Learning objective
Demonstrate how OUD-related stigma differs across diverse patient populations.
In the 1970s, the “War on Drugs” was declared by President Nixon as a means to decrease the prevalence of drug use. These policies resulted in the criminalization of cocaine possession and often led to incarceration, especially among individuals of racial minority groups. In the media, Black and Latinx residents in inner city neighborhoods were often portrayed as being “dealers” or “addicts” whereas white residents were often seen as victims.1 The shaping of public perceptions through media has led to widespread misinformation and stigma, which have further grown into frequent discrimination towards these communities.2
Today, a similar pattern has emerged for opioid use disorder (OUD). For example, news stories involving white individuals with OUD more often include a narrative of the background circumstances leading to the disorder. Individuals from minority communities are depicted with images of an arrest and criminal charges more often than white individuals. This is similar to heroin use in the 1970s and crack cocaine in the 1980s – both of which primarily impacted minority communities.1 These “drug policies” have led to a stark increase in rates of drug-related arrests and incarceration, especially among Black individuals.3,4
The stigma this generates has, in part, led to increased access for the treatment of OUD specifically for white patients.2 In fact, white patients are 35 times more likely to receive treatment for OUD compared to black patients.5
The media may fuel stigma by portraying people with substance use disorders in a particular manner. Additionally, individuals from minority communities are sometimes presented differently than individuals from predominantly white communities. Scroll through the pictures below. What stigmas are being illustrated by the media and what differences between the images do you observe?
The opioid epidemic has led to a startling increase in chronic infections related to intravenous drug use including hepatitis C.6 When untreated, hepatitis C leads to serious health consequences including cirrhosis and liver failure. In some cases, liver transplantation may be required. Patients who are receiving medications to treat OUD may be required to disengage from that treatment before they can be added to the waiting list for a donor liver. In fact, up to 50% of patients who are in recovery and receiving evidence-based medications for OUD treatment may be denied access to transplant.7 This discriminatory practice persists even though both the medications and the liver transplant would improve the health outcomes for these patients.
The opioid crisis has also resulted in dramatic increases of endocarditis8–10 – by over 400% for some hospitals.11 Advanced cases of these life-threatening heart infections often require replacement of a heart valve. Patients who undergo this procedure and later have a recurrence of OUD symptoms may be denied the opportunity for a repeat procedure.12,13 Surgical professionals may not find repeat surgery beneficial or cost-effective for this patient population despite its potential to be life-saving, and the providers also may refuse to refer patients with OUD to other surgical professionals who might offer a different perspective.14
People who are pregnant or postpartum who use non-prescribed opioids are often looked down upon by medical providers. OUD is doubly stigmatized because of the notion that well-intentioned parents do not use drugs and that using opioids inappropriately demonstrates the parent is willingly harming their fetus. These patients may be seen as being unfit for parenthood and referred only to child protective services rather than being referred to treatment. Importantly, these perceptions are rooted in bias and stigma and apply a “one size fits all” approach to OUD in and after pregnancy that increases alienation, shame, and ambivalence.15