Stories to change clinicians' views of substance use

Patients do not always receive effective treatment for substance use disorder, and one reason may be the attitudes of their clinicians, according to Michael I. Fingerhood, MD, FACP.

“A pervasive view in the United States has been that people who use drugs are bad people, and therefore we criminalize them and put them in jail,” said Dr. Fingerhood, who is director of the division of addiction medicine and an associate professor of medicine and public health at Johns Hopkins University in Baltimore. “And there continues to be a view that when we give medications for substance use disorders, that people aren't really in recovery.”

He and colleagues conducted a randomized clinical trial to test whether these stigmas could be reduced by visual campaigns or written narrative vignettes from the perspective of a simulated patient, physician, or health care system administrator.

There were two themes: “Words Matter” emphasized the harm of stigmatizing language, and “Medication Treatment Works” focused on the effectiveness of FDA-approved medications for opioid use disorder. For each, researchers divided a total of 1,842 physicians, nurses, and other clinicians into nine groups of about 200 and randomly assigned them to control, exposure to the visual campaign only, or exposure to the visual campaign plus the patient, clinician, or administrator vignette. They measured the effect on stigma by web-based survey.

While the visual campaign alone did not reduce stigma on either front, clinicians who received both the visual campaign and a narrative vignette did have more positive views, the study found. The patient vignette produced the largest effects. Clinicians who viewed both the visual campaign and the patient vignette were less likely to want social distance from patients with opioid use disorder, more likely to feel warmly toward them and toward use of medication, and less likely to endorse the terms “addict,” “substance abuse,” “clean,” or “dirty.”

In tandem with the study, which was published Feb. 4 by JAMA Network Open, Dr. Fingerhood and his colleagues developed a website at Johns Hopkins Medicine that outlines the effects of addiction stigma, including a list of words to use and not to use, and asks clinicians to take a “Words Matter” pledge. Two hundred fifty-five people at Johns Hopkins had taken the pledge online as of late April, Dr. Fingerhood said. He recently spoke to ACP Internist about stigma, addiction treatment, and other implications of the study.

Q: What are some take-home messages from your study for internists?

A: Internal medicine is so important, because it's such an entry point to engage patients. Once you open it up, it's actually a rapport builder as well. I provide very much patient-centered care, so as an internist I try to understand where patients are, meaning, “Where are you in terms of wanting to address your substance use disorder? Do you have naloxone? If you're injecting, do you have access to clean needles? Would you like me to prescribe buprenorphine to try to initiate treatment?”

In this field that I have chosen, as an internist, I have so many patients who say to me, “You've saved my life.” I think surgeons get that, but as internists, we don't often have patients say that. As internists, we can make an impact, and we're probably the best entry point for individuals who are seeking help for their overall health. We can't think that we can treat hypertension, diabetes, and other conditions if we don't address substance use disorder in a nonstigmatizing way.

I just had one of my long-term patients relapse and get reinfected with hepatitis C, and she knew she was at risk because she had used drugs with someone who had hepatitis C and hadn't been treated. But she was able to come back and say, “I relapsed. I'm really scared I got hep C again. I'm embarrassed, but I trust you, and I know I'm not going to be stigmatized by you, so I'm back.”

Q: What led you to research this particular issue?

A: As a primary care internist who does a lot of work in HIV and hepatitis C, I've tried to be an advocate for individuals with substance use disorders, and especially opioid use disorder. It's pretty clear that the general view of people with substance use disorders in the medical field and outside the medical field has been very stigmatized. Patients feel it. And in fact, even building rapport with patients, I realized I had to rather overtly talk about addiction. People self-stigmatize as well, and there's a lot of shame involved. There are people who actually internalize that “I am a bad person because I have substance use disorder.” To really provide good medical care, we had to overcome a lot of these barriers.

I was asked to lead an opioid overdose initiative for the university that crossed over to the nursing school and public health. As we thought about different aspects, some were more related to actual things like treatments. Part of it is realizing that there was a lot of work to be done in thinking about how we change the view of health care professionals towards individuals with addiction and thinking of what techniques or ways we can make that change. We realized that in order to have more people prescribe and treat and distribute naloxone and have an impact, we need to try to address stigma among our health care professionals.

Q: How did you design the messaging for the study?

A: I teamed up with my public health colleagues, who are experts at communications programs, to design the campaign. We talked about how to design a campaign with an impact, whether it be via visuals or vignettes, and what's effective in terms of wording and images. Pre-COVID, in August 2019, we held a session where we invited all sorts of people. We realized we needed to include physicians, nurses, people who worked as unit secretaries, people who greeted people in clinics, people who greeted people in the emergency department, registration people, as well as people with lived experience as individuals, specifically opioid use disorder.

We brainstormed through two full days of sessions about how to come up with techniques or methods. That's how we came up with the initial campaign and the narrative vignettes that are used in this paper, and that's also how we progressed to actually develop the antistigma campaign, including the website and the idea of coming up with a “Words Matter” pledge. We also wanted to tackle the way people view medications that we use for substance disorders, and that's why in this paper there's a focus not only on attitudes, stigmatizing language, but also the view of medications.

Q: Did anything about your results surprise you?

A: I wasn't surprised that the visual intervention by itself didn't have a big impact, but I wasn't sure, without a lived experience, that a narrative would. I'm glad it did. I think it teaches us that if we have required training for clinical staff, the use of vignettes such as in this paper could have an impact. I think it's clear that we can change stigma the more we have vignettes in medical settings where people meet individuals in recovery. The narrative vignettes humanize people with addiction.

Q: Could clinicians use your findings to examine their own bias toward patients with substance use disorder?

A: I think the aim of this is to cause reflection. I have become more aware, even when I read medical records. One of my patients was recently admitted to the ICU with an overdose, a 72-year-old woman with opioid use disorder, and there was stigmatizing language in the notes, in the electronic health record. I notified the writer and the person wrote back almost immediately, apologetic, and actually amended their note and changed it. I think it's really useful to say something when you see it.