The Opioid Epidemic is an Epidemic of Stigma

Kristie Serota and Daniel Z. Buchman argue that eradicating the stigma associated with opioid use is an ethical necessity and is critical for population health.

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The Government of Canada reports that over 2458 Canadians died of apparent opioid-related deaths in 2016 (excluding Quebec). Last November, an average of 4 people died from overdoses every day in British Columbia. Recent U.S. estimates project opioid-related deaths at over half-a-million people over the next decade. Interventions have been implemented in many jurisdictions to minimize opioid-related mortality, but each year the death toll continues to rise and shows no signs of relenting.

While people dying from opioids in large numbers is not new, the present epidemic arose due to several complex factors. For example, OxyContin was aggressively marketed and prescribed for chronic non-cancer pain. Doctors and the public were misled about OxyContin’s addiction risks. In addition, health professionals receive limited training on pain and addiction. There are also inequities due to the social determinants of health and the harmful effects of substance use-related stigmas.

Stigma, operating at individual, institutional, and social levels, has led to punitive legal, policy, and clinical responses toward people who use drugs. Stigma has also led to chronic underfunding of addiction research and treatment services relative to the burden of disease. Although the current epidemic does not discriminate across the social gradient, stigma disproportionately burdens people from less privileged social groups more frequently and harmfully than others. People with no history of a substance use disorder risk the pejorative label of ‘addicts’ when they are prescribed opioids for pain management. The stigma of substance use has also tainted the palliative care experience for some people with intractable pain at the end of life.

When lawmakers in the 20th century introduced legislation to control opioid production and distribution, doctors became the gatekeepers and poor and racialized communities were positioned as scapegoats. This began a global trend of failed anti-drug policies and harsh legal penalties for people who use, thereby creating additional barriers to healthcare and other social goods.

Reducing if not eradicating stigma is critical from an ethical and population health perspective. We propose four ways to address the stigma surrounding drug-use.

First, the contributions of people who use drugs should be at the forefront of action plans to address the epidemic. For example, the Canadian Association of People Who Use Drugs argue that the only way to reduce the stigmatization of drug use is for people who use drugs to be actively involved in action planning and implementing the solutions. As Claire D. Clark states, “counter-narratives will be essential to progress.”

Second, changing the everyday language around substance use is important. Recently, the Canadian Centre on Substance Abuse changed its name to the Canadian Centre on Substance Use and Addiction; the term “abuse” suggests intentional moral wrongdoing. In addition, the Associated Press denounced the use of addict as a noun. These recommendations include using person-first language to reframe media representations of drug use away from issues of morality toward recognizing addiction as a health issue.

Third, it’s important to increase and normalize access to life-saving interventions for people at risk of opioid poisoning. Naloxone is an opioid antidote. Access to naloxone has been improved as it no longer requires a prescription. It should be more widely available. People who use drugs may also be trained in overdose response and naloxone distribution. Increasing access to a life-saving intervention would improve health equity for people who have been historically marginalized from the healthcare system. Better access also reassigns some of the power and agency of healthcare to affected communities.

Several supervised injection sites are emerging in Canada, providing a medically supervised space for people to consume drugs such as heroin using sterile equipment. The programs reduce harms from overdoses and infections such as HIV and hepatitis C. Regulations have also improved access to evidence-based interventions such as buprenorphine-naloxone and heroin-assisted treatment.

Finally, we recommend the decriminalization and legislation of drug use. The harms associated with the criminalization of drug use are well documented. Criminal records for non-violent drug charges often lead to discrimination, stigma, and barriers to service provision. Decriminalization in Portugal was followed by increased uptake of drug treatment and a reduction in opioid-related deaths and infectious diseases. In Canada, the Good Samaritan Drug Overdose Act was recently passed. This provides people with immunity from possession charges after calling 911, or administering naloxone, at the scene of an overdose. The Act increases help seeking behaviour by reducing barriers to healthcare. While such “piecemeal policies” may be insufficient to address the stigma associated with the criminalisation of drug use, they are important steps toward recognizing overdose as a medical emergency and not a crime scene.

The current opioid epidemic shows no signs of slowing down. An effective and ethical response to this public health issue must involve steps to reduce or eliminate the stigma surrounding drug use and mental illness, more generally.

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Kristie Serota is a Master’s student in Psychology at the University of Guelph. Daniel Z. Buchman is a Bioethicist at the University Health Network and an Assistant Professor at the University of Toronto. @DanielZBuchman

The authors wish to thank Aaron Orkin for valuable discussion and feedback on this topic.