Removing the stigma of medication for opioid use disorder

Abstract

The national opioid crisis continues to be one of the most pressing public health issues in modern history. The average life expectancy in the United States declined annually from 2016 to 2019 due to opioid-related breathing emergencies and suicide.1Saiidi U. “US life expectancy has been declining. Here's why.” Health and Science. CNBC. Updated July 9, 2019, Accessed June 1, 2020.Google Scholar Death associated with opioids, or other drugs of misuse, is now the leading cause of death in Americans under the age of fifty.2Drug Policy Alliance. Drug Overdose. Accessed June 1, 2020.Google Scholar As the most accessible health care provider, pharmacists are positioned to play a leading role in the treatment of substance use disorder. Additionally, pharmacists can serve to better educate the public about the nature of substance use disorder as a mental health disorder and the benefits of its treatment. Unfortunately, the stigma associated with substance use disorder and its treatment stands as a barrier to accessing quality care for patients.3Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States; Results from the 2017 National Survey on Drug Use and Health. 2018.Google Scholar, 4Park-Lee E et al.Receipt of services for substance use and mental health issues among adults: Results from the 2016 National Survey on Drug Use and Health.September 2017Google Scholar Gaining a better understanding of how substance use disorder fits a disease state model and the true, evidence-based benefits of treatment will provide pharmacists the tools needed to help break the stigma and improve care to this patient population. The World Health Organization (WHO) states that stigma is a cause of discrimination across the globe.5Villa L. Shaming the Sick: Addiction and Stigma, American Addiction Centers, Accessed June 1, 2020.Google Scholar Often stigma is not based on any particular fact but rather predicated on myth, superstition, or prejudice against a group of people, usually those considered unwanted in society. This includes people who use drugs and suffer from a substance use disorder. Stigma is felt not so much from a physical standpoint but rather in the development of mental health disorders such as increased depression and anxiety.5Villa L. Shaming the Sick: Addiction and Stigma, American Addiction Centers, Accessed June 1, 2020.Google Scholar Stigma impacts those who suffer from a substance use disorder in multiple ways. A major reason for patients to not seek treatment is fear of the public's negative opinion.3Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States; Results from the 2017 National Survey on Drug Use and Health. 2018.Google Scholar Evidence shows that many in society label those with a substance use disorder as being “weak” or “lazy.”6Kulesza M et al.Stigma among individuals with substance use disorders: Does it predict substance use, and does it diminish with treatment?.J Addict Behav Ther Rehabil. 2014; 31000115 PubMed Google Scholar Substance use disorder is a condition hallmarked by a sense of shame, which can be exacerbated when others perceive the individual as weak.7Gaba S. “The link between addiction and shame.” Psychology Today. Published April 2, 2019. Accessed June 1, 2020.Google Scholar Rejection from friends and family further adds to the shame and isolation associated with substance use disorder.6Kulesza M et al.Stigma among individuals with substance use disorders: Does it predict substance use, and does it diminish with treatment?.J Addict Behav Ther Rehabil. 2014; 31000115 PubMed Google Scholar Accreditation informationProvider: APhATarget audience: PharmacistsRelease date: October 1, 2020Expiration date: October 1, 2023Learning level: 1ACPE Universal Activity Number: 0202-0000-20-247-H08-PCPE credit: 2 hours (0.2 CEUs)Fee: There is no fee associated with this activity for members of the American Pharmacists Association. There is a $25 fee for nonmembers. APhA is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-20-247-H08-P.Advisory board: Anita N. Jacobson, PharmD, clinical associate professor, University of Rhode Island College of Pharmacy, Eleanor Slater HospitalDisclosures: Thomas Franko, PharmD; Anita N. Jacobson, PharmD; and APhA's editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see the Education and Accreditation Information section at www.pharmacist.com/apha-disclosures.Development: This home-study CPE activity was developed by APhA. Learning objectives▪Describe the stigma associated with substance use disorder▪Describe the neurobiology of substance use disorder▪Discuss the role and impact of pharmacotherapy for substance use disorder▪Discuss the benefits and misconceptions about naloxone▪Discuss strategies to improve access to buprenorphine Provider: APhA Target audience: Pharmacists Release date: October 1, 2020 Expiration date: October 1, 2023 Learning level: 1 ACPE Universal Activity Number: 0202-0000-20-247-H08-P CPE credit: 2 hours (0.2 CEUs) Fee: There is no fee associated with this activity for members of the American Pharmacists Association. There is a $25 fee for nonmembers. APhA is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-20-247-H08-P. Advisory board: Anita N. Jacobson, PharmD, clinical associate professor, University of Rhode Island College of Pharmacy, Eleanor Slater Hospital Disclosures: Thomas Franko, PharmD; Anita N. Jacobson, PharmD; and APhA's editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see the Education and Accreditation Information section at www.pharmacist.com/apha-disclosures. Development: This home-study CPE activity was developed by APhA. ▪Describe the stigma associated with substance use disorder▪Describe the neurobiology of substance use disorder▪Discuss the role and impact of pharmacotherapy for substance use disorder▪Discuss the benefits and misconceptions about naloxone▪Discuss strategies to improve access to buprenorphine Preassessment questionsBefore participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment.1.Evidence shows that use of buprenorphine as pharmacotherapy for opioid use disorder results in which of the following? a.Increased rate of recidivismb.Increased probability of maintaining employmentc.Decreased family relationshipsd.Increased risk of relapse2.Which of the following best describes the role of dopamine in the disease state model of substance use disorder? a.Created in the extended amygdala to regulate the fight or flight systemb.Triggers a notion of stress and anxiety resulting in a compulsion to use a substancec.Dopamine pathways are “hijacked” by the drug causing the brain to prioritize the drug above all elsed.Results in activation of the prefrontal cortex which then limits the ability to make rational decisions3.Which of the following represents a conversation using appropriate, non-stigmatizing language? a.“Buprenorphine has great evidence as an opioid replacement option.b.“Pharmacotherapy for substance use disorder greatly reduces negative outcomes.c.“Most addicts find medication as reliable alternatives to drug use.d.“Medication is a great option to kelp kick a drug habit. Before participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment. 1.Evidence shows that use of buprenorphine as pharmacotherapy for opioid use disorder results in which of the following? a.Increased rate of recidivismb.Increased probability of maintaining employmentc.Decreased family relationshipsd.Increased risk of relapse2.Which of the following best describes the role of dopamine in the disease state model of substance use disorder? a.Created in the extended amygdala to regulate the fight or flight systemb.Triggers a notion of stress and anxiety resulting in a compulsion to use a substancec.Dopamine pathways are “hijacked” by the drug causing the brain to prioritize the drug above all elsed.Results in activation of the prefrontal cortex which then limits the ability to make rational decisions3.Which of the following represents a conversation using appropriate, non-stigmatizing language? a.“Buprenorphine has great evidence as an opioid replacement option.b.“Pharmacotherapy for substance use disorder greatly reduces negative outcomes.c.“Most addicts find medication as reliable alternatives to drug use.d.“Medication is a great option to kelp kick a drug habit. Stigma also affects the overall quality of life of not only patients suffering from a substance use disorder but also those who are in recovery. Recovery has many forms, and there are multiple treatment options available including medication, counseling, and group therapy. Unfortunately, there is great stigma associated with the overall treatment of substance use disorder itself. The use of pharmacotherapy for substance use disorder has a high level of stigma both toward patients and providers.8Madden EF Intervention stigma: how medication-assisted treatment marginalizes patients and providers.Soc Sci Med. 2019; 232: 324-331Crossref PubMed Scopus (17) Google Scholar Continued negative views from society even as patients enter recovery can be responsible for increased rates of relapse and depression. Even when compared against other social determinants of health such as socioeconomic status, race, and sexual orientation, stigma is noted to play the largest role in the overall negative impact on quality of life.6Kulesza M et al.Stigma among individuals with substance use disorders: Does it predict substance use, and does it diminish with treatment?.J Addict Behav Ther Rehabil. 2014; 31000115 PubMed Google Scholar Patients suffering from a substance use disorder already face barriers to care not seen by the general public. Many often struggle with lack of qualified treatment facilities and specialists, as well as limited insurance coverage.4Park-Lee E et al.Receipt of services for substance use and mental health issues among adults: Results from the 2016 National Survey on Drug Use and Health.September 2017Google Scholar Patients with substance use disorder also face various socioeconomic disparities not routinely encountered by those without the condition.9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar Such health care and sociological issues negatively impact patients within the substance use spectrum. Obstacles to accessing basic services, coupled with social pressures depicting substance use as a choice rather than a mental health disorder, further decrease the opportunity for patients to enter and/or maintain their recovery.10Livingston J et al.The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review.Addiction. 2012; 107: 39-50Crossref PubMed Scopus (344) Google Scholar Stigma acts as an access barrier to various social programs for patients with a substance use disorder. While great strides have been made to move treatment from the criminal justice system to the health care system, many still view substance use disorder as a crime rather than a mental health issue. This is especially seen when people use illicit substances such as heroin, which are socially more stigmatized due to their legal status.10Livingston J et al.The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review.Addiction. 2012; 107: 39-50Crossref PubMed Scopus (344) Google Scholar Patients with a known history of substance use disorder, whether plaintiff or defendant, are disadvantaged throughout the legal spectrum. Evidence shows these patients may receive less favorable legal outcomes, are more likely to be the victim of crime, and are less likely to be believed when reporting a crime.9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar Along with legal disparities, those with a substance use disorder often face difficulty obtaining reliable housing.9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar Local communities offer little support to institute residential treatment facilities.3Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States; Results from the 2017 National Survey on Drug Use and Health. 2018.Google Scholar, 9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar Whatever housing is available often carries strict rules, such as limiting family visits, which further increase feelings of isolation.9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar Difficulty finding employment further complicates obtaining reliable housing. Location, family situation, and education level are all potential barriers to gainful employment.11Sigurdsson S et al.Barriers to employment among unemployed drug users: Age predicts severity.Am J Drug Alcohol Abuse. 2012; 38: 580-587Crossref PubMed Scopus (21) Google Scholar Furthermore, patients face additional scrutiny not only from potential employers but also members of the health care industry.9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar Stigma among providers leads to decreased quality of care; even pejorative language in the medical record may negatively bias a provider against a patient.9Committee on the Science of Changing Behavioral Health Social Norms Board on Behavioral, Cognitive, and Sensory Sciences Division of Behavioral and Social Sciences and Education National Academies of Sciences, Engineering, and Medicine Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. National Academies Press, Washington (DC)2016Crossref Scopus (21) Google Scholar, 12Boekel L et al.Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review.Drug Alcohol Depend. 2013; 131: 23-35Crossref PubMed Scopus (584) Google Scholar, 13Goddu A et al.Do words matter? Stigmatizing language and the transmission of bias in the medical record.J Gen Intern Med. 2019; 34: 164Crossref PubMed Scopus (3) Google Scholar The interpersonal issues facing patients with a substance use disorder compound those seen on a larger sociological level. Many patients report a dramatic loss in friends and family members upon revealing their condition, which further adds to feelings of despair associated with substance use disorder.6Kulesza M et al.Stigma among individuals with substance use disorders: Does it predict substance use, and does it diminish with treatment?.J Addict Behav Ther Rehabil. 2014; 31000115 PubMed Google Scholar The National Survey on Drug Use and Health (NSDUH) evaluates substance use disorder trends across various demographics. Members of the LGBTQ community are significantly more likely to use cocaine, hallucinogens, and other substances compared with the heterosexual population.14Medley G, et al. Sexual orientation and estimates of adult substance use and mental health: Results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. 2016.Google Scholar Black, Asian, Hispanic/Latino, and Native Hawaiian/Other Pacific Islander groups had similar rates to the national average of both substance use disorder and substance use disorder treatment.15Substance Abuse and Mental Health Services Administration. 2016 NSDUH: Race and Ethnicity Summary Sheets. Published January 31, 2018. Accessed July 17, 2020.Google Scholar Those within American Indian/Alaskan Native communities had a slightly higher incidence rate of substance use disorder than the national average, but a similar rate of treatment in a specialty facility.15Substance Abuse and Mental Health Services Administration. 2016 NSDUH: Race and Ethnicity Summary Sheets. Published January 31, 2018. Accessed July 17, 2020.Google Scholar These data show that substance use disorder can affect any social demographic and further efforts are needed to bring awareness and access to all communities. Continued efforts are needed from both a curricular and continuing education standpoint to better educate pharmacists and other health care providers about the needs and challenges of various cultures. Through this, we can ensure better quality care for all patients. As the most accessible health care provider, pharmacists should take a leading role in changing the culture of substance use from that of shame, crime, and choice to that of hope, support, and recovery. The development of effective communication strategies addressing substance use disorder is an imperative component of this process. Conversations regarding substance use disorder can be difficult and may even be feared by providers. Initial focus should be on using person-first language while serving as a trusted resource for patients. Developing a person-first vocabulary is paramount to decreasing stigma associated with substance use disorder. Words such as “junkie” or “addict” carry a negative connotation and can further expand the shame associated with substance use disorder. It is necessary to better educate providers and the public about appropriate terminology aimed at reducing stigma associated with substance disorder. Several national organizations, including APhA and the Office of National Drug Control Policy, have issued recommendations on such terminology.16American Pharmacists Association. Let's Talk About Naloxone—It Saves Lives. Accessed June 10, 2020Google Scholar, 17Director of the Office of National Drug Control Policy Michael P. Botticelli to the Heads of Executive Departments and Agencies, January 9, 2017, Executive Office of the President. Accessed June 10, 2020Google Scholar For example, these resources suggest the use of “person with substance use disorder” instead of “addict.” This phrasing highlights the individual rather than the condition. Among the many suggested changes in terminology, pharmacists should pay particular attention to the word “overdose.” When used in patient counseling, the phrase “You may overdose on this medication” places the fault on the patient, which shames the patient and promotes the misconception that substance use disorder is a choice rather than a mental health disorder. Instead, providers should say “breathing emergency” or “bad reaction.”16American Pharmacists Association. Let's Talk About Naloxone—It Saves Lives. Accessed June 10, 2020Google Scholar The phrase “this medication may cause a bad reaction in which you may experience a breathing emergency” shows that respiratory depression is a potential adverse effect of the drug rather than a problem with the patient. Along with using a person-first vocabulary, pharmacists should also act as a resource to patients as opposed to a barrier to care. Rather than saying “We cannot fill this,” providers should say “We understand this medicine is important; while we cannot fill it today, we can get it tomorrow. Do you have enough until then?”16American Pharmacists Association. Let's Talk About Naloxone—It Saves Lives. Accessed June 10, 2020Google Scholar A response that opens the opportunity for discussion can enhance patient care and increase trust in the patient–provider relationship. Terminology does not just pertain to language used to discuss substance use disorder but also to overall pharmacologic treatment. Many patients may misconstrue withdrawal symptoms from opioid medications as a sign that they have developed an addiction. It is important to educate patients that withdrawal is a sign of physical dependence, a natural and normal response to chronic medication use, and not of addiction. Substance use disorder is defined as a maladaptive pattern of medication use that leads to significant impairment and distress.18Arnaout B and Petrakis I. Diagnosing co-morbid drug use in patients with alcohol use disorders. National Institute of Alcohol Abuse and Alcoholism. Accessed June 10, 2020.Google Scholar Providing this initial piece of education can grant insight and peace of mind to patients. A major reason for the high level of stigma around substance use disorder is the notion that it is a choice rather than a mental health disorder. Proponents of the choice argument note that patients may be “weak” or lack sufficient “will power” to stop using a given substance. While patients may be able to choose not to use a given substance, they will still experience a craving, which can lead to tremendous suffering. The evidence clearly demonstrates substance use disorder as a mental health disorder with known risk factors and pathology.19National Institute on Drug Abuse. Opioid Overdose Crisis. Updated May 2020. Accessed June 10, 2020.Google Scholar, 20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar Multiple factors place a patient at a higher risk of developing a substance use disorder. Common risk factors include a past medical history or family history of substance use, or a history of trauma.19National Institute on Drug Abuse. Opioid Overdose Crisis. Updated May 2020. Accessed June 10, 2020.Google Scholar These encompass the genetic and environmental factors that often predispose patients to substance use. The rise in prescription opioid use for chronic pain has dramatically risen over the past 25 years.21CDC. U.S. Opioid Prescribing Rate Maps. Updated March 5, 2020. Accessed June 10, 2020.Google Scholar While the risk of developing a substance use disorder is present with long-term opioid use, only a minority of patients will encounter this.19National Institute on Drug Abuse. Opioid Overdose Crisis. Updated May 2020. Accessed June 10, 2020.Google Scholar Current data show that about 8% to 12% of patients who take opioids for chronic conditions will develop opioid use disorder. However, about 80% of those who misuse heroin first misused a prescription opioid.19National Institute on Drug Abuse. Opioid Overdose Crisis. Updated May 2020. Accessed June 10, 2020.Google Scholar Substance use disorder is first and foremost a mental health disorder. Substance use disorder manifests physical changes in three key areas of the brain: the basal ganglia, extended amygdala, and the prefrontal cortex. Changes in these areas of the brain are responsible for the cycle of addiction: binge/intoxication, withdrawal/negative affect, and preoccupation/anticipation.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar Each of these areas plays a vital role in the reward pathway of the brain. The basal ganglia houses the ventral tegmental area which produces dopamine. Dopamine is associated with feelings of pleasure and reward. It activates the nucleus accumbens, responsible for positive reinforcement of reward, and the dorsal striatum, responsible for developing habits and behavior.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar, 22Kalivas PW Volkow ND The neural basis of addiction: A pathology of motivation and choice.Am J Psychiatry. August 2005; 162: 1403-1413Crossref PubMed Scopus (1929) Google Scholar Normally, dopamine is released in response to regular survival actions, such as having your favorite meal. Drugs that are often misused result in dramatic rises in dopamine levels either through direct or indirect mechanisms. It is through this process that a brain primed for substance use disorder can become “hijacked” so the drug becomes the primary means of survival.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar As patients continue to use substances, the brain will down-regulate dopamine (D2) receptors. This can result in patients no longer feeling pleasure from once-pleasurable activities, known as anhedonia. Patients also experience a consistent need to use higher doses of a given drug for a similar benefit.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar Furthermore, the brain releases small levels of dopamine in response to drug-related stimuli, such as needles. This small dopamine bump can push the brain into craving and cause the patient to relapse.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar Just as the basal ganglia is associated with managing reward, the extended amygdala is responsible for the feelings of “fight or flight” as well as negative emotions such as irritability and stress. During a heightened period of stress, corticotropin-releasing factor and dynorphin are released. Increased levels of these neurotransmitters along with the physical manifestation of withdrawal can create a powerful desire to use drugs. And with continued use, higher doses are needed to respond to a higher level of stress.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar The final affected area is the prefrontal cortex, which is responsible for decision making, organization, and control of impulsivity. When exposed to various drug-related stimuli, the prefrontal cortex releases glutamate, which stimulates the midbrain, resulting in an urge to use drugs. At the same time, the prefrontal cortex's ability to self-regulate is diminished resulting in compromised decision making ability and inhibition in behavior.20U.S. Department of Health and Human Services, Office of the Surgeon General. Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs and Health. November 2016.Google Scholar Recovery from substance use disorder is a lifelong process and requires ongoing treatment, which can consist of pharmacologic and nonpharmacologic options. Many are aware of the various nonpharmacologic therapies available such as counseling, behavioral modification, twelve-step programs, and Alcoholics/Narcotics Anonymous. However, the best evidence for recovery surrounds the use of pharmacotherapy for substance use disorder.23The Pew Charitable Trusts. The Case for Medication-Assisted Treatment. 2017. Accessed June 11, 2020.Google Scholar Continued education and increased access to pharmacoth