Guiding Principles for Addressing the Stigma on Opioid Addiction

This is the first of a two-part blog series. Read part 2, A Roadmap to Reduce Stigma on Opioid Addiction.

Public stigma—defined as negative attitudes toward a specific group of people among the general public1—is very high toward individuals with opioid use disorder. Public stigma is a barrier to implementation of evidence-based policies and program to address the opioid crisis. Research shows that:  

Many Americans view poor individual choices/lack of discipline as the cause of opioid addiction: 

• 78% of Americans believe people who are addicted to prescription opioids are, themselves, to blame for the problem.2 
• 72% believe that people addicted to prescription opioids lack self-discipline.2 

The large segment of Americans who view opioid addiction as caused by poor personal choices are often unwilling to support allocation of resources toward policies and programs that help people with opioid addiction.3 They may however support punitive and paternalistic policies. For example, one study of a nationally representative sample of Americans found that higher stigma was positively correlated with greater support for arresting and prosecuting individuals who obtain opioid prescriptions from different doctors.2 

Many Americans have very negative attitudes toward people with opioid addiction: 

•    16% of Americans are willing to have a person using opioids marry into their family.4

•    28% of Americans are willing to have a person using opioids work with them on a job.4

•    27% of Americans think that a person using opioids is deserving (vs. “worthless”).4

•    10% of Americans think that a person using opioids is strong (vs. “weak”).4

Many Americans want to put distance between themselves and people with opioid addiction. This has implications for intervention of evidence-based policies and programs because people who hold these stigmatizing attitudes are likely to resist implementation—of new addiction treatment programs, syringe services programs, overdose prevention sites, etc.—in their community.   

The stigma on addiction extends to a stigma on treatment. Only 49% of Americans believe that there is an effective long-term treatment for opioid use disorder.5 Yet a 2019 National Academy of Science, Engineering and Medicine (NASEM) report concluded that FDA-approved medications for opioid use disorder (methadone, buprenorphine, and naltrexone) are effective and save lives.6 The fact that half of Americans do not believe effective treatment exists can impede efforts to increase delivery of these medications, which the majority of Americans with opioid use disorder do not receive.6 

This issue is further complicated by the fact that the medications themselves, particularly the opioid agonists methadone and buprenorphine, are often misunderstood as replacing one addiction with another.7,8 This myth is perpetuated by large segments of the specialty addiction treatment community,7-10 which has historically operated outside of the general medical system and endorsed abstinence-based treatment without medication—despite the fact that treatment with medication has been conclusively shown to be more effective than approaches without medication (e.g., therapy only, support groups like Narcotics Anonymous).6,8,11,12   

Guiding Principles

The following evidence-based guiding principles should inform all activities intended to reduce the stigma surrounding opioid use disorder. 

1. Use person-centered language. Research shows that terms such as “addict” and “drug abuser” increase stigma relative to person-centered alternatives, for example “person with a substance use disorder.”13,14 The term “abuse” in general should be avoided as it has been shown to increase stigma, as should the terms “junkie” and “clean” (which imply that prior to stopping drug use, a person was “dirty”). 
   
    
2. Emphasize societal vs. individual causes of addiction. While drug use includes an element of personal choice, it is important to also emphasize external factors outside of an individual’s direct control that contributed to their addiction, for example an injury leading to medically recommended prescription opioid use that progressed into an opioid addiction.  Messages emphasizing societal causes make audiences more likely to support societal (large-scale public policy or program) solutions.15-18 
   
    
3. Incorporate solution messages whenever possible. Feelings of hopelessness contribute to stigma. Messages emphasizing evidence-based solutions that can prevent fatal overdose and help people experiencing addiction return to productive and fulfilling lives should be central to stigma reduction efforts.19-22 
   
    
4. Use sympathetic narratives. Narratives, or stories that humanize individuals experiencing addiction, engage audiences and have the potential–with the right “ingredients”–to reduce stigma and increase support for evidence-based policies and programs.23-25 Narratives combine a compelling, sympathetic story about an individual with messages about how external factors outside of the individual’s control contributed to causing and/or addressing addiction.26,27 Key narrative ingredients to consider are: 

   a. The sex, race/ethnicity, and socioeconomic status of the individual depicted. The individual depicted in the narrative should resonate with target audiences. In cases where the target audience may hold stigmatizing views about individuals of a certain sex, race/ethnicity, or socioeconomic status, avoid depicting individuals with those stigmatized characteristics.28 

   b. The narrative perspective—who is telling the story?  Some evidence suggests that for addiction, narratives told from the perspective of a parent, about their child with addiction, may elicit more sympathy from audiences than narratives told from the perspective of an individual experiencing addiction themselves.29

   c. Cause and solution messages—these messages, following the guidelines above, should be worked in to narratives when possible.18

5. Emphasize that effective treatment exists. Messages emphasizing that successful treatment exists, describing what that treatment (i.e., medication) looks like, and depicting individuals going through effective treatment and experiencing recovery can reduce stigma toward people with addiction.23,24  Effective messages related to recovery have emphasized participation in meaningful life activities such as parenting, working, engaging with religious and civic organizations, etc.23 
   
   
   
   Studies have shown that messages emphasizing the fact that effective services exist, but that people with addiction do not have access to those services, have been shown to increase public support for policies designed to overcome those barriers (e.g., support for allocating additional resources to the addiction treatment system in order to combat long waiting lists and provider shortages).25,31 
   
    
6. Avoid messages that are not effective at reducing stigma. Messages that focus on solely framing addiction as biologically based and/or as a disease have been studied and shown not to reduce stigma. There is some evidence to suggest that messages framing addiction as “a disease like any other” actually increase stigma, potentially by increasing audiences’ perceptions of the permanence and hopelessness of addiction.30 It is however possible that messages framing addiction as a disease in combination with messages emphasizing that treatment with medication is effective could increase audiences’ beliefs that effective treatment for opioid addiction exists and increase their support for improving access to medication treatment.18 
   
   
   
   While sympathetic narratives that mix a compelling story about an individual experiencing addiction with messages about the societal factors that contributed to causing/addressing their addiction can reduce stigma, individual depictions alone, without messages about societal causes/solutions, can actually increase stigma. These types of messages have been shown to increase the degree to which audiences blame individuals for their poor choices and, as a result, to decrease support for policy solutions.15,16 

References

1. Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice Hall. 1963. https://doi.org/10.1093/sf/43.1.127
2. Kennedy-Hendricks A, Barry CL, Gollust SE, Ensminger ME, Chisolm MS, McGinty EE. Social Stigma Toward Persons With Prescription Opioid Use Disorder: Associations With Public Support for Punitive and Public Health-Oriented Policies. Psychiatric services (Washington, D.C.). 2017;68(5):462-469. https://doi.org/10.1176/appi.ps.201600056
3. Schneider A, Ingram H. Social Construction of Target Populations: Implications for Politics and Policy. American Political Science Review. 1993;87(2). https://doi.org/10.2307/2939044
4. McGinty EE, Barry CL, Stone EM, et al. Public support for safe consumption sites and syringe services programs to combat the opioid epidemic. Preventive medicine. 2018;111:73-77. https://doi.org/10.1016/j.ypmed.2018.02.026
5. Blendon RJ, Benson JM. The public and the opioid-abuse epidemic. New England Journal of Medicine. 2018;378(5):407-411. https://doi.org/10.1056/NEJMp1714529
6. National Academies of Sciences EaM. Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press. 2019. https://doi.org/10.17226/25310
7. Olsen Y, Sharfstein JM. Confronting the stigma of opioid use disorder—and its treatment. JAMA : the journal of the American Medical Association. 2014;311(14):1393-1394. https://doi.org/10.1001/jama.2014.2147
8.  Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies—tackling the opioid-overdose epidemic. New England Journal of Medicine. 2014;370(22):2063-2066. https://doi.org/10.1056/NEJMp1402780
9. Alderks C. Trends in the use of methadone, buprenorphine, and extended-release naltrexone at substance abuse treatment facilities: 2003-2015 (UPDATE). SAMHSA National Survey of Substance Abuse Treatment Services, https://www.samhsa.gov/data/sites/default/files/report_3192/ShortReport-3192.html, Accessed November 2, 2018. 2017.
10. Mojtabai R, Mauro C, Wall M, Barry CL, Olfson M. Medication treatment for opioid use disorders in substance use treatment facilities in the United States Health Affairs. In Press. https://doi.org/10.1377/hlthaff.2018.05162
11. American Society of Addiction Medicine. National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. http://www.asam.org/quality-practice/guidelines-and-consensus-documents/npg, Accessed March 21, 2017. 2015.
12. US Department of Health and Human Services (HHS) Office of the Surgeon General. The Surgeon General's Report on Alcohol, Drugs, and Health. Washington, DC: HHS. 2016. https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf
13. Ashford RD, Brown AM, Curtis B. Substance use, recovery, and linguistics: the impact of word choice on explicit and implicit bias. Drug and alcohol dependence. 2018.  https://doi.org/10.1016/j.drugalcdep.2018.05.005
14. Kelly JF, Saitz R, Wakeman S. Language, substance use disorders, and policy: the need to reach consensus on an “addiction-ary”. Alcoholism Treatment Quarterly. 2016;34(1):116-123. https://doi.org/10.1080/07347324.2016.1113103
15. Iyengar S. Framing responsibility for political issues: the case of poverty. Political Behavior. 1990;12(1):19-40. https://doi.org/10.1007%2FBF00992330
16. Iyengar S. Framing Responsibility for Political Issues. Annals of the American Academy of Political and Social Science. 1996;546:59-70. https://doi.org/10.1177/0002716296546001006
17. Gross K. Framing Persuasive Appeals: Episodic and Thematic Framing, Emotional Response, and Policy Opinion. Political Psychology. 2008;29(2). https://doi.org/10.1111/j.1467-9221.2008.00622.x
18. McGinty E, Pescosolido B, Kennedy-Hendricks A, Barry CL. Communication strategies to counter stigma and improve mental illness and substance use disorder policy. Psychiatric Services. 2017;69(2):136-146. https://doi.org/10.1176/appi.ps.201700076
19. McIntyre K, Sobel M. Motivating news audiences: Shock them or provide them with solutions? Comunicación y Sociedad. 2017;30(1):39. https://doi.org/10.15581/003.30.1.39-56
20. McIntyre K. Solutions Journalism. Journalism Practice. 2017:1-19. https://doi.org/10.1080/17512786.2017.1409647
21. Lough K, McIntyre K. Visualizing the solution: An analysis of the images that accompany solutions-oriented news stories. Journalism. 2018:1464884918770553. https://doi.org/10.1177/1464884918770553
22. Curry A, Stroud NJ, McGregor S. Solutions Journalism and News Engagement. https://mediaengagement.org/research/solutions-journalism-news-engagement/, Accessed October 16, 2018. 2016.
23. McGinty E, Pescosolido B, Kennedy-Hendricks A, Barry CL. Communication Strategies to Counter Stigma and Improve Mental Illness and Substance Use Disorder Policy. Psychiatric Services. 2017:appi. ps. 201700076. https://doi.org/10.1176/appi.ps.201700076
24. McGinty EE, Goldman HH, Pescosolido B, Barry CL. Portraying mental illness and drug addiction as treatable health conditions: effects of a randomized experiment on stigma and discrimination. Social science & medicine (1982). 2015;126:73-85. https://doi.org/10.1016/j.socscimed.2014.12.010
25. McGinty EE, Goldman HH, Pescosolido BA, Barry CL. Communicating about Mental Illness and Violence: Balancing Stigma and Increased Support for Services. 2018. https://doi.org/10.1215/03616878-4303507
26. Niederdeppe J, Kim HK, Lundell H, Fazili F, Frazier B. Beyond counterarguing: Simple elaboration, complex integration, and counterelaboration in response to variations in narrative focus and sidedness. Journal of Communication. 2012;62(5):758-777. https://doi.org/10.1111/j.1460-2466.2012.01671.x
27. Niederdeppe J, Shapiro MA, Kim HK, Bartolo D, Porticella N. Narrative persuasion, causality, complex integration, and support for obesity policy. Health communication. 2014;29(5):431-444. https://doi.org/10.1080/10410236.2012.761805
28. Pescosolido BA, Martin JK. The stigma complex. Annual review of sociology. 2015;41:87-116. https://doi.org/10.1146/annurev-soc-071312-145702
29. Bachhuber MA, McGinty EE, Kennedy-Hendricks A, Niederdeppe J, Barry CL. Messaging to Increase Public Support for Naloxone Distribution Policies in the United States: Results from a Randomized Survey Experiment. PloS one. 2015;10(7):e0130050. https://doi.org/10.1371/journal.pone.0130050
30. Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. "A Disease Like Any Other"? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence. The American Journal of Psychiatry. 2010;167:1321-1330. https://doi.org/10.1176/appi.ajp.2010.09121743
31. Kennedy-Hendricks A, McGinty EE, Barry CL. Effects of Competing Narratives on Public Perceptions of Opioid Pain Reliever Addiction during Pregnancy. Journal of Health Politics, Policy and Law. 2016:3632230. https://doi.org/10.1371/journal.pmed.1002908