Addressing Substance Abuse Disorder Stigmas to Improve Care

• The stigma associated with substance abuse disorder contributes to health inequities and has been recognized as a significant barrier to healthcare.  
• It is essential to identify the effects of stigmas surrounding substance use disorder, as many patients are denied care or feel shame about their current or past usage of substances. 
• Knowledge deficits and nurse attitudes can impact how care is delivered to patients who use substances or have a history of use.

Addiction is a highly misunderstood and stigmatized chronic illness that healthcare providers, including nurses, frequently encounter during routine medical care. That stigma contributes to health inequities and is recognized as a significant barrier to people seeking and receiving necessary healthcare. Since patients often spend the most time with nurses in the clinical setting, nurses are better positioned to address addiction stigma. However, many practitioners lack knowledge of addiction, stigma, and the impact of the terms they use, whether in conversation or clinical documentation. 

Forty-six million people in the United States, ages 12 years or older, have an addiction. Yet, nine out of ten people do not receive treatment, according to the Substance Abuse and Mental Health Services Administration.  

Stigmas Surrounding Substance Use Disorder and the Effects on Healthcare

Healthcare-related stigma is considered particularly shameful, as it negatively affects people when they are seeking treatment and are most vulnerable — resulting in people not receiving the treatment they need. In addition to financial costs and a person’s geographic location where treatment is not always available, stigma is a leading reason people with substance use disorders do not seek and or receive medical attention. When addiction is not recognized as a medical condition, providers can be dismissive of people who have a substance use disorder.   

Patients might be denied care when presenting to their emergency departments because they are perceived as problematic or drug-seeking. Staff might not feel obligated to care for people with substance use disorders because they believe it is not part of their job. Other stigma experiences in the healthcare environment include verbal or physical abuse and name-calling. Stigma may negatively affect clinical care when nursing care is limited to shorter visits, more task-oriented, or delegated to personnel who lack knowledge and adequate training.  

The quality of nursing care might also be intentionally compromised by increasing patients’ wait times or delaying interventions. People with substance use disorders frequently feel written off or abandoned by healthcare staff and experience shame about their current or past substance use. As a result, they internalize that stigma and often refuse to return for care despite potentially severe health consequences. Those who have a substance abuse disorder will delay care or not disclose substance abuse to avoid experiencing stigmas. 

When internalized, stigma results in painful social isolation, which worsens the disease. It creates missed opportunities not only to provide evidence-based treatment for substance use disorders but also to prevent and treat potential complications. People who experience stigma about their substance use are less likely to seek treatment, including treatment for other conditions, which results in significant economic, social, and medical costs. Knowledge deficits among healthcare professionals and nurses largely contribute to healthcare-related stigma.  

Knowledge Deficits and Nurse Attitudes Affect Patients

Healthcare professionals, including nurses, often hold common misconceptions that addiction is a weakness, a lifestyle choice, or a moral failing, despite scientific evidence to support addiction as a complex brain disorder with behavioral components. People with substance use disorders are often blamed for their disease and perceived as being able to control their drug use when they cannot. These dangerous attitudes create barriers that prevent patients from receiving high-quality care.  

Nurses frequently reported experiencing moral distress, burnout, and feelings of frustration and hostility when caring for people with substance use disorders, often describing them as defensive and challenging. Mutual mistrust and the need for more training and support are usually identified as critical challenges to caring for people with substance use disorders. These findings highlight an opportunity to facilitate a better understanding of patients to increase mutual engagement and care. 

How to Ensure Substance-Use Patients Receive Adequate Care

Understanding the pathophysiology of addiction is critical to improving the care of people with substance use disorders. Nurses must recognize addiction as a medical disease, not a moral failing or a choice, and understand that people who have a substance use disorder cannot control their use without help. Healthcare professionals who recognize this are less likely to perpetuate stigma and more likely to support evidence-based treatment and endorse harm reduction interventions.  

Using person-centered care, choosing the person first, using medically appropriate language, and addressing implicit bias can drastically reduce stigmas associated with patients who have substance use disorders. 

Person-Centered Care: Patient-centered care aims to provide holistic care that focuses on the individual patient’s needs. Person-centered care, which was more recently introduced, expands the patient-centered perspective to include a person’s whole life. Empathy, engagement, coordination of care, and shared decision-making are all important aspects of this concept. Acknowledging that a patient with a substance use disorder is a person is an excellent first step. The goal is to recognize them separate from the disease of addiction and acknowledge their circumstances.  

The choice of language: Language and word choice significantly influence how people think, feel, and act, affecting patient care. Words also considerably impact the likelihood of someone seeking help and the quality of help they receive. Language can reflect attitudes and word choice can reinforce stigma.   

• Person-first language: Providing person-centered care starts with selecting a person’s first language. A person-first language emphasizes the person over the medical condition, acknowledging the whole individual and recognizing that a disease does not define the person. This applies to all areas of healthcare. For example, describing someone as a person with diabetes is preferred to calling them a diabetic, and a person with cancer is preferred to a cancer patient. In the case of addiction, a person with an alcohol use disorder is preferred to an alcoholic. Referring to a person with a substance use disorder instead of saying “junkie” or “addict” demonstrates that the person has a problem rather than the person is the problem. Like medically appropriate terminology, person-first language is more clinically accurate and nonjudgmental.  
• Medically appropriate terminology: Use of medically appropriate terminology, which is more accurate, neutral, and nonjudgmental, is an easy way for nurses to counter stigma that can be incorporated into everyday routines. Precise language is most scientifically correct, conveying the understanding that substance use disorders are chronic yet treatable health conditions. Language can suggest value or worth; a nurse’s word choice can promote or undermine a sense of mutuality and inclusion. Words influence people’s feelings, and nurses should avoid words that imply judgment.  

Addressing implicit bias: Bias, positively or negatively, influences a person’s attitudes, perceptions, and actions toward another individual or group. Everyone, including nurses, has implicit biases or prejudices of which they are unaware. These unconscious biases result from stored associations, influenced by attitudes and stereotypes, and can affect clinical decision-making. Stigmatizing language can cause explicit and implicit biases that negatively affect the quality of care and patient outcomes. This creates barriers for people with substance use disorders who are seeking care. Not only does implicit bias negatively impact the therapeutic relationships nurses have with their patients, but it can also affect treatment and interfere with potentially life-saving decisions. The first step to reducing implicit bias is identification and self-awareness. 

The Bottom Line

Addressing health and social inequities requires a shift toward human caring. Addiction is not a choice, but the language that is used to describe it – and the people affected by it – is. The first step in stopping addiction stigma is to use person-first language and medically appropriate terminology in all interactions and documentation. These strategies will help improve the quality of care, decrease barriers to care, and result in better patient outcomes. Nurses are not only leaders in healthcare but also role models throughout the community; therefore, nursing support is critical to ending addiction stigma.  

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