After attending Albany Government Law Review’s symposium, Script to Street: Opioids and the Law in the Capital District this past Thursday, there was several issues addressed but the one overarching concern was about the role of stigma in this opioid crisis. Many different types of stigma were identified and the different ways our negative judgments have impacted society. As one speaker during the first panel discussion stated, addiction is not a new problem. He described one historic painting that showed different reactions of society to addiction: disgust, numbness, shock, or simply ignoring the problem. All of these reactions illustrate stigma and shows how despite all our social advancements, we still have not eliminated (or destigmatized) stigma of the addiction problem.
Some definitions of stigma include a mark of disgrace, society disapproval of something, or a negative set of beliefs society has about something. All definitions include this perceived negativity and describe stigma as bad. Stigma is not something one like to face and usually, a judgment one tends to try avoiding.
The issue with stigma our current opioid crisis is that it is not just one type of stigma, it is layers of stigma on top of one another. There is the stigma of being a drug user and the stereotypes of who is a drug user (the poor, African American, Hispanic). Drug-users are perceived to be “bad” people who only care about drugs. This perception becomes a barrier to treatment as individuals do not want to seek treatment in fears they will be labeled as a drug user, even if these individuals are suffering from chronic pain. There is a list of characteristic behaviors of a drug-seeker based on our own judgments, even though there is a consensus that these behaviors do not accurately capture or describe drug-users. There is also the stigma of that those who are using mediated assisted treatment as still drug-users and that this medication is just going to back into the illegal drug market. This goes into the ethical debate of harm reductionist approaches and whether this still violates non-maleficence. There is the stigma that physicians face for their role in prescription opioids and the stigma methadone clinics face. One physician speaker described the negative reactions of other business when she opened her clinic in a business area. She was told her clinic was not in the right part of town, asked to leave, and her neighboring businesses were concerned about the type of people her clinic would treat. There is the stigma of being mentally ill for those individuals who have a dual diagnosis or misdiagnosis of mental illness along with drug addiction. There is the stigma of a felony for those individuals who only can get treatment through drug court. With all these negative judgments that one person can face, it is no surprise that drug-users wish to remain unknown.
Stigma is an ethical concern because it impacts how we treat each other in the clinical setting and in the public setting. It impacts who gets care and how they receive that care. For example as the moderator, Professor Anthony Farley stated, when the stigma of this crisis was a "black problem," there was not the same amount of attention to this crisis as there is currently. This racial-stigma blocked access to care. Yet, this crisis affects everyone and is not a “black problem.” Stigma influences patient autonomy, as it is an external influence that inhibits a patient’s expression of autonomy. Negative judgments are also not beneficent as stigmatized plans of care are realistically not in the patient's overall best interest.
Due to the potential negative impact of stigma in patient care, we ideally aim to eliminate it completely or reduce it. However, this may not be done.
Societal stigma is so broad that we may not even see that it is happening. Assuming we can identity it, how then does one change someone else’s views even if it is negative or untrue about someone else? If it is a professional such as physician, we have regulations and codes of ethics to prevent judgments but what about on the broader public level? As one speaker suggested, one of the best ways to combat stigma is changing language and how we talk about addiction and drug-users. But if we can not eliminate it, the next best option is acknowledging the powerful impact these unnoticed perceptions.
It was a powerful symposium where a diversity of professionals (lawyers, judges, nurses, physicians, and advocates) discussed our options in the opioid and heroine drug crisis. There is hope to have a follow-up meeting to continue these important conversations in order to come to a solution to address the opioid drug crisis and still treat legitimate pain needs.
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