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Dangerous, bad and weak: Stigma and the care of patients with addictions

I treat addiction for a living. My patients are often admitted to the hospital after inadvertently injecting bacteria into their bodies, along with heroin or methamphetamines. They have hot, red infections that become so tender they can’t bear the lightest pressure on the skin. Or worse, infections that have traveled past the site of the initial injury and now lodge in their joints or hearts or near their spines. 

These are life-threatening conditions. But most of my patients avoid the hospital until it is almost too late. They come only when the pain is so terrible they can no longer walk, or when their fevers make it impossible to sleep, or when friends or relatives or ambulances bring them in delirious, or unconscious. They avoid the hospital because they are drug users and they are afraid that their drug use will mark them as a different class of patient, that their treatment will be worse, and they will suffer. 

They are correct. 

Addiction is profoundly stigmatized. I recently treated a patient whose illness left her so weak she was unable to walk more than a few steps without help. She’d been admitted with complications from an old infection, but now was on the mend. We planned to discharge her to a nursing facility where she could improve her strength before finally going home.  

But at the last minute, the facility refused to take her. My patient was on buprenorphine, a medication to treat opioid addiction. It is a pill she takes once a day, like the blood pressure, pain and antidepressant pills nursing facilities give patients every day. But this pill, this condition, made her “too complicated,” they said.

In other words: Sorry, this won’t work. We don’t accept her kind. 

In a health care setting, the problem with stigma associated with drug addiction isn’t just that it hurts people’s feelings, or that it is shaming, or that it is unjust — though all of these things are true. The problem with stigma is that it results in harmful discrimination: patients dealing with drug addiction get much, much worse care. 

This discrimination shows up as nursing facilities unwilling to take patients with histories of drug use, and state policies that bar Medicaid from paying for medications that cure hepatitis C if the person with hepatitis also uses illegal drugs. It arrives as eyes rolled when the drug user complains of pain, fear and loneliness. It announces itself with, “Well, you did this to yourself.” As if patients with tobacco-ravaged lungs, or with complications from diabetes, or clogged arteries, or broken legs from driving too fast or skiing off trail didn’t also contribute to their own hospitalizations. As if we can make the assumption that people who use drugs simply don’t care about their health and don’t care whether they live or die.

Drug addiction doesn’t mean that a drug user is uninterested in health, or life. It means that the drug user is addicted to drugs. It means his brain changed, he has lost control, and use has become compulsive. It means that even when she wants to stop, she can’t. That is why addiction is a problem. That is why we consider it a medical condition. That is why it needs to be treated. And there is no evidence that shaming, or isolating, or otherwise punishing someone who is addicted to drugs will cause them to want to stop using. 

And yes, patients addicted to drugs can be hard to treat. They often have histories of physical and emotional trauma. They are almost always craving. They are often withdrawing. Patients who are craving, withdrawing, and traumatized can be angry, even abusive. But these patients are impossible to treat if the doctor or nurse or insurance company or nursing facility believes they are not worth the effort. 

In his seminal work on stigma, the sociologist Erving Goffman explained that the stigmatized are considered “in the extreme, quite thoroughly bad, or dangerous, or weak.” Indeed. Individuals who suffer from addictions are considered all of those things: bad, dangerous and weak. And here is another thing Goffman understood: Stigma isn’t a thing. It isn’t like a label, or leech, something unwanted that attaches to a person and travels with her wherever she goes. Rather, Goffman wrote, stigma is relational: “a process by which the reaction of others spoils normal identity.” It thrives, or dies, in the ways people treat one another. 

Which means we can kill stigma if we choose to.

The stigma around addiction will die if we acknowledge the friends, neighbors and family members who struggle with this condition, and if we recognize that their addictions are only part of the whole of who they are. Stigma dies if we acknowledge our own secrets and our own struggles. It dies if we ask drug users about their lives and hopes. Their hobbies. If we know about their addiction and love them (and we do, already love so many of them) anyway, then stigma dies. That is when discrimination ends, and healing begins.

This viewpoint was originally published May 5 in the New York Daily News. Jessica Gregg, M.D., Ph.D., is an associate professor of medicine (general internal medicine and geriatrics) in the OHSU School of Medicine. She is board certified in internal medicine and addiction medicine. Her research focuses primarily on social and cultural barriers to disease prevention among underserved communities in Oregon. She is medical director of the OHSU ECHO (Extension for Community Healthcare Outcomes) clinic for addiction medicine and associate program director for OHSU’s addiction medicine fellowship.


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