At the individual-level, the anticipation of being stigmatized can lead to a desire to hide one’s addiction, and the internalization of stigma may prevent someone from seeking help or engaging with lifesaving services. At the health system-level, stigma can influence providers’ interactions with people with substance use disorders and contribute to underinvestment into high-quality addiction treatment infrastructure. At the societal level, stigma can lead to collective “not-in-my-backyard” (NIMBY) resistance to community-based services, shape public opinion in favor of punitive responses rather than public health-oriented solutions, and result in discrimination related to insurance benefits, employment, and housing.
The evidence base for effectively combatting public stigma related to addiction is greatly underdeveloped; however, available research does point to a number of principles that can guide stigma reduction campaigns. First, it is critical to use “person-first” language, with terms such as “person with a substance use disorder.” Research has shown that using terms such as “substance abuser” exacerbate stigma, as well as other negative terms such as “addict,” “clean,” and “drug habit.” Second, emphasizing solutions appears to reduce public stigma. Limited evidence suggests that “treatment works” messaging can mitigate addiction-related stigma and that negative attitudes towards harm-reduction programs can be reduced by emphasizing overdose prevention.
Messaging campaigns should emphasize the societal rather than individual causes of addiction. People have a cognitive bias to assume that individual actions depend more on intrinsic characteristics than on situational/societal factors, which may lead to over-attributing addiction to an individual’s poor choices as opposed to factors such as poverty, a history of trauma, or structural barriers to accessing evidence-based treatment. Finally, research suggests that sympathetic narratives – stories that humanize people with addiction – may reduce stigma. However, the details are critically important. Studies have shown that the socioeconomic status of a pregnant woman with opioid use disorder influenced the degree to which the audience blamed the woman for her addiction – with only a high socioeconomic status depiction reducing stigma. This highlights the intersectional nature of addiction stigma: negative attitudes about addiction are inextricably linked to stigma against certain races and socioeconomic classes.
To be most effective, these public education campaigns focused on reducing addiction stigma must be embedded in comprehensive strategies for tackling the addiction crisis. In health care settings, for example, stigma reduction is necessary but not sufficient for overcoming substance use disorder care delivery barriers. A rigorously studied and evidence-based communication campaign can only work so well in an area where clinicians are unable to get patients with addiction into effective evidence-based treatment programs. The best anti-stigma campaigns are no match for clinicians with no access to evidence-based treatment and a community that has little-to-no examples of people in recovery. But – when done in combination – effective stigma reduction campaigns may amplify the benefits of high quality, evidence-based addiction treatment by increasing providers’ enthusiasm, improving patients’ experiences, and showing a community what recovery looks like.
This concerted effort is being undertaken in West Virginia with the State Substance Abuse Response Plan. The state plan uses a multi-faceted approach to addressing the addiction epidemic through prevention, treatment expansion, increasing community engagement and support systems, expanding pathways from law enforcement to treatment and recovery, and public education. Including public education as a piece of the larger framework increases the likelihood of success because it works on moving public attitudes in a concerted effort to change the way we think about and address addiction.