Substance Use Stigma Is Real and Deadly: We Need a Public Health Response

Posted on July 31, 2024 by Kenneth D. Smith

This entry is part 3 of 3 in the series Sep 2024

Including the presence of people in long-term recovery into conversations surrounding substance use disorder (SUD) can be one way of mitigating the effect of structural stigma against those with SUD. The public health community can play a role in helping to connect recovery community leadership with policy makers to ensure “nothing about us without us,” as the saying goes. This is a good example of building community power.

Read the article

My new JPHMP commentary, co-authored with Robin L. Peyson, “Eradicating Substance Use Stigma through Community Power,” comes at a very poignant time. This past June, my niece died from a drug overdose. It makes me and my family a part of the millions of Americans affected by the epidemic of opioid overdose deaths. I keep asking myself why no one administered Narcan to her. The Food and Drug Administration made Narcan available over the counter a year ago. Could stigma prevent someone from purchasing Narcan? What can be done regarding stigma?

The CDC ranks my state, Tennessee, second in the nation for opioid overdoses. If anyone needs access to Narcan, we do. However, I have encountered some Tennesseans qualifying the availability of Narcan. To paraphrase, “Yes, Narcan should be accessible, but not too accessible.” The underlying mindset suggests that Narcan incentivizes drug use. This is odd. Are there instances where someone with substance use disorder (SUD) stopped use because Narcan was unavailable? Why would they change behavior when it is available? The attitude underlying this illogical belief is that people with SUD are somehow unworthy or less than.

In October 2023, I started following Tennessee Opioid Abatement Council meetings on YouTube. One agenda item was to consider emergency funding to flood the state with Narcan. It was a $7 million proposal by Meharry Medical College that would use its extensive network to ensure that Narcan was available across communities in the state. The chair, Dr. Stephen Loyd, gave a presentation putting a face to the epidemic in the state. He provided compelling data showing the need for emergency funding. If they waited for the first round of grants, as planned, there would be 2,808 deaths over the next eight months. However, with emergency funding, they could flood the state within one month, thereby stopping the hemorrhage of opioid-related deaths.

I am a practitioner of deep listening. Although the format of the recorded meetings concealed body language, the responses were odd. After presenting the numbers—about a dozen preventable deaths per day saved if they moved quickly—I perceived no group sense of urgency. Instead, the discussion quickly moved to administrative issues. Unlike other states, Dr. Loyd offered this opportunity for Tennessee to show leadership by taking immediate action. However, many seemed nonplussed. While the motion for emergency funding for the project was tabled and later rejected, the proposal was ultimately accepted, as well as the deaths that could have been avoided.

Could stigma, including unconscious bias, against a stigmatized population be related to the outcome? I am not sure. If so, it would be a good example of structural stigma, which is discussed in the commentary. One thing I am sure of is that the greater presence of people in long-term recovery may have changed the nature of the debate. The presence of people in long-term recovery can be one way of mitigating the effect of structural stigma. The public health community can help connect recovery community leadership with policy makers to ensure “nothing about us without us,” as the saying goes. This is a good example of building community power, which is also discussed in the commentary.

My niece’s death occurred in Texas, where pharmacy retailers in her metropolitan area should have carried Narcan over the counter. However, Rice University’s Baker Institute for Public Policy’s 2023 report “How Available Is Over-the-Counter Naloxone in Houston?” showed that 71% of those who reported carrying OTC naloxone kept it behind the counter (BTC), and many consumers required assistance from a pharmacy or cashier to obtain it. Pharmacy retailers’ BTC policies limit accessibility by making people unaware of Narcan’s availability. However, as the report notes, “People who use drugs may be hesitant to ask for naloxone due to the real and perceived stigmas against them.” There could be many reasons why a retailer might have a BTC policy. Narcan is not cheap, and there could be concerns about theft. However, some studies have pointed to naloxone stigma as a potential barrier to distribution and access.

The impact of substance use stigma on addiction treatment, recovery, and mortality is not hyperbole. Substance use stigma requires an appropriate public health response. There is an opportunity for the public health community to work collaboratively with recovery community leaders at the local, state, and national levels to address substance use stigma. Check out “Eradicating Substance Use Stigma through Community Power” in the Journal of Public Health Management and Practice to see how.

About the Author

Kenneth D. Smith: Kenneth D. Smith, PhD, is Assistant Professor of Public Health in the Department of Public Health at the University of Tennessee Knoxville.