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Counseling a Stigmatized Patient Population

September 1, 2009
by Mark W. Parrino, MPA
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Article four in the NAADAC New Innovations in Opioid Treatment: Buprenorphine Life-Long Learning Series

I suspect that the majority of people reading this article will have some strong feelings, perhaps negative, about patients who access methadone or buprenorphine treatment for chronic opioid addiction. In spite of the fact that medications have been used successfully to treat chronic opioid addiction for more than 40 years (principally methadone, and more recently buprenorphine), and in spite of overwhelming research demonstrating the efficacy of such medications, there is extraordinary stigma toward such individuals.

This stigma is fairly widespread in the general society but is also present in addiction treatment experts as well. Generally speaking, feelings of stigma include negative views and attitudes toward what is perceived to be an undesirable group of people.

There have been a number of researchers who have written extensively on this topic, including Drs. Herman Joseph1 and Charlie Winick.2 Most recently, William White discussed this issue in addressing the national conference of the American Association for the Treatment of Opioid Dependence (AATOD). He provided a moving and eloquent exploration of attitudes, including his own, toward patients who use methadone or buprenorphine to treat their chronic opioid addiction.

Stigma often meshes with mythology. Illustratively, many people believe that it is counterintuitive to provide a dependency-producing medication in order to treat an addiction. Some representatives from AA have characterized methadone as “giving a bottle of scotch to a recovering alcoholic.”

At times, stigma meshes with mythology to denigrate the medication being used to treat an illness as an extension of perceptions toward the illness as well. It is fair to state that many in our society still do not believe that opioid addiction is an illness; rather, they see it as a moral failing and a reflection of undisciplined will. These attitudes are shifting very slowly, but attitudes in the alcohol and drug treatment community are still entrenched in old beliefs about using medication to treat chronic opioid addiction.

The National Institute on Drug Abuse (NIDA) funds approximately 95% of the world's research in treating addiction. It has funded a significant number of studies, which have shown time and again the success the patient has experienced during the course of treatment.3 The Center for Substance Abuse Treatment (CSAT) within the Substance Abuse and Mental Health Services Administration (SAMHSA) has also published extensive Treatment Improvement Protocols (TIPs)4 and other advisories, which combine research with evidence-based practice. Such information has helped to strike down a fair amount of mythology and stigma in the use of medications. For example, methadone does not rot teeth, nor does it decay bone marrow.

Many people in the addiction treatment community also feel that there should be some time limit if patients need access to medication to treat an illness. A frequently asked question is: “How long should a patient remain in treatment?” The answer is as long as the patient continues to benefit from the ongoing use of such medication. It would be impossible to imagine a psychiatrist treating a chronically depressed patient, who has finally stabilized on an antidepressant, to suddenly terminate the medication to see how the patient might do. Equally impossible would be to imagine a cardiologist saying to a stable patient, who had years of coronary disease, that he/she should discontinue the medication that is stabilizing blood pressure. Why is it, then, that we have such a need to limit patients' continued use of medication even though they benefit from such treatment? Stigma and misunderstanding are the key ingredients that fuel such perspectives.

This stigma affects national policy in addition to the views of state policy-makers and communities. At the national level, there are governments, such as Russia's, which still will not provide access to medications such as methadone to treat chronic opioid addiction. Their view is that the science is still insufficient to understand the value of such medication. At a much darker level, a senior Russian narcologist once discussed such an issue during a meeting at the Kremlin. The general view was that individuals who use heroin are already lost to society, therefore it is not useful to treat them since they will never be productive citizens to “the mother country.” Accordingly, it is better not to treat them and let them die from the diseases that an untreated heroin user is prone to, such as HIV/AIDS.

The effective stigma is also significant in state policy-making. A number of states still do not provide access to methadone, while others have resisted providing access to methadone treatment. At a 1995 Maine public hearing considering the use of methadone maintenance treatment for its chronic addicted population, a senior health official took the position that the 200 or so patients currently being treated through outpatient detoxification programs were not really residents of the state.