|Year : 2020 | Volume
| Issue : 2 | Page : 118-121
Stigma and substance use disorders: A contextual review from an Indian perspective
Udit Kumar Panda1, Soumya Swaroop Sahoo2, Romil Saini3
1 Department of Psychiatry, Centre for Addiction Medicine, NIMHANS, Bengaluru, Karnataka, India
2 Department of Community and Family Medicine, AIIMS, Bathinda, Punjab, India
3 Department of Psychiatry and NDDTC, AIIMS, New Delhi, India
|Date of Submission||28-Mar-2020|
|Date of Decision||13-May-2020|
|Date of Acceptance||15-May-2020|
|Date of Web Publication||25-Nov-2020|
Dr. Udit Kumar Panda
Department of Psychiatry, Centre for Addiction Medicine, NIMHANS, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
The prevalence of substance use disorders is on an upsurge in the Indian population. Unfortunately, they remain one of the most under reported and undertreated medical conditions. Stigma, in its various forms, can act as a barrier to treatment, reduce willingness of policy-makers to allot resources, and that of health-care providers, to effectively screen and treat. This makes it difficult and challenging for the recovery and reintegration of the patients into mainstream healthcare. In the Indian context, it becomes all the more difficult because of factors such as low literacy, prevalent socio-cultural beliefs, and lack of stringent law enforcement. We intend to highlight the problem of stigma in substance use and its consequences along with the amenable solutions in future.
Keywords: Discrimination, drug abuse, stigma, substance use disorder
|How to cite this article:|
Panda UK, Sahoo SS, Saini R. Stigma and substance use disorders: A contextual review from an Indian perspective. Ann Indian Psychiatry 2020;4:118-21
|How to cite this URL:|
Panda UK, Sahoo SS, Saini R. Stigma and substance use disorders: A contextual review from an Indian perspective. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Sep 27];4:118-21. Available from: https://www.anip.co.in/text.asp?2020/4/2/118/301442
| Introduction|| |
Substance use disorders (SUDs) constitute a group of complex conditions in which the use of one or more substances leads to clinically significant impairment or distress. SUDs pose a substantial challenge to the individuals directly affected, health-care providers, and society as a whole. According to the National Mental Health Survey report (2016), the prevalence of any SUD was 22.4%, which signifies the high burden of the condition. There has been a humongous gap between the number of individuals with these disorders and those who receive treatment, known as the “treatment gap.” Stigma poses an essential barrier for treatment-seeking among substance users. As an attribute, it has far-reaching consequences, often leading to prejudice and active discrimination. In addition, stigma prevents affected individuals from disclosing their drug/alcohol use to their health-care providers, forming a treatment barrier and a feeling of despair and loneliness. Understanding mental illness stigma has been a focus in several studies, but unfortunately, there has been a dearth of research on drug use-related stigma compared to mental illness stigma. We intend to give an overview of the stigma associated with the prevalent SUDs.
| Nature and Impact of Stigma Related to Substance Use Disorders|| |
Stigma in SUD's can be divided into three distinct major types, namely (i) structural, (ii) public, and (iii) self-stigma
- Structural stigma refers to the rules, policies, and procedures of the institution that restrict the opportunities of the stigmatized individuals
- Public stigma, also known as social stigma, endorses prejudice and discrimination against the concerned group in the society
- Self-stigma is the subjective process that is characterized by negative feelings about self, maladaptive behavior, identity transformation through an individual's experience, perception, and anticipation of negative response from the community.,
Stigma toward substance users has been noted across all geographical regions and ethnic groups. Public stigma toward individuals with SUDs is more compared to those with mental illness. Their life is seen with suspicious eyes with the general notion that the addiction to these substances makes them a burden on society. Stigmatizing attitudes include perceiving them as dangerous, unpredictable, unable to make decisions, to blame for their own conditions and a willingness to coerce treatment, and maintaining a social distance. Thus, these individuals are subjected to exclusion and discrimination in the various aspects of personal and social well-being. The feeling of shame and worthlessness engendered through stigmatization render individuals with SUDs and their families delaying the process of seeking treatment. They experience discrimination in the health-care setting and receive comparatively lower attention and quality of care. Their precarious condition makes them victims of delayed and inadequate treatment. Professional attitudes also reinforce stigma and lower the expectations of recovery.,
The five common stereotypes as reported by Yang et al. in a study on the general population are as follows:
- Substance using individuals are dangerous and unpredictable
- Decision making capability of patients with SUD is grossly impaired
- Individuals with SUD are consistently rated as substantially more to be blamed for their condition than individuals with other psychiatric disorders
- Patients with SUD can “pull themselves together” without treatment
- Individuals with SUD are perceived more immoral than those with depression, diabetes, or schizophrenia.
The most common social-emotional response toward persons with SUDs includes a feeling of fear, anger, and pity. A study in the US reveals >70% think IVDUs are “disgusting” and a “threat to society.” Stigma toward substance users results in “status loss” in the society and discrimination in the daily living of the patients in general and treatment availability in particular. Common discriminatory attitudes can be divided into the following categories:
- Treatment coercion: Indicated by the willingness to impose treatment or policies that limit treatment opportunities such as financial reimbursement for treatment
- mposing restrictions: Indicated by the willingness to restrict people with addiction from taking responsible roles in society
- Desire for social distance: Due to endorsement of stereotypes, the general unwillingness to interact with people with addiction compounded by decreased intention to offer help
- Decreased feelings, tolerance, benevolence, and support toward community-based care
- Increased familiarity with substance users is associated with increased avoidance and decreased intention to engage in help promoting behavior.
In summation, stigma can act as a protective barrier for nonusers but paradoxically it promotes drug use once a person has entered “drug culture.” Stigma puts barriers in the way of recovery and reintegration, making it difficult to bring them to the mainstream. In the long run, this results in detrimental effects on psychological and social well-being among individuals who use drugs.
| Variables Related to Stigma in Substance Use Disorders|| |
Public stigma toward substance use is shown to decline with age. Higher perceived stigma toward substance use is associated with lower levels of education, married, and currently employed status. Female substance users experience a higher social stigma than their male counterparts. Self-stigma is positively related to drug/alcohol use frequency and severity of dependence. Public stigma is found to be higher for active users than those receiving treatment. Both social and self-stigma are higher in injection drug use than with any other form of drug use. If we consider the kind of substance used, tobacco use is less stigmatized than alcohol or cannabis use, as witnessed in our society. In individuals who use drugs, self and perceived stigma is positively correlated to the symptoms of depression or anxiety while negatively related to overall psychological well-being. Finally, patients who use drugs suffer from more severe public stigma than those with other mental/physical disabilities.
| Stigma and Substance Use in the Indian Context|| |
There is a paucity of studies regarding stigma in substance use in Indian society, which has distinct cultural attributes and varies considerably across the state boundaries. We analyzed the available studies by using key search terms “stigma” “SUDs,” “Opioid” “Alcohol,” and “India” in literature database of PUBMED and Google Scholar. We could find 6 articles relevant to the context of our search. We describe the key findings from these studies below.
Gyawali et al. in a study from a tertiary care institute in North India highlighted that the stigma was mostly in males and those from the rural background. Clinical parameters such as duration of substance use, type of substance use, and injectable drug use were not significantly associated with perceived stigma. This finding is contradictory to existing literature which says that intravenous opioid users experience more stigma, but they explain their finding basing on the study population, most of which were already on treatment with Opioid Substitution Therapy. Mattoo et al. in their study on patients of SUD have suggested that alcohol-dependent patients report a higher stigma than opioid dependent patients in a tertiary care set up. They also report that being currently employed, recent abstinence from drug use and duration of dependence are positively correlated with perceived stigma in both opioid and alcohol dependence. Perceived stigma among opioid users was found to be associated significantly with an inferior quality of life. This was also the case in the study by Sarkar et al. in which internalized stigma and dissatisfaction with the quality of life were higher among the Indian participants. Even the stigma was perceived by the substance users and their family members alike. A lot of substances abused in India have differential cultural sanctions. A study by Gupta et al. have reported lower internalized stigma in users of natural opioids such as Afeem/Bhukki when compared with users of Heroin or other synthetic/semi synthetic opioids. This demands harmonized efforts, with the health system and including the family member's perspective, for reducing the burden of SUD and the stigma associated. The local, cultural, and contextual factors need to be taken into consideration while designing the methods for stigma reduction, since factors such as lower education, rural background, and struggles with law enforcement agencies make the task more difficult.
| Measures of Stigma among Substance Users|| |
There have been various scales suggested for measuring various aspects of stigma among substance users. We have compiled a list of nine commonly used measuring instruments to assess various aspects of stigma in SUD and their salient features in relation to type of stigma measures, population intended and substance of use [Table 1].
| Interventions to Reduce Stigma Related to Substance Use Disorders|| |
Evidence-based programs that can mitigate societal-level stigma toward those with SUDs are needed.,,, These crucial interventions need to be kept in mind while devising and implementing programs for reducing stigma.
- Improve the knowledge and understanding among the general public about drug dependency and recovery to reduce the levels of fear and blame. Coalitions, awareness campaigns, and media can be used as sources to improve knowledge, which will bring about a change in attitude
- Ensure workforce development across the range of professionals who work with people with drug problems to improve service response. That would include proper training of professionals, promotion of good practice, and leadership among them
- Removal of legislative and administrative barriers that reinforce stigmatization toward people with substance use
- Supporting and promotion of self-help and voluntary organizations as the medium for reintegration to society in the patients of substance dependence
- Inventing and constructing new ways for support and promote community participation and increased contact with recovering substance users to foster a more constructive perception about substance use
- Facilitating and support grassroots efforts to build the capacity of the recovery community, which discusses drug dependence, treatment, and recovery
- Promoting the dignity of people in treatment and recovery, encouraging respect for their rights as in other illnesses
- Proper use of tools such as psycho-education, community programming, contact strategies, peer support, mass media messaging to target various aspects of stigma toward SUDs
- Finally, policymakers should strive for integrating substance use with related communicable disease programs such as National AIDS Control Programme and National Hepatitis control Programme, which would pave the way for interventions through a common platform with the use of limited available resources.
A number of intervention methods have demonstrated promise in achieving a meaningful reduction in stigma in SUDs. Group-based acceptance and commitment therapies have shown to reduce self-stigma. Motivational interviewing and communicating positive/success stories of people with SUD are shown to be an effective tool in addressing social stigma. To alter stigma at a structural level, contact-based training and education modules-targeting professionals involved in an interaction with people with substance use (medical or otherwise) are effective.
| Conclusion|| |
The prevalence of SUDs has increased substantially over the years, and tackling stigma related to SUDs has been a challenge in its entirety. The cultural and social factors influencing stigma toward substance use demands a tailored approach to understand and tackle stigma in individual populations. Apart from various public advocacy and community-campaigns, society should also look at itself to begin challenging its negative attitudes and barriers that can keep those with SUDs locked into their dysfunctional lifestyles. Thus, promoting recovery from SUDs goes hand in hand with challenging stigma toward SUDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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