Stigma in healthcare
When healthcare becomes part of the problem
Healthcare should be one of the safest places to say what is really happening. When stigma is present, the place a person turns to for help can become another reason to stay away.
Where it shows up
Nine things stigma can influence
None of these require anyone to intend harm. They happen through assumptions, time pressure, inherited language and systems that were never designed with these patients in mind.
Communication
Tone, eye contact, how much time is offered and how much of the conversation is spent explaining rather than listening.
Clinical decision-making
Which differential diagnoses are considered, how quickly investigations are requested, and how confidently a person's own account is used.
Whether symptoms are taken seriously
Chest pain, breathlessness, confusion, infection and injury can all be attributed to substance use before other causes have been excluded.
Pain management
Pain may be under-assessed or undertreated. People with opioid tolerance can require careful, specialist-informed analgesia rather than less.
Assumptions about medication-seeking
"Drug-seeking" is often used as shorthand for distrust. It rarely appears alongside a documented assessment of the pain or withdrawal being described.
Access to treatment
Referral criteria, abstinence conditions, missed-appointment rules and discharge policies can filter out the people with the least stable circumstances.
Trust between patients and professionals
Trust is built or lost quickly, and is often shared across a community — one poor experience can shape how a whole group views a service.
Willingness to disclose substance use
Non-disclosure creates real clinical risk: interactions, withdrawal, overdose risk and infection can all be missed.
Willingness to return for future care
Disengagement is frequently read as the person's choice, when it began as a response to how they were treated.
A person is not one diagnosis
Someone who uses substances can also have any other physical or mental health condition, at the same rate as anyone else — and often at higher rates, because the circumstances associated with dependence also affect physical and mental health. Substance use is relevant clinical information. It is not an explanation for every symptom.
Where substance use is treated as the whole picture, other causes get investigated later. That is a diagnostic problem as much as an ethical one. Assessment should follow the presenting symptoms, with substance use considered alongside them — including tolerance, interactions and withdrawal risk, which may mean a person needs more careful management rather than less.
People who use substances also experience
- Pain — acute, chronic, post-operative and cancer pain
- Infections, including skin, chest, dental and blood-borne infections
- Cardiac, liver, respiratory and neurological conditions
- Mental health conditions, including anxiety, depression, PTSD and psychosis
- Pregnancy, contraception and sexual health needs
- Injury, disability and long-term conditions unrelated to substance use
Each of these deserves appropriate assessment, appropriate treatment and appropriate pain management, on the same clinical basis as for any other patient.
References & further reading
Stigma in healthcare settings is a documented research area. The systematic review below is the main source for the statements on this page about professional attitudes and their effect on care.
Stigma research
Link, B.G. & Phelan, J.C. (2001). Conceptualizing Stigma. Annual Review of Sociology, 27, 363–385.
The labelling, stereotyping, separation, status loss and discrimination model of stigma used on this page.
van Boekel, L.C. et al. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and Alcohol Dependence, 131(1–2), 23–35.
Systematic review of health professional attitudes and their effect on care.
Kelly, J.F. & Westerhoff, C.M. (2010). Does it matter how we refer to individuals with substance-related conditions? International Journal of Drug Policy, 21(3), 202–207.
Experimental evidence that the term used ("substance abuser" vs "person with a substance use disorder") changes judgements, including among clinicians.
Corrigan, P.W. et al. Work on self-stigma, public stigma and structural stigma in mental health and substance use.
Widely used framework distinguishing self, public and structural stigma and their different remedies.
Room, R. (2005). Stigma, social inequality and alcohol and drug use. Drug and Alcohol Review, 24(2), 143–155.
Discussion of why substance use attracts stigma differently from other health conditions.
UK guidance and policy
Drug misuse and dependence: UK guidelines on clinical management (the "Orange Book")
Department of Health and Social Care and devolved administrations, 2017. Treatment and prescribing practice for drug dependence in the UK.
Open source ↗NICE guidance on alcohol-use disorders and drug misuse
Includes CG115 (alcohol dependence and harmful drinking), CG100 (alcohol-related physical complications) and CG51 (psychosocial interventions for drug misuse).
Open source ↗Office for Health Improvement and Disparities — alcohol, drugs and tobacco collections
UK Government guidance, commissioning support and data on treatment and recovery in England.
Open source ↗Independent review of drugs (Dame Carol Black)
GOV.UK, 2020–2021. Examines treatment capacity, funding and system barriers in England.
Open source ↗Rights, respect and recovery: alcohol and drug treatment strategy
Scottish Government, 2018. Sets out a rights-based, stigma-aware approach to alcohol and drug support.
Open source ↗Medication Assisted Treatment (MAT) standards
Scottish Government / Public Health Scotland. Standards on same-day access, choice, harm reduction and retention in treatment.
Open source ↗Public Health Scotland — substance use and stigma resources
Population health information and work on reducing stigma in services.
Open source ↗NHS inform and NHS.uk
Public-facing health information and service finders for drug and alcohol support.
Open source ↗World Health Organization — alcohol, drugs and addictive behaviours
International guidance, including WHO/UNODC International Standards for the Treatment of Drug Use Disorders (2020).
Open source ↗
This website provides educational information and is not a substitute for individual medical assessment, diagnosis or treatment. Information should be interpreted alongside current clinical guidance and evidence.