The Real Culprit of Unsafe Drug Use: STIGMA

Debunking Stigmatizing Myths: Why Harm Reduction Matters in Your Community

Victoria Donkin, Sara Mansueto, Hannah Rasiuk & Amy Rzezniczek

Rates of overdose-related deaths in Toronto reached new records in 2020, exceeding COVID-19 mortalities in the month of June1. While media attention remains focused on the local impact of the pandemic, the opioid crisis continues after claiming over 14,000 Canadian lives over the past four years.1 The severity of this public health issue has prompted researchers to investigate the barriers that prevent access to harm reduction services for those affected by addiction. Harm reduction utilizes an evidence-based, public health framework, to decrease substance-related risk.2 This includes reducing rates of overdose, spread of infectious diseases, and ensuring safer substance use practices.3

In a study by McGinty and colleagues (2018) it was found that individuals with a substance use disorder were highly stigmatized and were seen as less deserving.2 Stigma refers to the negative attitudes and beliefs that are developed about an individual or a group.4 This ultimately reduced public support for harm reduction strategies, affecting the accessibility to these services.2 A local example of this can be seen in Premier Doug Ford’s decision to defund safe injection sites in the affluent neighbourhood, Cabbagetown, due to residential complaints.5 

We aim to further examine the effects of stigma and debunk common false beliefs about harm reduction strategies and those who use substances. Therefore, this post provides factual information on what these services actually do and how they are essential in supporting those with substance use disorders. To engage in the process of de-stigmatization, it is necessary to identify our own stigmatizing beliefs to improve the opioid crisis.6 The “Fact or Fiction” portion of this post serves to assist readers in this process. Additionally, how stigma impacts the lived experience of those with a substance use disorder is crucial in identifying barriers to harm reduction services and how it maintains the opioid health crisis. In order to do this, we interviewed an individual with an opioid-related substance use disorder, who also is a harm reduction worker. N.S. is a 24 year old male, who works at a homeless shelter in an affluent Toronto neighbourhood, where he provides safe syringe services and clean supplies for substance use and disposal. 

Firstly, we asked N.S. what the response has been within the neighbourhood surrounding his workplace, to better understand how citizens from affluent communities react to harm reduction services:

Debunking Myths About Harm Reduction Strategies 

5 Types of Harm Reduction Strategies and What They Actually Do 

1. Opioid Agonist Therapy: In this service, medication based treatment plans are provided to individuals with severe opioid-related substance use disorders. Opioid agonist therapy can enable individuals who are addicted to opioids to stabilize their lives, as it alleviates cravings of opioids, terminates withdrawal symptoms, and prevents the “high” feeling that opioids provide.7

There are two main opioid agonist therapies available in Canada: 

a) Methadone Maintenance Therapy (MMT): an orally provided synthetic opioid used to transition individuals off of opioids. This is a long term program that intends to reduce and ultimately eliminate opiate use, as well as reduce the contraction of injectable drug-related infections such as HIV, and Hepatitis B and C.8

b) Buprenorphine Maintenance Treatment (BMT; also known as Suboxone): an orally provided synthetic opioid that is composed of both buprenorphine and naloxone. This form of therapy bears similar results and effects as MMT with the addition that the suboxone blocks the effects of other opioids. Therefore, it also causes immediate withdrawal-like symptoms (e.g. uncontrollable vomiting) if individuals on this program partake in additional opioid consumption.7

We asked N.S. how MMT has helped him:

2. Naloxone Services: Naloxone is a medication based therapy that is an opioid antagonist, used  during an overdose to rapidly reduce its effects, similarly to an epipen during an allergic reaction. It can save someone from an opioid overdose as it works by immediately stopping the effects of the opioid. It comes in injectable or intranasal (i.e. inhalable) forms. Many safe injection sites, homeless shelters and healthcare facilities provide this service, as well as train others to be able to help community members in case of overdose emergencies.3

3. Safe Syringe Programs/Services: The distribution of sterile syringes for individuals who use injectable substances, as well as the safe disposal of materials to ensure no cross contamination occurs, reducing rates of HIV and Hepatitis.9

Fact or Fiction? Supervised Injection Sites Provide Individuals With Drugs.

FICTION!

4. Supervised injection sites do not provide individuals with substances. Those wishing to consume substances within supervised injection sites bring their own injectables onto site, and are provided with sanitary supplies (e.g. syringes) to consume their substance in a safe, neutral, sanitary and supervised environment, reducing rates of infectious diseases and overdoses.3 Once the individual has injected their substance, they are then monitored to ensure they do not experience a negative drug reaction or overdose.10 Additionally, individuals can be provided with further resources or referrals related to health or social support.11

Fact or Fiction? There are Harm Reduction Services That DO Provide Substances. 

FACT!

5. Safe Supply Programs prescribe pharmaceutical grade substances (e.g. hydromorphone; also known as dilaudids) to individuals at risk for overdoses. These services aim to regulate opioid use as the opioids distributed in unregulated markets (the streets) have a higher chance of causing death as they are often of high-potency, or are unknowingly mixed with other substances such as fentanyl. Between 2016 and 2018, 10,000 Canadians died due to an opioid related overdose. Of these individuals, 73% were accidental opioid related deaths caused by fentanyl.

Therefore, safe supply programs are necessary as they:

a) Reduce the rate of injectable drug use by 25% by providing an oral alternative.

b) Reduce the rate of contracted HIV and Hepatitis11.

To see how this myth posed as a barrier to receiving harm reduction services, we asked N.S. what his experience was:

Fact or Fiction? Harm Reduction Services Encourage Drug Use.

FICTION!

The success of harm reduction strategies is NOT measured by lower rates of drug use, but is measured by an increase in quality of health. This misconception is often what perpetuates societal stigma, as people think that harm reduction efforts perpetuate drug use. No research has shown that these services increase drug use.12 The stigma around these programs have led to the devaluation of the research that supports these evidence-based strategies. Many individuals using these services already have long-term substance use disorders; therefore, these services aim to prevent overdoses and decrease public drug use.10 Additionally, no research has found that these services enable individuals to relapse.13 

Fact or Fiction? Harm Reduction Services Increase Criminal Activity In My Neighbourhood.

FICTION! 

Harm reduction services have not been shown to increase crime rates in neighbourhoods.13 These sites are specifically placed in neighbourhoods where there is a pre-existing need for them (where drug consumption already has an impact on that community). Some research has even demonstrated that these services are associated with a decrease in crime.13 Additionally, using drugs is not a criminal concern, however, using this framework criminalizes people who need help. The stigma surrounding substance use instills unnecessary fear and labels populations who need harm reduction services as “dangerous.” This stigmatizing narrative further encourages residential protests against services from populating in neighbourhoods that need it most.

How Do Harm Reduction Services Benefit My Community? 

1. Lowers public drug use.3

2. Decreases the usage of other healthcare services, enabling lower wait times for community members, and providing a cost-effective solution.13

3. Provides resources and makes referrals for individuals interested in mental health, physical health or social services. This connection enables an increase in the use of detox programs and medication assisted therapy (e.g. MMT), which can reduce drug use.3

Debunking Myths About People Who Use Substances

Fact or Fiction? People Who Are Addicted To Drugs Lack Self-Control and Have Failed Morally.

FICTION!

Addiction cannot be reduced to the simple conclusion that individuals just lack self-control. Many more complicated physiological and psychological factors contribute to drug use. Additionally, using drugs has nothing to do with morality. People who have a substance use disorder do not have control over their drug use. This is why treatment and harm reduction strategies like syringe service programs or safe consumption sites exist.

Fact or Fiction? Individuals Who Use Substances Are Different From Everyone Else In Society.

FICTION!

People who use drugs are more similar than dissimilar from those who do not. People who use drugs are human, but social stigmatization constructs them as inherently different. This stigmatization isolates people who use drugs from society, creating a sense of alienation that has real consequences. 

What is different in people who use drugs is the way they respond to the drug being used. Serious substance use can actually rewire the brain of individuals.14 When people use drugs, the brain’s pleasure pathway is activated. When drugs are used frequently this pleasure pathway can become less active in response to using the drug. Therefore, the experience of pleasure from using drugs diminishes. Instead, the pathway starts to activate before drugs are even consumed.14 This causes an increase in wanting a drug and a simultaneous decrease in liking a drug. Evidently, rewiring begins to occur making serious substance use a health issue rather than a personal issue! As a health issue, rehabilitation methods can be used to work towards rewiring the brain back to its previous state. 

What are the Consequences of Stigmatizing Drug Use?

On the individual level, stigmatization can be internalized which can lead to feelings of shame and to self-blame for drug using behaviour.15 This can lead to further mental health problems, such as depression, which may maintain and exacerbate drug use.16 Individuals who use drugs are affected on a social level by learning to fear the discriminatory effects of stigma. This fear has real-world consequences, as it impacts health care behaviour, seeking treatment, and healthcare system engagement. Stigmatization is associated with dangerous health behaviours. For example, people who use drugs often avoid stigmatization that may be experienced when buying syringes at the pharmacy by reusing or sharing syringes with others.16 This increases risk for contracting and spreading HIV. Additionally, individuals with addictions struggle to enroll in treatment because they fear being stigmatized for needing help.

N.S. demonstrates this stigma by stating: 

In the healthcare system, individuals with addictions report experiencing discrimination.15 They report slower care, receiving less empathy, being dismissed or ignored and experiencing poorer quality treatment. Individuals who use drugs quickly learn to expect future discrimination; therefore, they are less likely to seek care from the healthcare system. This can be dangerous, as untreated needs can lead to death.17

N.S. elaborates on how he has experienced discrimination in healthcare: 

What Can We Do Moving Forward? 

Although evidence based research has aimed to dismantle misconceptions on harm reduction practices, negative beliefs continue to be held by the general population. It is quite common to rely on our automatic negative thoughts and others’ opinions when it comes to matters such as these; however, it is important to fact check and do research before making assumptions about harm prevention programs, and the people they serve. 

As demonstrated  throughout this blog post, opinions of community members have a strong influence on decisions made by the government – especially when it comes to implementing safe injection programs, homeless shelters and safe syringe exchange programs. It is our job as civilians to properly educate not only ourselves, but those around us about the importance of these programs, as well as to debunk myths and dissolve these stigmas.

It is also the government and public health organization’s responsibility to determine ways in which the general public can easily understand the importance of these programs. Experts in the field suggest that using personal stories, evidence-based stigma reduction content and educational information can increase public support for policy decisions regarding safe injection sites and syringe exchange programs.2 Therefore, it is critical that we continue to amplify the voices of those that use harm reduction services, and advocate for the widespread implementation of these services where they are needed.  

To Learn More About:

Safe Injection Sites

Syringe exchange programs

Toronto Harm Prevention Locations (Safe Injection Sites and Syringe Exchange Programs)

Opioid Agonist Therapy and GTA Locations

Opioid Agonist Therapy and Canada Wide Locations


References

1Rider, D. (2020, August 11). Toronto overdose deaths hit a grim new record in July, taking more lives than covid-19. Toronto Star. https://www.thestar.com/news/city_hall/2020/08/11/toronto-overdose-deaths-hit-a-grim-new-record-in-july-taking-more-lives-than-covid-19.html

2McGinty, E. E., Stone, E. M., Kennedy-Hendricks, A., & Barry, C. L. (2019). Stigmatizing language in news media coverage of the opioid epidemic: Implications for public health. Preventive Medicine, 124, 110-114. https://doi.org/10.1016/j.ypmed.2018.02.026

3CAMH. (2016). Opioids and addiction: A primer for journalists. http://www.camh.ca/-/media/files/5217-opdsaddic_primer-pdf.pdf

4CMHA. (n.d.). Stigma and discrimination. https://ontario.cmha.ca/documents/stigma-and-discrimination/

5CBC News. (2019, April 1). Province cut some injection sites because area residents ‘upset’, Ford says. https://www.cbc.ca/news/canada/toronto/province-cut-some-injection-sites-because-area-residents-upset-ford-says-1.5079616

6Strike, C., Miskovic, M. (2017). Zoning out methadone and rising opioid-related deaths in Ontario: Reforms and municipal government actions. Canadian Journal of Public Health, 108(2), 205-207. https://doi:10.17269/CJPH.108.5858

7Alberta Health Services. (2018). Opioid dependency program: Suboxone information for clients. https://www.albertahealthservices.ca/assets/programs/ps-1000286-odp-suboxone.pdf

8CAMH. (2020, August). Methadone: Modifications to opioid agonist treatment delivery – march 22, 2020. 

9Abdul-Quader, A. S., Feelemyer, J., Modi, S., Stein, E. S., Briceno, A., Semaan, S., Horvath, T., Kennedy, G. E., & Des Jarlais, D. C. (2013). Effectiveness of structural-level Needle/Syringe programs to reduce HCV and HIV infection among people who inject drugs: A systematic review.AIDS and Behavior, 17(9), 2878-2892. https://doi.org/10.1007/s10461-013-0593-y

10Kennedy, M. C., Karamouzian, M., & Kerr, T. (2017). Public health and public order outcomes associated with supervised drug consumption facilities: A systematic review. Current HIV/AIDS Reports, 14(5), 161-183. https://doi.org/10.1007/s11904-017-0363-y

11Ontario HIV Treatment Network. (2020, April). Possible benefits of providing safe supply of substances to people who use drugs during public health emergencies such as the COVID-19 pandemic. https://www.ohtn.on.ca/rapid-response-possible-benefits-of-providing-safe-supply-of-substances-to-people-who-use-drugs-during-public-health-emergencies-such-as-the-covid-19-pandemic/

12City of Toronto. (2019, February 12). Expanding opioid substitution treatment with managed opioid programs. https://www.toronto.ca/legdocs/mmis/2019/hl/bgrd/backgroundfile-126527.pdf

13City of Toronto. (n.d.). Supervised injection sites. https://www.toronto.ca/community-people/health-wellness-care/health-programs-advice/supervised-injection-services/

14Erickson, C. K. (2018). The science of addiction: From neurobiology to treatment. WW Norton & Company.

15Muncan, B., Walters, S. M., Ezell, J., & Ompad, D. C. (2020). “They look at us like junkies”: Influences of drug use stigma on the healthcare engagement of people who inject drugs in new york city. Harm Reduction Journal, 17(1), 1-9. https://doi.org/10.1186/s12954-020- 00399-8

16Latkin, C., Davey-Rothwell, M., Yang, J., & Crawford, N. (2013). The relationship 

between drug user stigma and depression among inner-city drug users in Baltimore, MD. Journal of Urban Health, 90(1), 147-156. https://doi.org/10.1007/s11524-012-9753-z

17Paquette, C. E., Syvertsen, J. L., & Pollini, R. A. (2018). Stigma at every turn: Health services experiences among people who inject drugs. The International Journal of Drug Policy, 57, 104-110. https://doi.org/10.1016/j.drugpo.2018.04.004

Image References

Noelville Pharmacy. (2020). [Naloxone kit]. NoelPharm.com. http://www.noelvillepharm.ca/opioid-overdose-risk-save-a-life-with-a-naloxone-kit/

Recovery Centers of America. (n.d). [Support group]. Recovery Centers of America. 

Reed, M. (2020). [Protest against safe injection sites in Philadelphia]. The Philadelphia Inquirer. https://www.inquirer.com/opinion/commentary/safe-injection-sites-safehouse-philadelphia-20200203.html

The Star News. (2017). [Safe injection site in Surrey, British Columbia]. The Star News. https://www.thestar.com/news/canada/2017/06/27/health-canada-allows-oral-and-nasal-use-of-drugs-at-2-bc-safe-injection-sites.html

Resource References

CAMH. (2018). Harm reduction: Where to go when you’re looking for help. https://www.camh.ca/-/media/files/community-resource-sheets/harm-reduction-resources-pdf.pdf?la=en&hash=A175EF581BD43ACE51D964DEEBD09DD2738CB7D7

Canadian Centre for on Substance Use and Addiction. (2004). Needle exchange programs FAQ. https://www.ccsa.ca/needle-exchange-programs-neps-faqs 

National Institute on Drug Abuse. (2020, May). Drug facts: Prescription Opioids. https://www.drugabuse.gov/sites/default/files/drugfacts-prescriptionopioids.pdf

St. Michael’s Unity Health Toronto. (n.d.). Mental health and addictions service: Rapid access clinic. St. Michael’s Hospital. https://www.stmichaelshospital.com/programs/mentalhealth/rapid-access-clinic.php

True North Addiction Medicine Program. (n.d). Substance use and treatment. https://www.truenorthmedical.com/treatment

Why the words we choose matter

by Sarah S. Dermody, PhD @SarahSDermody

“Addict” or “junkie” are some of the words that are used to refer to people who have difficulties with their substance use. These are words used by people in the media (just one for example) and in our communities, and perhaps you have even used them as well. These words should be avoided, and here are some of the important reasons why.

An important place to start is to understand stigma.

Close your eyes and take a moment to imagine a recent media story or film that spoke about or portrayed someone who uses substances heavily. Perhaps they shared some negative beliefs and attitudes (or stereotypes) about how this person would behave, what they look and sound like, and what it would be like to spend time with them. The negative beliefs and attitudes towards people with addiction is called stigma.

“Day 003 – Shame” by marcandrelariviere 
is licensed under CC BY-NC-ND 2.0

Stigma is a problem with many health conditions, and we continue to see it with addiction. Stigma can truly hurt people coping with substance use related difficulties in many ways. Research has shown that fear of stigma is one of the top reasons that people choose not to get treatment for their substance use (Table 7.67B).1 When someone gets treatment, stigma can also get in the way of their successful treatment and recovery.2 Unfortunately, we also see that stigma can be an issue for treatment providers who are not properly trained to work with people who use substances.3

There is a ripple-effect of individual’s stigmatizing beliefs. The effects of stigma can go well-beyond the interactions between someone who uses substances and other individuals. People in positions of power may make decisions based on stigmatizing beliefs that can ultimately harm individuals who use substances.

Image: “Ripple Effect” by sea turtle is licensed under CC BY-NC-ND 2.0

A timely example of this is with the COVID-19 pandemic. Dr. Nora Volkow, the director of NIDA, recently wrote about this issue in her blog.

“the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.”4

Dr. Nora Volkow

How the words we use promote stigma.

Remember the saying “sticks and stones may break my bones, but words can never hurt me”? Whoever coined this phrase did not consider the effects of stigmatizing language.

Research has shown that the language we use to refer to people who use or have difficulties with substance use can impact how we treat them. One example of this is a study by Goodyear, Haass-Koffler, and Chavanne (2018) where participants read descriptions of people referred to as a “drug addict” versus official terms like “opioid use disorder.”5  They found that there were more stigmatizing attitudes towards individuals labeled as a “drug addict” than those labeled as having an “opioid use disorder.”  

It is not hard to imagine how stigmatizing language can play out in a number of real-world settings to make a major impact.

Tips: Use words that describe – not stigmatize.

“Dictionary – succeed” by flazingo_photos is licensed under CC BY-SA 2.0

At this point, you may be wondering, what words could I use to describe these experiences? There are many helpful online resources that describe terms to avoid versus terms to use, and why, such as the primer on Overcoming Stigma through Language.6  Here is a summary of some of the important takeaways:

  1. Use “person-first” language: Put the words that refer to the individual before the words that describe their behaviours or conditions. For instance, instead of using terms like “alcoholic” or “addict”, a person would be described as “person with an alcohol use disorder.”
  2. Use official terms the reflect the condition: Using the medical language can help frame addiction as a health issue and a disease. Therefore, it is best to use official diagnostic language like “substance use disorder” instead of use words like “drug abuse” or “junkie.”
  3. Avoid slang and idiomatic expressions: Using slang to describe an individuals’ involvement with substance use often means that pejorative or biased language is being used (“pot head”, “strung out”, “getting clean”, as examples). Instead, it is best to describe behaviours and experiences with literal terms, like “someone who uses cannabis”, “someone who is intoxicated”, or “someone who is in treatment for their substance use.

This is just the start of the conversation.

Now that you know about the power of words and how to talk about substance use is a less stigmatizing way, it is time to put this knowledge into action! Together, we can make a real impact to reduce stigmatizing language by correctly the words that we use and educating the people around us to use less stigmatizing language.  


Sources


  1.  Substance Abuse and Mental Health Services Administration. (2020). Key substance use and mental health indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved Sept 28, 2020, from https://www.samhsa.gov/data/
  2.  Crapanzano, K. A., Hammarlund, R., Ahmad, B., Hunsinger, N., & Kullar, R. (2018). The association between perceived stigma and substance use disorder treatment outcomes: A review. Substance Abuse and Rehabilitation10, 1–12. https://doi.org/10.2147/SAR.S183252
  3. Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2), 111-116. https://doi.org/10.1177/0840470416679413
  4. Volkow, N. (2020, April 22). Addressing the stigma that surrounds addiction. Nora’s Blog. https://www.drugabuse.gov/about-nida/noras-blog/2020/04/addressing-stigma-surrounds-addiction
  5. Goodyear, K., Haass-Koffler, C. L., & Chavanne, D. (2018). Opioid use and stigma: The role of gender, language and precipitating events. Drug and Alcohol Dependence185, 339-346. https://doi.org/10.1016/j.drugalcdep.2017.12.037
  6. Canadian Centre on Substance Use and Addiction. (2019). Overcoming stigma through language: A primer. (Guide.) Ottawa, Ontario. Retrieved Sept 28, 2020, from https://www.ccsa.ca/overcoming-stigma-through-language-primer