Beyond stigma: Treating opioid use disorder

Imagine you fracture your arm and go to the emergency department, only to be told that you cannot receive appropriate pain medications to relieve your pain. How would that make you feel?

Experiences like this are common for people living with opioid use disorder (OUD). Their acute pain often is dismissed and/or insufficiently treated over concern for potential non-medical use of opioid pain relievers. While guidelines exist for opioid stewardship and the management of OUD, there is little to no guidance surrounding pain management with opioids for individuals living with OUD.

Despite the changing landscape of opioid use and OUD in Canada, negative public perceptions of stigma have become entrenched within the health-care system, making it difficult for patients living with OUD to receive well-coordinated, high-quality care, resources and support.

In 2018, nearly one in eight Canadians were prescribed opioids. However, there is limited formal undergraduate medical education about the care needed for people who use opioids and the treatment of OUD. Only 32 per cent of Canadian medical schools provide formal pain management content within their undergraduate programs.

In Canada, prescribing regulations for opioids are governed at the federal and provincial levels, and by guidelines established by regulatory bodies and collaborative partnerships. Opioids can be divided into two subclasses: (1) Opioid analgesics (e.g., morphine, hydromorphone, oxycodone) often prescribed for acute and chronic pain relief after exploring non-opioid therapies; and (2) opioid agonist therapies (OATs such as methadone and buprenorphine) used to treat moderate to severe OUD by supporting patients with abstinence and withdrawal symptoms.

Each province has specific norms for the provision of opioid analgesics and OATs such as dose and duration limits and surveillance of opioid prescriptions. However, clinicians face additional regulatory hurdles to prescribing OATs. Until 2018, practitioners were required to obtain special federal exemption from the Controlled Drug and Substance Act. However, variable requirements from provincial regulatory colleges – such as maintaining documentation and audit trails and seeking formal mentorship – are still in place to prescribe methadone and sometimes buprenorphine. These extra steps to OAT prescribing compared to opioid analgesics can drive perceptions that providing OUD treatment is dangerous and complex, which can negatively affect clinician willingness to prescribe and dispense OATs. Consequently, this can result in limited opportunities for patients to access care for OUD.

The low priority given to quality pain and substance use education in medical schools and the restrictive access to OATs are manifestations of stigma surrounding opioid use. Opioid-related stigma is a multifaceted social phenomenon arising from structural forces and can manifest in negative attitudes of health-care practitioners, the public, peers, and even family members. It is not sufficient to selectively address stigma in siloes. However, the cross-cutting feature of stigma and its impacts continue to be overlooked when providing care for patients living with OUD.

To explore the impact of stigma on all aspects of treatment for people living with OUD, The Subject Matter Lab created the animated video below in collaboration with academics, clinicians and people with lived/living experience. The video is intended to reinforce the fact that substance use is a health issue deserving of respect, support and care like any other medical concern.

Stigma can be a growing burden for patients that can impact health-seeking behaviour.

Stigma can be a growing burden for patients that can impact health-seeking behaviour. As the video shows, stigma can be recognized in overt and covert instances such as turning away patients living with OUD due to perceived difficulties with managing their treatment and suspicions of double-doctoring. Even seemingly innocuous interactions such as requesting patients consult with their methadone provider to address their pain can also have harmful effects on the quality and continuity of care.

Redressing the stigma must occur across the individual, interpersonal, community and structural levels. Here are some ways in which we can collectively address the stigma tied to OUD in health care and the wider society.

For patients with lived/living experiences with OUD:

• Play an active role in overcoming self-stigma. Educate yourself about opioid use and OUD and understand that this is a medical condition rather than a moral failing. Challenge self-stigmatizing beliefs and be more aware of negative self-talk and internalized messages about OUD.
• Practice self-compassion. Recognize that you are not defined by your opioid use. Challenge self-critical thoughts by asking yourself if they are based on facts or are influenced by social or self-stigma. Seek evidence that contradicts these negative thoughts and reframe them.
• Build a support system. Surround yourself with a support network of family, friends and professionals (such as a therapist) to combat self-stigma through non-judgmental support, understanding and encouragement. This can boost your self-esteem and build your self-efficacy.

For health-care professionals:

• Substance use should be treated in the same manner as other medical conditions. The belief that substance use is a personal choice and therefore addiction is a “disorder of choice” can result in fragmented care delivery. Harm reduction, prevention and treatment services should be routinely offered to people who use opioids (and their friends and family members).
• Use compassionate, patient-centred and trauma-informed approaches to care. Take into account patients’ individual needs, preferences and circumstances to develop tailored treatment plans and seek to empower patients to feel safe, valued and involved in their own care.
• Provide evidence-based care. This is critical to being informed about the latest research and addressing misconceptions that may lead to the under-treatment of care and exacerbation of health outcomes for patients living with OUD.
• Empower patients by facilitating open, bi-directional communication. Stigma can discourage clinicians from discussing their patients’ opioid use. This, in turn, can impact patient engagement. Creating a non-judgmental and supportive environment that encourages patients to trust and collaborate with their health-care provider can lead to shared decision-making and increased patient satisfaction.

For the community:

• Use compassionate language. Avoiding derogatory labels and deficit-based terms (e.g., using “person living with OUD” rather than “addict” or “non-medical use” rather than “misuse”) can help humanize and prevent the othering of patients living with OUD.
• Advocate for policy changes that prioritize evidence-based care. For example, decriminalization of OUD, increased access to harm-reduction services, and addressing restrictive regulation of and access to OATs can help alter the structural stigma surrounding opioid use and facilitate equitable allocation of treatment resources.
• Build opportunities for education. This can work to disrupt stigmatizing narratives and build community capacity through increased knowledge of OUD, awareness of local opioid use and resource locations, and prevention and treatment awareness.

Together, we can move beyond stigma.