Why addressing stigma around substance use matters

By Jessica Werb

People gathered in discussion about mental health.
We can all play a role in tackling the overdose epidemic. Photo: iStock

Experts say we need to normalize the conversation, as we’ve done with other health conditions

Attitudes around mental health have undergone a seismic shift in recent years, with celebrities, politicians and advocates openly and compassionately talking about their personal experiences and the importance of support and awareness. Now, with North America in the grips of an overdose epidemic fuelled by an increasingly toxic illegal market, researchers say it’s time for substance use to also come out of the shadows.

“There’s been so much work and effort by society to have people talk about their struggles with mental health or mental illness, and that conversation has really changed over the last couple of decades,” says Cheyenne Johnson, Executive Director of the BC Centre on Substance Use (BCCSU) and an adjunct professor in the UBC School of Nursing. “Often, people are too embarrassed because of the stigma and shame around their own or a loved one’s substance use. We need to normalize it and talk about it in the same way that we talk about other health conditions, rather than it being a family’s so-called ‘dirty secret’.”

“People are often forced to use alone or use quickly or in a risky situation, because of a fear of being criminalized or a fear of stigma. That puts people at increased risk.”

Cheyenne Johnson, Executive Director of the BC Centre on Substance Use
and adjunct professor, UBC School of Nursing

One of the biggest risks of overdosing is using alone, notes Johnson, and that is intricately tied to stigma. “People are often forced to use alone or use quickly or in a risky situation, because of a fear of being criminalized or a fear of stigma by friends, family members, community, etcetera. That puts people at increased risk because no one’s there to reverse an accidental overdose.” (Find out how to recognize the signs of an opioid overdose and what to do.)

With BC surpassing more than 1,200 overdose deaths in the first seven months of 2021, most of which occurred while individuals were using alone, the situation has never been more pressing. “We want to encourage people to talk about issues around overdose, drug policy and substance use with their families and friends,” urges Johnson. “We need to normalize the conversation around substance use at school, in our homes, in the workplace and as a society.”

Two people sitting outside and having a discussion about mental health.
Opening up conversations around substance use can encourage people to seek help. Photo: iStock

Fear drives stigma

Stigma around substance use permeates everything from societal attitudes, to access to health care and treatment, to public policy, says Dr. Evan Wood, a professor in the UBC Department of Medicine and a clinician scientist at the BCCSU.

“If I had any other health condition, I could just tell my employer, ‘I have a medical condition. I need to take medical leave. I need help,’” he notes. “But if your drinking has gotten out of control, or you’re struggling with opioids, it’s a different story. People don’t want to share that. People who may benefit from support or treatment are often afraid to ask for help.”

Even when individuals are able to ask for help, Dr. Wood adds, the stigma continues: “Health policymakers have not prioritized creating a safe and effective system of care. There is work to do from so many angles.”

“The stigma that people who use drugs face in the health-care system is very, very real.”

Dr. Evan Wood, professor, UBC Department of Medicine
and clinician scientist, BCCSU

In her work with young people who use substances, medical anthropologist Dr. Danya Fast, a research scientist with the BCCSU and assistant professor in the UBC Department of Medicine, notes that stigma around substance can be internalized by those who use drugs and alcohol, deepening suffering and harms.

“When somebody internalizes the belief that people who struggle with substance use are ‘morally weak,’ and have simply allowed their substance use to ‘overtake them,’ we have seen in our research with youth that it can lead to them telling themselves, ‘I’m worthless, I’m a bad person, I should be able to do better, but I can’t,’” she says. “The pervasive stigma around substance use in our society makes it much easier to attach on to the idea that ‘Maybe I’m just someone who cannot stop using and will never get that life that I’m reaching for, that I’m dreaming of.’ That’s really heartbreaking. And it can actually lead to more substance use, because it seems like there is no other path.”

Even among care providers, says Dr. Wood, “the stigma that people who use drugs face in the health-care system is very, very real.” That stigma, says Johnson, has been well documented, and stems from a lack of adequate training for health-care professionals about substance use and its treatment options.

“Physicians and nurses and social workers and pharmacists learn about Type 2 diabetes, they learn about heart disease, they learn about screening for cancer. The scope and size of addiction and substance use in our society is so immense, yet we still pay very little attention to it in undergraduate education,” she says. Johnson notes that the BCCSU and UBC Health have recently partnered to improve substance use and addiction education for health professional students at UBC.

A family having a conversation about mental health.
Most people know someone who is dealing with a substance use disorder in their family circle, whether it’s around cannabis, alcohol or other substances. Photo: iStock

Why decriminalization and regulation could make a difference

To truly combat stigma around substance use, Dr. Wood and his colleagues say we need to address it at its source: public policy.

“What’s really important for people to understand is how much of the stigma flows from criminalization,” says Dr. Wood. “The same thing that’s driving overdose deaths is the same thing that’s driving stigma in the health-care system, and the same thing that’s leading to gang violence and organized crime concerns—and that’s prohibition.”

In Portugal, he adds, where all drugs were decriminalized in 2001, “the architects of that program have said that the biggest thing that has helped reduce stigma is decriminalization.”

“As a society, we really judge people who use substances. That’s very intricately linked to policy.”

Cheyenne Johnson, BC Centre on Substance use

There’s a double standard, adds Johnson, around what sorts of substances are deemed acceptable, and which are not. “As a society, we really judge people who use substances,” she observes. “That’s very intricately linked to policy. We’ve decided alcohol is legal and cannabis is legal and nicotine is legal, but opioids, methamphetamines and cocaine are illegal. That criminalization further subjugates and stigmatizes people who use drugs.”

The BCCSU has called for an end to the criminalization of drugs, and the introduction of regulated, legalized approaches to combat organized crime and create a safer model for people who use drugs. In a 2019 report co-authored by Johnson, Dr. Wood, and several people with lived and living experience of substance use, the centre recommended the urgent implementation of controlled, regulated sales of heroin in BC through the creation of co-op models for people using opioids at high risk of overdose. This model would enable them to purchase non-fentanyl-adulterated heroin legally, rather than channeling funds to organized crime groups that currently control the drug market.

While there is public support for decriminalization in Canada, the prospect of a regulated and legal supply of opioids makes some people uncomfortable, concedes Johnson. “People get nervous when you think about regulating currently illegal drugs like heroin. They think, ‘Oh, it will be available at every corner store.’ That’s not what it is,” she insists.

A regulated legal market would include strict guidelines on who can participate and where the substances are consumed and accessed. It would ensure a standardized, quality-controlled supply and, notes Johnson, provide tax revenues that could fund health and social supports for substance use. Whether or not changes to federal policies around controlled substances occur, we can all play a role in tackling the overdose epidemic by spreading awareness, compassion and acceptance around substance use. “Drug use doesn’t discriminate,” says Dr. Johnson. “I think every person has someone they know who is dealing with a substance use disorder in their family circles, whether it’s around cannabis, alcohol or other substances. It just looks different depending on the social structures that either oppress people or lift them up. As a society, we really need to do more hard work.”

Explore more resources on stigma and substance use

BC Centre for Disease Control Foundation

Canadian Association of People Who use Drugs

Health Canada

Stop Overdose BC

Toward the Heart

BC Centre on Substance Use

Jessica Werb is a freelance writer for UBC Brand and Marketing. This article was published on October 8, 2021.
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