Great, so just a few more seconds and we'll get started. Okay, good afternoon, everybody. Welcome to today's AOAM webinar on drug stigma and health by Dr. Robin Polini. My name's Julie Kmic and I'll be your moderator for this session. This is the fourth of a six hour webinar series on hot topics in the treatment of opioid use disorder and stimulant use disorders. I'd like to introduce Dr. Robin Polini who is a substance abuse and infectious disease epidemiologist whose research focuses on mitigating the adverse health impacts of injection drug use. These include overdose, HIV, viral hepatitis and serious injection related bacterial infections like endocarditis. She uses innovative mixed methods study designs to examine how individual and structural level factors influence drug related morbidity and mortality as well as health services access and utilization among people who inject drugs. Dr. Polini has been the principal investigator of several grants funded by NIDA. So good afternoon, Dr. Polini. Good afternoon, thank you for having me. Welcome and welcome back to the folks who were with us last week. This is the sort of the Q&A portion of the two webinar series. I'll start by saying I have no conflicts of interest to declare. And we are gonna do Q&A but I wanted to start because there was one more thing in addition to what I talked about last week that I wanted to talk about today. We talked last week, we started by talking about different types of stigma if you'll recall. So there's stigma from individuals, that's when someone perpetuates negative stereotypes about other individuals in this case folks with substance use disorder. There's institutional stigma when stigmatizing assumptions and stereotypes are translated into public policy practice or funding decisions. There's self stigma, which is when individuals who are part of a stigmatized group adopt negative stereotypes about themselves. And then stigma through association, which is when those negative assumptions and stereotypes are applied not to the person in the stigmatized group, but to those around them. That could be family members or even physicians who treat people with substance use disorder. What I didn't talk a lot about last week that I wanted to just touch on this week is stigma around medication for opioid use disorder. We talked a little bit about how people in positions of leadership or authority can stigmatize folks at the structural level by saying things like medications for opioid use disorder are just substituting one drug for another. But in looking at this a little bit more since last week, I came across some really nice articles by Aaron Madden, who's a professor at Wayne State University, who uses the term intervention stigma and specifically talks about intervention stigma in the context of medications for opioid use disorder. So this is a stigma that's a little bit different than we talked about last week, because it's stigma not related to a person in the stigmatized group, but stigma that's specifically associated with a certain medical treatment separate from the assignment of stigma to a specific person. And Madden talks about that this isn't just medications for opioid use disorder. There are, for example, some types of cosmetic surgery that might be stigmatized, medical interventions like abortion, but she's done some really nice work about intervention stigma and medications for opioid use disorder. And I think that this kind of intervention stigma, we see it in the fact that we have limited access and utilization of these therapies, even though they're evidence-based and they're considered the gold standard for the treatment of opioid use disorder. So last week I talked about and showed you a slide that said there were, I think, 41 million people with substance use disorder in the United States and only about 6 1⁄2% of those folks get treatment for their substance use disorder. But when it comes to methadone and buprenorphine, which are evidence-based treatments for opioid use disorder and opioid agonists, only 41% of that very small number of people who are getting opioid use disorder treatment actually get medications for opioid use disorder. And that drops to less than 5% in carceral settings. And in fact, what happens in many of our carceral settings is that people who are on medications for opioid use disorder when they enter incarceration are taken off of those medications, although there are legal decisions that have recently come out that challenge that under the Americans with Disabilities Act. And then another article I was looking at by Allen and colleagues had this really nice quote, which I think sort of brings us home, which says, for no other condition for which an effective treatment exists, does the healthcare system fail to give that treatment so frequently. And so where does this stigma around medication for opioid use disorder come from? Some of it is institutional. So I'm sure you all know that we regulate methadone and buprenorphine differently than we regulate other medications. Methadone has to be dispensed, usually directly observed from special clinics that are very strictly regulated. I mentioned last week that in my state of West Virginia, we've had a moratorium on the opening of new methadone clinics since 2007, even though we arguably have the worst opioid problem in the country. Physicians who want to prescribe buprenorphine have to have additional training, register with SAMHSA, get an X waiver, and then there are limitations on the number of patients they can treat. Although those regulations are evolving, I think we now have an exemption because of COVID for folks who want to treat under 30 patients, but it's still regulated quite differently from other medications. So there's institutional stigma. Stigma from others. There's a really clear societal preference, I think, and I think most of you would agree for abstinence-based treatment as opposed to recovery involving medications for opioid use disorder, even though there's better evidence for those medications than there is for abstinence-based treatment. This can also be structural. So again, there's some legal cases at play, but you will see a strong preference, for example, for naltrexone in criminal justice settings versus the opioid agonist buprenorphine and methadone. There's self-stigma. So participation in treatment with these medications can be associated with shame and disempowerment at the individual level. That can affect treatment choices in terms of delaying or foregoing these medications altogether, and it can also have an effect on outcomes if people aren't getting the best medications for their substance use disorder, but also it can result in people discontinuing treatment because of the outside pressures put on them to not be on these medications or to taper off them pretty quickly. And then stigma by association. Some physicians may not want to prescribe medications for opioid use disorder, particularly buprenorphine, because of the extra regulations, but also because of stigma by association. And I've seen this myself, family members being opposed to having a loved one on these medications because of misconceptions about the more the stigma associated with them. We do have a question from that last slide where you've mentioned 41% in terms of who's receiving medication. What was the date from that or where? That is from, it's very recent. It's from the Allen article, which is, I can tell you that right now, that's a 2019 article. So it might be a little higher now, but it's still quite low. Okay, thank you. Sure. And then given the stigma around these interventions, what's the impact on access and outcomes? The limited community support for these medications can mean inadequate funding, support for the restrictive policies that I just talked about. And then there's also the NIMBY issue, not in my backyard, where people are opposed to having like methadone clinics in their community. This applies to syringe services programs as well. We've even seen this with, in my own state, I was looking for the articles and I couldn't find them, but a couple of years ago, we had some physicians who wanted to set up a practice and they'd be prescribing buprenorphine. And there was a lot of opposition to that in the surrounding community. There can be limited access, including primary care physicians not wanting to prescribe. There are also a number of pharmacies that don't stock and dispense buprenorphine. Some of that might be because of concerns about DEA, but also not wanting sort of those people in the pharmacy. So it can be very difficult once you even obtain a buprenorphine prescription to get it filled. Patients who would benefit from these medications, as I said before, may delay or avoid them altogether. A really big concern, which I'll talk a little bit more in a minute, is that being on these medications can be a barrier for participation in 12-step programs, residential treatment, and sober living. There are residential treatment programs and sober living programs that will not accept people on buprenorphine or methadone. And a lot of 12-step programs view folks on these medications as not actually being sober or living in sobriety. And they're often not welcomed into those 12-step settings. Given all of these things, it can be a lot harder to maintain yourself on these medications. And so those external stigmas and even internal stigma can lead to cessation of those medications and relapse, which puts folks at risk. And then lastly, as I mentioned, this sort of pressure for tapering people off medications versus keeping them on long-term. So often what I hear is people go into these treatments and there's immediate talk about how long they're gonna be on them, rather than dealing with that over time or just knowing that being on those medications long-term is okay and often medically indicated. So as I was going through some of the articles on these medications and stigma, there was a really nice case series article that was done by Hadlam and colleagues. And I thought I'd just read you one of these case studies that they talk about, because it gives an idea of what these stigmas look like in real life for real patients. So LD, they're calling this patient LD, is a 20-year-old female with severe opioid use disorder, bipolar one disorder, and PTSD who presented to our program after recently moving from across the country to attend college. She had previously been stable on buprenorphine and another treatment program prior to her move, but after starting college had begun to use heroin again and wanted to reinitiate buprenorphine and re-engage in treatment. We successfully performed an induction on buprenorphine naltrexone, and subsequently she ceased heroin use corroborated by urine drug tests. As a component of her treatment, she also began attending a 12-step program to receive peer recovery support. One month into treatment, however, she presented in crisis, having reinitiated prescription opioid use with urine drug test positive for fentanyl, as well as benzodiazepines. After meeting with our team, it was clear that LD had suddenly stopped taking her buprenorphine naltrexone and had taken prescription pills she had purchased from a friend after experiencing severe cravings. LD revealed that at her 12-step program, she had received messaging that she was not truly sober, quote unquote, while on buprenorphine naltrexone, and so had suddenly attempted to stop her medication. After a careful discussion with our clinical team regarding the potential benefits and risks of this medication, LD elected to reinitiate buprenorphine naltrexone. She has continued to attend 12-step meetings, electing not to share with her peers that she is on this medication, and to date has not used any other opioids and remains engaged in care. So it is true, and this is true of our programs here, that people in buprenorphine treatment are often encouraged or even required to engage in 12-step programs, but are not welcome there as people who use medications for opioid disorder, and so they have to hide that as part of their recovery, which can be detrimental. So people keep asking me in the presentation last week and some of the questions for this week, what is the solution? I think we're really struggling with this because as I mentioned last week, we don't have really good evidence-based interventions to deal with stigma. I certainly think at the structural or macro level, we need regulatory changes to increase access to these medications. So thinking about changing the regulations around methadone, in some countries it's available in pharmacies, so people can go to the pharmacy, or there is more liberal take-home dosing. Removing the X-waiver for buprenorphine and special training restrictions on buprenorphine treatment would also be useful. Improved training in medical school, but also pharmacy school and nursing school. We already know that medical students are not getting enough in their curriculum on substance use disorders, but dealing with these issues during medical school as opposed to dealing with them later on would be helpful. And I do hear when I talk to folks who are recently out of pharmacy school, for example, that they are getting a lot more information about naloxone and harm reduction and MOUD than maybe folks who have graduated further back. Detailing campaigns. I don't know how familiar some of you are with academic detailing, but in some places they've done sort of door-to-door interventions with physicians, with pharmacies, talking about, this can be students do it, public health does it, going in and actually talking about these issues, why things are important, dealing with stigma in more of a one-on-one way. Public education campaign. So this photo here is from a buprenorphine campaign in Philly where they did several of these all around the city that say, I am living proof that buprenorphine works, featuring different folks on those Again, I don't know that there's good data that that's helpful, but I don't particularly think that it hurts. And then I think what we really need, and this relates to the first bullet, is federal and state leadership to support and promote medications for opioid use disorder. And I wanted to mention, it's very timely, the Biden administration's new National Drug Control Strategy came out last week. I was really happy to see a lot of discussion in that document about stigma as a barrier to services for people with substance use disorder. There's an emphasis in that strategy on expanding MOUD and an entire section on harm reduction, which is a first for a National Drug Control Strategy. That harm reduction focus is really important in our current context because the illicit drug supply in our country is poison. And so many of us have started talking not about an overdose crisis, but a poisoning crisis because our illicit drug supply is literally poison. There's really no, it's very difficult to navigate the street drug supply safely. And so now we have over 100,000 overdose deaths a year. And in my opinion, and the opinion of many others, we don't really have the luxury of requiring abstinence as a goal of treatment. And instead we need to focus on keeping people alive and opioid agonists like methadone and buprenorphine are very effective in doing that. This is a quote from one of the Madden articles. Again, that I think is really useful. If the patient is going to work, they're gonna keep it together with their family life. I consider that a win. This is from a physician. Basically, if they're not using illicit drugs, I consider that a really good start. Physically, they have to be good before we can even think about working on the mental stuff. But colleagues say you're changing one drug for another. That's so 1900s. You gotta catch up with the current times. They read online how it's horrible to get off MAT, but I just want everyone to follow the evidence, okay? And the evidence says this keeps people off illicit drugs and alive. So shifting our outcome goals from abstinence to just keeping people alive so that we can do the other good work that we're capable of doing and give people a good quality of life, I think is something that we should really be prioritizing. Some people might be able to achieve this through abstinence-based recovery, and I think that's fantastic. But for others, methadone or buprenorphine is the key, and we should support that. I really think that people should have the whole sort of buffet of options available to them to choose what kind of treatment they want and what kind of goals or outcomes are gonna work best for them. So that's what I wanted to say about intervention stigma. I do have questions from last week, but I wonder if there are any other questions. I can't see the whole screen. If there are any other questions about these medications or stigma related to these medications. Oh, we had one comment about, thank you for covering stigma related to MOUD. Even in a progressive state like Rhode Island where medication is accepted, patients are still encountering stigma. Yeah, yeah. And there are states like Rhode Island who are doing a really excellent job on a lot of these fronts, but people still encounter barriers for sure. Yeah, thank you for noting that. And we did have one person who entered a question here. He says that he's presented a talk on rational treatment of opioid use disorder and address the 12 step issues with meds, including meds for alcohol use disorder, stimulant use disorder at a major conference where 75% or more of the attendees are SUD professionals who themselves are in recovery and they have very anti-medication attitudes. None attitude surveys pre and post the talks. And he feels like he's making little or no difference based on these surveys. Do you know what does work for changing attitudes? Yeah, I mean, this is the holy grail, isn't it? We have to find what works to do this. And so I think we do need more studies kind of like the one I talked about last week about how do we cultivate empathy? Is it knowledge that we have to change I do think that changing some of the societal pressures and the societal standards will matter. But I also am really hoping that changing the narrative around this to one that focuses on abstinence to focusing on keeping people alive and giving them quality of life will be helpful. People are overdosing at such high rates that we need to keep them alive so that we can even think about getting them to abstinence. And so I have started talking about it that way. I am starting to feel like abstinence is a luxury. The priority is to keep people alive long enough that we can talk about what medications or what treatment regimen is gonna be the best for them. And maybe that's because I come from more of a harm reduction orientation. The other issue is that we have a lot of people, I hear this anecdotally, I don't see good data on it, but a lot of people who are relapsing from abstinence-based treatment and dying of overdose, because the drug supply is just so toxic. Having an agonist on board or having Suboxone on board can be protective against that. There is some work on that. And so I just think focusing on keeping people alive should really be the priority, and maybe that helps. I'd be curious to hear what people think about that. We do have, we'll wait for some more of those comments to come in, but in the meantime, we have one question. We are seeing stigma in Oregon, in which pharmacies are claiming there are DEA barriers to increasing buprenorphine supply in the pharmacy. Recently hit us hard because one local chain closed and a major national chain placed barriers to bringing on buprenorphine clients that lost access. There are a couple of papers that have come out recently. I think one was from North Carolina about these sort of DEA quotas. DEA does not have quotas, but there's a big perception in the pharmacy community that there really are, or that there are sort of quotas that will raise a red flag, but nobody knows what those quotas are. So I think there's real fear about dispensing any kind of opioid, but I also think, as I said, that not dispensing buprenorphine is a way to keep folks that you don't particularly wanna deal with in the pharmacy out of the pharmacy, and that's stigma, right? So I know that some pharmacies don't carry other opioids as well, but again, what other medications do you not carry? Is the issue, and particularly if you're carrying other opioids, I don't know why you wouldn't carry buprenorphine. The way I think about this a lot is that, are you treating these opioids different than other opioids? If you are, usually stigma plays some part in that. We don't require people who are prescribed oxycodone to go get it every day in a special clinic, right? Or hydrocodone, or whatever else. So I tend to compare opioid to opioid and look at, are we treating the recipients of those opioids differently? Yeah, but there is a real fear, and there's some really nice qualitative work coming out where people interview pharmacists, and the pharmacists are like, yeah, there's quotas, and I'm worried about it. Thanks. I have something similar here with our pharmacy where they could only order a certain amount at one point, but then they were able to increase this. I did have a patient similar to what you're saying. He goes up North to go to his camp on weekends, and one time that happened after one of our appointments, and so he took his prescription for buprenorphine up there, or it got sent up there, and then it had to get transferred to several different pharmacies because they wouldn't carry it, it's more rural location. And then when he did finally get to a pharmacy, they asked him a bunch of personal questions in front of other people. When was the last time that you used heroin? And just all these different things. When's the last time you saw your doctor? When are you gonna see your doctor again? That he said, you know what, never again. I'm never gonna get this filled up there. I'll just keep going to my local pharmacy here. And so it was really hard for him to go for a day or two trying to find this medication, but also to feel like he was less than for being on his own. And that goes back to some of the quotes I presented last week about people going into pharmacies for syringes or naloxone, that it can feel embarrassing or stigmatizing, or like you are not having your confidentiality protected when you're questioned like that around certain purchases. Yeah, and so that keeps people away, yeah. Definitely. We have another participant who is saying that maybe some of the substandard or profit-based programs can poison the atmosphere around the use of medications, especially like for-profit chains. I'm just wondering if you had a comment on that. I don't really know a lot about the differences between the different providers of these medications. I will say that anytime someone acts irresponsibly in the prescribing of these medications versus being perceived as being irresponsible, that isn't helpful to anybody, but it does happen. I don't think I can really speak to that. It's not in my area of expertise. Right. I think sometimes that ends up being a concern that it's a pill mill with certain programs. And I think that that can lead to some bad, some stigma around the medications. I've seen that kind of thing happen in the past, but that was a while ago around here. So I don't know what it's like in other areas. I do think that we're just working on a paper from West Virginia where we interviewed, well, my colleagues interviewed physicians about prescribing opioids like oxycodone or hydrocodone during this sort of evolution of the opioid crisis. And a lot of them really do fear enforcement actions and just stop prescribing those medications. Right. And so that fear is very similar, I think, to what pharmacies feel too. And it leaves patients in a really difficult spot. And I think it would be really nice for there to be some leadership maybe by DEA around, we don't have quotas or we're not doing this because people really are just, they stop prescribing and dispensing. You all know this better than I do. Stop prescribing or dispensing because they're really afraid of having charges brought. And even if you're not convicted, the charges alone will ruin your reputation. So I do think it's a problem and I'm not sure that anyone has figured out a good way to deal with it yet. We have another comment that somebody has problems getting opioids for their patients, non-buprenorphine and opioids. So it's not limited just to buprenorphine and this is in New Hampshire and Vermont. Yes. Yes. And so I've seen this too from pain patients where not only does it become sometimes more difficult to find someone to prescribe those medications, but then it's very difficult sometimes to find a pharmacy that will fill those slots. And then it also is challenged. Somebody is bringing up the challenges too that patients have to go and they have to pay if they don't have insurance, pay for the prescription, but also pay for the visit to the provider, perhaps the urine drug test as well. Yeah, I think there's a correction that's happening with have we swung the pendulum too far? We obviously want to prevent diversion, but the big problem now is sort of, quote unquote, street opioids. It's not prescription opioids in most places. And so the question is, have we swung the pendulum too far by making it difficult for patients with chronic pain or even cancer pain to get the medications that they need? We're just working on analysis where in West Virginia, we saw not only a reduction in prescribing medications for non-cancer pain, but also cancer pain. And so I think there's a lot of conversation about whether we need to make an adjustment. This question is a little bit off topic, but it's asking about, given the use of crystal meth, I'm wondering if there's a study on the amount of fentanyl found in methamphetamine as it has been reported that fentanyl is being added to it. Given that, should it be recommended that if somebody uses methamphetamine and they're not being seen for opioid use disorder, should they be told to have Narcan available just in case? Yes. So I would word it a little differently. I think people in my field, if you really know illicit drug markets, there's no good reason to lace methamphetamine with fentanyl. What most of us think is happening is there's contamination during the packaging process, the cutting process, all these different things, and it doesn't take a lot of fentanyl contamination in a stimulant in someone who has no tolerance to opioids to cause an overdose. So I'm not sure that you'll find stimulants are laced purposefully with fentanyl. It's more likely that they've been contaminated with fentanyl sometime during the process. But that said, what we hear is that we are finding fentanyl in stimulants as well. And it is a really good idea to have both fentanyl test strips and naloxone if you're using stimulants, perhaps even more so if you're using stimulants, because I think most people in most places who use opioids now assume that there's fentanyl in their drugs or that it's 100% fentanyl with cutting agent or whatever. But for stimulants, people may not even be thinking about that. And so I absolutely think that's good harm reduction to make sure people who use stimulants are thinking about that and are prepared for it. And next week, our talk is going to be on the fourth wave stimulant use disorder intertwined with opioid use disorder. So tune in. That's it. I think that's Dan Ciccarone, and that's a great question for him because he studies this stuff all day, every day. I think, well, just one last comment was that it takes a long time to change beliefs and discrimination as a result of stigma tends to hold. So changing laws and policies can be effective for that. Yeah, I think I totally agree with that. I think the higher up this happens, the better off we are. And so that's why that that new national drug control strategy is so encouraging to a lot of people because it appears to be trying to change the mindset, you know, the narrative around how we should be addressing this problem. It's not perfect, but I do think it's a good step forward in terms of framing the issue and the solutions. Right. And some of these lawsuits that have been for people getting discriminated against or the ADA, if somebody is incarcerated and not being prescribed their medication, I think that's moving things forward. Absolutely. In West Virginia, the vast majority of folks who come in on buprenorphine or methadone are cold turkey about those medications just with symptom support, and that is not what should be happening. We don't do that with other medications, and that's not what we should be doing there. And I don't want to necessarily call it West Virginia because I'm sure that's happening in a lot of other places as well. Would you like me to address some of the questions from last week? Yes. And then feel free to interrupt me if there's other questions that come up, because now I do see the things that it's hard for me to do both things at once. Is stigma different for different types of drugs? For example, crack versus powder, powder cocaine, opioid pills versus heroin, and different routes of administration. So injected versus intranasal or oral, and if so, do these differences impact treatment seeking? So for sure, and I'm sure some of you know this, but stigma is different on different types of drugs. Undoubtedly, crack cocaine is more highly stigmatized than powder cocaine. There are some racial aspects to that from around the crack issue in the 1980s, and the different racial, how do I say this, the different disproportionate numbers of folks of color versus not using different kinds of cocaine or crack. Also, partly because of that, the penalties, the criminal penalties are harsher for crack versus powder cocaine, even though they're basically the same drug. So it used to be that the penalties were like 100 to one for crack versus powder cocaine by weight. Now it's something like 18 to one, so they're still not equivalent. But that, I would consider crack to be much more stigmatized than powder cocaine. I think the same is true for opioid pills being less stigmatized because they have some medical use versus heroin, which is considered to be a street drug. And one thing I want to note was we actually just did a study, I think I might've mentioned it last week, of family members of people who use opioids. And one thing that they said was that they perceived that their loved one's risk of overdose was lower because they were using prescription pills instead of heroin. In fact, prescription pills are still very dangerous. And if you know much about fentanyl, you know they're starting to press what looks like opioid pills are pure fentanyl, right, or they're fentanyl. So they actually are quite dangerous. So I do think that there are different stigmas around different drugs. There are for sure different levels of stigma around how you use these drugs as well, with injection obviously being the most stigmatized. One thing that's really interesting is that there are also different stigmas within drug using communities. So over the many years that I've worked within communities of people who use drugs, people might say, oh yeah, I smoke this drug. I should have put smoking here too. A lot of people smoke their drugs. I smoke these drugs, but at least I don't inject. Or well, I do inject, but I don't inject in these parts of the body that are much more risky. Or I inject, but at least I'm not homeless. There's like this whole hierarchy of stigmas that apply. But definitely injection is the most stigmatized. In terms of how it impacts treatment seeking, I'm not sure. In the literature, what it says, and I would agree with this, is that people who are taking just pills are more viewed as having kind of a medical problem than people who are using street drugs. But that's less stigmatized. I've also seen, and again, I haven't seen this literature, but in my experience, people having stigma, more stigma around stimulants, for example, especially meth versus sedatives. Some of that comes from the physical manifestations of people who use meth, which is like the skin lesions and the picking and that kind of stuff, or just the way they might act on stimulants. But yeah, there's very interesting hierarchies of stigma around, this is really a great question, on different kinds of drugs, different routes of injection, for sure. It's something that I've seen quite a bit in people that I treat, but also sometimes there'll be a difference to like patients. You can tell that they have the self stigma or internalized stigma because they find it important to tell me that they got addicted to opioids because they were prescribed them in the beginning. Absolutely. No, I'm not a bad person. I didn't just start taking these kind of things. Absolutely. I do this, but I don't do that, right? Which is a stigma within the community, for sure. Yeah. Let's do another one. How would you suggest auditing your practice to look for stigma in both oneself and staff? What does effective anti-stigma training for staff look like? In terms of auditing your practice, as I said last week, I really think that looking for stigmatizing language is a good place to start and also modeling more appropriate language for other people. I was saying that sometimes I reflect back, people will say something about an addict and I will say, oh, so what you're saying is that person who uses drugs, yada, yada, and just try to model more appropriate language. Certainly, if you are higher up, you can demand that people familiarize themselves with less stigmatizing language and use that. And there are trainings about stigma and minimizing stigma, just like we have it sort of an example for diversity, equity, and inclusion. I don't think that we have a good evidence base, as I said, for what works and what doesn't. So I do know, because I do some work in DEI as well, is that sometimes people have trainings and say, okay, this is the expectation now that you will try to adhere to these examples. And so that's one thing you can do, but I almost just think starting with language is a good place to start. Is there anti-stigma training for people who use drugs to help reduce self-stigma? This is a great question. Last week, I talked about a study that we had done on cultivating empathy, and the participants that we tested that intervention on were members of the public. And when we started thinking about doing this study, we thought about trying to use it to address self-stigma first. And what we decided was that it's potentially futile to try to reduce self-stigma if you don't deal with community or societal stigma first. So you're trying to change self-stigma when people are still operating within an environment where they are stigmatized virtually every day. So the answer is that I don't think that we have specific training around self-stigma. I could be wrong, but my hope is that by addressing some of the external stigma that people who use drugs experience, that will help with the self-stigma. And at that point, it might make sense to work on self-stigma too. But I think that that might be futile in the absence of dealing with external stigma. How do we create systemic change? Last week, you mentioned stigma in government officials, moratoriums on opening new treatment centers for MOUD, police officers not wanting to carry naloxone. Are there examples of how this can be accomplished? So I talked about, I think systemic change requires leadership from the very top. And I talked about the very timely National Drug Control Strategy is part of that. So one of the things that report does is it talks about stigma as an issue in our efforts to address substance use disorder. There's a part of the strategy where they're proposing coordinated anti-stigma efforts at the federal level. And I think that looks more like taking an inventory of what's available and maybe funding research around that, but at least they mention it and talk about it as a need. There's also support for updating the regulations around methadone and buprenorphine, which I think is useful and addresses some of the things I talked about earlier with intervention stigma. And then also expanding access to low barrier, low threshold settings for treatment, including MOUD. So leadership at the federal level, I think, is extremely important to address some of these things already in place that are stigmatizing. But also at the state level, your ability to access services for substance use disorder often depends on where you live. And I've given some examples of some of the constraints we have here in West Virginia. The other thing I would point to are things like the laws around the ability of syringe services programs to function can be very different from state to state, or even from community to community, where local ordinances are at play. Naloxone standing orders differ from state to state. So the state level is a place where I think some leadership and change needs to happen as well. Another issue can be these sort of community anti-stigma campaigns, but again, I don't think we really know what works well. And then the last thing that I wanted to mention is I think we all have a responsibility to push back on misinformation. There's a lot of misinformation out there about virtually every aspect of substance use disorder. But one thing that I wanted to talk about very briefly is fentanyl. So you have probably seen in the news media stories about people overdosing, particularly police officers from sort of casual contact with fentanyl. So this is a still from a video that was widely circulated from San Diego, where this police officer was sort of standing near a trunk that had suspected fentanyl in it, and immediately without even touching it, sort of keeled over and they said, oh my gosh, he's having a fentanyl overdose and squirted naloxone up his nose. You cannot overdose on fentanyl just by standing next to it. You will not overdose on fentanyl from having it on your skin. It is not easily absorbed through the skin. That's why we have fentanyl patches. But these stories keep coming out and keep coming out, and the result is likely that people who see someone overdosing are not going to respond to those overdoses because they're going to be afraid of overdosing themselves. And that means people aren't going to get the help they need. So definitely all pushing back on that. The other thing that's happening is now we're starting to see laws proposed and even passed that have heavier penalties for fentanyl than other drugs, much like the crack laws that I talked about a few minutes ago. That's not useful. It's not based on science, and it makes people afraid to access services if they're in possession of fentanyl, which a lot of people don't even know what's in their drugs to start with. They're going to get additional charges. So I think we all really need to push back on these kinds of narratives because they are, not only are they based on misinformation, but they're dangerous. Is stigma ever good? For example, stigma around smoking and not letting people smoking in public places. So can stigma ever be a good thing? There are people in the addictions field who think that stigma is good and that it motivates people to get into treatment. I do not agree with that position at all. The only good that I have ever seen stigma do is to keep people from getting the care and the services that they need. The example of smoking, I do think that laws around secondhand smoke have been effective, but there's a way to implement those. For example, explaining to people that the health effects of passive smoke exposure are a problem, and so that's why we do this. It's not necessarily stigmatizing people. In my experience, and again, it's limited to people who inject drugs, mostly, I have never seen stigma do anything but harm. And so that's my position on that. Other people might have a different answer, but I would love to see the science on stigma being a good thing. Okay, so we had a few comments and questions that came in in the interim. One person had commented that they've seen a number of SMART recovery meetings talk about self-stigma, and they discourage that language, unlike in 12-step where they might use stigmatizing terms like addict, alcoholic. So can you say that first part again? SMART recovery? Yeah, that they discourage self-stigma, so they don't encourage people to have to label themselves. Yeah. Yeah. Absolutely. Yeah. Again, I don't think there is any science that demonstrates that self-stigma is helpful to the recovery process. We did have somebody who put in an article in the chat. In the chat or the Q&A? Yeah, in the chat. It's by Livingston et al., 2012, and it's called The Effectiveness of Interventions for Reducing Stigma Related to Substance Use Disorder, a Systematic Review. Oh, awesome. Okay. Thank you, girl. I can see if I can put this to everybody. Yeah, it looks like that's due for an update, an updated systematic review. Maybe whoever said that, we should do it together, it's 2012. Yeah. So I'm just going to put that in the chat box. I do think that's a really important point that stigma is not static, right? Our stigmatization and the reasons that we stigmatize drug use changes over time and in different ways. So yeah, it's definitely not static. Well, Judy, could you try to cut and paste that in the chat box for everybody to be able to see? I'm having a little trouble doing that. One of the other comments that we had was also that it seems like the stigma has just extended to opioids in general. So if you have chronic pain, you're stigmatized for going and getting these opioids. And then there's more barriers set up for people to have to go and get prescriptions or prior authorization for providers to have to do to be able to prescribe these medications for people who need them. So that was another comment that came in a little bit ago. We had somebody else say that there is a study that suggests that the effect of anti-stigma training only lasts about three months. My understanding is that the only effective anti-stigma campaign is going on in the UK. It's a multi-year, multifaceted campaign. Yeah. Well, like I said, I think I just really think we need more work in this area, particularly if stigma is so important. One of the, I actually am just waiting on the notice of a grant for this. One of the problems is that stigma is really difficult to measure. So when you do studies of stigma, like what is the outcome measure that you use? There are scales. The question is, do we use the same scales? Do they apply in all places? The study that I'll be doing is looking at, does the stigma scale that was developed among people in treatment in New York City, is that actually a valid instrument for measuring stigma in rural America, for example? So I think the measurement issue is one that's pretty tricky, and there are new instruments like that coming out increasingly right now. And then we had some comments related to the one about the police officer and the open trunk containing fentanyl. So somebody was, you know, so it's not possible to die from an overdose, die or overdose from skin contact with fentanyl was the question. You would have to be exposed for a prolonged period of time to a lot of fentanyl for that to happen. Right? So that again is why we have fentanyl patches, because it is not readily absorbed by skin. And then I think this is about the same thing. Somebody commented that the primary care community thought that the video didn't look like an opioid overdose. Anesthesiologists have said that it was consistent with the stiff chest syndrome specific to fentanyl overdose. While this is very unlikely to happen and shouldn't stop us from intervening, this probably was a fentanyl overdose caused by high concentration of fentanyl aerosolized on a hot day. So I guess there's. Yeah. Yeah. I don't know. You can look at it like it's in the trunk and it's wrapped up like, you know, if I had fentanyl right here, I would gladly put it on my hand. There's actually videos online of a toxicologist who works in this field, putting fentanyl on their hand. Like if it was if you were going to overdose from fentanyl like that, all of our drug dealers would be dead. Right. Yeah. So. So I. Yeah. I mean, I think the issue is when you say that it's a fentanyl overdose, we we almost never get lab confirmation that that person had fentanyl in their system. So most people that I know say that that looks a lot more like a panic attack or an anxiety attack. But I'm not a clinician. So yeah. Right. And so in regard to the idea that stigma can be motivating, developmental and learning evidence based practice directly contradict the use of shame, does evidence supporting motivational interviewing, which demonstrates this repeatedly back in the 70s, 80s and 90s when conflict and shame was commonly used in treatment, and I was found to be superior every time. Yeah, absolutely. Yeah. I feel like there's some other people that could give this webinar. Then I guess, can you clarify the risk of overdose using fentanyl transdermal patches? I don't know enough about that, really. I would defer to a clinician or toxicologist. Right. I would say that it could be possible, especially if somebody is naive to opioids, or like I've seen a case where a child stepped on a patch, and so- Or multiple patches, right? Right. So this is multiple patches. Yeah. So it is a concern, but with opioid storage, you should always instruct your patients and work with them on safe storage and keeping those kind of things out of reach of kids. And then I think there's a question about if you've heard of a new opiate drug that's hitting Tampa, Sarasota, Florida, that's more powerful than fentanyl. Have you heard anything? I haven't. No. I mean, there's parfentanyl, right? Yeah. There's all kinds of fentanyl, fentanyl analogs, parfentanyl. There is a drug that's being found in a lot of the drug supply. You can ask Dan about this for the next webinar called xylosine, and xylosine is a sedative, but it's not an opioid. So Narcan won't reverse it, and that's definitely a concern. But in terms of another opioid, I'm not sure. I guess that's it so far from the chat box and the Q&A. I think just because I was thinking about this talk, I was just thinking about all the different ways that somebody who uses drugs could encounter stigma. If they're not even seeking treatment, it could be they want to have clean syringes or they want to have naloxone. They could get that if they go to the pharmacy. In some of the research articles that you've published, you show that people often are treated well at harm reduction programs and don't encounter stigma there. But then if somebody decides to get into treatment, they might go to an ED or to a doctor's office and then get treated with stigma there and then picking up their medications or other things just related to our system of treatment here. So it's a very important topic to think about how this presents barriers to people wanting to come and engage with us. This actually segues really nicely into the way that I wanted to end this session today. I was talking to a friend and colleague last night, and we have a growing number of people in West Virginia who have gotten infected with HIV from injecting drugs, and more than half of them are homeless. It's extremely challenging to get folks in to even start, they do their labs and start HIV treatment, and she's an HIV case manager. And so this is her population. She works with this population all day. And she was telling me that where they go at one of the hospitals for phlebotomy, the phlebotomist there on the day shift does not like dealing with these people at all. And you can imagine it's quite difficult to get a vein sometimes, but she said, you know, I bring them in, and you can just feel the stigma and the hate coming off this person and her clients are like, that's it, I'm out of there. So the other day, she said, why don't we, she had a couple of folks in her car, and she had been trying forever to get labs on these kids, basically. So why don't we try this other lab? It's like down the street. And so they went in there and one of the phlebotomists said, you know, you seem really dehydrated. She said, you know, it's going to be hard to get a vein. And she said, my friend said, yeah, well, you know, they're homeless, and it was cold last night, and I haven't had enough water and whatever. And immediately the phlebotomists were like, oh, okay. And then they said, okay, well, let's think about like how we can do this. And one of the patients said, well, I keep good veins in my, in my ankle and my leg because I know eventually I'm going to be in the hospital and y'all are going to need a good vein. And the phlebotomist said, awesome, is that where you want us to take do the blood draw? And the kids were like, yeah, can you do that? So they called and got an order for a lower extremity blood draw. And this is them, the phlebotomist got down on the floor. And we're taking, you know, we're problem solving with these patients, okay, which vein do you think I should use? Where is a good place to do this? And my friend was literally in tears. And I was sort of in tears hearing about it. Because to go from an environment where you are stigmatized to a place where they're willing to kind of problem solve this with you made all the difference. These kids are totally willing to go back and see those phlebotomists again. Now they have the labs that they need to start getting them on medication. So sometimes it's just as easy as this, right? One phlebotomist can be the difference between a person who injects drugs getting into HIV care and not. And so I just thought this was kind of a powerful way to end. Because honestly, it's not that hard. It's just thinking about how do we figure this out together without stigma in between us as providers and patients? Well, thank you so much for this great Q&A period and extended discussion on stigma and health. I really appreciate you doing this webinar for us. And Dr. Polini has put her email there if you have any further questions. And I thank you all for attending next week. We have our talk from Dr. Daniel Ciccarone, who's going to present on the fourth wave addressing the intertwined fentanyl and stimulant overdose crisis. So we look forward to that. It'll be at five o'clock next Wednesday. So thank you so much. Yeah, thank you. It's been a pleasure. Thank you.

stigma

MOUD

institutional stigma

limited access

patient outcomes

medications for opioid use disorder

deterrence

systemic changes

substance use disorder