Stigma and bias against individuals with addiction may not appear outright, but these disparities inevitably present when treating patients with addiction. Stigma comes in many shapes and sizes, and is often disguised as other things. However, if you work with patients with addiction, you don’t have to look very hard to find it.
I work primarily with patients with opioid use disorder (OUD) — usually heroin, which is one of the most stigmatized illnesses in medicine — and am familiar with the type of stigma and bias that these patients face.
If a patient is in methadone treatment for OUD, they don’t need anesthesia for dental procedures.
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This statement is false, and believing this often results in the highly unethical practice of denying anesthesia for patients with OUD undergoing dental procedures that would otherwise require anesthesia. This erroneous belief stems from providers assuming that if patients are taking methadone, they achieve pain control from the use of the drug. Patients with OUD actually become tolerant to the analgesic effect of methadone. This tolerance, coupled with the fact that people with addiction have a permanently altered endogenous endorphin system, results in an out-of-whack pain control system, one that requires more medication than required by patients without OUD.
Pregnant patients with OUD on treatment with methadone need to stop taking the drug for the health of the baby.
Conversely, methadone is considered to be the gold standard along with suboxone for the treatment of OUD in pregnant patients. Infants may be born with a slightly lower-than-average birth weight; otherwise, taking the medication temporarily is safe. The dangers of withdrawal and relapsing to heroin and other street drugs without methadone use is a greater risk to the fetus than the methadone use itself.
Undermedicating heroin users when treating abscesses in the emergency department (ED) will help the user understand the need to stop using heroin.
Many patients have told me that they were undermedicated when they presented in the ED for incision and drainage of abscesses. They stated that they were told, “This is what you get when you do this to yourself.” It is disturbing to think that a clinician would say such a thing to a patient. However, I’ve heard versions of this story from more than a handful of patients when returning from ED care for abscesses, and I consider most of those telling me this to be reliable historians.
Another version of this story is the assertion that some emergency medical technicians and/or clinicians purposely provide more naloxone than is needed when treating overdoses, sometimes causing the patient to awake violently. I’ve personally witnessed this unethical, cruel, and probably illegal practice.
Methadone is just swapping one addiction for another.
There is consistent and strong evidence that OUD is a chronic relapsing illness, and that treating it with methadone or buprenorphine is an effective way to stabilize the abnormal neurophysiology of patients with opioid addiction.
Heroin addiction is the result of bad personal choices.
Like almost all chronic diseases, the causes of addiction are multifactorial. For example, diabetes has many factors that cause or exacerbate the illness, such as poor nutrition, weight gain, and genetics. The same can be said for heart disease. Personal choices certainly play a role in all of these, including addiction, but so do many other factors.
The good news is that the inaccurate and nonmedical beliefs and biases against people with heroin addiction appear to be gradually decreasing. An increasing number of students with whom I work don’t share these biases and beliefs and are willing to address the inaccuracies when seen and heard. When I interact with community providers, I hear less biased and stereotypic responses to heroin addiction. However, while there has been progress, much of the medical community still appears to be in the “precontemplation” phase of truly seeing addiction as a medical disease.
