Health Care Among Underserved Populations, Final Paper
Dan Cohen, MS-3
December 2010
“Wanna see how nasty I can be to a drug addict?!” This was confidently and enthusiastically said to me with a big
smile from across a hallway by a nurse during my obstetrics clerkship. She was referring to a woman who
was pregnant and addicted to heroin, presenting to Magee to be converted to methadone. She was in
withdrawal and in a great deal of pain and discomfort. More importantly, she was making what medical
evidence would indicate is an excellent decision for herself and her unborn baby, as both continued IV
drug use or opiate withdrawal are dangerous to the fetus. Perhaps this woman would even use this as a
turning point, and recover from her addiction to heroin by staying on methadone maintenance after
pregnancy. I did not see the utility in being nasty to someone like this. I wish this was the only story I had
of overt expressions of dislike for patients with substance use disorders during my 8 months of clinical
rotations, but I lost count some time ago.
Addiction, or substance use disorders (SUDs), could be defined as a collection of disorders related to use
of psychoactive substances that leads to use despite negative consequences. Effects of different drugs vary,
but in the example of opiate addiction, severe chemical dependency develops and causes illness if
exogenous opiates are not taken. The disorder usually leads to behaviors that focus on attaining the drug.
Addictions can be devastating illnesses leading to many health, psychological, social, family, and financial
problems. Research has begun to uncover the biological substrates of addiction, with findings such as
alterations in neural pathways and disturbances in neurotransmitters, but the medical model of addiction
lacks widespread acceptable by society. Illicit drug users face significant stigma, and while this stigma may
have the positive consequence of deterring people from starting to use certain drugs, such stigma has far
less value in promoting recovery in an already-addicted individual, and may actually serve as a barrier to
successful treatment. Unfortunately, the streets are not the only place face stigma. Healthcare providers as
a group hold significant negative views of substance users, and such stigma affects the way in which they
deliver care to people suffering from these illnesses. People suffering from substance use disorders are
consequently an underserved population in our current system.
***
It is well documented that physicians in general do not feel comfortable in treating addictions, do not like
caring for these patients, and hold pessimistic views about recovery from addiction (reviewed in1). A study
of Emergency Department staff found that not only did providers dislike working with patients with
addictions, but the factors that seemed to predict this dislike were different than those for other illnesses2.
This was true even when comparing SUDs to other illnesses obviously influenced by volition in the
vignette (for example a patient who was sick as a result of failing to take a prescribed medication or follow
a diet). The ED physicians rated interactions with patients with SUDs as less rewarding even when all the
other variables measured in the study (cooperativeness, seriousness of illness, responsibility for current
state, degree of curability, etc) were rated equally.
Another clearly important and consistently discussed factor in doctor-patient relationships in SUDs is the
provider’s fear of being deceived or manipulated. This was clearly identified as a major theme in a study of
observed interactions between opiate addicts and treatment teams in a teaching hospital3. They found
physicians consistently reported fear of deception, and that patients would over-report pain symptoms and
thus cause them to prescribe opiate medications for “non-medically indicated” reasons. They were also
weary of contributing to addiction, and the medically unsafe effects of excessive opiates. The authors of
the study note that such practices are not satisfactorily explained by “clinical or regulatory demands, since
pain and withdrawal symptom management is both clinically prudent and legally sanctioned. Rather, it
might be hypothesized that they reflect the influence of negative societal attitudes toward opiate-addicted
persons…[and] may result in part from insufficient clinical tools to address pain and addiction
management.”
Evolutionary psychologists have studied the concept of cheater-detection in social interactions. They assert
that in order for cooperative and reciprocal social behavior to exist in a species (such as the very social and
cooperative human), there must be a strong mechanism to detect and react unfavorably to “cheaters,” or
individuals that break social rules in order to benefit themselves at the expense of cooperators4. This
human tendency may be relevant to interactions of prescribing physicians and opiate-addicted patients.
While such a tendency was valuable in hunter-gatherer days, it does not necessitate that it is currently
adaptive. Furthermore, even if it is a natural human reaction, it does not mean it is appropriate in a doctorpatient relationship, in which it is the job of the physician to take care for the patient, regardless of
personal reaction. Concerns about deception by patients with addictions is certainly legitimate – in one
study three quarters of addicted patients admitted to past manipulation of healthcare providers5 – and
concerns about doing harm via prescribing opiates are certainly valid as well. However, I would argue that
providers often “don’t like” patients who have attempted to scheme the system, generalize such
experiences to stereotypes about other people with substance use disorders, and thus treat these patients
differently. This is unacceptable and something good physicians must be aware of and strive to avoid.
***
There is evidence that the negative attitudes and stigmas held by physicians described above adversely
affect health outcomes of people with substance use disorders. Stigmatization has been found to be a
barrier to seeking treatment for substance use disorders, for a variety of reasons including fear of poor
treatment by healthcare providers6-8. A review concluded that negative attitudes among nurses often
prevent them from carrying out “effective and humane nursing care” to patients with addictions9.
In the previously mentioned study of physicians in teaching hospitals, physicians were inconsistent in their
approach to pain management, often relying on their subjective reaction to patients3. Furthermore,
physicians in this study often avoided addressing primary pain complaints, and rarely addressed the
underlying addiction as a medical illness. Patients were prone to perceive inconsistency as intentional
mistreatment, especially if they had previous bad experiences. In a study of methadone clinic staff
members, opinions on treatment duration of the patients was influenced not by opinions medical evidence
of efficacy or safety, but was associated with the degree to which their views on illicit drug use were
punitive10. The authors of this study concluded that the fact that so many methadone programs operate in
conflict with established medical evidence may be due in large part to personal views and biases.
There is no standard algorithm on how to handle treating patients with addictions, and thus personal style
in treatment philosophy and provider-patient interactions become important. Therefore, I would argue
that it is highly likely that stigma against people with addictions affects the care of these patients even more
than the current literature indicates. Worse outcomes in the form of missed opportunities to address
underlying addiction and psychological harm of being treated as less worthy of medical care than others
are hard to quantify and study.
People suffering from addictions are an underserved population in our healthcare system as the result of
the attitudes and beliefs of healthcare providers. This is particularly disturbing considering the healthcare
professions should be striving to treat every patient with basic respect and empathy. Furthermore, there is
a severe lack of treatment programs available for substance use disorders, and thus the provision of care is
another important reason addictions are underserved. Not only that, but patients suffering from addictions
are vulnerable to being parts of other underserved populations as well. Although it is a problem
everywhere, substance use has historically been an exaggerated problem in economically depressed
communities. Again while it is certainly not always the case, substance use disorders often develop in
individuals self-medicating mental health disorders. In a particular person, the interaction of any
combination of substance use, social isolation related to stigma, mental illness, financial problems related
to use, financial problems unrelated to use, low expectations of achievement or prospects for the future
can lead to viscous spiral in which these factors and others feed off each other. For patients suffering from
substance abuse with other risks for low access to care, another injustice is done through being mistreated
by healthcare professionals.
***
Something must be done to improve this situation, as after all, healthcare professionals have a social
responsibility as the members of society whose training should lead to them to understand chemical
dependency, who have tools to treat addictions, and whose job it is to help people who come to them.
Mental health professionals responding to a vignette supported more punitive treatment of a person if
described as “substance abuser” rather than “having a substance use disorder”8. When the words we use to
describe people make a difference, it should be clear that the pervading attitudes of the overall professional
culture certainly do as well. Reframe how we talk about substance disorders alone may help how we think
about them.
A logical place to start such interventions would be in medical training, before students are socialized to
stigmatizing attitudes. In the UK, a study showed that while significant negative beliefs about substance
disorders existed, these attitudes improved substantially as students progressed through medical school11.
Disturbingly, a study from America showed views actually got worse as students progressed through
medical school1. The study also found that, despite the prevalence of substance use disorders, there is little
education on opiate addiction and pain management in medical school. There is evidence that a course in
addictions improves medical students’ attitudes towards substance use disorders, especially when the
course is not given at the same time as demanding basic science courses12. A good first step would be to
implement such courses in more medical schools.
However, educating students is not enough, as what is taught in the lecture room will be of much less
value if there are not good role models once students get onto the wards. Steps also need to be taken to
educate practicing physicians. This could be done in the form of continuing medical education aimed
changing attitudes and providing skills to treat substance use disorders. If physicians felt more comfortable
treating such disorders, some may cease to seem them as “non-medical,” and more effectively address
them. Primary care providers should obviously be targeted to improve early detection and treatment of
substance use disorders, hospital-based internists because pain-control issues often occur in this setting,
and emergency room physicians because many patients present to the ED for primary care. Perhaps
performance-tracking programs could be developed, especially in settings with electronic medical records,
with regard to the treatment of patients with addictions compared to those without. Finally, while beyond
the scope of this paper, policy changes need to occur to allow the provision of more substance abuse
treatment programs, possibly by lessening the restrictions on opiate replacement therapy13.
We cannot expect these changes to occur overnight, as stigma against drug use is engrained in our culture.
Even if this stigma in the general public may dissuade initiation of illicit drug use, it has no place in guiding
the clinical practice of providers treating people with a substance use disorder. Addictions are common,
and those affected by them often come to healthcare providers in times of crisis. We need to do a better
job of helping these people by recognizing our biases and their ethical unacceptability, and coming to the
conclusion that it is not
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who
have alcohol- and drug-related disorders. Acad Med 2001;76(5):410-8.
Biener L. Perceptions of patients by emergency room staff: substance-abusers versus non-substanceabusers. J Health Soc Behav 1983;24(3):264-75.
Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual mistrust in the medical care of
drug users: the keys to the "narc" cabinet. J Gen Intern Med 2002;17(5):327-33.
Cosmides JTaL. Evolutionary Psychology: A Primer. 1997.
McLaughlin DF, McKenna H, Leslie JC. The perceptions and aspirations illicit drug users hold toward
health care staff and the care they receive. J Psychiatr Ment Health Nurs 2000;7(5):435-41.
Cunningham JA, Sobell LC, Sobell MB, Agrawal S, Toneatto T. Barriers to treatment: why alcohol
and drug abusers delay or never seek treatment. Addict Behav 1993;18(3):347-53.
Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: evidence
from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health
Soc Behav 1997;38(2):177-90.
Kelly JF, 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;21(3):202-7.
McLaughlin D, Long A. An extended literature review of health professionals' perceptions of illicit
drugs and their clients who use them. J Psychiatr Ment Health Nurs 1996;3(5):283-8.
Caplehorn JR, Irwig L, Saunders JB. Attitudes and beliefs of staff working in methadone maintenance
clinics. Subst Use Misuse 1996;31(4):437-52.
Landy JH, J; Checinski, K; Crome, I. Knowledge of and attitudes to substance misuse in
undergraduate British medical students. Drugs: education, prevention and policy 2005;12(2):137-48.
Chappel JN, Veach TL. Effect of a course on students' attitudes toward substance abuse and its
treatment. J Med Educ 1987;62(5):394-400.
Merrill JO. Policy progress for physician treatment of opiate addiction. J Gen Intern Med
2002;17(5):361-8.