Shame on You, Shame on Me, Shame No More:

Practices to Decrease Stigma and Shame in Patients with Opioid Use Disorder

Susan DeVuyst-Miller, B.S., Pharm.D., AE-C

Assistant Professor, Ferris State University

Clinical Pharmacist, Cherry Health

Sponsored by the Florida Alcohol and Drug Abuse Association and the Florida Department of Children and Families

At the completion of this activity,

participant will be able to:

Define key terms related to opioid use disorder and stigma

Describe the relationship between stigma and opioid use disorder and treatment

Identify practices to decrease stigma and shame in patients with opioid use disorder

Consider…

Photo credit: Susan DeVuyst-Miller

https://www.reddit.com/r/pics/comments/6tpy9t/fair_question/

Why are we talking about Opioids?

Opioid Prescriptions

6

https://www.cdc.gov/drugoverdose/data/prescribing.html.

8

www.cdc.gov

www.cdc.gov

201770,237 overdose deaths

47,600 opioid relatedhttps://www.cdc.gov/drugoverdose/data/statedeaths.html

15,469 heroin

Substance Use and Misuse

31.5 million illicit drug use

Marijuana

Prescription pain relievers

11.4 million opioid misuse

11.1 prescription pain relievers

886,000 heroin

19.7million Substance Use Disorder

https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

Substance Use and Misuse

31.5 million illicit drug use

Marijuana

Prescription pain relievers

11.4 million opioid misuse

11.1 prescription pain relievers

886,000 heroin

19.7million Substance Use Disorder

https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

Opioid Use Disorder

2.1 million with Opioid Use Disorder

1.7 million prescription pain relievers

0.7 million heroin use disorder

Substance Abuse and Mental Health Services Administration (SAMHSA) (2017). Key Substance Use and Mental Health Indicators in the United States: Results from the

2016 National Survey on Drug Use and Health.https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

Treatment …who gets it?

20.7 million need it

6.5 million received it

2.5 million treatment at specialty facility

1 million perceived they needed specialty facility

1 in 3 did not have health coverage/unable to afford

https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

Definitions & Impact

http://i.dailymail.co.uk/i/pix/2012/02/25/article-2106374-11E79B05000005DC-75_634x504.jpghttps://metrouk2.files.wordpress.com/2015/01/sleepygif.gif?w=620&h=265&crop=1https://memeguy.com/photos/images/he-falls-asleep-like-this-in-class-every-day-with-the-pen-just-like-that-he-wakes-up-immedi-baffling-94295.jpghttp://media medicalbag com/images/2016/02/09/waiting room best practices jpg

http://rups.blogspot.com/2011/04/two-steps.htmlhttp://www.medfriendly.com/images/abasia.jpg

• Decrease in pharmacologic response• Increase dose to achieve similar effectsTolerance

• High or chronic doses are abruptly discontinued

• Withdrawal symptomDependence

• Change in behavioral patterns• Despite the potential side effects and harmAddiction

Tolerance, Dependence and Addiction

Shame

A painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior

A loss of respect or esteem; dishonor

A regrettable or unfortunate situation or action

Uncomfortable = Avoid, Ignore

https://en.oxforddictionaries.com/definition

Stigma

A mark of disgrace associated with a particular circumstance, quality, or person

(medicine: stigmata) A visible sign or characteristic of a disease

A self conscious emotion, informs one of an internal state of inadequacy, unworthiness, dishonor, regret, or disconnection

https://en.oxforddictionaries.com/definition

https://www.psychologytoday.com/us/blog/intense-emotions-and-strong-feelings/201104/shame-concealed-contagious-and-dangerous-emotion

Stigma & Shame

Purpose

Regulate

Isolate

Relegate

Discriminate

Stigma & Shame

Impact

Health

Limits willingness to access care or services

Internalization

Discrimination

Stigma and Shame

Prior to Use

With Use and Misuse

Prescription

Illicit

Drug of Choice

Mode of Use

With Treatment

Abstinence versus Medication Assisted Treatment

Providers, peers, community

Shame

Relationships

Parents, family member

Behaviors

Employment

OpioidsThe Good….

The Bad…

Pain relief

Positive reinforcement

Emotional distress relief

Sedation

“Hug”

Constipation

Sedation

Confusion

Qtc prolongation

Pruritus

Hyperalgesia

Respiratory depression

Decreased testosterone

Opioid use disorder

Opioid Use Disorder

Taking larger amounts or taking drugs over a longer period than intended

Persistent desire or unsuccessful efforts to cut down or control opioid use

Spending a great deal of time obtaining or using the opioid or recovering from its effects

Craving, or a strong desire or urge to use opioids

https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder

Opioid Use Disorder

Problems fulfilling obligations at work, school or home

Continued opioid use despite having recurring social or interpersonal problems

Giving up or reducing activities because of opioid use

Using opioids in physically hazardous situations

https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder

Opioid Use Disorder

Continued opioid use despite ongoing physical or psychological problem likely to have been caused or worsened by opioids

Tolerance

Experiencing withdrawal or taking opioids, or a closely related substance, to relieve or avoid withdrawal symptoms

https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder

Why is there stigma with

OUD?

https://www.crimemuseum.org/crime-library/drugs/opium/Nelson, Harry. The United States of Opioids A Prescription for Liberating a Nation in Pain. 2019..

Stigma & OUD

1. Misconception of weakness or choice

2. Separation of Health care and OUD

3. Language

4. Criminal Justice System

5. Outcomes

6. Models

Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014;311(14):1393–1394. doi:10.1001/jama.2014.2147.

Misconception of weakness or

choice

Stigma with OUD condemn the person

Prescription OUD less stigma

Degree of relationship

Parents

Work colleagues

Recovery depends on willpower

Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014;311(14):1393–1394. doi:10.1001/jama.2014.2147.

Separation of Health care and

OUD

Providers treat their diseases

Primary care may not treat OUD

Stigma towards OUD and symptoms

Medications treat one disease state

Policies

Reimbursement

Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014;311(14):1393–1394. doi:10.1001/jama.2014.2147.

Language

“Do not talk about it”

Judgmental terminology

Stigmatizing language

Detoxification, dirty, drug seeking

Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014;311(14):1393–1394. doi:10.1001/jama.2014.2147.

Criminal Justice System

Prohibit MAT

Withdrawal

Punishment

Increased risk for overdose

Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014;311(14):1393–1394. doi:10.1001/jama.2014.2147.

OutcomesOverdose

Relapse & Recovery

Treatment

Models of thought

Criminal

Moral

Disease

Public Health

https://www.mentalhelp.net/articles/public-health-model-of-addiction-and-recovery-implications/

Impact

Discrimination

Disempowering

Marginalizing

Excluding

Unwilling to seek help

Shame

Withdrawal

Self harm, blame

Exacerbation

Shame No More

Stages of Change

1. Pre-contemplation

2. Contemplation

3. Preparation

4. Action

5. Maintenance

Relapse and Recovery

Prevention

Open conversations

Prior to prescribing

Refills

Discontinuation

Pharmacogenomics

Prevention

Family history

Personal history

Adverse Childhood Experiences (ACEs)

CDC – Kaiser ACE Study

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html

Treatment

Patient focused care

Chronic disease management

Access to medications

Behavioral interventions

Coordinated care

Recovery support services

https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder

Medication Assisted

Treatment

Knowledge

Methadone

Buprenorphine

Naltrexone

Open communication

Duration

Relapse

Treatment Plan

Treatment … Improve access

20.7 million need it

6.5 million received it

2.5 million treatment at specialty facility

1 million perceived they needed specialty facility

1 in 3 did not have health coverage/unable to afford

https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

Modify our Language

Dirty, Clean

Using

Addict, Junkie

Habit

Clean

Dirty drop

Abuse

NEGATIVE POSITIVE

Present, Not Present

Substance free

Person with OUD

Condition

Recovery

Detectable

Misuse or use

Change Policy

Health care coverage for OUD, MAT, counseling, behavioral therapy

Allow MAT in jails, prisons

MAT acceptance

Public awareness as a chronic disease

“Thinker” moment

Photo credit: Susan DeVuyst-Miller

References

www.cdc.gov

https://en.oxforddictionaries.com/definition

https://www.psychologytoday.com/us/blog/intense-emotions-and-strong-feelings/201104/shame-concealed-contagious-and-dangerous-emotion

https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder

Substance Abuse and Mental Health Services Administration (SAMHSA) (2017). Key Substance Use and Mental Health Indicators in the United States: Results from the 2016 National Survey on Drug Use and Health.

https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report

https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/about.html

Olsen Y, Sharfstein JM. Confronting the Stigma of Opioid Use Disorder—and Its Treatment. JAMA. 2014;311(14):1393–1394. doi:10.1001/jama.2014.2147.

Nelson, H. The United States of Opioids A Prescription for Liberating a Nation in Pain. 2019.

Questions