Stigma: Overcoming a Pervasive Barrier to Optimal Care

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    Takeaways

    • Stigma refers to negative beliefs about individuals or groups based on characteristics that may set them apart from others, such as mental health conditions including alcohol use disorder (AUD).
    • Stigma can exacerbate AUD by contributing to a person’s negative emotional states that drive AUD and by deterring people with AUD from seeking treatment.
    • You can reduce stigma and encourage patients to seek AUD treatment by conveying that AUD is a health condition with effective, evidence-backed treatments that can be delivered on an outpatient basis, preserving patient routines and privacy.

    Stigma refers to negative judgments, avoidance, and discrimination levied against those who are devalued for any number of reasons, including having a mental health condition such as alcohol use disorder (AUD).1 People with AUD can feel isolated and rejected because they have come to believe that the negative attitudes and false beliefs about AUD they have heard from others2,3—or have picked up from society at large—apply to them.4 Some may even sense stigmatizing attitudes from their healthcare providers, which can compromise their care.5,6

    The consequences of stigma can be severe. It is part of the reason only about 1 in 10 people with AUD in the U.S. seek formal treatment.4,7,8 Research indicates that the more stigma perceived by a person with AUD, the less likely they are to seek treatment.4,9 Thus, recognizing and addressing stigma can help remove a barrier to care for people in need.10,11

    Here, we look at signs of AUD-related stigma, factors under the surface that fuel stigma among both patients and providers, and strategies to reduce stigma and encourage more patients to seek treatment.

    How might the effects of stigma show in patients?

    You may not see clear signs of stigma in the exam room, but it could be working under the surface in your patients with AUD. One clue may be when patients acknowledge they have AUD but do not accept a referral to an addiction specialist and say they want to manage their alcohol problems on their own.7 This go-it-alone attitude could stem from fear of social judgment or professional consequences.

    Other clues, which can be harder to detect, are when patients downplay or withhold information about the amount of alcohol they consume or alcohol-related problems, for fear of judgment by the clinician.

    What underlies stigma for patients with AUD?

    In population surveys, several reasons people cite for not seeking treatment for AUD relate to stigma, such as “too embarrassed to discuss it with anyone” and “should be strong enough to handle it alone,”7 and concern that others might have a negative opinion.8 Qualitative research digs deeper, finding that patients living with AUD report the following:12–14

    • Shame: Patients may view AUD and its treatment as shameful, a personal failure, or a blow to self-esteem. Some people with AUD emphasize the importance of keeping up appearances and the need to hide their drinking for fear of being judged. Shame may drive even more drinking via negative reinforcement, that is, drinking to reduce the discomfort of the shame caused by drinking.
    • Identity issues: When people realize they have AUD and need treatment for it, they can face a troubling change in identity. They may internalize society’s negative, stereotypical views of people with AUD. Even when they recognize that the stereotype is at odds with their own situation, the stigma can persist.
    • Lack of knowledge about treatment: People may be aware only of treatment options that may be unappealing to them. These options may include residential treatment, which could interfere with work or home life and be a barrier to confidentiality; the use of an older AUD medication (disulfiram) that causes very unpleasant effects when alcohol is consumed; and a perceived need for lifelong abstinence. They might prefer options that offer more flexibility and autonomy but are unaware that such choices exist (see Patient-level strategies below).

    In short, many patients with AUD see the prospect of treatment itself as potentially stigmatizing. This view understandably leads to a reluctance to seek treatment.

    How might clinicians contribute to a patient’s sense of stigma?

    Stigma may consciously or unconsciously create biases within everyone, even experienced healthcare providers. Although most may hold positive attitudes toward patients with alcohol problems, clinicians may still:

    • shorten visit times with patients with AUD15
    • engage less with and show less empathy for patients with AUD5,16
    • use labeling language such as “alcoholic” instead of “a person with AUD”5

    What misconceptions contribute to stigma in a clinical setting?

    In qualitative research into stigma as a barrier to care, some clinicians report false beliefs that patients with AUD:5,13

    • have chosen their condition
    • have complete control over their AUD and could quit if only they were willing to do the work
    • have character flaws

    Conversely, some healthcare professionals might be reluctant to discuss AUD with patients because they are concerned about stigmatizing them.17

    What knowledge about AUD and its treatment may lessen stigma?

    The insights below may help counteract some common misconceptions about AUD.

    • There is a misunderstanding that AUD is a choice. Yes, there is an element of choice when a person first starts drinking. For some people, however, a mix of genetic and environmental factors facilitates a transition, often without full recognition, to increasingly heavier drinking and to AUD (see next bullet). Drinking heavily does not always lead to AUD,18,19 but when it does, changes in the brain make it difficult for people to control or stop their drinking.20 If told at this point that their condition is a choice, rather than being offered treatment, patients can feel shame and a lack of self-efficacy, which can lead to more drinking to cope with the negative feelings. (See Core articles on neuroscience and AUD.)
    • Vulnerability to AUD is influenced by a complex mix of genetic and environmental factors. About 50% of the risk for developing AUD is due to genetics.21,22 Other risk factors include trauma, particularly adverse childhood events;23 mental health conditions such as anxiety and depression;24,25 stress;26 exposure to alcohol prenatally;27,28 drinking in adolescence;29 and drinking too much, too often, at any age.30,31 Awareness of contributing factors may promote empathy and reduce stigma. (See Core articles on risk factors.)
    • Evidence-based AUD treatment is available, change is possible, and most people recover or markedly improve. Many healthcare professionals may still believe that treatment options for AUD are limited and that AUD typically persists in severe form for life. However, evidence-based care is available (see Core article on treatment), and the majority of people who have AUD recover,32 often after a few attempts.33 (See Core article on recovery.) Even those who cut back on drinking rather than quit can markedly improve how they feel and function.34
    • The historic separation of AUD treatment from other healthcare has contributed to stigma. Care for patients with AUD and other substance use disorders traditionally has been separated from medical and mental healthcare. As a result, many healthcare professionals are not trained sufficiently to assess, diagnose, or treat AUD. This sense of AUD being a “different” health issue contributes to stigma.

    What can clinicians do to reduce perceived stigma among patients with AUD?

    Strategies to reduce stigma can be applied at both the patient level and the practice level.

    Patient-level strategies

    • Explore patients’ understanding of their alcohol use and its consequences before offering a diagnosis of AUD. (See Core article on assessment.) Diagnoses that are made too quickly may be perceived as judgmental.
    • Use non-stigmatizing, encouraging language.35 Use precise, medically-focused language to describe the diagnosis as mild, moderate, or severe “alcohol use disorder” or “AUD,” rather than “alcoholism,” “alcohol abuse,” or other imprecise terms that may imply that the person holds full responsibility for causing or controlling their condition.36 Use person-first terms such as “people with AUD” rather than “alcoholics” or other slang or idioms. Reinforce that people can and do recover from AUD. (See Core article on recovery.) Point to any strengths you may know about your patient.
    • Educate patients about AUD and evidence-based treatment. Help patients understand that AUD is a common medical condition that can happen to anyone. Share that AUD can be mild to severe and that it responds to evidence-based treatments. Note that flexible outpatient options can help protect patients’ daily routines and privacy, that newer medications don’t make people sick if they drink, and that individualized drinking goals can be set on the path to recovery.
    • Encourage patient autonomy. Empower patients by involving them in decisions regarding treatment and providing choices among treatment options and goals. If a patient finds a treatment program to be stigmatizing or raises privacy concerns, recommend switching to an option more conducive to their comfort level.

    Practice-level strategies

    • Normalize addressing patients’ alcohol use in healthcare settings. Create workflows and systems that incorporate alcohol screening, assessment for AUD, and standard procedures for follow-up. (See Core articles on screening and assessment and practice change.)
    • Educate the whole care team. Make sure everyone interacting with patients understands that AUD is a medical condition and that they need to avoid stigmatizing language and behaviors. When speaking with your colleagues, model the use of medically accurate, person-first language.
    • Consider offering AUD medications in primary care. Many patients with AUD would prefer to receive initial treatment in a primary care setting.13 Primary care providers who prescribe AUD medications see this strategy as a potentially effective “foot in the door” to treatment that reduces stigma and other barriers.5 FDA-approved medications for AUD are non-addicting and no more complicated to prescribe than those for other common medical conditions. See the Resources section below for support in prescribing AUD medications.
    • Consider creating an interdisciplinary AUD care team. Some primary care providers are more comfortable managing the care of patients with AUD if they work collaboratively with therapists for behavioral care and addiction physicians or pharmacists for prescribing support.5 When healthcare practices support such collaborations, this can enhance the willingness of clinicians to work with and empower their patients with AUD.15
    • Update your referral list to include options that maximize patient privacy. Use the portal for healthcare professionals on the NIAAA Alcohol Treatment Navigator to explore the full range of providers near you, including specialist addiction physicians and therapists who offer lower intensity outpatient choices well-suited for patients with mild to moderate AUD. These options can include flexible outpatient care, including telehealth options, that can preserve autonomy, privacy, and patient routines.

    In closing, by acknowledging and taking steps to mitigate the stigma your patients with AUD may experience, you can help them overcome this common barrier to getting the treatment they need.

    Resources

    Stigma Reduction Resources

    Making Referrals

    Alcohol Use Disorder Medication Guides

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

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    14. Cucciare MA, Lewis ET, Hoggatt KJ, et al. Factors Affecting Women’s Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with U.S. Military Veterans. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2016;26(2):232-239. doi:10.1016/j.whi.2015.07.010
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    21. Reilly MT, Noronha A, Goldman D, Koob GF. Genetic studies of alcohol dependence in the context of the addiction cycle. Neuropharmacology. 2017;122:3-21. doi:10.1016/j.neuropharm.2017.01.017
    22. Tawa EA, Hall SD, Lohoff FW. Overview of the Genetics of Alcohol Use Disorder. Alcohol Alcohol Oxf Oxfs. 2016;51(5):507-514. doi:10.1093/alcalc/agw046
    23. Enoch MA. The Role of Early Life Stress as a Predictor for Alcohol and Drug Dependence. Psychopharmacology (Berl). 2011;214(1):17-31. doi:10.1007/s00213-010-1916-6
    24. Anker JJ, Kushner MG. Co-Occurring Alcohol Use Disorder and Anxiety: Bridging Psychiatric, Psychological, and Neurobiological Perspectives. Alcohol Res Curr Rev. 2019;40(1). doi:10.35946/arcr.v40.1.03
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    28. Baer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. Arch Gen Psychiatry. 2003;60(4):377-385. doi:10.1001/archpsyc.60.4.377
    29. Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. Arch Pediatr Adolesc Med. 2006;160(7):739-746. doi:10.1001/archpedi.160.7.739
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    36. Kelly JF, Saitz R, Wakeman S. Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an “Addiction-ary.” Alcohol Treat Q. 2016;34(1):116-123. doi:10.1080/07347324.2016.1113103
    Earn CME/CE Credit

    We invite healthcare professionals including physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Stigma: Overcoming a Pervasive Barrier to Optimal Care

    Released on 5/6/2022
    Expires on 5/10/2024

    FREE

    This activity provides 0.75 CME/CE credits for physicians, physician assistants, nurses, pharmacists, and psychologists.
    Learn more about credit designations here.

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    Learning Objectives

    After completing this activity, the participant should be better able to:

    • List factors that contribute to stigma associated with alcohol use disorder (AUD).
    • Describe the relationship between stigma associated with AUD and likelihood of seeking treatment.
    • Develop patient-centered strategies to overcome stigma as a barrier to treatment of AUD.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    NIAAA Writers and Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    H. Westley Clark, MD, JD, MPH
    Dean's Executive Professor of Public Health,
    Santa Clara University, Santa Clara, CA

    Hector Colon-Rivera MD, MRO
    Medical Director of Asociacion
    Puertorriquenos En Marcha, Inc;
    Attending at University of Pittsburgh Medical
    Center, Philadelphia, PA

    Joseph Edwin Glass, PhD, MSW
    Associate Investigator Kaiser Permanente,
    Washington Health Research Institute,
    Seattle, WA

    Shelly F. Greenfield, MD, MPH
    Chief Academic Officer and Professor of
    Psychiatry, McLean Hospital/Harvard Medical
    School, Belmont, MA

    John F. Kelly, PhD, ABPP
    Elizabeth R. Spallin Professor of Psychiatry in
    Addiction Medicine, Harvard Medical School;
    Director, MGH Recovery Research Institute,
    Massachusetts General Hospital, Boston, MA

    Richard Saitz, MD, MPH (Deceased)
    Professor of Medicine and Professor and
    Chair of Community Health Sciences,
    Boston University School of Medicine, Boston

    Emily C. Williams, PhD, MPH
    Professor of Health Systems and Population
    Health, University of Washington;
    VA Puget Sound Health Services Research,
    Seattle, WA

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Nancy Diazgranados, MD, MS, DFAPA
    Deputy Clinical Director, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Falk W. Lohoff, MD
    Lasker Clinical Research Scholar;
    Chief, Section on Clinical Genomics and Experimental Therapeutics, NIAAA

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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