03. OUD Stigma Across Diverse Populations

MODULE 1 | SECTION 3 OF 5

OUD Stigma Across Diverse Populations

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Learning objective

Demonstrate how OUD-related stigma differs across diverse patient populations.

Stigma of patients with opioid use disorder can be seen in a diverse group of populations.

Racial and Ethnic Minorities

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

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Media Portrayal of Drug Use

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?

Infectious Disease and Organ Transplants

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.

Endocarditis and Valve Replacements

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

Pregnancy and the Postpartum Period

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

REFERENCES

  1. 1-Santoro TN, Santoro JD. Racial Bias in the US Opioid Epidemic: A Review of the History of Systemic Bias and Implications for Care. Cureus. December 2018. doi:10.7759/cureus.3733

 

  1. 2-Hansen H, Siegel C, Wanderling J, DiRocco D. Buprenorphine and methadone treatment for opioid dependence by income, ethnicity and race of neighborhoods in New York City. Drug and Alcohol Dependence. 2016;164:14-21. doi:10.1016/j.drugalcdep.2016.03.028

 

  1. 3-Lopez G. Everyone does drugs, minorities get punished. Vox. https://www.vox.com/2014/7/1/5850830/war-on-drugs-racist-minorities. Published July 1, 2014. Accessed December 10, 2019.

 

  1. 4-Borden T, Neier A, Human Rights Watch (HRW), American Civil Liberties Union (ACLU). Every 25 Seconds: The Human Toll of Criminalizing Drug Use in the United States. New York: Human Rights Watch; 2016.

 

  1. 5-Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. 2019;76(9):979. doi:10.1001/jamapsychiatry.2019.0876

 

  1. 6-Zibbell JE, Asher AK, Patel RC, et al. Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014. Am J Public Health. 2018;108(2):175-181. doi:10.2105/AJPH.2017.304132

 

  1. 7-Wakeman SE, Ladin K, Brennan T, Chung RT. Opioid Use Disorder, Stigma, and Transplantation: A Call to Action. Ann Intern Med. 2018;169(3):188. doi:10.7326/M18-1099

 

  1. 8-Ronan MV, Herzig SJ. Hospitalizations Related To Opioid Abuse/Dependence And Associated Serious Infections Increased Sharply, 2002–12. Health Affairs. 2016;35(5):832-837. doi:10.1377/hlthaff.2015.1424

 

  1. 9-Kadri AN, Wilner B, Hernandez AV, et al. Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016. JAHA. 2019;8(19). doi:10.1161/JAHA.119.012969

 

  1. 10-Schranz AJ, Fleischauer A, Chu VH, Wu L-T, Rosen DL. Trends in Drug Use–Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017: A Study of Statewide Discharge Data. Ann Intern Med. 2019;170(1):31. doi:10.7326/M18-2124

 

  1. 11-Napoli N. Opioid Use Associated With Dramatic Rise in Dangerous Heart Infection. American College of Cardiology. http://www.acc.org/about-acc/press-releases/2019/03/06/10/36/opioid-use-associated-with-dramatic-rise-in-dangerous-heart-infection. Published March 6, 2019. Accessed December 12, 2019.

 

  1. 12-Goodnough A. Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get? The New York Times. https://www.nytimes.com/2018/04/29/health/drugs-opioids-addiction-heart-endocarditis.html. Published April 29, 2018. Accessed December 12, 2019.

 

  1. 13-Rodolico J. Doctors Consider Ethics Of Costly Heart Surgery For People Addicted To Opioids. NPR.org. https://www.npr.org/sections/health-shots/2017/03/21/520830183/doctors-consider-ethics-of-costly-heart-surgery-for-people-addicted-to-opioids. Accessed December 12, 2019.

 

  1. 14-Aultman JM, Peshel E, Harfouche C, Firstenberg MS. The Ethics in Repeat Heart Valve Replacement Surgery. In: Firstenberg MS, ed. Advanced Concepts in Endocarditis. InTech; 2018. doi:10.5772/intechopen.76844

 

  1. 15-Howard H. Reducing Stigma: Lessons from Opioid-Dependent Women. Journal of Social Work Practice in the Addictions. 2015;15(4):418-438. doi:10.1080/1533256X.2015.1091003

 

  1. 16-Shaw M. Photos reveal media’s softer tone on opioid crisis. July 2017. https://www.cjr.org/criticism/opioid-crisis-photos.php. Accessed December 10, 2019

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