Whether or not a drug is socially acceptable is determined by culture, not pharmacology. That is to say, the effects and sensations that a drug produces are not an important factor with regard to its social acceptability. Rather, it is the cultural perceptions and beliefs of society broadly or a social group that determine whether, when, and under what circumstances a drug is acceptable to use. For example, alcohol use is socially acceptable in most cultures but not in all situations (e.g. at work, before driving a motor vehicle). Heroin use is not socially acceptable in most cultures, but pharmacologically similar opioids, like morphine, are socially acceptable when used to treat pain and under medical supervision. Caffeine (a stimulant) is socially acceptable in many cultures in nearly all situations, but chewing coca leaves (which contain cocaine, another stimulant) is not.

And the social acceptability of a substance can change with time. Tobacco (nicotine) use was previously socially acceptable in many cultures and could be consumed without situational limitations. Today, tobacco use is socially frowned upon, and there are significant situational limitations to its use (both through laws and cultural norms). Cannabis (cannabinoids) use was socially unacceptable in many cultures, but today is widely seen as acceptable for medical purposes. Indeed, many now feel it is acceptable to consume cannabis simply because it makes the user feel “good.”

How we experience the effects of a drug is strongly influenced by our expectations. Our expectations, and not just the pharmacology of a drug, create the sensations we feel when consuming the substance. There is a growing body of evidence that our beliefs about a drug markedly alter our response. Both the placebo effect (positive effects) and the nocebo effect (negative effects) are the result of our expectations.2 These expectations lead to both physiological changes and psychological perceptions. Our belief in a medication amplifies its positive pharmacological effects and willingness to take it. Antihypertensive therapy reduces blood pressure more in those who believe it will be effective. And, conversely, people who believe they will experience side effects from an antihypertensive medication are more likely to report side effects. These effects are not merely “in your head.” The biological response to a drug is altered by our expectations, too.

Context, beliefs, and expectations have a tremendous influence on what we experience and how we perceive the sensations created by stimuli. Thus, how we respond to and experience a substance, like alcohol, morphine, or cannabis, is influenced by the messages we receive from the people and media around us. A person who is told that Ecstasy/Molly (MDMA or 3,4-methylenedioxy methamphetamine) will heighten their sensory perceptions will likely notice those effects and, if they voluntarily consume it, perceive them as pleasant.3 Alternatively, a person who believes MDMA is dangerous and was warned that people “freak out” after taking it is more likely to experience anxiety, paranoia, and memory loss. And these negative effects would be amplified if the drug was not consumed voluntarily.

To illustrate this concept, consider how you feel when someone you love and trust touches you. Perhaps caresses your arm. Or touches your cheek. Or kisses you. Most of us would perceive these sensations as pleasant and enjoyable. If we are sexually attracted to the person, we might signal that we want more physical contact! If, instead, it was a stranger sitting next to you on a bus, perhaps someone who appeared disheveled, who touched you, caressed your arm, touched your cheek, or kissed you, your perceptions of the encounter would be entirely different. The very same physical sensations but in a different context would likely be perceived quite negatively. Based on your cultural norms and beliefs, you might feel disgusted or assaulted.

Thus, drug use, the sensations we experience, and our perceptions about its acceptability are largely determined by social and cultural influences. The physiologic / biologic / pharmacologic effects of a psychoactive substance are secondary factors. This likely explains why substance use disorders and addictions are so complex in terms of causes and treatment. It is not simply about chemistry or physiology.

The pharmacologic properties of a substance, of course, matter. Some drugs have more addictive potential than others because they promote greater or more rapid dopamine release. Larger doses and higher potency drugs will produce greater effects that last longer and, if too large, result in overdose and potentially death. The route of administration makes a difference, too – inhaling, snorting, and injecting drugs results in a much quicker onset of effect. Repeated use downregulates receptors, leading to withdrawal and negative sensations in the absence of the substance. Dependence and withdrawal are physiologic. So, we can’t ignore pharmacology; it's part of the equation.

Addiction, however, is fueled by many other factors, including deeply rooted, often unconscious, beliefs. We all have expectations of how we might or should feel when taking a psychoactive substance, and those expectations shape what we experience.4 And expectations determine whether those sensations are interpreted as pleasant and satisfying or, alternatively, unwelcomed and negative.

Stigma is rooted in beliefs and judgments about what is “right” or “appropriate” or “acceptable.” They are instilled into us and influenced by people in our social circle and cultural norms. As health professionals, our understanding of the world should be informed by science – empirical evidence. While we can not divorce ourselves from the society and culture in which we live, we can question assumptions and beliefs. We can consider whether these judgments and beliefs positively serve us. Or whether they have (unintended) negative consequences. While drugs have chemical properties that influence biological systems, judgments are human inventions that can be reconsidered and changed.

References

These are people. They’re not dogs. They’re not animals. They’re people.
Your job as a health provider is to take care of people.

Brenda Foster, RN

The treatment of patients with substance use disorder demands an understanding of the complexities of addiction, coupled with a compassionate and non-judgmental approach. Health professionals must recognize that substance use disorder is a chronic medical condition, not a moral failing. Stigma is often perpetuated by societal misconceptions and outdated stereotypes that hinder the recovery process and perpetuate a cycle of isolation and despair. By fostering a culture of compassion and care, healthcare providers can empower individuals with substance use disorder to seek help, engage in treatment, and ultimately reclaim their lives.

Stigma is rooted in fear and misunderstanding that can have far-reaching consequences for individuals struggling with substance use disorder. It can lead to discrimination, social exclusion, and denial of healthcare services. When health professionals harbor stigmatizing attitudes, they may unintentionally reinforce negative stereotypes and create a hostile environment that discourages individuals from seeking help. This can delay diagnosis, impede treatment adherence, and increase the risk of relapse. Furthermore, stigma can erode self-esteem and self-worth, making it even more difficult for individuals to overcome the challenges of addiction.

One of the fundamental principles of healthcare is the obligation to care for all patients, regardless of their circumstances or diagnoses. This principle extends to individuals with substance use disorder, who deserve the same level of compassion, respect, and evidence-based treatment as any other patient. By treating individuals with substance use disorder with dignity and empathy, healthcare providers can foster a therapeutic alliance, build trust, and create a safe space for open communication. This supportive environment is the cornerstone of effective treatment and recovery.

Compassionate care for individuals with substance use disorder involves a multifaceted approach that addresses the biological, psychological, and social factors contributing to addiction. This may include medication for addiction treatment, counseling, behavioral therapies, and support groups. Healthcare providers must also be mindful that trauma and adverse childhood experiences are risk factors for developing a substance use disorder. By integrating trauma-informed care principles, healthcare providers can create a healing environment that promotes resilience and recovery.

Health professionals, regardless of practice setting, play a critical role in combating stigma and promoting compassionate care for substance use disorder. By challenging stereotypes, educating the public, and providing evidence-based treatment, healthcare providers can help to reduce stigma, improve access to care, and enhance the overall well-being of individuals, families, and communities affected by addiction. Ultimately, our goal is to create a society where people with substance use disorders are treated with dignity, respect, and compassion and empowered to lead fulfilling and productive lives.

References

Van Boekel L, Brouwers E, Van Weeghel J, Garretsen H. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug Alcohol Dependence 2014; 131 (1) : 23-35.

Roberts L, Dunn L. Ethical considerations in caring for women with substance use disorders. Obst Gynecol Clinics N America 2003; 30 (3): 559-582.

Pack JN. Leaving Past Judgments Behind: Decreasing stigmatization within mental health professionals and students toward individuals with substance use disorder. Thesis Dissertation, Notre Dame de Namur University, Department of Marriage and Family Therapy, Spring 2016.

All too often, people with a substance use disorder (SUD) get reduced to a “label.”

“Alcoholic”

“Junkie”

“Drug Seeking”

“Addict”

But these labels dehumanize and reinforce underlying stigmatizing beliefs. By labeling a person a “junkie” or “addict,” health professionals (unconsciously) begin to regard the person as someone less worthy of attention, care, and empathy. Rather than seeing a person as someone whose life has been derailed by a mental illness that is beyond their control, these labels reinforce societal notions of moral culpability. And these beliefs get internalized and shape behavior. So it’s not surprising that people who are “hooked on drugs” actively conceal their use because they understand it is socially unacceptable and assume (often correctly) they will be judged.

But here in lies the Catch-22. People are unlikely to admit to substance use, much less seek treatment, if they believe they will be blamed for their circumstances and seen as unworthy. But in the absence of treatment, the socially unacceptable behaviors that are associated with SUD (lying, manipulating, neglecting family and work responsibilities) continue and worsen with time. And this reinforces beliefs that people with a SUD are less worthy. It is a vicious cycle that undermines our ability to address the underlying causes.

Addiction is the result of multiple factors that, in the right milieu, lead to a self-reinforcing compulsion. Most people who consume alcohol, take stimulants (like dexamphetamine), or try heroin don’t become addicted. So substance use, in and of itself, isn’t the inherent cause of SUD. There is an interplay between several contributors that must be uncovered and addressed. People with a SUD often have a co-morbid mental health issue that “dance together.” Each person needs to be seen and treated holistically rather than as a set of separate and distinct disorders.

Worse still, some clinicians mandate that a person be abstinent and in remission for a lengthy period of time before they are considered “worthy” of receiving treatment for their comorbid conditions. It would be unconscionable to mandate that someone lose weight before receiving any treatment for type 2 diabetes and its complications. Obesity and type 2 diabetes often “dance together” and need to be addressed concurrently. Perhaps prioritizing one but never ignoring the other. We shouldn’t expect abstinence or require people to enroll in a “detox” program as a condition for receiving care.

People with SUD all too often receive inequitable treatment in our healthcare system. Diagnostic overshadowing leads clinicians to minimize or ignore symptoms that would otherwise trigger a thorough diagnostic work-up but are instead misattributed to substance use.1 It is a cognitive bias whereby the person with a SUD (and, in many cases, additional mental health concerns) is seen exclusively through the lens of their labels. Complaints are not investigated. Treatments are delayed or withheld.

Our stigmatizing beliefs show up in subtle and not-so-subtle ways in our language, actions, and behaviors. None of us likes to believe that we are capable of harming another human being who has entrusted their lives to us when they seek help. When people who use substances sense they might be judged, it’s unlikely they will admit they have a problem or seek help. And that’s a tragedy.

References:

I'll always remember it ... I wish he hadn't said that.

-Brynn, Peer Support Specialist

Stigma toward substance use and people with substance use disorder (SUD) is a major driver of the overdose and addiction crises in the United States, impacting people with SUD, their loved ones, and their communities in innumerable ways.

The impact of shame and stigma can be profound, shaping the course of one's addiction journey. Brynn's encounter with judgment led to a setback, underscoring the critical role healthcare professionals play in fostering a supportive environment. Although Brynn's story is unique and personal, shame and stigma are all too common among those with a substance use disorder.

Let’s take a closer look at shame and stigma, unraveling why these elements stand as significant barriers to seeking help for individuals grappling with addiction. 

Shame and stigma are often perceived as interchangeable concepts, but in truth, they are distinctly different phenomena that are interconnected. Both involve negative attitudes and judgments based on characteristics like identity or behaviors. While interconnected, it's crucial to discern the differences.

Stigma refers to the negative stereotypes, beliefs, and attitudes held by society toward a group of people based on characteristics such as where they live, who they love, or their physical attributes, behaviors, or customs. Media and entertainment significantly influence societal perspectives, thereby shaping our individual views. For instance, people with a substance use disorder are often portrayed on television as scary, dangerous, and violent. In truth, they are often the victims of violence. These stigmatizing beliefs result in prejudice, discrimination, and social exclusion, hindering affected individuals from fully participating in society and influencing public policy, laws, and access to care.

Shame, sometimes called self-stigma, is a powerful, self-conscious emotion that arises from the perception of one's own actions, behaviors, or characteristics. Unlike stigma, which is driven by external factors and imposed by others, shame is an internalized feeling of personal inadequacy or disgrace. Think about a time when you answered a question incorrectly in front of others. When you think back on it, even if the incident was many years ago, you probably still feel uncomfortable or embarrassed. That feeling is shame. This intense negative emotion can have a significant impact on an individual's overall well-being, contributing to low self-esteem, isolation, and reluctance to seek help. ​

Shame and stigma share similarities but are not interchangeable. They are, however, interconnected, with stigma playing a pivotal role in fostering feelings of shame. We often internalize societal judgments. Our shame leads to a sense of inferiority. Consequently, shame and stigma reinforce and perpetuate each other. People who are stigmatized often avoid seeking help, afraid they will be judged.

When Brynn was actively using cannabis and was vulnerable to a setback, she did not receive the support and affirmation she needed. In our next blog post, we will explore the ways health professionals contribute to stigma and the impact this has on individuals seeking treatment.

Most patients don’t want to think that their healthcare providers may be misusing or addicted to substances. Similarly, most health professionals believe that, due to their advanced knowledge, they know how to keep their substance use under control. Unfortunately, this is not the case.

According to a 2015 study from the Substance Use and Mental Health Services Administration (SAMHSA), 7% of healthcare workers between the ages of 18 and 64 years old met the criteria for a substance use disorder within the previous year. Moreover, according to the American Addiction Centers, pharmacists are even higher risk of developing a substance use disorder — 46% of pharmacists and 62% of student pharmacists admit to having used a controlled substance without a prescription.¹

As a current student pharmacist, I’ve been taught how to recognize, diagnose, and pharmacologically treat substance use disorders. While this is obviously important information for me to know, I was never taught what to do if I, one day, struggled with substance misuse. It wasn’t until I had the opportunity to attend the American Pharmacists Association Institute on Substance Use Disorders in Salt Lake City, Utah, that I began to recognize how substance use disorders impact health professionals too. And I learned about the resources available to those who need them.

While at the Institute, I was welcomed into a close-knit community of recovering pharmacists. Many of the pharmacists shared their stories of substance use and recovery during our Alcoholics Anonymous and Narcotics Anonymous meetings. For many of them, their recovery journey was guided by other recovering pharmacists and included a trip to the Institute.

In his memoir “Unfit for Recovery,” Jake Nichols recalls his first time attending the Institute as a recovering pharmacist.² Jake states that the people he met during his time in Utah had a profound impact on his recovery and that he continues to attend the conference every year.

I realized I was not alone in all of this and that there were many pharmacists who had struggled as I had. It was the first time that I can recall being able to be in a crowd and not feeling the shame that had permeated my life.

-Jake Nichols

For me, attending this conference truly felt magical. That may seem silly to say, but those who have attended the conference can attest to this feeling. I felt an overwhelming sense of support, acceptance, and friendship from everyone in attendance. It is easy to see why so many recovering pharmacists continue to come back each year.

During my time in Utah, many recovering pharmacists mentioned the amazing work that is done by PRN groups. I was shocked that I had never heard this term before.  PRNs, or Peer Recovery Networks, provide support and resources to help pharmacists and other health professionals during their recovery. PRNs are typically organized and authorized by the state licensing board and can help recovering health professionals find treatment centers, advocate for them to earn their licenses back, and help them find jobs.

PRNs are just another testament to the importance of community when it comes to recovery. PRNs allow recovering health professionals to build relationships with people who have had similar experiences and show them that they have a group of people who will advocate for them.

I believe that all health professionals and, just as importantly, health professional students should be informed about recovery networks. You never know if you or someone you know may need these communities. We know that health professionals are vulnerable to substance use disorders, but we can’t let shame and stigma stop us from talking about it.

Sources:

1. Webster A.  Drug and Alcohol Rehab for Pharmacists. American Addiction Centers. January 3, 2024.  Accessed September 4, 2024.

2. Nichols  J. Unfit For Recovery: Fighting Addiction in an Unforgiving World. Independently Published, 2022. ISBN-13: 979-8847222396

I learned so much at the treatment center, and I was following the Twelve Steps of Alcoholics Anonymous. But once outside of the very structured treatment environment, it was up to me to implement the things I’d learned into new skills and habits. Some days were easy, but some days were difficult. It helped me, more than mere words can express, to be able to talk to someone who knew, really knew, what those bad days felt like. Addiction can be difficult to explain to a person who has never experienced it. There are only so many times I could hear some version of, “Why don’t you just stop?” When I talk to someone who struggles with addiction like I do, they know it’s not that simple.

Peer support has been instrumental in helping me find a job and a recovery community. In recovery, there is a to-do list for maintaining sobriety and being successful in life. Early in my recovery, my brain saw these tasks like they were the size of mountains. I’d get stressed out just thinking about them. But my peer-support specialist helped me to see them as small, doable things. I just needed to tackle them one at a time. She didn’t do things for me, but she empowered me to do them myself. Eventually, I needed her less and less. I became increasingly capable of accomplishing tasks and staying motivated.

I was very fortunate to be surrounded by a group of women in my recovery community, and I became part of something bigger than myself. When the time came, becoming a peer support specialist (myself) felt like the right next step. I’ll never forget how much my peer support specialist helped me in early sobriety, and I wanted to be that support for someone else.

The Role of Peer Support Specialists in Substance Use Disorder Recovery

Peer support specialists, also known as peer recovery coaches, are individuals who have successfully navigated the recovery process and now assist others experiencing similar situations.¹ They play a crucial role in the recovery journey of individuals with substance use disorders (SUDs), offering a unique perspective and understanding that stems from their personal experiences. Indeed, peer support specialists are important members of SUD treatment teams.

Peer support specialists engage in a wide range of activities, including advocating for people in recovery, sharing resources, building skills, leading recovery groups, and mentoring.¹ They help individuals create personalized recovery plans and develop their own recovery pathways. The support they provide extends beyond the clinical care setting into the everyday lives of those seeking a successful, sustained recovery process.

Recovery coaches provide many different types of support:²

• emotional (empathy and concern)

• informational (connections to information and referrals to community resources that support health and wellness)

• instrumental (concrete supports such as housing or employment)

• affiliational (connections to recovery community supports, activities, and events)

The unique relationship between the peer recovery coach and the individual in recovery is grounded in trust, shared understanding, respect, and mutual empowerment.

Evidence Supporting the Effectiveness of Peer Support

People who have worked with peer recovery coaches often provide strong testimonies about the positive impact that peer recovery support played in their recovery journeys.² Several studies have evaluated the effectiveness of peer recovery support for individuals with SUDs.^2,3 While the body of research is still growing, there is mounting evidence that people who receive peer coaching reduce their substance use, have greater housing stability, are less likely to be re-admitted to the hospital or seek care in an emergency room, and are less likely to be arrested. Moreover, those with a peer coach indicate they feel greater social support, improved self-efficacy, increased satisfaction with their treatment experience, and greater engagement and better relationships with their treatment team. Peer recovery support services have also been associated with lowering the risk of sexually transmitted infections, like HIV and hepatitis B.

Finding My Purpose

Today, my life is full of meaning and purpose. I get the opportunity to share my experience, strengths, and hopes with someone who has lost all hope.

Each day is different. Not every patient is ready to take action. It’s difficult to watch someone struggle when you know there is a way out. But it’s all worth it when I get to talk to a patient who is open, willing, and ready to change. Watching them succeed is the greatest honor.

Every organization should make peer support available to those in recovery, and health professionals should facilitate connecting someone who’s struggling with addiction with a peer coach. It makes an enormous difference. There’s something special about that shared experience.

The Big Book of Alcoholics Anonymous says it best:

We are average Americans. All sections of this country and many of its occupations are represented, as well as many political, economic, social, and religious backgrounds. We are people who normally would not mix. But there exists among us a fellowship, a friendliness, and an understanding which is indescribably wonderful. We are like the passengers of a great liner the moment after rescue from shipwreck when camaraderie, joyousness and democracy pervade the vessel from steerage to Captain's table. Unlike the feelings of the ship's passengers, however, our joy in escape from disaster does not subside as we go our individual ways. The feeling of having shared in a common peril is one element in the powerful cement which binds us. But that in itself would never have held us together as we are now joined.

References

1. Peer Support Workers for those in Recovery. Substance Abuse and Mental Health Services Administration (SAMSHA), May 29 2024.

2. MacLellan J, Surey J, Abubakar I, Stagg HR. Peer support workers in health: a qualitative metasynthesis of their experiences. PLoS One 2015;10:e0141122.

3. Reif S, Braude L, Lyman DR, et al. Peer recovery support for individuals with substance use disorders: Assessing the evidence. Psychiatric Services 2014;65(7), 853-861.

Among the many factors that contribute to stigma are two ubiquitous, unavoidable, and well-understood psychological phenomena: attributions and counter-transference. Both of these phenomena are useful for our effective functioning in the world. However, each has a dark side that yields unintended consequences, including stigmatizing individuals, groups, or conditions.

Attributional Theory was developed in the field of Social Psychology and focuses on the interpretations we develop to explain why things happen. As each of us navigates the world, we routinely make conscious, intentional efforts to explain, understand, and figure out the “why” of what we encounter. My computer freezes, and I start ticking through my list of possibilities. Was I trying to run too many programs at once? Did the information technology (IT) department decide this was the best time to install an update? Did my virus scan start? Over time, many of our attributions become automatic, effortless, and outside of awareness. They work like habits, operating in the background without using our limited cognitive resources. Our automatic attributions are often tinged (or even saturated) with emotion. I don't feel the same about you if I assume I have been inconvenienced on purpose rather than by mistake. And I don't feel the same about you if I assume pain and suffering in your life is self-inflicted as opposed to the consequence of external factors out of your control.

In a study conducted at the University of Alabama, college students were asked to list the causes of alcohol and drug problems. They also completed a survey that measured their attitudes and beliefs toward people with these problems. Through qualitative analyses, they found that the explanations the students formulated coalesced into five clusters, which the researchers labeled “Biological,” “Self-Medication,” “Familial,” “Social,” and “Hedonistic.” These were further consolidated into two groups, broadly “Medical” and “Moral” explanations.  Importantly for understanding stigma against those who experience problems with drugs or alcohol, these researchers also found that students whose explanations aligned most closely with the Moral model had the highest level of stigma on the Stigma Attribution Scale. This study provides clear evidence that person-centered attributions (rather than external attributions) about why people develop an addictive disorder foster stigmatizing beliefs.

If attributions are normal, and mostly helpful in negotiating life, what can be done about their dark, stigmatizing side? It is axiomatic that we can’t change something until we gain awareness of it. Having accessed awareness, we must also be willing to make a change. Awareness and willingness form the foundation of personal change. Each of us should dispense with the self-congratulatory belief that, unlike other people, we are free from stigmatizing and biased attributions. We're not! If, on the other hand, we engage in the private work of self-examination and the self-change effort needed to better align our attributions with an evidence-based, disease-centered understanding of addictive disorders, we will have made a crucial start.

The concept of counter-transference was developed by Sigmund Freud to aid in understanding how the personal, private history of the psychoanalyst “shows up” in the context of conducting psychoanalysis with patients. This phenomenon sometimes impedes and harms the therapeutic process. Today, this concept, often described using different terminology, is also a core element of behavioral and cognitive-behavioral psychology. Namely, we are the product of our learning histories – we are shaped into whom we are by the accumulated rewards and punishments we have experienced. There is no escaping this: I bring the core of “me” into every interaction I have.

Each of us is exposed over the course of our lives to both subtle and overt messages about alcohol, drugs, and life problems precipitated by their use. Further, given the high prevalence of substance use in our culture, virtually all of us have encountered someone whose life is (or has been) adversely affected by substance use. For some of us, the relationship is with someone very close (e.g., a family member), and for others, the exposure has been more distal, such as a friend, coworker, or neighbor. Those encounters make an enduring imprint on our thoughts and emotions and, ultimately, on our behavior. Experiences that were painful or traumatic leave especially potent emotional traces.

One illuminating study that sheds light on how this psychological phenomenon impacts are attitudes toward individuals with an addictive disorder was conducted in a large cohort of medical residents across training years and medical specialties.² Each participant filled out a questionnaire asking about their satisfaction in working with patients with different mental health conditions, the worthiness of those patients for receiving medical care, and the likelihood of benefit from medical care. Collapsed across experience and specialty, participants rated individuals with a substance use disorder (alone or comorbid with schizophrenia) less satisfying to care for than individuals with schizophrenia alone or with major depression. Further, the more experience the residents had (i.e., the more advanced in their specialty training), the more negative their attitudes toward those with a substance use disorder. Moreover, emergency physicians, who often encounter these patients in the moments of their greatest need, had the most negative attitudes of any specialty. In sum, the increasing experience of residents with those suffering with substance use disorders served to increase rather than decrease their stigmatizing attitudes. This is a striking example of how cumulative experience can augment stigmatizing attitudes.

Of course, we don't have the luxury of freeing ourselves from autobiographical influences and their attendant emotional consequences. But by becoming more self-aware about these influences, we can take an important step toward eliminating stigmatizing counter-transference. If we have not yet attained competence in managing our own issues and negative attitudes toward substance use disorders, the best option, seemingly, might be to minimize contact with those who suffer with an addictive disorder. However, this is neither a satisfying nor effective option. Indeed, it is through increased contact and interaction – especially with individuals who experience remarkable and rapid positive changes when participating in treatment – that we can revise our attitudes and address our stigmatizing beliefs.

In sum, if we have a willingness to critically examine our attitudes toward substance use and those suffering with addiction, we will do well to think about both the attributional and experiential factors that have fostered our beliefs. This work is for each of us.

Sources

1.     Henderson NL & Dressler WW. Medical disease or moral defect? Stigma attribution and cultural models of addiction causality in a university population. Cult Med Psychiatry 2017; 41(4): 480-498.

2.     Avery JD, Taylor KD, Kast KA, et al. Attitudes toward individuals with mental illness and substance use disorders among resident physicians.  Prim Care Companion CNS Disord 2019; 21 (1): 18m02382.

Their stories are compelling. The authors take us on a journey with them. They critically reflect on their personal assumptions and our collective beliefs.

Politically speaking, these two authors are very different in their worldviews. Johann Hari is a Scottish journalist and a gay man who generally supports ideologically liberal policies. Christina Dent is a mother of three and a devout Christian from Mississippi who is ideologically conservative. But both have arrived at the same conclusions. Shaming and demonizing people with a substance use disorder does not lead to positive outcomes. People with a substance use disorder are suffering from psychological traumas. Criminalizing drugs creates dangerous, unregulated markets incentivized to distribute increasingly potent drugs. Prohibitions, restrictions, and punishments only worsen suffering. The road to recovery requires addressing each person’s underlying psychological needs and responding with empathy and concern.

The Drug War

Hari traces the roots of the so-called “war on drugs” back to Harry Anslinger, the first commissioner of the Federal Bureau of Narcotics (the predecessor to the Drug Enforcement Agency [DEA] today). Anslinger played a pivotal role in criminalizing drugs in the 1930s and fueling fears by linking marijuana use to psychosis, insanity, and violent crime, even though scientific evidence didn’t support these claims. He exploited racist ideology, associating drug use, particularly opioids and cannabis, with minority groups. Anslinger’s fear-driven campaign was intended to scare politicians and the public into supporting drug prohibition.

In writing his book, Hari spent three years interviewing a wide range of people directly involved in illicit drug sales and use. Among those he encounters during his journey are a cartel hitman, an addiction specialist, a researcher, and people with substance use disorders who become activists. Through their stories, Hari challenges prevailing beliefs about addiction and drug policies. He concludes that the criminalization of drugs is more dangerous than the drugs themselves. By exploring the alternative strategies that places like Portugal, Switzerland, and Uruguay have adopted, Hari develops an evolving understanding that leads him to advocate for a more compassionate and evidence-based approach—one that moves beyond prohibition and focuses on healing rather than punishment.

From Curiosity to Advocacy

Someone who participated in one of our recent workshops told me about Christina Dent — “You really need to meet her.” He immediately connected us. I watched her TEDx talk and downloaded her book on my Kindle.

The book chronicles Dent’s transformation after a life-changing encounter with the mother of her foster son. She weaves personal anecdotes, research, and interviews with individuals impacted by addiction into her narrative. These stories provide a vivid and detailed look at the negative impacts of using the legal system to address a health problem. As she delves deeper, Dent discovers unexpected solutions that can save lives, heal families, and promote public safety. Her vision challenges prevailing norms and invites readers to join her in exploring a more compassionate and evidence-based approach to addiction.

Curious isn’t just a story—it’s an invitation. Dent encourages readers to get curious alongside her, considering how cultures worldwide might shift their approach to drug use and response to people suffering from a substance use disorder. Her journey eventually led Dent to create a non-profit, End It For Good, through which she hopes to create an opportunity for all of us to thrive, emphasizing compassion, and implementing effective solutions to address drug use and addiction in our society.

I’ve Changed

Like Hari and Dent, I’ve been changed by the stories of people adversely impacted by stigma. The stories of health professional colleagues who have lost their livelihoods due to substance use. The stories of young men and women with unaddressed childhood trauma. The stories of social pressure to consume drugs. The stories of anger and frustration by law enforcement. While stories are anecdotal and intended to pull on our emotions, the evidence is irrefutable. Forcing drug use “underground” has created dangerous illegal marketplaces, and stigmatizing beliefs have led to enormous hardships, destroyed families, and prevented people from seeking treatment.

Even if drugs were legalized tomorrow, the deep cultural beliefs about the unworthiness of people with an addictive disorder will remain unless we are willing to re-examine those beliefs. We can’t legislate compassion. Indeed, the “drug war” is a reflection of our widely held societal views—and our failure to see addiction as a health problem.

If you want to learn more (and I assume you do since you are reading this essay), Chasing The Scream and Curious should be on your shortlist to read.

Post Script

After writing this essay, I had the honor of meeting Christina Dent. She brought me a signed copy of her book (which I will cherish). My impressions, initially formulated based on her writing, were affirmed. She’s warm, sincere, passionate, and committed. She explained how her newfound viewpoints are grounded in her values—that life is sacred, and public policy should serve society by fortifying families, keeping people safe, and promoting personal responsibility. And, while change comes slowly, she’s hopeful about the future. With Christina shepherding this seismic social movement, perhaps the people of Mississippi can model the way.

The primary treatment objective when using medications for addiction is to mitigate cravings, reduce withdrawal symptoms, and support individuals in leading productive lives during their recovery journey. Before diving into common misconceptions, it is important to review the potential treatment options available for various substance use disorders (SUDs). With the increased publicity and stigma associated with medications for opioid use disorder (MOUD), particularly methadone and buprenorphine, it can be easy for us to forget that there are many treatments available for SUDs. Here’s a high-level overview of the FDA-approved medications for SUDs.

Medications for Substance Use Disorders

Debunking a Few Myths

Unfortunately, there are lots of myths about medications for SUDs.  Here are a few common ones:

Medications are just substituting one addiction for another.

This is probably one of the most common misconceptions I hear from patients, my students, friends, AND many health professionals. As a society, we often forget that “replacement therapy” has been used for years with nicotine addiction.  Smoking cigarettes causes lots of harm, and they contain a bunch of nasty chemicals that cause lung damage and increase the risk of heart disease and many cancers. The purpose of NRT isn’t to get someone “addicted” to a nicotine patch.  Rather, it’s to mitigate craving and reduce withdrawal symptoms so that the person is no longer thinking about smoking all of the time.  NRT is typically combined with smoking cessation counseling, giving the person a better chance of remaining smoke-free.  Some people use NRT for a few weeks.  Some people use NRT for years.  We’d much rather have a person use NRT than have a setback into smoking cigarettes again.  Sure, it would be great if the person didn’t need NRT and never had a desire to smoke cigarettes again.  But there is nothing “wrong” with using NRT.  Most people would agree that using NRT is perfectly acceptable and an important part of the recovery process for many people who smoke.

But for some odd reason, many in our society view medications for other addictions, particularly medications for opioid use disorder, very differently. This misconception fails to acknowledge the nuanced pharmacologic differences between heroin (and other drugs obtained on “the street”) and medications like buprenorphine and methadone. Unlike short-acting opioids, these medications are longer-acting and carefully dosed to limit feelings of euphoria while reducing, sometimes eliminating cravings. It is important to highlight that just as we use insulin to “replace” something the dysfunctional pancreatic can’t produce, medications for opioid use disorder address neurochemical deficits the brain is experiencing.  Remember, addiction is a neurobiological disease, and dopamine deprivation leads to discomfort and pain.  Without medication, many people will continue an endless cycle of intoxication/binge, withdrawal/negative affect, and craving/preoccupation.

You should not need medications for addiction long-term.

The notion that medication treatment should be taken for only a few weeks overlooks the fact that addiction rewires our brains.  Most people suffered through their addiction for many years before seeking treatment.  Establishing new habits (conditioning model) will take a significant amount of time (see Chaz Richardson’s blog post Addiction is a Neurobiological Disease). Consider your own habits you have tried to “break” – how long have you been trying to adjust your routine without success? Additionally, SUD medications vary in their effectiveness from person to person (just like any treatment!). Several factors influence the pace at which someone can reduce the dose and eventually taper off their medications, including the substance of misuse and the severity of the addiction. Rushing this process risks a setback in the recovery journey, and setbacks often have significant psychological as well as physiological consequences.  Therefore, we need to continually assess the person’s progress and engage in open discussions about when someone feels ready to begin the tapering process. Not everyone will succeed with the initial taper attempt.  Ultimately, there is no “recommended timeline” for patients to be maintained on medications for SUD.

Medication should not be started until someone has completed withdrawal and remains abstinent.

It’s true that certain medications require complete abstinence for a period of time before they can be safely used – otherwise, they could induce severe withdrawal symptoms. For example, naltrexone for OUD and disulfiram for alcohol use disorder. However, these medications are the exceptions. Many medications for SUD can be safely initiated when a person is experiencing mild to moderate withdrawal symptoms and even when someone is still using substances. Initiating medications in this early timeframe takes a harm-reduction approach that results in positive treatment outcomes. Current guidelines for OUD advocate for the initiation of methadone or buprenorphine as first-line therapy to prevent opioid withdrawal.¹ Abrupt cessation of opioids can trigger intense cravings and an acute withdrawal syndrome that, in turn, promotes drug-seeking behavior, overdose, and even death.

The buprenorphine/naloxone combination product should be the only burprenorphine product used for OUD.

This misconception may seem plausible.  Naloxone, after all, is supposed to deter misuse. However, the reality is more nuanced. When developing this product, pharmaceutical scientists identified the potential for buprenorphine misuse and included naloxone to deter diversion. However, naloxone is minimally absorbed orally and must be administered intravenously, intramuscularly, or by nasal spray to reverse an opioid overdose. Consequently, the naloxone component in the oral combination product has no effect unless the medication is crushed and injected. So yes, it can prevent misuse to a degree, but when taken as prescribed, naloxone has no effect. Opting for the combination product may be warranted if diversion and misuse are a concern. However, not everyone can tolerate this particular product, and some require an alternative formulation. We shouldn’t restrict access to buprenorphine based on this misconception.    

Although these misconceptions may appear harmless, they create significant barriers to care at both the individual and system levels. In 2022 alone, an estimated 54.6 million people needed treatment for a SUD, yet only 26% of those people received any help.² This is a very wide gap, and the reasons are multifaceted.  But anecdotally, I have witnessed stigma surrounding medications for SUD deter patients from seeking treatment, providers from prescribing them, and pharmacies from stocking them. At a system level, there are significant barriers to getting access to medications like buprenorphine and methadone. There are strict dispensing limitations for pharmacies, and methadone can only be obtained from a licensed OUD treatment facility rather than through a local pharmacy.

Medications for SUDs are intended to complement behavioral treatments but can be used alone.  It all depends on what the individual deems most effective for their recovery journey. Dispelling misconceptions and combatting the stigma surrounding these medications facilitates informed decision-making. By acknowledging the positive role that medications can play in addiction treatment, individuals can use a variety of strategies in recovery. Medications can improve a person’s sense of well-being, and there is strong evidence that they can increase the odds of sustained success. Let’s work together to debunk myths and foster an acceptance of medications for addiction.

Resources:

1. Crotty K, Freedman KI, Kampman KM. Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. Journal of Addiction Medicine 2020; 14(2): 99-112.

2. 2022 National Survey on Drug Use and Health (NSDUH) Releases. Accessed May 11, 2024.

The Emotional Toll

For the individual suffering from SUD, feelings of shame and guilt are common. We know that stigma is a major driver of the addiction crisis, and it discourages people from seeking help or even talking about their illness. It’s telling that many will avoid attending a 12-step support group where they might encounter a co-worker or neighbor. They might feel regret for the pain they have caused loved ones and for the mistakes they have made under the influence. Suicide is all too common.²

Family members often must bear witness to their loved one's self-destruction, and this causes significant emotional distress.³ They can live in a constant state of worry and fear for the well-being of their loved ones. The unpredictable nature of SUD can lead to a chaotic and unstable home environment, which can be particularly damaging for children who suffer emotional turmoil and psychological damage.

Family members also experience addiction stigma and shame. Parents are often reluctant to admit that their child has a substance use disorder. Children actively hide a parent’s addiction, knowing that it is socially unacceptable. When a loved one dies of an overdose, family members often must grieve in silence and isolation.¹

Witnessing an overdose or discovering a loved one who has died from an overdose is traumatic. Millions of Americans experience a devasting sense of loss that can linger for years.¹ Overdose loss survivors, friends and family as well as people who use drugs, have few resources available to them to process their experience.

The Economic Toll

Similar to other prevalent chronic diseases, like diabetes, cancer, and heart disease, the economic burden of substance use disorder is huge. Individuals dealing with SUD often face financial difficulties. The cost of sustaining the substance use, coupled with the potential loss of employment due to the inability to function effectively at work, leads to financial instability. At the same time, medical treatments and rehabilitation programs for SUD are costly, further exacerbating the financial strain on individuals and their families.

The direct medical cost to treat substance use disorder is more than $15k per person per year and totals more than $35 billion.⁴ But that pales in the face of the broader, indirect costs. In the United States, the estimated economic cost of opioid use (alone) was 1.5 trillion dollars in 2020. In addition to direct medical costs, substance use disorder leads to lost work productivity, increases the risk of withdrawing from school, and contributes to the high cost of running our criminal justice system. Dropping out of school affects not only the individual's future prospects but also the community's productivity and long-term economic growth.

The Societal Toll

The cycle of addiction perpetuates a cycle of poverty and disenfranchisement, trapping individuals, families, and communities in a downward spiral with limited avenues for escape. Communities affected by high rates of SUD can experience collective emotional distress. Higher crime rates and a deterioration in social cohesion can lead to feelings of fear and mistrust. The strain on public services such as law enforcement can create a sense of frustration and helplessness.

The negative social impacts of substance use disorder permeate every facet of society, underscoring the need for comprehensive prevention and intervention strategies.

If you put shame in a petri dish, it needs three ingredients to grow exponentially: secrecy, silence, and judgment. If you put the same amount of shame in the petri dish and douse it with empathy, it can’t survive.
-Brené Brown

References:

1. Athey A, Kilmer B, Cerel J. An Overlooked Emergency: More than One in Eight US Adults Have Had Their Lives Disrupted by Drug Overdose Deaths. Am J Public Health 2024; 114 (3): 276-279.

2. Lynch FL, Peterson EL, Lu CY, et al. Substance use disorders and risk of suicide in a general US population: a case control study. Addict Sci Clin Pract 2020; 15: article 14.

3. Landers L, Howsare J, Byrne M. The Impact of Substance Use Disorders on Families and Children: From Theory to Practice. Soc Work Public Health 2013; 28 (3-4): 194-205.

4. Li M, Peterson C, Xu L, et al. Medical Costs of Substance Use Disorders in the US Employer-Sponsored Insurance Population. JAMA Netw Open. 2023;6(1):e2252378. doi:10.1001/jamanetworkopen.2022.52378

Language is the lens through which we perceive reality—it frames our understanding of the world.  Attitudes are not merely reflected but constructed through language.  Our attitudes and beliefs are often unconsciously formed by the words we use.  Words, therefore, shape how health professionals view people and how they treat them. This interplay between language and belief underscores the importance of critically examining the words we use. To ensure patients with SUD can access healthcare and evidence-based treatments, we must address the conscious and unconscious biases that providers often hold.  Stigma is propagated through words.

To underscore the impact words have on the care of patients, one landmark study compared the responses from clinicians who were presented with a case vignette and asked a series of questions.¹  All of the participants received the same case except in one vignette the individual was described as “a substance abuser” and in the other “having a substance use disorder.”  When the patient was described as a “substance abuser,” the respondent was more likely to indicate that the individual in the vignette was personally responsible for the disorder and should be punished.  Furthermore, the participants were significantly less likely to offer to help the “substance abuser” seek treatment.

The words clinicians use often get transmitted through medical records and influence how other providers perceive the patient. In another study, research conducted a qualitative analysis to determine if physicians use stigmatizing language in their clinical care notes.² The researchers found that providers frequently express their biases towards patients in the medical record.  These positive and negative attitudes can profoundly change the care a patient receives. Some of the most common forms of negative language included statements questioning the patient’s credibility, expressing disapproval of a patient’s reasoning, portraying the patient as difficult, and emphasizing the provider’s authority over the patient.

While any patient with a SUD is likely to encounter stigmatizing language and beliefs, stigma is often compounded by other patient-specific factors, including stereotypes based on race, social class, or history of incarceration. (See related essay Double Jeopardy by Stuart Haines)

Words have impacted me at my most vulnerable times. Some words felt like attacks, attempting to replace my true identity. Instead of intelligent, funny, or hard-working, I became homeless, indigent, and incapacitated. The words become grenades— strategically spoken at times in order to do the most damage.

These labels erased my humanity. Total strangers felt allowed to criticize or judge me, saying that I was ‘such a waste of life,’ ‘useless,’ or ‘just a drunk or addict.’

After a while, I began to believe these words.

Spoken words cannot be un-said, and they have the power to build up a person, or to destroy a person.

-Marissa Angerer, Mother, Friend, Lawyer, Person in Recovery, and Shatterproof Ambassador

Quote excerpted from the Shatterproof Addiction Language Guide

While addressing stigma is not easy, there is hope for both patients and providers. There is a growing body of evidence to suggest that we can change people’s attitudes and beliefs through training and self-reflection.^3,4,5  Changing one’s language can have reverberating affects not just for patients with SUD, but also among health professional colleagues and for our communities at large. Shatterproof ADDICTION LANGUAGE GUIDE is a free resource that provides a list of recommended language to use when speaking about and to people with a substance use disorder. Plus, it includes helpful suggestions for implementation.

Shatterproof Addiction Language Guide

It cannot go without saying that the job of healthcare workers comes with many challenges, both professionally and emotionally. The burden of this work should not fall solely on the shoulders of those working on the front lines with patients. We also must seek to address systemic stigma, holding institutions accountable for instituting policies and practices that prioritize the health of all patients in their care.

References

1. Kelly JF and Westerhoff CM.  Does it matter how we refer to individuals with substance-related conditions?  A randomized study of two commonly used terms.  Int J Drug Policy 2010; 21(3): 202-207.

2. Park J, Saha S, and Chee B.  Physician use of stigmatizing language in patient medical records.  JAMA Netw Open 2021; 4 (7): e2117052

3. Avery J, Knoepflmacher D, Mauer E, et al.  Improvement in residents’ attitudes toward individuals with substance use disorders following an online training module on stigma.  HSS J 2019; 15 (1): 31-36.

4. Greer D, Barta L, Liu MT, Andrews LB.  Subjective and objective benefits of a novel opioid-related disorders simulation learning experience for pharmacy students.  J Am Coll Clin Pharm 2024; 7: 133-1349.

5. Bielenberg J, Swisher G, Lembke A, Haug NAC. A systematic review of stigma interventions for providers who treat patients with substance use disorders. J Substance Abuse Treat 2021; 131: 108486.

Given that an estimated 40 million people (roughly the population of Florida and New York combined) 12 years old and older have a substance use disorder, all of us know and regularly interact with people who have an addiction to drugs or alcohol.  Health professionals who do not understand the pathophysiology of addiction can (unintentionally but unfortunately) worsen the stigma and reduce the likelihood that people will achieve recovery.

First, let us lay a foundation with a few definitions:

• Dependence is the state of being influenced or determined by another.  In the case of substance use, the person would not feel normal without taking the substance.

• Addiction is a chronic, relapsing brain disease that is characterized by compulsive behavior, such as seeking and using an addictive substance or engaging in a behavior, despite harmful consequences.

• Substance use disorder (SUD) is the recurrent use of a substance that causes significant functional impairment, including negative health consequences and problems at home, work, or school.

I include these definitions to make sure we are all on the same page and using these terms in the right context.  Dependence is an important one to point out because dependence alone does not mean a person has an addiction. For example, I have been drinking a cup of coffee in the morning for most of my adult life.  If I do not drink my morning coffee, I will (more than likely) have a withdrawal headache. A withdrawal headache is uncomfortable but not serious. It indicates that I’m dependent on caffeine to feel “normal.”

The terms addiction and SUD are similar and overlapping concepts.  Addiction refers to the cyclical, repetitive, and compulsive nature of the disease.  Individuals can develop an addiction to many things.  Gambling.  Gaming.  Dermatillomania (skin picking).  Chewing ice!  SUD is a specific type of addiction that causes impairment and dysfunction, and the person is unable to stop the substance use on their own. 

Dopamine is a key player in the development of addiction. (See the article Motivated by Dopamine by Stuart T Haines).  In short, the behavior or substance use releases dopamine in the brain.  Dopamine plays a central role in our natural reward system, prompting us to seek food, water, shelter, and sex.  It also prods us to nurture our young.  Thus, dopamine is critical to our survival!

Addictive substances often mimic a natural neurotransmitter, stimulating an endogenous receptor in our brain, and potentiate dopamine release.  Examples include opioids, cannabis, alcohol, and nicotine. Amphetamines and cocaine release abnormally large amounts of dopamine. This likely explains why stimulants are more addictive than other substances. Stimulants can cause as much as 100 times more dopamine release when compared to our natural reward system. Other substances range between 10 and 50 times more. 

Another key element of addiction is conditioned response.  You probably remember Pavlov’s dogs.

Dogs salivate when they see food. They anticipate eating the food, so their bodies are preparing for it. And they are motivated to consume it. This “unconditioned response” is created by the natural reward system.  We are all motivated to eat in order to survive.  In Pavlov’s experiment, he began announcing the arrival of food with a bell.  At first, of course, the dogs didn’t know what the bell signaled – it was a neutral stimulus.  But over time, by repeatedly ringing the bell as food was being served every day, the dogs learned that the sound of the bell was associated with food.  Thus, the neural pathways in the dogs’ brains were being “conditioned” to respond to the bell in a way that was similar to food. Eventually, when the bell rang, the dogs' mouths would salivate, even when food was NOT presented.

At this point, you might be saying, what’s your point?  But when you see this picture, what is the first thing that comes to your mind?

It’s “just a sign”, right? But it is probably associated with all sorts of things in your brain.  Perhaps a favorite menu item. A funny story. Or maybe thoughts about the obesity epidemic. Through repeated exposure to the sign, your brain has created neuronal tracks that stimulate certain thoughts. It might even trigger your natural reward system. Your brain is very good at noticing patterns and anticipating.

The brain is always looking for associations and patterns to release dopamine.  A delicious piece of chocolate cake -> release dopamine; a funny TV show -> release dopamine; an enjoyable conversation/laugh with a friend -> release dopamine. The brain notices the association and subconsciously puts the circumstances of these events together.  For example, the last time you and a friend had an enjoyable conversation, there was a song playing. The next time you hear the song, you might have a brief recollection of the event, you might smile to yourself, and you might be motivated to call your friend. The trigger (hearing the song) might induce a small release of dopamine, motivating you to initiate action toward recreating the previous experience. There is nothing wrong with calling your friend and maintaining a close relationship. In this case, the release of dopamine has resulted in a positive behavior that will improve your survival.

But this can work against you. When a person repeatedly uses a substance or engages in a behavior that releases a lot of dopamine, it can develop into a cycle that is exceedingly difficult to stop. The person begins seeking the substance far more than the natural rewards would ordinarily promote because the brain becomes accustomed to a larger and larger amount of dopamine.  The brain adapts. Without these high levels of dopamine, the person doesn’t feel normal and has compulsive thoughts about the substance or behavior. Which brings us back to the addiction cycle.

Binge and intoxication

• Dopamine production and release in the ventral striatum (limbic and nucleus accumbens)

• Conditioned responses are formed and reinforced

• Dopamine release becomes anticipatory through association with triggers and cues

• Hedonic adaptation (substance is now needed in larger amounts in order to feel “normal”)

Withdrawal and Negative Affect

• Diminished euphoria and then dysphoria

• The amygdala is activated – this promotes a sensation of fear

• Habenula is activated – triggers misery-fleeing²

• Consumes substances or engages in behavior to avoid dysphoria

Preoccupation and Anticipation

• The hippocampus (memory) and anterior cingulate (planning, organization) are activated

• The orbitofrontal cortex (executive function) is impaired, diminishing the ability to resist cravings

• Compulsive substance use occurs and perpetuates the cycle of addiction

There are some specific risk factors that have been identified in addiction research.^3,4  Family history is a significant one.  If a family member has a SUD or addiction, there is a much higher risk of developing one.  Early exposure is another, particularly if the exposure occurs in adolescence when the person’s brain is still developing.  Environmental stimuli can also increase the risk.  For example, a person’s environment teaches them that using substances is acceptable or even encouraged when “having a bad day.”  A mental health problem or trauma also increases the risk as some patients ‘self-medicate’ their depression or anxiety rather than developing more healthy ways of coping or receiving treatments that are unlikely to promote addiction.  In people with impaired executive function, such as those with attention deficit hyperactivity disorder (ADHD), the risk of SUD and addiction is also higher.

The bottom line: addiction is a disease. Addiction is not a lifestyle choice; any more than cancer, diabetes, or osteoarthritis are choices. Behaviors contribute to all of these diseases, but no one chooses them. Similar to other diseases, addiction causes dysfunction and impairment. Like other chronic diseases, addiction has proven risk factors, genetic predispositions, and a pathophysiologic model (the addiction cycle). As the disease progresses, the symptoms become stronger and harder to treat. Thus, addiction becomes progressively worse as the neural pathways are recurrently reinforced. Patients who struggle with addiction experience cravings or triggers (thoughts of use) even when they are in recovery for many years. The associations in the brain persist. And like other chronic diseases, there are medications that help. Medications can lessen the impairments, reduce the cravings, and disrupt the addiction cycle. 

When we understand that addiction is a disease, we are more likely to offer help, display compassion, and be a supportive advocate to those in need.

References

1. Volkow ND, Koob GF, McLellan AT.  Neurobiological Advances from the Brain Disease Model of Addiction. N Engl J Med 2016; 374: 363–371.

2. Batalla A, Homberg JR, Lipina TV, et al. The Role of the Habenula in the Transition from Reward to Misery in Substance Use and Mood Disorders. Neurosci Biobehav Rev 2017; 80: 276–285. doi:10.1016/j.neubiorev.2017.03.019.

3. Galanter M and Kleber HD. The American Psychiatric Publishing Textbook of Substance Abuse Treatment. American Psychiatric Publishing, 2015.

4. Sadock BJ, Sadock VA, and Ruiz P. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11^th edition. Lippincott Williams & Wilkins, 2015.

I started drinking as soon as I got to college. We were all having a great time celebrating our newfound independence and the absence of curfew.

But I seemed to be doing it differently than the people around me. I was that girl who always took it a little too far and ruined a perfectly good time. My goal was to get blackout drunk, and I didn’t understand why anyone would choose any other way. Why were these people just drinking in moderation? They were missing the point.

I didn’t understand it at the time, but I had a disease.¹ 

As you can imagine, I wasn’t at the top of any invite lists because people around me got tired of my antics. Nobody wanted to babysit me or have the whole night focused on the drama I manufactured. I didn’t have a lot of girlfriends in college because the only group of people that really accepted me was a group of NROTC* Marines in my dorm that drank whiskey like I did. I clung to those guys. They appreciated my love for liquor. They were my people. They got me.

Fast forward ten years … those Marines started families and had careers. I’m sure they would drink occasionally, but they weren’t chained to it. Controlled by it. Meanwhile, you would find me—by myself—at the local bar while my parents watched my son at home. It was all fun and games in college, but other people were able to grow up and have new priorities. I was still attached to and completely dependent on alcohol.

Day drinking became normal for me. Within a few years, it turned into morning drinking. I drank before I took my son to school. I drank before work and at work. I was never not drinking.

I don’t write these words flippantly. These aren’t inconsequential details that pop up in my head, like something I forgot to put on the grocery list. These are the hard facts of my alcoholism that I would love to leave out. These are the moments that bring me the most shame.

But these are also the things I have worked on with therapists over time so I can be a productive person and learn from my past instead of staying stuck in a hole of self-pity. 

The fact that I consistently drove my son around while highly intoxicated still makes my stomach turn. But I have to tell you these things because that is addiction. I was a slave to alcohol, and I had no power. Ask any person if they would take several shots of tequila before driving their sweet, precious child to school. No logical person would do that. Only a monster would do that. That’s who I had become.

When I finally got help and received inpatient treatment for my alcoholism, I felt like a monster. The fog in my head was clearing; I was getting my sanity back.  I felt like the worst mother in the world.

Fortunately for me, I had people in my life who believed in me.  Who understood that addiction is a disease – a brain disorder. The clinical team at my treatment center guided me and gave me the tools I needed to work through my thoughts and feelings. The 12-Step Program² taught me that lack of power over alcohol was the problem. I needed access to a power greater than myself to get me out of this mess.

The women around me who were also fighting their way out of this madness were the ones who taught me how to be there for others. Receiving that support was a godsend. And in giving support to others, I found my purpose. I am now a peer support specialist and love helping others who struggle with addiction.

I know what addiction feels like. I wanted to stop drinking more than anything.  But I couldn’t. Until I received help, support, some tough love, but also compassion. I owe it to those who suffer from a substance use disorder to share the good news.

There is a way out. You are not doomed. There is hope. 

And I am living proof.

*NROTC = Naval Reserve Officer Training Corps

1.     Massachusetts General Hospital, Recovery Research Institute.  The Power of Perceptions and Understanding: Why Addiction is a Disease, and Why It’s Important.   Resource Guide, 2022.

2.     Alcoholics Anonymous. The Twelve Steps. Alcoholics Anonymous World Services, Inc. 2024

It is crucial to understand the nature of addiction to appreciate how each of us is susceptible. Addiction is not a moral failing or a lack of willpower; it is a complex interplay of numerous factors, including genetic predisposition and environmental influences. It’s true that there is a genetic component of addiction, and substance use disorder can “run in families.”  However, habituation of behavior is inherent in all of us. Anyone can develop unhealthy patterns of behavior facilitated by environmental stimuli. Likewise, trauma, either psychological or physical, often serves as a catalyst for substance use. Anyone can experience a traumatic event or a toxic relationship.  These facts should disabuse all of us of the notion that certain individuals are protected from addiction based on their upbringing, lifestyle, or societal status.

All too often, we associate addiction with specific stereotypes, such as the homeless man living on the streets, the rebellious teenager, or the “party-hard” thrill seeker. These stereotypes not only perpetuate harmful biases but also contribute to the illusion that addiction is a problem only in certain groups or stages of life. We cannot forget that there are millions of people who, on the surface, appear to “have it all together” but are silently battling an addiction behind closed doors. Their ability to “function” masks the severity of the addiction, leading to misconceptions about who is susceptible to this disease.

As health professionals, we are supposed to be the champions of healthy habits. But few of us live up to the ideal. Our behaviors often fall short. We are human, after all, and subject to the same genetic and environmental influences.  So, we are just as susceptible to experiencing addiction. In fact, substance use and addiction rates among health professionals are not much different than the general population.^1-3 A report published by the Substance Abuse and Mental Health Service Administration (SAMHSA), culling data from their National Surveys on Drug Use and Health (NSDUH), found that 5.7% of healthcare and social assistance professionals employed full-time reported suffering from a substance use disorder (SUD) in the previous year.⁴ However, these data pre-date the COVID-19 pandemic, and it’s likely an underestimate of the current prevalence of SUD. Moreover, health professionals often feel uncomfortable sharing this information for fear of losing their license or ability to practice. This is why it’s so important that licensing boards provide pathways for health professionals to seek help and remain in recovery without fear of losing their license. Most, if not all, states will have a formal mechanism to help and support health professionals living with SUD. For example, in Mississippi, the Mississippi Physician Health Program (MPHP), the Mississippi Nurse Voluntary Program (MVP), and the Mississippi Association of Recovering Pharmacists (MARP) are officially recognized organizations that provide ongoing support to those in recovery and host educational programming to increase awareness.

The stigma surrounding addiction often prevents individuals from seeking help. Stigma is rooted in misconceptions and leads to shame and isolation. Millions of people and many of your patients and colleagues are silently struggling. We all need to help break down the walls of denial that individuals often build around themselves. Seeking help is not a sign of weakness, but rather, it is a courageous acknowledgment of one’s vulnerability. As health professionals, we are called to reduce suffering. Through our collective efforts, we can promote awareness, provide support, and foster environments where seeking help is encouraged.

No one is immune to addiction.

Everyone deserves compassion and a path to recovery.

References:

1.     Bennett J and O’Donovan D. Substance misuse by doctors, nurses, and other healthcare workers. Current Opinion in Psychiatry 2001; 14 (3): 195-199.

2.     Baldisseri MR. Impaired healthcare professional. Critical Care Medicine 2007; 35 (2 suppl): S106-S116.

3.     Merlo LJ, Trejo-Lopez J, Conwell T, and Riverbark J. Patterns of substance abuse initiation among healthcare professionals in recovery. Am J Addict 2013; 22: 605-612.

4.     The CBHSQ Report. Substance Use and Substance Use Disorder by Industry.  Substance Abuse and Mental Health Administration.  April 16, 2025. 

I am April. I am a pharmacist.

And I have a substance use disorder.

My struggles with substance misuse began soon after graduating from pharmacy school. As I transitioned from the highly structured academic environment, where performance was rewarded and acknowledged, to working a traditional pharmacy job, I had a lot more free time.  I had feelings of dissatisfaction. The job was stressful. When I wasn’t working, I wanted to relax and escape boredom.  After all, I’d worked hard and deserved it, right? Conveniently, my husband was in his first professional year of pharmacy school, and I could hang out with him and attend pharmacy school parties.  

Just a little over a year after I had become licensed, I faced the consequences of my substance misuse. On that day, in early August 2008, my world came crashing down on me. I was investigated by the Board of Pharmacy and required to become a “member” of the Mississippi Association of Recovering Pharmacists (MARP).  

I never envisioned my career and life would head in this direction.  I was just doing my partying a little later in life. But it got out of hand. I wanted so very much to be able to go back in time and change the course of events. I hoped everyone would just forget what happened. I promised myself I would never do it again. 

While I was resistant to the idea at first, MARP has been a critical part of my recovery.  They supported me step by step through the process. With reassurance and encouragement, they helped me pursue treatment. Over the next 6 years, I met all the requirements of the Board of Pharmacy and MARP.  I was able to get my career back on track.

Although I was able to regain my professional standing, I was deeply embarrassed. I wanted to avoid everyone in the pharmacy field who might know about my issues with substances. To my family and friends, I acknowledged I had made poor decisions. I did things I was not proud of, but in my mind, my issues were minor. I didn’t view myself as someone with an addiction or a substance use disorder.  Everything was great. 

Until …

August 2016. I relapsed.  But this time was different. I was able to be more open-minded.  I now recognized that I needed treatment.  I began to work on myself and address the root causes of my substance use.

I've struggled with the stigma of being a pharmacist in recovery.  And it’s made my recovery so much harder.1

One experience sticks out in my mind. I was working in the banking industry between pharmacy jobs in 2018. As it happened that day, two pharmacists I went to pharmacy school with walked into the lobby of the bank. I left my workstation and hid in the break room to avoid them seeing me. 

I felt like a failure, a fraud. Not good enough. A pharmacist should be smarter than to end up addicted to medications, right? Seeing these people stirred up all these negative feelings.  In reality, these two individuals said nothing to me.  They probably didn’t even know I was there.  But I anticipated their judgment (stigma), and I felt shame (self-stigma).

I've lost many job opportunities over the years due to unfair company policies that prohibit hiring pharmacists with a license on probation.  It’s hard to describe the feeling when you nail an interview, and the manager seems very interested in hiring you.  You think the job is a good fit.  But once you mention MARP or a history of substance use, the entire conversation and tone changes. The interview and chat wrap up quickly. You never hear back. That's stigma.

These feelings of inadequacy and being ostracized by my colleagues kept me in a cycle of relapsing and recovering.  I went through numerous cycles. The self-stigma became stronger. 

Many pharmacists (and nurses and other health professionals) in recovery are forced to take minimum-wage jobs or remain unemployed for years, praying they can find meaningful employment.  Fortunately for me, I have found work that capitalizes on my advanced knowledge and skills.

We need to stand up for our fellow healthcare professionals in recovery and advocate for opportunities for them to continue to practice their profession in a safe environment.  This requires education and advocacy.  Working in a pharmacy can be especially problematic for someone with a substance use disorder, given the access to controlled substances.  It’s a temptation.  Nurses, physicians, dentists, and veterinarians face similar challenges. This is why we need to think outside the box. We need to help those with an SUD find non-traditional roles working in settings where there is little or no access to controlled substances.  Health professionals who have experienced addiction have real-world knowledge and can help educate others.  Unfortunately, our society and our institutions erect many barriers to employing health professionals with an SUD.  These barriers are often too difficult to overcome. 

We can all work to support health professionals in recovery by critically examining our biases and reconsidering institutional policies.

I am a wife, a mom, a friend, and a coworker. And I’m a strong and proud advocate for stigma reduction. Today, I’m in recovery, and I no longer let my addiction define me.

References

The United States has more people incarcerated than any other nation on earth. According to the Prison Policy Initiative, there were 2.3 million people in the United States in jail or prison in 2019.1 That translates into a rate of about 0.7% of the population, or 698 per 100,000 people. It might not sound like a lot, but it's higher than any other country. Most European countries have rates of less than 100 per 100,000 people. The rate of incarceration in Finland and Sweden is just 57 per 100,000 people (that’s more than 10-fold lower than in the US). In the United Kingdom, it’s 77. And for our friends to the north, Canada, the rate is 114.

And rates of incarceration within the United States vary wildly. Mississippi, Louisiana, and Oklahoma have the highest rates of incarceration (all above 1000 per 100,000 people). While states like Vermont, Massachusetts, Rhode Island, and Minnesota have consistently had rates less than 400. Which is on par with South Africa, Brazil, and the Russian Federation. So, it's not something to brag about.

Drug-related offenses and crimes fueled by drug and alcohol use are among the most common reasons people are incarcerated.2 Before the COVID-19 pandemic, police were making more than 1 million drug possession arrests each year. And drug-trafficking convictions are a defining feature of the Federal Prison system.3

Systemic racism also plays a critical role in criminalizing drug use and compounds the health inequities seen in our society.4 Suburban White people are often portrayed in the media as “victims” of the medical system that prescribed opioids or other addictive substances. Black and Hispanic patients, on the other hand, are often depicted in TV and movies as people engaged in illicit drug trade. Black and Hispanic people have less access to medical professionals willing to treat SUD or provide evidence-based treatments, like buprenorphine. Moreover, providers are more reluctant to prescribe medications to people from marginalized communities due to fears of diversion. Finally, people of color are more likely to be incarcerated for drug-related crimes, even in cases where similar criminal offenses have been committed.5

People trapped in our criminal justice system often have lots of unmet needs - social, psychological, and physical. Unfortunately, few local jails or state prisons have the resources or expertise to treat individuals with SUD. An estimated 50% of those in state prisons have a SUD before their arrest, but only a small fraction (10%) receive any kind of treatment, and a very small percentage receive medication-assisted treatment (MAT). The number of prisoners who died from acute intoxication or withdrawal while in jail increased by 400% between 2000 and 2018. Jails and prisons are just not well-equipped to address the underlying causes, and once released, most people convicted of a crime don’t receive SUD treatment. So, it’s little wonder that recidivism is high.

Now, this essay is not intended to be a political statement about whether we should or should not be “tough” on crime. Rather, my intention is to question our cultural beliefs about substance use and addiction. It’s widely considered a moral failing to use “drugs.” And we believe that those who use “drugs” should be punished. However, there is a bit of hypocrisy in that some substances are more socially acceptable than others. Like alcohol (ethanol), tobacco (nicotine), and coffee (caffeine). And, in recent years, cannabis (THC and CBD). So, what is considered acceptable and unacceptable is determined by social norms, not their potential to cause harm. Tobacco use was considered acceptable 40 years ago. Today, tobacco use is considered socially unacceptable, and its use is restricted to certain physical locations. But we haven’t made tobacco use a crime. We tried to criminalize alcohol use in the United States (18th Amendment to the U.S. Constitution). But, by most accounts, that didn’t work out so well. While alcohol consumption was curtailed during Prohibition, injuries and deaths from criminal activities, as well as contaminated illicit sources of alcohol, soared.

So, criminalizing drug use has unintended societal consequences. But for the person who gets ensnared in the criminal justice system, it makes the vicious cycle of addiction so much worse. Not only does the SUD go unaddressed (in most cases), but once released, the “offender” is less likely to get a job (leading to poverty) and more likely to be ostracized from social circles that might have a positive influence on their lives. The stigma of addiction is compounded by the stigma of having a criminal record.

There are many enlightened police (individuals and departments), prosecutors, and judges who recognize that substance use is the root cause of so many crimes. For example, the Hinds County Circuit Drug Court in Jackson, Mississippi, provides an alternative to incarceration for substance-using offenders through judicially monitored treatment and intensive supervision.

As a society, we should not tolerate crime. And some substances are quite harmful, have significant addictive potential, and don’t have any well-established medical uses. So, I don’t think “legalizing” the sale and distribution of any and all substances is the way to go. That won’t solve the problem. But if we fail to address the root cause of these crimes, it comes at great cost to our society and the individuals who suffer from addiction.

Rather, I propose that we don’t put people with an SUD in double jeopardy. They need help. They need stability. They need structure. They need evidence-based treatment. They need to feel like they still belong in our society and that people are ready and willing to assist them. I believe health professionals have a special responsibility to model the way. However, research suggests that health professionals and those training to become health professionals share the same biases and beliefs that our society, at large, holds.6 Some introspection and working directly with people with SUD can change hearts and minds.

And that’s what this project is all about.

And that is how change happens.
One gesture.
One person.
One moment at a time.

-Libba Bray, American Author

Subscribe now

References

In his memoir, Friends, Lovers, and the Big Terrible Thing, Matthew Perry describes his life starting from the very beginning – growing up in a “broken” home — to stardom. And his addictions are woven throughout. He reveals the explicit details of his drug and alcohol use. Perry’s story is living proof that addiction is a disease that can affect anyone, and the path to recovery is not a simple or easy process.

Perry’s history with alcohol began before fame and money, as a 14-year-old boy trying alcohol for the first time with some friends and learning the power held within the bottle. While all his friends were sick from the alcohol consumed, Perry felt, for the first time in his life, “complete, at peace.” His alcohol use continued into young adulthood when he realized it had become an obsession and something his peers were not struggling with. He was consuming what most would consider a worrisome amount of alcohol and doing so alone. As Perry realized his disease was controlling his life, he hid it, managing to show up to work every day, even after long nights of drinking. He did not want anyone to think he was broken, and most importantly, he feared they would make him quit drinking.  For him, quitting seemed impossible, like asking someone to stop breathing.

The introduction of opioids into his life began in an all too common way – following an injury. It was the ‘90s when physicians readily prescribed opioids.  We had not yet fully appreciated the long-term complications that prescribed opioids would cause. Perry took one pill and was “hooked.” He began taking Vicodin (acetaminophen and hydromorphone) daily, eventually needing 55 pills a day for maintenance. As tolerance developed, Perry eventually transitioned to OxyContin (oxycodone), a more potent opioid, but swore he would never use heroin. His opioid use eventually led to life-threatening complications when his colon “exploded” in 2019. Perry, like others with a substance use disorder, understood that drug and alcohol use could lead to death, but the disease does not care. His addiction continued despite the potential dire consequences.

Over the years, Matthew Perry made multiple quit attempts, writing that he attended drug detox and rehabilitation programs 15 times and spent millions of dollars on recovery. According to the National Institute of Health, relapse is common and an expected part of recovery.1 About 40-60% of people with a substance use disorder will relapse.2 Perry’s first experience in rehab was in 1996 after a girlfriend took him to a doctor, and he was referred to a facility. He writes that he learned nothing from that experience and had his first drink 68 days after his discharge. Even Perry, a celebrity who could afford to be treated by the best of the best, did not receive appropriate education or support on how to maintain sobriety in the many rehab programs he participated. Eventually, he learned about Alcoholics Anonymous (AA) and began to understand the principles of addiction and treatment. During Perry’s treatment, he tried both methadone and buprenorphine. In the book, he focused on his experience with buprenorphine and described it as a very helpful drug. Despite its significant benefits, he explained the difficulties and pain that came when he tried to stop buprenorphine — so he remained on it until his passing. Perry’s story proves that sobriety isn’t easy and spending lots of money doesn’t fix addiction. It is not a matter of willpower. It is a disease that requires rewiring the brain.

“I am me. And that should be enough, it always has been enough. I was the one who didn’t get that. And now I do. I’m an actor. I’m a writer. I’m a person. And a good one at that. I want good things for myself, and others, and I can continue to work for these things. There is a reason I’m still here. And figuring out why is the task that has been put in front of me. And it will be revealed. There is no rush, no desperation. Just the fact that I am here, and I care about people, is the answer. Now when I wake up, I wake up curious, wondering what the world has in store for me, and I for it. And that’s enough to go on.”

-Matthew Perry, exerpted from Friends, Lovers, and the Big Terrible Thing

Matthew Perry spent most of his life searching for something to make him whole but came up short. Drugs and alcohol were the only things he found to patch his holes or at least make him forget the emptiness. He was finally able to discover that he, himself, was enough, and only then was he able to find sobriety. At the time of his death, Perry was sober for almost 2 years, taking it day by day to overcome The Big Terrible Thing.

References

Stigma lives at three levels.

Public or individual stigma refers to a set of negative attitudes and beliefs that motivate individuals to fear, reject, avoid, and discriminate against people with SUD. Structural or institutional stigma refers to the societal-level conditions, cultural norms, and institutional practices that constrain the opportunities, resources, and well-being of stigmatized populations. Lastly, self-stigma refers to the negative attitudes, including internalized shame, that people with SUD have about themselves.

The three types of stigma are interconnected. For example, people (individuals) who create public policies and treatment structures (institution-level practices) have their own biases and beliefs that influence their decisions.  Conversely, even those who don’t hold high levels of addiction stigma are subject to existing systems that perpetuate bias and discrimination. Over time, existing structures that stigmatize substance use, people who use substances, and people with SUD can perpetuate and increase individual stigma. Both public and structural stigma lead people with SUD to internalize negative beliefs about themselves and their disease, promoting isolation and silence. Stigma infiltrates virtually every aspect of an affected person’s life at multiple levels, exacerbating the SUD.  Negative feelings and beliefs lead to a desire to use substances, which further worsens negative feelings and beliefs … and more substance use. A vicious cycle.  Self-stigma negatively impacts the individual’s health, well-being, life satisfaction, friends and family, and life opportunities.

While academic and clinical definitions of stigma are helpful in creating a shared language, these definitions don’t capture the feelings of shame and isolation or the experiences of discrimination and ostracization that result from being stigmatized.  They also can’t fully convey what it’s like to exist in systems that have, historically, not been built to support people living with SUD, to help them find treatment, recovery, health, and well-being. In short, stigma is something that is hard to fully understand until you feel it yourself.

This is why sharing people’s stories and experiences is helpful.

Consider Emily’s story:

Emily is 39 weeks pregnant, due next week, with a history of opioid use disorder, though she’s currently in recovery. She wants to be excited to have her baby, but no one has talked to her yet about plans for pain control in labor. She’s worried about an epidural, if she’ll need a C-section, and how she’ll recover after the birth. She’s worried whether the nurses and providers will take good care of her, or if their own biases could negatively impact her care. She’s not sure what will happen after the birth of her baby. Will social services be called? Will her baby be taken away? What if she’s prescribed opioids for pain? Could she relapse? Should she not take them?

In what should be one of the most joyous moments in her life, Emily is worried.

Alternatively, think about Marissa’s story from her time in active addiction:

“Words can become grenades, strategically spoken at times to do the most damage. When those words come from family and friends, they cut deeper. Labels erased my humanity. Total strangers felt allowed to criticize or judge me, saying that I was ‘just a drunk,’ or ‘an addict.’ These words also carried the connotation that I was lazy, selfish, or a criminal. After a while, I began to believe these words, concluding that I never served a purpose or deserved hope. Luckily for me, these feelings were eventually replaced with words that provided healing.”

We have a great deal of work to do. We need to continue elevating the efforts, stories, and expertise of advocates with lived experience. We need to change our language to promote healing and acceptance. We need to couple our dedication to ending addiction stigma with antidiscrimination and pro-acceptance initiatives to ensure widespread adoption and effective interventions. It’s up to all of us to dismantle existing systems that discriminate, that stigmatize, that reduce access to care, and that harm people with SUD, their loved ones, and our communities.

We have an extraordinary chance to take steps toward reducing stigma toward people with SUD. By recognizing the humanness of people with SUD and by offering evidence-based resources and opportunities for prevention, treatment, and recovery — without judgment — we have an opportunity to build a more tolerant, more compassionate, and healthier future.

Shatterproof is a non-profit organization dedicated to transforming addiction treatment by improving payment and coverage, educating health professionals, setting national standards, enhancing treatment quality, and conducting research to understand the needs of people living with addiction.  You can read more stories from people with lived experience, including their tattoos to celebrate and remember, on the Shatterproof website.

I rarely re-read books. But The Tennis Partner, an autobiographical work by Abraham Verghese, MD, is an exception. My current engagement on the Advisory Board of a substance use disorder (SUD) stigma reduction grant brought the book back to mind — many years after my initial reading. The book has several thought-provoking threads, and SUD stigma among healthcare providers is one of the more subtle of them.

In short, as a new attending internal medicine physician at Texas Tech University in El Paso, Texas, Verghese strikes up a relationship, centered around playing tennis, with a fourth-year medical student, David Smith. David had briefly been a tennis professional. The evolving complexity of this relationship provides powerful tension in this book. One key dynamic emerges when David discloses that he is in recovery from cocaine use disorder. David has just returned to medical school after an extended leave of absence during which he was treated for his SUD and started a 12-Step recovery program with close monitoring by the medical school requiring random drug testing. During the 18-month period that the book covers, David returns to cocaine use twice.

Four stigma-related themes emerge in the book.

First, the medical school practices a non-stigmatizing approach to David's struggles. How? By word and practice, they address his struggles as the symptoms of a serious medical condition. Their response following each episode of cocaine use is to suspend training and mandate treatment. In other words, as they would with any other chronic illness that has negative consequences for the student’s well-being and optimal learning, and which impacts professional behavior and patient safety, they treated David, rather than punish him. This would be enlightened today, let alone in the early 1990s when these events took place.

Second, the book lays bare the self-deception that so many of us comfort ourselves and judge others with. We are not immune. The clear fact is that David's great intelligence, his winsome personality, advanced education, medical training, access to professional treatment, engagement in self-help, plus support from enlightened and caring mentors – none of these, could insulate him or free him from his disorder. The uncomfortable lesson for us is that the advantages that enabled us to become health professionals and the additional privileges we enjoy as members of a professional elite do not insulate us from substance use disorders and the mayhem they engender in their wake. Yes, they may positively influence the trajectory of a nascent SUD, but they do not grant immunity.

Third, we see Dr. Verghese's very typical reaction to David's struggles. In part, this is a consequence of the complexity of the relationship. He is not just an attending physician in David's training program, but a deep friend – surrogate family. Dr. Verghese, at times, personalizes David's behavior, including his return to cocaine use, as if David was doing this to him – Abraham – rather than to David. His professional judgment is also clouded, as he fails, as David's supervisor, to report a new episode of cocaine use to medical school leadership. Known colloquially as “enabling,” he (briefly) shielded David from the consequences of his illness. The cornerstone to behavior change is the understanding that behavior is shaped by its consequences. To the extent that consequences are minimized, their role in motivating behavior change is diminished.

Fourth and finally, we see Dr. Verghese's deep compassion. He was one of the early HIV practitioners, practicing at a time before there were any treatments. He captures this in his 1995 book, In My Own Country, which describes his HIV practice in Johnson City and the Tri-Cities area in Eastern Tennessee. In The Tennis Partner, we see the same open, non-stigmatizing approach to those he treats for complications of SUD, some of them repeatedly.

The starting point for any personal change is to gain awareness that we need to change. None of us decide to think, talk, and act in stigmatizing ways. It's simply “in the water.”  We are all prone to categorize people into “us” and “them.”  We often build defenses against things (people, information, beliefs) that are personally threatening. One of the most significant steps any of us can take is to replace the question, “Do I stigmatize those with SUD?” with “How and when do I stigmatize those with SUD?” The beginning of change starts with awareness.

Though I am fascinated by knowledge, I am even more fascinated by wisdom.
-Abraham Verghese

According to the American Addiction Centers, 1 in 7 young adults (18 to 25 years old) has a substance use disorder. That statistic is probably not surprising, given the culture of substance use on college campuses. Most American colleges and universities have initiated robust prevention programs to support students as they navigate higher education (I myself am a former university Prevention Coordinator). We created campaigns, events, support programs, and education initiatives to prevent substance misuse. This sounds amazing!...right? While prevention efforts are vital, they don’t address the needs of the 1 in 7 young adults who have a substance use disorder. How are we supporting these students? Surely, universities invest in recovery efforts as heartily as prevention programs!

Unfortunately, no — treatment and recovery programs are not widely available on college campuses. The Association for Recovery in Higher Education lists only 150 collegiate recovery support programs in the United States (and there are nearly 4000 colleges/universities in the US!). This lack of focus on recovery is a huge barrier to treatment access for those with an SUD, and it leaves a significant portion of the collegiate population without the support they need.

When we look at the structure of most collegiate prevention programs, recovery support can easily be included in these efforts. The William Magee Center for AOD and Wellness Education at the University of Mississippi exemplifies the integration of wellness education and recovery support services. However, student services staff often shy away from this approach, perhaps because they believe recovery programs require interventions from licensed clinicians. While it’s true that certain treatments require special training, there are crucial elements that can be delivered by student services professionals that would positively engage students with an SUD. The lack of resources and openness to addressing the needs of students with SUD may contribute to stigma and marginalization.

Ryan Doyle is the Substance Use Prevention, Education, and Prevention Strategy Specialist at Iowa State University. In a recent article published on the CampusDrugPrevention website, he highlights the impact of stigma on students in recovery:

 The process of including recovery support programs and staff in substance use prevention efforts on campuses can be made more difficult by negative attachments to the concept of recovery. Part of the negative attachment can come from the language. Terms such as ‘substance abuse prevention’ are often what many prevention efforts are categorized under, despite numerous studies that indicate that terms like ‘substance abuse’ generate stigma for those being referenced … When it comes to getting students engaged with recovery support services, attraction to services can be very difficult and using problematic language that exacerbates self-stigma is an unneeded additional barrier.

Here are three actionable steps we should take to connect prevention and recovery better:

1. Work to eliminate stigmatizing language in prevention campaigns and, to the extent possible, institutional language.

2. Connect student services staff who are engaged in drug use prevention education with those who provide recovery support.

3. Engage campus stakeholders (faculty, staff, and administrators) in conversations about substance use and addiction; help them develop the skills to be able to compassionately discuss recovery and refer students to appropriate resources.

Dismantling stigma is no easy task. It starts with an understanding that addiction is a chronic disease. Student service professionals need to continue to work to create a welcoming space for students in recovery and to collaborate with other professionals to build holistic recovery programs for the millions of young people who have a substance use disorder.

Doyle R. The impact of stigma on efforts to reduce substance use. The Impact of Stigma on Efforts to Reduce Substance Use. Campus Drug Prevention.  https://www.campusdrugprevention.gov/