At some point, everyone experiences hardship. This is a universal truth that shapes our lives: we overcome personal struggles and arrive at resolutions to reach a healthier and happier place, having grown and learned more about ourselves. This is a road that we all travel.
Along with that common struggle, many individuals often encounter more burdening circumstances — whether due to trauma, stress, or other environmental factors — which means that they require professional and careful help beyond their own efforts to deal with problems like mental illness or substance use disorder, for example.
But what happens when those who need a helping hand to live a more stable life are pushed away because of their past? And what about the people who are pushed away before they can even hold out their hand for support?
Imagine you sustain an injury. After your treatment and during your recovery, you experience pain, for which you could be prescribed pain medication — including opioids — to help with pain relief. However, after you speak with a health care professional about your background, they deny you the prescription, or they reluctantly prescribe a small dose for the short term and direct you to get the medication elsewhere.
You could meet with your primary care physician, but you would have to make an appointment and wait several days. You need relief now. As you look for appropriate care, you’re going from place to place, exhausted by the runaround, all the while being mistreated and feeling like you’re judged as untrustworthy because of your past.
This is the kind of thought experiment Dr. Abhimanyu Sud and Dr. Kirsten Dixon, along with their team, explored in their collaborative animated video project called “Beyond Stigma.” The video was developed and published by the Subject Matter Health Research Lab, which is a research lab that examines health care and how it’s delivered to the public.
Sud, who leads the Subject Matter Health Research Lab, is a family physician and an assistant professor at U of T, with a focused practice in chronic pain. He researches the relationships between and intersections of pain, opioid use, and mental illness. Dixon is a family physician as well, who works closely with the shelter system in Toronto and with organizations such as Centre for Addiction and Mental Health (CAMH) and Inner City Health Associates, supporting people with mental illness and substance use disorders.
The “Beyond Stigma” video follows an individual living with opioid use disorder who has sought help and has been trying to live a healthy life. However, when seeking treatment for pain after an injury, they face stigmatic obstacles in health care because of their history — as described in the scenario above — and eventually fall back to their old means of coping, left ashamed and at a greater risk of losing all of their hard work and progress.
In an interview with The Varsity on what brought them to the development of “Beyond Stigma,” Dixon said, “I’ve been working with [Sud] and the rest of our team on education for physicians and other health care providers around safer opioid prescribing for the last several years, and that’s also how we [made] our way over into talking about stigma and developing this video.”
What does stigma really mean?
Dixon explained that stigma is ultimately made up of beliefs or practices that discredit and reject individuals based on something about them or their experiences. When considering stigmatized individuals and those who stigmatize them, Dixon described a power dynamic where an in-group determines and defines an out-group of other people who are excluded because of a specific set of characteristics.
Commenting on the complexity of stigma, Sud said, “There’s probably 50 different videos we could have made relating to substance use and stigma and the health care system, because it manifests in so many different ways.” He explained that there are different layers to stigma. “There’s stigma related to drug use, [and then] there’s even something that we call intervention stigma.”
Intervention stigma is present within the health care world and is specifically related to treatment strategies. For opioid use, for example, one common therapy — known as agonist therapy — is the use of an opioid drug called methadone, which is highlighted in “Beyond Stigma.” According to the CAMH, the use of this drug prevents withdrawal and reduces cravings and further harms, allowing people with an opioid use disorder to stabilize their lives.
“You hear people [say], ‘What’s the good of methadone? It’s just replacing one drug for another.’ And that ignores a whole body of work and evidence and knowledge around the appropriate use of methadone or buprenorphine or even heroin as agonist therapy for substance use,” said Sud.
Why is talking about stigma important?
Sud noted that educating people on stigma is not about pointing fingers, but rather recognizing that it is ultimately a problem in the system. “We can get to whether you can eliminate stigma or not, but you’re not going to get there until we’re aware of it. And that was the whole point of this video: to raise awareness,” he said.
Sud highlighted that some drug screening methods, such as urine drug screenings, can give useful information to health care providers, but can also be weaponized in a way that makes it more difficult for people to access proper care or have a trusting, caring relationship with their health care provider. He concluded, “I do really think awareness is key, and then understanding how stigma plays out in so many different ways, regardless of what you individually may think of another person.”
Sud and Dixon further noted the importance of changing one’s language and communication in reducing stigma significantly. “In some of the educational material we’ve developed most recently… we’ll use language as the most obvious example of ways [in which we can individually] engage in trying to mitigate the effects of stigma,” said Dixon.
She highlighted that in order to maintain a safe environment for people seeking help, it’s important to avoid using certain phrases or words that communicate or imply that their substance use disorder is their fault, or that they’re not worthy of treatment.
Sud used the example of the term ‘clean.’ He explained that when checking a person’s urine test results, if there are no unusual substances found, or if the expected substances are there as per medical guidance, then that person is considered ‘clean.’ “In some ways it has an obvious meaning, but when you think about what not being clean means, it means you’re dirty. So if you use substances, you’re dirty. Imagine how that would make somebody feel,” he said.
“I think we can still do a lot in terms of language and how we engage people,” Dixon concluded.
As stigma around opioid use continues to present a significant barrier for those who require support, we must consider how stigmas persist in the absence of compassion and compassionate communication. If we take the time to learn about individual people, and unmask stigma to show the ways it further isolates, shames, and hurts vulnerable individuals, we can move forward and leave it behind for good.
As Sud pointed out, “We can develop all the education that we want, or we can develop changes in clinical practices — but if we don’t address stigma head on, it’s going to be very difficult to achieve systemic change.”