Discrimination Persistent Barrier to Care for OUD Patients

In the 1980s, Andrew Saxon, M.D., worked in an opioid use disorder (OUD) treatment program. It was early in his career and, because his knowledge was limited, he relied on the experience of the staff who worked there.

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He soon realized, however, that the staff, like much of the general public, harbored stigma toward the patients seeking their care. “It was clear that they blamed the patients for making bad decisions,” said Saxon, a member of APA’s Council on Addiction Psychiatry, a professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington, and director of the Center of Excellence in Substance Abuse Treatment and Education at the VA Puget Sound Health Care System.

“At the time, even the supposed experts in the field had no real understanding that this was a brain disorder,” he continued. “Until fairly recently, we conceptualized these patients as being weak-willed people who were self-destructive and could easily make a choice to behave differently if they wanted to.”

Though there have been improvements, discriminatory beliefs about patients with OUD and other substance use disorders (SUDs) are still prevalent, Saxon said. Such discrimination violates the Americans With Disabilities Act (ADA), and the federal government has cracked down on it in some situations. In May 2020, for example, the Office for Civil Rights of the U.S. Department of Health and Human Services reached a voluntary resolution agreement with the West Virginia Department of Health and Human Services over allegations of discrimination. The complaint involved an aunt and uncle who were seeking to adopt their niece and nephew, but the aunt and uncle alleged their request was denied because the uncle was prescribed Suboxone due to his OUD.

In Massachusetts, the Civil Rights Unit of the U.S. Attorney’s Office settled with health care facilities, such as skilled nursing facilities or rehabilitation centers, three times in the past three years to resolve allegations that they violated the ADA by turning away patients who were being treated for OUD with buprenorphine or methadone.

In one such settlement at the end of 2020, a news release stated that a skilled nursing facility denied individuals seeking admission on more than 350 occasions because they were being treated with buprenorphine or methadone.

Saxon was pleased that the Department of Justice intervened in those cases, he said, because the problem of nursing facilities turning away patients receiving treatment for OUD is one with which he is intimately familiar. He encounters it with patients he treats, and the problem is especially pronounced for those prescribed methadone. The irony, he explained, is that skilled nursing facilities often accept patients who receive prescription opioids for pain but refuse patients being treated for OUD.

The repercussions for patients who are denied care are dire. Sometimes patients must stop taking the prescription medications on which they depend, he said. “Sometimes patient must go home and receive care from family members who are unqualified,” he added.

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Actions by institutions like the Department of Justice are an important part of the overall effort to dismantle discrimination against people with OUD and improve access to care, said Alene Kennedy-Hendricks, Ph.D., an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. But ultimately, such discrimination is just one piece of a larger puzzle, she said.

Kennedy-Hendricks has studied stigma toward people with OUD extensively. In a 2017 study published in Psychiatric Services, Kennedy-Hendricks and her colleagues found that, in a survey of 1,071 members of the public, respondents expressed high levels of stigma toward those with OUD. The levels of stigma were about the same even among respondents with a relative or close friend with the disorder.

More recently, Kennedy-Hendricks and her colleagues studied primary care physicians’ views of medication treatment for OUD. In a July 2020 study in the Annals of Internal Medicine, they found that, among 336 primary care physicians, a third did not perceive OUD medication treatment to be more effective than nonmedication treatment. “Physicians reported low interest in treating OUD and low support for policy proposals allowing office-based physicians to prescribe methadone for OUD and eliminating the buprenorphine waiver,” the authors wrote.

“It’s not as though the medical community is immune to these beliefs,” Saxon explained. Unfortunately, he said, health care professionals often see these patients only at their worst. When psychiatrists or other physicians first encounter individuals with OUDs, it is usually in an emergency setting in which the individual is in an intoxicated state, skewing physicians’ perception of people with OUD.

“They need to see individuals with OUD who have received the proper treatment and have stabilized,” Saxon said. “You couldn’t pick them out of a crowd. You’d never notice them in a workplace or at a family gathering.”

In a comprehensive article published in PLOS Medicine in 2019, Alexander Tsai, M.D., Ph.D., an associate professor of psychiatry at Massachusetts General Hospital, and colleagues outlined the various dimensions of stigma experienced by individuals with OUD and argued that stigma continues “to fundamentally hinder the response to the crisis.”

The authors described several types of stigma, such as structural stigma that has become encoded in laws and policies, stigma held by members of the general public, and internalized stigma in which individuals with OUD anticipate the public stigma attached to their illnesses. “Each of these dimensions of stigma … serve to reinforce each other, resulting in poorer health outcomes even as the epidemiology of opioid overdose mortality continues to change,” the authors wrote.

Kennedy-Hendricks and her colleagues’ research suggests that solely emphasizing that OUD is a disease may not be the best way to counter stigma. “It may reinforce the perception that it’s permanent, there’s no hope, and people can’t get better, and it doesn’t directly push back on the idea that there is some flaw in these individuals,” she said.

Instead, in addition to efforts at the federal level, tailored and targeted interventions to reduce social stigma among those who work most with people with OUD, such as health care professionals and law enforcement, may be more effective. “To address stigma, we need an all-hands-on-deck, multifaceted approach,” she said. ■