're ready. So he called Dr Close saying he had a fever and a wound on his arm and we know as ER doctors for many years that injection, drug use plus fever equals, you know, big deal and we told him please go to the hospital. This could have gotten into your bloodstream, it could have gotten into your heart. And he said no, they're going to judge me, I will not go to the hospital. So Dr Clow's prescribing his antibiotics. Unfortunately, it wasn't enough. She reached out to him trying to encourage him to go to the hospital and he wouldn't go. He did not want to be judged for who he was and he died of an overwhelming infection from his infected injection site. Mike died from stigma.

Speaker 1:

Now, I talked about structural stigma. There is structural stigma in medicine against patients with addiction. Take a look at the rates at which we treat chronic diseases. In America, we treat almost 80% of people with high blood pressure, 70% of people with diabetes, 70% of people with major depression and less than 20% of people with addiction. That is structural stigma in American healthcare, and I think, of all the conditions that I researched for this presentation, addiction is by far the most stigmatized. But stigma truly casts a very wide net. As I mentioned, there's stigma about epilepsy. There's stigma of urinary incontinence. There's stigma towards Hereduronitis suppurativa, which is an unusual skin condition. Stigma towards neglected tropical diseases. So much stigma is in healthcare.

Speaker 1:

Now what do we do about stigma? Well, the good news is that there's actually three strategies to really break down stigma. The first is very easy Educate about stigma. This presentation that I'm giving to you now I've given to probably over 100 nurses at CHOMP and it's now a training available to the staff at CHOMP. So absolutely, we are educating about stigma.

Speaker 1:

One thing that can be learned about stigma is that the words that we use are very important when we are around clients and patients, and I'll give you some examples. There are two things we can do to reduce stigma around healthcare facilities, and the first is to use person-first language, which I'll give you examples of, and the second is to avoid terms with a judgment, so person first language. I personally have asthma. I am not defined by my asthma. I don't identify an asthmatic, I identify as a dad and a doctor. So first I would prefer to be called a patient with asthma or a person with asthma rather than an asthmatic. So a person is not an alcoholic, they are a patient with alcohol use disorder. This is a person with diabetes rather than a diabetic, and it takes a little bit of time to get used to the change in language, but it's nice to identify people as people first and then to identify the condition that they have.

Speaker 1:

Now the other thing is a lot of the words we use in healthcare have judgment. This one bugs me. Patients do not have dirty urine. It is not dirty, they are not inherently dirty. That is very judgmental. It is an abnormal urine drug test. And I try to correct my patients like hey, doc, I'm dirty. I'm like no, no, you're not dirty, your test is abnormal. It means we have more work to do. Here's another one the J word. I almost can't even say it. Ooh, junkie, ah, that is so inherently judgmental. That is a person with substance use disorder and this one absolutely is a major pet peeve of mine when psychiatrists call people crazy. Crazy is not a useful medical word. Call it what it is that person is anxious, that person has psychosis. Our patients do not deserve to be judged. I love this quote If you want to care for something, call it a flower. If you want to kill something, call it a flower. If you want to kill something, call it a weed. The words we use as health care providers truly matter. So what do I do? I really and this is several years of work I only use person-first language and I will not use judgmental terms in casual conversation or in my practice, and sometimes I will actually correct my colleagues terms in casual conversation or in my practice. And sometimes I will actually correct my colleagues and their patients Be like no, no, no, no, no, it's not a dirty test, it is an abnormal test. And if this is something that you feel like you want to incorporate into your practice and your work, great. And you can remind colleagues hey, remember we were going to try to avoid that term, let's use abnormal urine drug test. And for patients, sometimes I try to empower them that they're not defined by their addiction. If mentally, they want to identify as an alcoholic because it helps them, great. But there's also a lot of shame and stigma around addiction, as we all know. So trying to use person-first language and avoid judgmental terms is great. Now there's one other bit to this. I'm going to go back a few slides here. I mentioned that there were three basic strategies around addressing stigma. The first is education. The second is to work and have contact with the stigmatized group, and I'm going to explain what I mean by that. So people know me as a doctor. I've been practicing medicine for 14 years. They look at me. They see Casey Grover, practicing addiction doctor, former ER doctor. I do my best to practice good medicine. Hopefully I earn their respect. I try to be a nice person. Hopefully I earn the spot as a trusted colleague. I'm going to share with you some of the stigmatizing conditions that I had. I used to engage in self-harm, I had anorexia, I had bulimia and I had major depression. When people look at me, they don't see that when I tell them that those are conditions that I lived with in my early 20s, the response I get is usually something to the effect of I never would have guessed or but you're so normal. And this is how stigma really gets broken down. Many of you are in recovery but are successful in your recovery and now successful professionals. When someone meets you, they meet a successful professional person and that's the relationship that you foster. If you decide to tell them that you're in recovery, you probably get a similar response to something like but I didn't know, or I never would have guessed. And the idea is is that you meet them as a person first. You earn their trust, you develop a relationship and when you let them know about your past, it changes what they think about the stigmatizing condition that you have In the ER. Anorexia and bulimia, eating disorder patients really get treated badly. My staff, I believe, respected me and when I would tell them can you not use that term about that person with an eating disorder, I had one. That's where really the magic happens around breaking down stigma. They may not know the patient or have gotten to respect the patient yet, but they respect me and out of respect to me they're willing to make a change in the language that they use and the behaviors that they have. Before I was an addiction doctor. A close friend of mine died from an overdose and when I was in the ER and I'd hear disparaging remarks about addiction, I would actually tell my staff if you could not say that that would mean a lot. One of my friends died of an overdose. They were getting contact with someone who had been affected by a stigmatizing condition and that's what really helps to change things the fastest. So when someone's in recovery and they're in a recovery program and everyone's open about their addiction, that's kind of a different environment. It's more around the hospital where we don't necessarily see that same group. Someone might be in the hospital for diabetes or a heart attack or high blood pressure, and the majority of the hospital staff don't openly identify as having a stigmatizing condition. Everyone tries to present as normal. But if we are willing to be vulnerable, when we present well and we are successful about our pasts, and people make that statement oh wow, I never would have guessed with you that changes their whole perception about the stigmatizing condition that we've had. So some take-home points. Stigma is a set of negative and often unfair beliefs about patients with a particular condition. Addiction is horribly stigmatized. Stigma hurts patients in multiple ways, including changing their behavior. They may avoid healthcare and increases their risk of premature death. And reducing stigma is as simple as trying to be careful with the words that we use and, if we have a stigmatizing condition, educating friends and colleagues about how stigma has affected us, our condition and people with a similar lived experience. Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives.