Stigma surrounding opioid use disorder presents challenges for treatment

The number of fatal drug overdoses in Philadelphia has increased in recent years, with an estimated 1,215 deaths in 2017 and 2020. And preliminary numbers for 2021 show an increase in deaths from the previous year, putting the city on on track to have as many as 1,250 deaths once all the data is counted.

As deaths continued to rise, attention intensified on medications for opioid use disorder (MOUD); the Food and Drug Administration has approved three drugs — methadone, naloxone, and buprenorphine — to treat OUD. The Pew Charitable Trusts have held a few meetings with experts to help define the issues with using MOUD. The first meeting in May was a virtual roundtable with leaders from the Philadelphia area health system to discuss emerging opportunities and looming challenges related to the use of MOUD, specifically buprenorphine. One of the main themes that emerged was the role that stigma plays in creating barriers to provision and access to this life-saving treatment.

The December panel explored in more detail the barriers that stigma presents as well as opportunities to help overcome them. Panelists included Nicole O’Donnell, Certified Recovery Specialist at the University of Pennsylvania Health System; Rachel Haroz, division chief of toxicology and addiction medicine at Cooper University Healthcare; and Hector Colon-Rivera, medical director of the Asociación Puertorriqueños en Marcha, which serves the city’s Latino residents. The discussion was moderated by Priya Mammen, an emergency physician and public health consultant who served as an advisor to Pew. Alene Kennedy-Hendricks, a professor at Johns Hopkins University, kicked off the session by presenting research on the role stigma plays in the healthcare system. The event, presented in the accompanying videoexplored several key questions:

The stigma surrounding OUD is pervasive throughout the health care system, including among health care providers.

Alene Kennedy-Hendricks’ research has shown that among major groups of healthcare professionals such as primary care physicians, there are high levels of stigma towards people with TOU. His work suggests that stigma manifests both in the absence of OUD and MOUD from medical school curricula and in the development of often punitive policies targeting those with OUD. Kennedy-Hendricks pointed out that “among clinicians, higher levels of stigma are associated with lower levels of interest in working with patients with opioid use disorder.” (Go to 14.55 in the video.)

The stigma extends beyond those who provide medical treatment to include other systems that patients rely on.

Hector Colon-Rivera explained how the stigma around OUD exists within the healthcare system, but also in other systems that patients rely on, including pharmacies, insurance, housing, transportation and others, which can create additional barriers to obtaining treatment. (Go to 29:03 in the video.)

Nicole O’Donnell, a peer counsellor, said stigma can even be found in the recovery community, especially in abstinence-based self-help programs, through attitudes that aren’t supportive. evidence-based treatment. “I see a lot of people who don’t have access to care because they’re afraid of being judged within the recovery community,” O’Donnell said. (Go to 44.37 in the video.)

Stigma discourages people from seeking OUD treatment, which can have serious consequences.

Panelists reported examples in which people seeking treatment for an OUD faced punitive measures, shame, complicated administrative requirements and long waiting times. This treatment is often rooted in a distrust of people with TOU and is markedly different from treating people with other conditions. Certain populations, including women, pregnant women and trans people, often face additional stigma.

Priya Mammen noted the pitfalls of a “one size fits all” approach to treating TOU and singled out populations particularly affected by stigma. She noted that this group often includes women, “especially pregnant women or mothers. The amount of shame and hatred that is inflicted on them is enormous. that, and that keeps people further away from us. That’s a huge disparity. (Go to 46:13 in the video.)

Nicole O’Donnell explained how stigma can contribute to healthcare trauma when people don’t trust hospitals or providers. She relayed an account in which, after reversing a patient’s overdose, he said, “I would rather die than go to hospital”, due to his concern about how he would be treated. Or, worse, that he wouldn’t be offered treatment. (Go to 1:19:10 in the video.)

Systemic stigma creates barriers for providers treating OUD.

Providers treating OUD also often face challenges rooted in stigma. Some may be able to offer immediate services to their patients, but may encounter barriers and be rejected when referring patients for additional care and services. Providers are also required to undergo additional training and licensing to treat OUD, which creates barriers that do not exist when treating other conditions.

Rachel Haroz reflected on how stigma affects providers trying to connect their patients to additional care and services. “I realized that this whole area of ​​addiction, and especially opioid use disorder, lived outside of medicine. It didn’t even exist inside of medicine. It had his own house somewhere down the street in a corner somewhere and people who weren’t, ‘I’m not ready to talk about it or deal with it.’ (Go to 27:51 in the video.)

Hector Colon-Rivera spoke about the stigma around prescribing buprenorphine for OUD that has its roots in fear that helps shape policy, and how the same stigma does not exist for other drugs, or even for buprenorphine when prescribed for something other than OUD, such as pain management. (Go to 48:31 in the video.)

Stigma is embedded in processes and systems, including limited training in the area. Low-barrier access to treatment, streamlined referrals, partnerships and coordination, and positive reinforcement can support systems change and culture change.

Rachel Haroz spoke about her practice’s approach to reducing barriers to waiver, prescribing and referral, designed to empower physicians treating TOU. She emphasized that low-barrier access is an important aspect of her practice. “Every afternoon we have [a] walk-in clinic. You can just walk in. I held a walk-in clinic yesterday and 25 people signed up in the first 17 minutes. So it is so necessary. This does not come without difficulty. We have had to step up and step up and step up to meet those needs. But I think it’s worth it…we have to meet the patient where they are, which is not in a structured and predictable environment. ” (Go to 35:15 in the video.)

Sophie Bryan is senior executive and Marcelo Fernandez-Vina is manager of the Philadelphia Research and Policy Initiative of The Pew Charitable Trusts.

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