Substance Use Disorder: Stigmatizing Language and Opiophobia

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This month’s Palliative Pearl is an addendum to the “Substance Abuse and Pain” case posted in October 2017.

INTRODUCTION

In 2017, about 19.7 million Americans ages 12 and older had a substance use disorder in the past year.1 Alcohol, illicit drugs and/or prescription drugs, including opioids are commonly abused substances. It’s important to be mindful about the terminology used to describe those with substance use disorder, as many terms are considered negative and stigmatizing. Stigma creates shame and guilt, which leads to isolation and prevents many people from seeking treatment. When stigma and ignorance take hold, so does opiophobia.

Opiophobia is the fear to prescribe or use opioids, even for legitimate medical purposes.2 The opioid epidemic and its relationship to prescribed opioids has led to debate about the role of opioids in the medical community, especially for chronic non-malignant pain. It’s also led to some patients who truly need opioid therapy for pain having difficulty finding anyone willing to prescribe it.

WHY IS SUBSTANCE USE DISORDER STIGMATIZED? 3

  • Years of criminalizing illicit drug use sent the message that using drugs is immoral and associated with other criminal activity
  • High rates of relapse often lead to shameful feelings and negative judgment from others
  • Many of the words used to describe drug use and those who use drugs illicitly are stigmatizing

PREFERRED AND STIGMATIZING LANGUAGE COMPARISONS 3

Example: The term “substance use disorder” is preferred instead of “Addiction” which is stigmatizing

  • “Person with Substance use disorder” instead of “Addict”
  • “Has a X use disorder” instead of “Addicted to X”
  • “Person suffering from alcohol addiction” instead of “Alcoholic”
  • “Abstinent” instead of “Clean”
  • “Actively using” instead of “Dirty”
  • “Regular substance use” instead of “Drug habit”
  • “Person who uses drugs” instead of “Drug abuser”
  • “Person in recovery” instead of “Reformed addict”
  • “Medication-assisted treatment (MAT)” instead of “Opioid replacement”

STEPS TO REDUCE STIGMA 3

  • Treat people affected with substance use disorder with respect
  • Learn about the science of mental health conditions
  • Support resources for people affected by mental illness
  • Correct others who have misconceptions about substance use disorders and mental illnesses

ADDRESSING OPIOPHOBIA 2,4

  • Allow patients and caregivers to voice their concerns
  • Optimize other therapies, when appropriate, such as NSAIDs, corticosteroids, muscle relaxants and gabapentin, as well as non-pharmacological approaches
  • Explain that abusing a drug means that a person uses the drug to “get high”, and has lost control of the urge to take the drug
  • Most patients with cancer or end-of-life pain do not “get high” from taking opioids, and abuse is unlikely if their risk for abuse is low
  • Describe the benefits of pain management and voice concerns about needless suffering- goal is to improve quality of life
  • Remind patients and caregivers that opioid prescribing guidelines have exceptions for those with cancer and who are receiving palliative care

SAMPLE SCRIPTS

  • “The opioid epidemic is a real and concerning problem, but under medical guidance, these medications can be used safely and are intended for people like your mom who has pain from her cancer.“
  • “We have a lot of research that shows the benefits of using opioids for pain related to cancer or in end-of-life situations.“
  • “All of the pain management guidelines make exceptions for those with cancer, recognizing the important role opioids have in safely managing pain for this population.”
  • “Your mom has no previous history of alcohol or drug abuse and has been using her pain medication responsibly these past few months. In fact, we are concerned that she is not taking her medication often enough- making it harder to control her pain.”
  • “We will optimize other therapies as well. Your mom is currently taking an NSAID for her bone pain and we can explore the use of other types of therapies, but opioids work well and tend to be well tolerated. Our goal is for your mom to sleep through the night and be more functional during the day.  A long-acting pain medication can help to achieve that.”

KEY TAKE-AWAYS

  • Substance use disorder is common, including 19.7 million Americans age 12 years and older in 2017
  • The use of stigmatizing language when referring to substance use disorders contributes to shame and prevents some people from seeking help
  • Be aware of the terminology that you and your colleagues use
  • Allow patients and family members to express their concerns about opioids
  • Provide reassurance and take steps to ensure safe prescribing including the use of non-opioids as appropriate

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FOR ADDITIONAL INFORMATION ON THIS TOPIC, PLEASE REVIEW THE BELOW REFERENCES:

References:

  1. Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services  Administration. Available from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf
  2. Opiophobia (n.d.) In Pallipedia. Houston: IAHPC. Accessed February 13, 2019. Available from: http://pallipedia.org/opiophobia/
  3. DrugRehab.com. Stigma of Addiction. Updated May 31,  2018. Accessed February 13, 2019. Available from: https://www.drugrehab.com/addiction/stigma/
  4. National Institute on Drug Abuse. Opioids. Accessed February 13, 2019. Available from: https://www.drugabuse.gov/drugs-abuse/opioids

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