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DAVID LEVIN: You’re listening to Harvard Chan: This Week in Health. I’m David Levin. Today, we’re talking about stigma and addiction.
SHELLY GREENFIELD: Addiction itself doesn’t discriminate. It’s not about white or black or other ethnic or racial minorities or male or female or young or old. All individuals are actually vulnerable, depending on their individual circumstances.
DAVID LEVIN: That’s Shelly Greenfield from Harvard’s McLean Hospital. She’s a psychiatrist that specializes in addiction and the stigma that’s around it. She studies how patients cope with it, how it factors into which people get treatment, and how it works its way slowly into policy. She says that’s especially important today as the nation responds to a massive opioid crisis.
Dr. Greenfield talked about that during a recent conference at Harvard called Stigma and Access to treatment. In this episode she covered some of those same themes with Mary Bassett, director of Harvard Chan’s FXB Center for Health and Human Rights.
MARY BASSETT: You’re an addiction specialist who is a psychiatrist. And so I thought what it would be great to talk about is the whole problem around stigma and reflecting on why there’s so much shame associated with having problem drug use, shame that affects the patients living with a problem drug use, their families their communities. I’m sure that you confronted this often and have had the chance to think a lot about it.
SHELLY GREENFIELD: Yeah, Mary, thanks for that question. Of course, that is such a large question and one that so many people are thinking about these days. The place that I start is that I think there has always been and unfortunately continues to be a great deal of misinformation or lack of information in the general public among clinicians, including physicians, policymakers, and also others in our society and communities that treatment works, that there actually is treatment available, that people actually get better when they’re treated, and that anyone can be affected by addiction. There’s a just foundational lack of information and education.
We actually have a range of really effective treatments now but only probably around 20% of people we think are treated. And so we have this giant treatment implementation gap. And it is a complex challenge. And stigma and discrimination clearly play into that.
But it’s also there’s a real reciprocal relationship with the fact that the addiction treatment systems are insufficient, poorly integrated into our health system. And there’s really just inadequate funding for all of it. So all of these things, I think, relate to one another.
And stigma discrimination fuels the lack of funding and the poor integration into our health system. But the fact that there is inadequate funding and a poor integration in our health system further fuels, in fact, stigma and discrimination.
MARY BASSETT: So it really is almost cyclical–
SHELLY GREENFIELD: –or a vicious cycle.
MARY BASSETT: It’s become almost a vicious cycle. But there are these really strong belief systems. I remember as a health commissioner in New York City, I used to point out to people that we should stop using language like getting clean, that this idea that people who become dependent on drugs are dirty is a framing that we should all seek to get away from. But there’s such a heavy belief that somehow people who develop problem drug use of any sort or alcohol, that they are flawed human beings not that they have encountered a substance that would affect anybody.
SHELLY GREENFIELD: So I think that’s a great point. And I totally agree with you that language is so important in how we use language to describe any phenomenon is important. And I think that we’ve been moving away from using language that is stigmatizing.
And so we do talk about things like substance use problems and substance use disorders. I know that in certain police departments, one attempt at lowering stigma amongst that workforce was to stop calling these things overdoses and to call them opioid poisonings, just like you would take care of any other type of poisoning and to move a person who had ingested a poison basically into immediate urgent emergency care.
MARY BASSETT: Well, I did want to get to talking about your work as an addiction psychiatrist and about the challenges there are not only saving people’s lives and making sure that naloxone is available wherever people are using opioids, getting them into treatment, but also how we keep them in treatment.
SHELLY GREENFIELD: Well, I think the one thing that I would want to say– I know you and I’ve had conversations before about the fact that I am an addiction psychiatrist, which means that one aspect of what I do is to think about people with opioid use and other substance use disorders who have co-occurring other mental health conditions that are very common, such as depression and anxiety, and trauma related disorders. And we increasingly find that people with opioid problems also have these other co-occurring disorders.
And it is really very hard for people to get well unless those disorders are also treated simultaneously, because those disorders can be quite debilitating in and of themselves. So I think that’s quite important.
And I think the more that we think about tailoring treatment and retention strategies to individuals, the better we will do, because individuals do need to stay connected to care. And for some individuals it will be a trusted counselor, a PCP, a psychiatrist. For some, it will be a group treatment that they engaged in where they’ve gotten tremendous support from peers. For others, it’ll be family supports that were put into place or coaching or mutual support groups.
And for some, they will have little access to those things because they’re in isolated places. And we need to really be thinking about how we can utilize technology to help those people as well so that they can be sort of continuously engaged.
But you see, I also really believe that in walling off our substance use treatment services from the rest of health care and pretending that this is something different than health, we think about it differently than other health conditions. So by this I mean the following. Most health care that requires any type of behavioral change, whether that’s diabetes or heart disease, whether it’s increasing your exercise, changing your diet, requires a multipronged approach.
And we think very little of giving people nutritional counseling and other types of treatments to help them adhere to their medications better, to help them use other kinds of behavioral strategies to keep themselves healthy.
And I think of these things as actually very similar. And I think this artificial separation of substance use treatment as if it is something different than health care as we generally deliver it in all settings is very damaging to patients and their families.
MARY BASSETT: I wonder often– and in New York City this was tried and I know in many other settings– trying to just tackle head on with people that we should fight back against the stigma that surrounds addiction. Do you think that there’s a role for public education campaigns directly to the public, or is the best strategy the one that you’ve been talking about so effectively that what people have to understand is this is treatable and the solution is access to treatment, or do we need it say, look, we have to stop stigmatizing something and it’s become so common that it’s changed the life expectancy for our entire country?
SHELLY GREENFIELD: That’s a great question. I actually think that because stigma and discrimination are multifactorial problems, we really need a real full on multifactorial approach. I think of it, in some ways, as three approaches we could take. There probably more but just to start with three.
To your point, I think public education, using many modalities depending on the target populations and the best ways to reach certain populations, whether it’s through institutions they might trust in their community, whether that’s schools or maybe it’s churches or other religious institutions or community groups, public education I think is giant.
I also think workforce training is incredibly important. We still do not have a highly trained workforce. And what I mean by that is physicians, nurses, social workers caseworkers, psychologists– I just could go down the list you name it in terms of a workforce in clinical care that will be critical to recognizing, hopefully early rather than later, someone who is beginning to manifest a problem. We have a lot of workforce training to be done. And that includes all of our schools, whether their medical schools, our graduate medical education programs, et cetera. So I think that’s a second place.
And then one thing to consider is universal screening in all health care settings. If we are going to screen in all health care settings all people all the time, then we’re doing that for everybody. And we did that universal screening, we’ve done that for HIV.
When you’re going to screen everybody for that, then you’re just screening everybody for it. And it doesn’t allow for any type of judgment or discrimination. It’s universal screening, we’re doing it for everybody.
And so I think these are three approaches that I think can work in concert with one another. But I also think we have lots of other people to educate. I think that includes law enforcement and criminal justice in terms of moving us from punitive approaches to actually medical and treatment approaches. I think those things are incredibly important.
Diverting people into treatment, getting people to treatment before there even is any type of criminal justice involvement would be even better. I think expanding our evidence based treatments so that people know that they can go to treatment when they need treatment as soon as they need treatment is very important.
MARY BASSETT: Well, one of the things that I always really love about talking with you, Shelly, is that you always come back to the fact that we have the tools and that we can make things much better for people. And people struggle enormously with mental health disorders, with substance use disorders. But we have the tools, and we can help them.
And I really have to say that I have enormous respect for people who work with such challenging problems as you do all the time as a researcher, as a clinician, as a mentor and director of training programs. And it’s been great. It’s been great.
SHELLY GREENFIELD: Thanks so much.
DAVID LEVIN: Special thanks to Dr. Shelly Greenfield and Mary Bassett for sitting down to this interview. You can hear more conversations with public health experts and learn about new solutions to the opioid epidemic on our website. That’s hsph.harvard.edu.
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Shelly Greenfield to unpacks the stigma that surrounds addiction. A psychiatrist from McLean Hospital, Greenfield specializes in addiction—how patients cope with it, how it factors into treatment, and how it works its way slowly into policy. Greenfield sat down with Mary Bassett, director of Harvard’s FXB Center for Health and Human Rights.
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