When Taylor’s father asked a doctor for help, he did everything right: He made the appointment, showed up, and told the truth. “I need help,” he said. “I think I’m struggling with addiction.” But the doctor just looked at him and shrugged: “Well, what do you want me to do about that?”
The truth is, as a medical community, we dismiss substance use disorder and the people who live with it all too often. Care quality is only likely to worsen now that an Executive Order decreases support for harm reduction efforts and access to medication treatment, both proven to save lives and enhance long-term recovery.
Taylor replayed that sentence in her head for over a decade, wondering how it followed her dad into the rest of his life. In a moment when he was vulnerable enough to ask for help, he was made to feel like the problem. There was no direct refusal of care, but it was a quiet dismissal that many people know well: the message that your suffering isn’t real or medically worthy.
Today, we have a name for experiences like this. Medical gaslighting. It can be as subtle as a shrug or raised eyebrow, implying you are wasting someone’s time. In addiction, this dismissal can be deadly.
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February marked the two-year anniversary of Taylor’s father’s death. He died from an overdose, battling addiction for more than ten years after that doctor’s visit. And perhaps equally, he died from stigma and bias. While Taylor will never know if a different response would have changed her father’s trajectory, we do know that his story is not an isolated failure. It is a deeply personal example of a systemic one.
The cost of being dismissed in a doctor’s office is anything but theoretical. In a country where 1 in 6 (over 48 million individuals) struggle with addiction, fewer than 1 in 5 receive treatment. And more than 80,000 die each year from overdose. We also know that boys and men are 1.9 times as likely to die from addiction than women and girls, with Black boys and men disproportionately represented.
Public stigma and bias against people with substance use disorders are pervasive across society, including stereotypes of people who are dangerous, unpredictable and untrustworthy, leading to marginalization and discrimination, rather than support for recovery. Structurally, stigma shows up in the high numbers of people with SUD who are unhoused and in prison, where roughly 65 percent deal with addiction. We also know that the “war on drugs” disproportionately targets people of color, though rates of SUD are similar across populations.
This discrimination reflects the inaccurate belief that addiction is a moral failing, instead of a chronic and manageable health condition from which patients recover and lead healthy lives. But in fact, nearly 3 in 4 people with substance use disorder report being in recovery.
Getting treatment makes recovery much more likely. And clinical language and attitudes can powerfully influence who makes it there. The words that end up in our charts can quietly bias future providers against us. In one randomized study of 516 mental health clinicians, just one word in a clinical vignette made a difference in how a patient was judged and likely to be treated. Clinicians reading a vignette with the words “substance abuser” versus someone with a “substance use disorder” were more likely to blame the individual for their situation, endorsing that they made “poor choices,” rather than facing a complex and biopsychosocially determined medical condition. In fact, we know that about half (34 to 61 percent) of addiction risk is inherited, comparable to chronic conditions like asthma and type 2 diabetes.
Furthermore, clinicians reading the “abuser” vignette were more likely to endorse punishment as justifiable and needed, such as a “jail sentence as a ‘wake-up’ call,” as opposed to treatment.
Words matter: “Abuse,” of course, is a crime. “Substance use disorder” is an illness, rather than a willful choice, and one that deserves compassionate medical care. An “addict” is someone whose illness defines and even limits them; a “person with a substance use disorder” has many facets to their personhood apart from their illness, and is a person for whom recovery is within reach. Words like drug tests being “clean” or “dirty,” as opposed to simply showing X or Y, contribute to the sense that SUD is a moral stain on someone’s character.
For every family whose loved one was dismissed like Taylor’s, there are many more whose struggles are minimized long before they ever enter a clinic. Stigma and bias discourage patients from believing they can get better, and can change outcomes. Patients may avoid disclosing their struggles or stop seeking care altogether because they are judged or dismissed. When clinicians display discriminatory attitudes, such as displaying low empathy and increased suspicion or distrust, this can lead to people with SUD dropping out of treatment and increased self-blame, reducing chances for recovery. In one study, 100 percent of SUD patients had perceived discriminatory behavior in health settings.
Increased training in and comfort with medical treatment for SUD can meaningfully decrease discrimination and increase the likelihood of treatment success. One study shows that addiction specialists were most likely to agree that addiction is a disease, and had the least fear and anger towards patients with SUD, followed by general psychiatrists and then by general practitioners (primary care doctors) like Taylor’s dad’s. Stigma and bias can be lessened, for example, through training that includes nuanced, stereotype-countering contact with people with mental illness.
But with recently reduced federal support for medication treatment and harm reduction efforts, we are likely to see this delicate system splintering further, and stigma and clinical bias worsening.
Although people with substance use disorders often have similar or more frequent contact with the health care system than others, they consistently receive 30 percent less guideline-adherent care for conditions like cardiovascular disease and diabetes, significant causes of death for people with SUD. This contributes to dramatically shorter lifespans, by up to 23.6 years.
But even these numbers fail to capture the full scope of the problem. They only count the people who made it past the clinic doors to receive a formal diagnosis, not those whose understandable mistrust kept them from ever reaching the clinic at all.
If you are a patient or a family member, here are ways to advocate for yourselves:
- Find a clinician you trust: Choose one who listens to you, and don’t hesitate to shop around.
- Focus the appointment: Bring your questions and your most urgent concerns, and if you need more time, ask for a follow-up visit.
- Disagreeing is OK: This leads to often healthy dialogue. If it doesn’t, don’t be afraid to get another opinion.
- Bring support: Have a family member or friend with you, to listen, ask questions, and advocate for you.
- Document refusals: If a clinician refuses your request, ask that the refusal and reasons for it be documented.
- Raise awareness: Naming current failures and possible solutions is key. Taylor shares her father’s story because his experience was far from acceptable, or isolated.
But the burdens cannot rest on the patient alone. We also need systemic solutions like better reimbursement for behavioral health care, anti-bias and behavioral health training for health providers, and expansion of evidence-based SUD treatment models. Collaborative care, where an addiction specialist advises and coordinates whole-person treatment with a primary care doctor, is a promising model to enhance access to specialized and integrated care. Peer support, from someone with lived expertise with SUD in recovery, engagement with community and in meaningful, purposeful activities such as through clubhouses, also bolster recovery. Even within an imperfect system with limited time, we also need clinicians who are willing to see people with SUD as worthy of investment.
Taylor’s father did not need a miracle. He needed someone to take him seriously and to view his substance use as a treatable medical condition. A shrug suggested otherwise and closed a door, while a different response might have kept it open.
This article is discussed on The Podcast by KevinMD: Addiction stigma costs lives, and one word can change that.
Taylor Moss is a medical student. Devika Bhushan is a public health physician.
