Addiction stigma costs lives, and one word can change that [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

A man told his doctor he was struggling with addiction. The doctor told him this was not something he could help with. Devika Bhushan is a public health physician and a former acting surgeon general of California. This episode is based on her article “How addiction stigma in health care costs lives,” co-written with medical student Taylor Moss and published on KevinMD. You will hear what happened when about 500 clinicians read the same patient described two ways, as a substance abuser in one version and as a person with a substance use disorder in the other. Devika explains why fewer than 1 in 5 people with addiction ever get appropriate treatment, why they receive 30 percent less guideline-based care for conditions like heart disease and diabetes, and why life expectancy can run up to almost 24 years shorter. You will also hear which words open doors in addiction care and which close them, plus six things patients and families can do when a clinician will not listen.

This episode is brought to you by ModMed.

Welcome to your new AI-Powered Practice from ModMed. We’re transforming specialty care by embedding AI Assistants across your entire workflow. Our all-in-one platform of EHR, patient engagement, practice management, and RCM helps reduce repetitive work while keeping you firmly in control.

Trained on de-identified data from nearly a billion patient encounters, this isn’t just smarter software. It’s a new way of working for specialty medicine, more efficient and more connected to the patient experience.

Start building your AI-Powered Practice at modmed.com.

VISIT SPONSOR → https://www.modmed.com/

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Devika Bhushan. She’s a public health physician. We’re going to talk about the KevinMD article, “How addiction stigma in health care costs lives.” Devika, welcome to the show.

Devika Bhushan: Thanks so much, Kevin. Good to be here.

Kevin Pho: All right, so let’s start by briefly sharing your story, then we’ll jump into why you decided to co-write this article with medical student Taylor Moss.

Devika Bhushan: Absolutely. So my background: I’m a pediatrician and public health practitioner. I’ve spent time in the health equity research world as a clinician and as an appointed public health official, including as acting surgeon general of California, where we really focused on trauma-informed health care, an expansion of a model that tried to do something very new here in California. And I’ve spent time now in the last several years as a strategic advisor in the mental health ecosystem, including to venture capital investment, startups, and nonprofits.

And I’m also a mental health advocate. I live openly with bipolar disorder and have several levels of understanding of my own around mental health stigma and the ways that it can show up for patients, families, systems, and in our culture.

Kevin Pho: And you decided in this article to write about how addiction stigma in health care costs lives. It’s an article that you co-wrote with a medical student, Taylor Moss. So for those of you who get a chance to read your article, just tell us why you decided to focus on this area, and then talk about the article itself for those who didn’t get a chance to read it.

Devika Bhushan: Absolutely. So Taylor and I got connected because I was giving a series of webinars for clinicians on how to reframe clinical language to be less stigmatizing, and many of the case studies that I use in that very practical and hands-on webinar series look through the lens of substance use. That is such a common area of both misunderstandings and stereotypes within medicine as well as outside of it, but it is also an area where you can demonstrably show that shifts in clinical language, very subtle ones, actually shift the quality and outcomes of health care.

And so Taylor was one of the folks who showed up to one of these webinars, and she had a very poignant personal story of her own that she had actually previously written about. So for those of you who haven’t read the piece, we start the piece with a story from Taylor’s own life. The first sentence is, “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 essentially what happens is that the doctor he opened up to about this basically looked at him and said, “This is not something that I can help you with.” And Taylor’s father subsequently passed away as a result of his addiction, which was untreated up until the point that he died, unfortunately.

For Taylor, it was a very personal reminder that we have so much work to do in this field, and it has actually prompted Taylor to want to become somebody who specializes in addiction medicine, to bring the kind of compassionate care to bear that her father did not receive.

So she and I wanted to get our heads together and really write a piece that showcases the personal costs of this addiction stigma in medicine, but also helps to contextualize us and the data of what it looks like when addiction is well treated versus when it is not well treated.

We also spend some of our time in this article talking through the consequences of clinical language, what opens doors in clinical medicine around stigma and addiction care, and what closes doors. So one of the examples that we use is from a randomized controlled trial where they looked at two different vignettes, randomizing about 500 mental health clinicians to read two different vignettes with just one word that had been changed. One vignette read “substance abuser,” versus somebody with a substance use disorder. So just that shift, abuse to use disorder.

And it turned out that that was significantly able to shift people’s perceptions of this individual and shift their perceptions of what kind of care and next steps they were worthy of. So for example, when people read “substance abuser,” they were much more likely to blame the individual for having the substance use disorder and all of its sequelae, including the fact that they made poor choices. Really this willful individual agency over the condition, rather than understanding it as a biopsychosocial, very complex, and often biologically determined condition, comparable in fact to chronic conditions like asthma and type 2 diabetes in terms of its heritability.

And then further, the clinicians who read the abuser vignette were more likely to endorse punishment as justifiable and also as needed, things like a jail sentence as a “wake-up call,” as opposed to treatment for a very treatable health condition.

Kevin Pho: One of the statistics that you cite in the article was that fewer than one in five people with addiction ever receives the appropriate treatment. So when we break it down in terms of the many, many reasons why that is, what would you say are some of the top reasons why so few people who need treatment get that treatment?

Devika Bhushan: It’s hard to say what percentage is attributable to which causal factors, but we know that public stigma, bias, and discrimination against people with substance use disorders is still pervasive. And unfortunately, that also does still show up in the ways in which clinicians receive people in care, specifically clinicians who are not trained in addiction medicine.

And so one of the other statistics that we do cite in this article is a study that shows that general practitioners, like primary care doctors, who are most likely to interface with people who are struggling with pre-addiction or addiction, just are not comfortable dealing with the medical sequelae of this illness, and they showcase more fear and anger and mistrust toward patients who come in like Taylor’s father, followed by general psychiatrists, and then followed by people who are addiction specialists.

But we also know that folks with substance use disorder often have co-occurring mental health conditions as well as other physical health conditions, and there is a dramatically shorter life expectancy when you have a substance use disorder, by up to almost 24 years.

And part of this is not only that clinicians are less well versed in addiction care, it is also that people who come in with a stigmatizing diagnosis on their chart are less likely to achieve guideline-concordant care for other medical conditions. So for example, folks with mental health conditions, including substance use disorders, have a much higher burden of cardiovascular disease, but they are consistently less likely to receive guideline-coherent care for conditions like cardiovascular disease or diabetes, which ends up contributing to that shorter life expectancy. So people with substance use disorder receive 30 percent less guideline-adherent care for those other conditions too.

So this is a whole related series of mishaps, if you will, in the health care system that is really undergirded by the stigma and the stereotypes that folks carry.

Kevin Pho: One of the things that you said earlier was that there are a lot of misperceptions or misunderstandings regarding the addiction medicine patients that we see. So what are some of the top things that you want to clear up? Perhaps primary care physicians like myself, like you said, we don’t have that appropriate training. What are some of the misconceptions that you want to clear up?

Devika Bhushan: Yeah. Let’s go back to that study that I cited where they changed one word, abuse to substance use disorder. Abuse is a crime. It’s something that the person is held responsible for in a way that is very distinct from a medical condition. Whereas a substance use disorder is an illness. It’s not a willful choice, and it’s one that deserves compassionate clinical care.

So I think there are all of these pervasive stereotypes about people who struggle with addiction, including the fact that many people don’t expect people with addiction to actually recover from it. But the data show that nearly three in four people with substance use disorder in a particular survey, and you might argue that those who maybe weren’t well enough to take the survey may not show up here, but those who did show up in this survey, three of four people reported being in long-term recovery. And this is despite the fact that only one in five are in treatment of any kind.

So some of this data is perhaps a little incomplete, but I think the point is that when people are supported, they can sustain recovery in a way that’s similar to other chronic health conditions, and that’s how we have to think about this.

This is a very complex condition, as I said, about 50 percent heritable, but about 50 percent shaped by circumstances and supportive structures in a person’s life, and those are the pieces that we can boost and help somebody amplify in treatment.

And treatment has to be about finding purpose, about finding community. It has to be about shifting some of the coping strategies that end up perpetuating use. And once you understand that it really takes a village to recover from any complex medical condition, including this one, and to sustain that hope that recovery is indeed possible from a substance use disorder, that’s when you can walk forward with a patient and their family and their support system in hope rather than in judgment.

Kevin Pho: And I’m hearing a lot that the words that we choose can have a huge impact in terms of how physicians perceive addiction patients, but also how that treatment advice is being received by the patients themselves. Simple words like clean and dirty in the context of a drug test certainly have power, and you wrote more about that in your article as well.

Devika Bhushan: Absolutely. There are so many words. And this is a movement all across medicine. We now don’t want to label people as solely being defined by their medical condition. So for example, it’s very common in medical signouts to say, “Oh, the sickler in room 305.” And so similarly, addict is one of those terms that is extremely limiting and ends up reducing somebody to that illness by itself, instead of being a complex and three-dimensional person.

So saying a person with substance use disorder is really helpful, because that acknowledges there are many facets to that person apart from the illness.

And then words like clean or dirty also reinforce this idea that substance use disorder is a moral stain on somebody’s character rather than something that they live with. So simply saying something like, “This test shows the presence or absence of X or Y,” that’s much more objective and free of judgment.

Kevin Pho: So as my listeners know, I’m an internal medicine primary care physician. I mentioned that offline. And you said that primary care is often the first interaction that we have with patients with potential addiction concerns. So we talked briefly about the verbiage that we use in the exam room. In terms of paths forward, what are some other ways that we can use to alleviate the stigma?

Devika Bhushan: Absolutely. So the truth of the matter is that patients and family members who are coming in with addiction as one of their medical problems will face stigma, for better or for worse, in our current setup.

And so some of what we spend this article doing is saying, “Hey, patient, family member, advocate, if you are walking into an exam room and you want to shore yourself up against the possibility of being medically gaslit, here are a few things that you might be able to do for yourself.” And not to put the entire onus of this on the patient, because that’s just not fair. There are other strategies at the systemic level that we can talk about.

But for the patient, we wanted to make sure that there were six clear messages. So one was, if you have a clinician that you just don’t trust, don’t be in a position where you continue that relationship if you’ve given that person a chance. It is your prerogative and your right to find a provider who listens to you.

The second is to really focus the appointment, so come in with an agenda, a set of questions that you’ve thought through that you want that person’s expertise and co-input on.

Disagreeing with somebody is OK. That was our third point, and this often leads to healthy dialogue. If you have a question, if you have a way of pushing back on something that your provider or clinician is saying, feel free to do that. That is constructive and helpful.

And then bringing somebody with you to an appointment, because it helps to have a loved one, a family member, a friend, or a neighbor in the room with you, listening. Sometimes it’s really hard to listen when your emotions are heightened or when your fear or level of mistrust is heightened. We just recede into a different part of our brain, and our prefrontal cortex is less available to us. And so having somebody else there as a listening agent is really helpful, but then secondarily, that person can help you speak up for yourself if you do have a different perspective, if you have another set of questions that haven’t yet been addressed. That person can help steer the dialogue in those ways.

And then if a clinician does not think that a particular test that you would like to have done, or that you think is important to have done, if they don’t feel like that is an appropriate next step, ask them to document that refusal and their reasons for it in the record. And I think this is really helpful if you ever see a different clinician and have a follow-up question about it.

And then the final one is to raise awareness in the ways that Taylor has been able to do after her family’s experience. And this can look like peer support. It can look like advocating for legislation or for policies at a local level that help to protect patients who live with stigmatizing health conditions, including addiction.

And in terms of some of the systemic solutions, we definitely need better reimbursement for behavioral health care, for training, for addiction-supportive care for providers of all levels. We need anti-bias and anti-stigma training for everybody in the health care system as well as culturally in the public. And then we need expansion of evidence-based substance use disorder treatment models, including for co-occurring conditions, recovery models like clubhouses and others.

Kevin Pho: We’re talking to Devika Bhushan. She is a public health physician. Today’s KevinMD article is “How addiction stigma in health care costs lives.” Devika, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Devika Bhushan: I think that sometimes when we think about conditions like stigma, we perceive them as something that’s very soft and unknowable, and something that can’t be shifted readily. But I think when you get down to it, the consequences of stigma for the real lives of the people who are living with stigmatizing health conditions and other stigmatizing identities is that people are dying, people are not receiving the care that they deserve, and they are not living the full lives that they are capable of living, were we to eradicate the different layers of stigma that impede recovery.

And so I want to close with the idea that not only can we measure those impacts, but we can shift those impacts using small shifts in the ways in which we perceive people, the ways in which we talk about people, and the ways in which we, at the end of the day, treat people.

Kevin Pho: Devika, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Devika Bhushan: Thanks, Kevin. It’s good to be here.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes