Tang K. Stigma and its impact on harm reduction approaches in addiction: the case for opioid substitution. HPHR. 2021;30.
North America has been grappling with an ongoing opioid epidemic, which has now been exacerbated by the concurrent coronavirus disease of 2019 (COVID-19) pandemic, leading to a deadly convergence the public health system must contend with now and for years to come. Indeed, in the United States (US), a recent study found that recreational use of opioids has increased 50% since the start of the pandemic (Niles et al., 2021). Likewise, in Canada, a survey by the Canadian Institute for Health Information (CIHI) reported an increase of about 4000 stays in hospital care for alcohol and substance use, including opioids (Canadian Institute for Health Information, 2021). Notably, there was an 82% increase in opioid-related deaths in the country during the first six months of the COVID-19 pandemic (Canadian Institute for Health Information, 2021).
Among clinicians, an addiction refers to a disorder where an “individual becomes intensely preoccupied with a substance or behaviour that initially provides the individual a desired effect” (Sussman et al., 2011, p. 4). The negative influence of addictions is considerable to both the individual and society (Sussman et al., 2011). Moreover, individuals with an addiction may also have to contend with the stigma of having an addiction, especially as perceived by the public. Stigma is a sociocultural development construct that encompasses various negative attitudes and beliefs about an individual. It can be defined as an ‘attribute that is deeply discrediting’ and reduces an individual ‘from a whole and usual person to a tainted, discounted one’ (p. 3; Goffman, 1963). Stigma can lead to the devaluation of social identity in a particular social context and can be related to personal traits perceived to arise from character flaws such as mental illness, leading to the stigmatized individual experiencing embarrassment, shame, and the fear of being judged (Crocker et al., 1998; Goffman, 1963; Hing et al., 2016). Indeed, in the mental health and addiction literature, stigma remains a major barrier for help-seeking or accessing treatment (Corrigan et al., 2014).
When it comes to harm reduction, stigma from the public may be one of the most predominant barriers to accessing treatment today, especially surrounding the opioid crisis in North America. Indeed, opioid substitution treatment (OST), an evidence-based treatment approach promoting harm reduction (as opposed to abstinence) adheres to bioethical principles and does provide benefits to a segment of the target population, and thus, should not be stigmatized by the public. In fact, OST may be crucial in alleviating the concurrent opioid crisis, which has been perpetuated by the pandemic and remains a public health concern.
Currently, the gold-standard and most common approach for treating addiction is based on the disease model of addiction, which promotes complete abstinence, and hence, encourages all individuals to cease all use of substances (Mckeganey et al., 2009). On the other hand, the emergence of an alternative treatment approach, the harm-reduction model, has been in the public’s eye in recent years with the introduction of supervised injection sites (e.g., safe injection sites; Woo, 2017). Although there is no clear-cut definition, the International Harm Reduction Association (IHRA) defines harm reduction as “policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption” (International Harrm Reduction Association, 2010, para. 5). The IHRA touts that harm reduction has its merits and benefits drug users, their families, and the community as a whole (International Harm Reduction Association, 2010), where the aim is to decrease use or the harmful consequences associated with use.
Harm reduction programs encompass and are not limited to supervised injections sites, needle exchange programs, nicotine replacement, alcohol harm reduction, and OST. A metanalysis compiled research on the effectiveness of harm reduction in alcohol and substance use in a plethora of settings and in a variety of target populations (Logan & Marlatt, 2010). Overall, interventions and studies promoting harm reduction was demonstrably effective for both alcohol and substance use in diverse settings and populations. The authors concluded that they were also effective in recruiting a larger proportion of clients and in reaching divergent populations (e.g., homeless, worksites) than abstinence-only treatments. In terms of supervised injections sites and needle exchange programs, a metanalysis of 45 studies deemed the programs as safe, effective, and cost-effective (Wodak & Cooney, 2006), with no deleterious effects noted (Strathdee & Vlahov, 2001). For nicotine replacement, research has consistently found that individuals show an increase in cessation rates (by 1.5 to two) compared with placebo or no additional aid (e.g., McMurry, 2006; Shiffman, 2007). Harm reduction interventions are vital for college students as many do not view alcohol as a problem due to the social norms of their environment (e.g., binge drinking in college), hence these are more effective than abstinence-based programs (Vik et al., 2000). Clearly, empirical research supports harm reduction programs as beneficial for a variety of substances from reducing alcohol use in students to nicotine replacement, and these have become (mostly) widely accepted harm reduction approaches in our society today. However, the use of OST as a harm reduction approach appears to remain the most controversial of them all, given that it appears to be the most stigmatized (along with supervised injection sites in general). Interestingly, there may be a link between harm reduction and abstinence approaches, which may assist in swaying the public’s perception.
Harm reduction benefits a segment of the population and may be integral to abstinence. One study by Mckeganey and colleagues (2009) surveyed drug users’ aspirations and what they are looking for in treatment. The majority (56.6%) of those surveyed identified extensive support for “abstinence” as the only goal they hoped to achieve from attending treatment. On the other hand, a small percentage identified harm reduction goals: 7.1% for “reduced drug use” and 7.4% for “stabilization.” The authors of this study concluded that although individuals indicated that abstinence may be the primary treatment goal, harm reduction and abstinence are not two mutually exclusive principles—in fact, if clinicians deem recovery as a process, then harm reduction should be an essential element of transitional support (Mckeganey et al., 2009). If this attitude is adopted, then user’s capacities for and commitment may change over time, to the point where abstinence may be deemed an achievable treatment goal for “many if not most” substance users (Mckeganey et al., 2009, p. 433, para. 1). Additionally, the authors noted that the results should be interpreted holistically—that is, it does not suggest that one approach (abstinence) “should be provided in preference to another (harm reduction)” (Mckeganey et al., 2009, p. 432, para. 3). In fact, only a minority of individuals make an immediate and single transition from substance user to abstinence, hence, harm reduction programs are still relevant to individuals as long as they are still using—harm reduction is warranted as long as it still helps some individuals. Similarly, complete abstinence may not be a realistic goal for some—hence, whether persistent failed attempts at abstinence is more damaging or disheartening than at least some level of harm reduction should be taken into consideration. Harm reduction benefits many and should not be stigmatized simply as it does not promote complete abstinence.
OST is a harm reduction treatment method for substance users dependent on heroin, fentanyl, or oxycodone. OST includes prescribing buprenorphine, methadone, and medically-prescribed heroin as substitutes or replacements (Aceijas, 2012). Detractors of OST argue that prescribing addicted individuals with the very addictive substance or substitute that caused their addiction in the first place is ethically questionable (Aceijas, 2012; Bell et al., 2012). However, proponents of OST argue that abstinence-based programs are similarly a form of social control. For example, in the American criminal justice system, rehabilitation centers have been used as a crucial component of prison diversion programs, with the aim of “re-socialization and control of the poor” (p. 70; Gowan et al., 2012).
Indeed, advocates emphasize that OST adheres to bioethical codes given that it benefits users. Although individuals in OST consume or intake a substitute (e.g., replacement) which may prolong or continue their addiction, the autonomy (i.e., self-determination) of the patients is preserved as they may be choosing to tackle their addiction through substitutes versus heroin itself (e.g., choosing the lesser of the two evils). Beneficence (e.g., the duty to “do good”) is also preserved as OST provides active and specific help to those who cannot, or are unable to, commit to abstinence; seeking OST may be the initial step needed for individuals to seek adequate health care (e.g., open doors to further treatment). Lastly, under the principle of justice, all potential risks of using an addictive substitute are addressed—instead of leaving the individual to grapple with their addiction, harm reduction allows those to preserve and stabilize their current quality of life to ensure that further deterioration (e.g., mental, physical health) does not occur. Similarly, all harm reduction programs do not mean clinicians or researchers ignore consequences associated with an individual’s decisions to continue using substances—it simply means that the situation is not as black and white as some may argue. Reducing or minimizing harm is a starting point to inspire change and build efficacy and rapport—beneficence is preserved. Harm reduction allows clinicians to meet the client at their standpoint and helps the client along as much as the client allows themselves to be helped.
Indeed, research indicates all three of the widely used replacements (i.e., buprenorphine, methadone, and medically-prescribed heroin) are evidenced-based treatments and follow bioethical principles. For example, the principle of nonmaleficence is preserved: in 1965, a pioneering study on methadone was conducted on 22 individuals (Dole & Nyswander, 1965). This study demonstrated that methadone (a form of OST), is a safe and effective way to manage heroin addiction (Aceijas, 2012) and reduces the use of opiate use and criminal behaviour (Sorensen, 1996). Later, all other substitutes have been or submitted to clinical trials or other extensive forms of research; research has shown that there is no harm attributed to the substitutes, along with high effectiveness in varying outcome measures (Aceijas, 2012). The World Health Organization has concluded that OST is linked to substantially “reduced illicit opiate use, HIV risk behaviours, death from overdose” (Kermode et al., 2011, para. 2) and also reduces other stressors (e.g., financial) in substance users and their families.
Similarly, consider the role of OST in medical ethics. The Hippocratic Oath outlines the principles that guide physicians and healthcare professionals, and these principles include respect for the sanctity of all human life, in conjunction with a medical duty of care and to act in the best interests of the patient. As such, the fundamental imperative of healthcare professionals is to preserve and protect human life. Considering the record-breaking number of drug-overdose deaths in the US in 2020 (Stephenson, 2020), with opioids being the chief drivers of this deadly trend, this remains an evident public health crisis. With the concurrent COVID-19 pandemic leading to financial challenges, social isolation, and hindering treatment for individuals with substance use issues, in Canada, a heightened increase in opioid-related deaths in the initial months of the pandemic has been observed (Canadian Institute for Health Information, 2021). Thus, when drawing on principles of medical ethics, harm reduction approaches such as OST adheres to the Hippocratic Oath as it takes a non-judgemental stance towards substance use and allows for the preservation of life. OST reduces harm supports by acting in the best interests of the patient by substantially reducing risk of death (Larney et al., 2014) and the transmission of blood-borne diseases such as HIV (Mukandavire et al., 2017). Additionally, OST allows users to begin their recovery journey and contribute to social reintegration (Noble & Marie, 2019). Indeed, OST reduces poly drug use (Bizzarri et al., 2016), and can have mental health impacts including reduced psychopathology (Maremmani et al., 2011). That is, OST is another tool that can be used to preserve human life, which aligns with medical ethics, and may assist in the abatement of the public health opioid crisis.
Despite the evidence for the use of OST as an evidenced-based form of harm reduction, injection drug use in North America continues to be highly stigmatized and criminalized (Ahern et al., 2007; Drucker, 2012). The belief that illicit drug use is a moral weakness remains politicized and runs rampant in the media (Lancaster et al., 2011; Montagne, 2011; Taylor, 2008). These unfounded views may feed into a community’s perception of harm reduction approaches, including supervised consumption sites for OST, leading to stigmatizing views of clients of these sites (Kolla et al., 2017). From a public health standpoint, the public’s view of OST has greatly impacted the treatment of heroin users by limiting the expansion of OST and thus, impacting access to a potentially lifesaving treatment. Indeed, even police (Watson et al., 2012), key stakeholders of safe consumption sites, remain detractors. This has led to the US favoring non-OST treatment approaches, despite research evidence supporting the efficacy of OST (Perlman et al., 2015). Similarly, although 37 federally authorized supervised injection sites are available across Canada (Government of Canada, 2021), the US does not have a single state-sanctioned site. In fact, the only approved site in 2020 had to withdraw a week prior to its opening, due to an onslaught of public and political backlash (BBC News, 2020). Clearly, stigma from the public as perpetrated by the media and politicized remains a barrier to implementation of and access to treatment, especially OST. Therefore, as a society, we must continue to mitigate the stigma from the public surrounding OST, and broadly, harm reduction approaches.
To combat the concurrent opioids epidemic and COVID-19 pandemic, it is imperative that OST be considered a socially acceptable treatment approach. Harm reductions models or programs are not a panacea and remain a contentious issue in the public eye, especially OST; however, simply dismissing OST as a treatment approach is unwarranted. Society must consider the value of abstinence compared to differing levels of substance use, such as harm reduction treatments. The public must remember that treating addiction is a paradigm between harm reduction and periods of remission (or reduced) use and requires balancing the risks and benefits in minimizing the negative effects of addiction; therefore, considerable thought is put into the principles of bioethics, especially beneficence and nonmaleficence, and medical ethics such as the Hippocratic Oath, when treating individuals coping with addiction, especially opioid users. Indeed, OST remains an evidenced-based treatment that has demonstrated efficacy and is low hanging fruit in the opioid crisis (Beetham, 2019)—it is time for society as a whole to reduce the stigma associated with OST.
Karen TY Tang earned a Bachelor of Arts (Honours) from the University of Calgary. She is currently a PhD student and Killam Scholar in the Clinical Psychology program at Dalhousie University in Canada. Her current research is on addictive disorders (substance and behavioral), as well as comorbid psychiatric conditions and social factors (stigma, culture).