feliz
feliz
  • Users Online: 168
  • Print this page
  • Email this page


 
 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 118-121

Stigma and substance use disorders: A contextual review from an Indian perspective


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 Submission28-Mar-2020
Date of Decision13-May-2020
Date of Acceptance15-May-2020
Date of Web Publication25-Nov-2020

Correspondence Address:
Dr. Udit Kumar Panda
Department of Psychiatry, Centre for Addiction Medicine, NIMHANS, Bengaluru - 560 029, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_23_20

Rights and Permissions
  Abstract 


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 Top


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.[1] 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.[2] As an attribute, it has far-reaching consequences, often leading to prejudice and active discrimination.[3] 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 Top


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.[4],[5]


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.[6] 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.[7] 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.[8],[9]

The five common stereotypes as reported by Yang et al. in a study on the general population are as follows:

  1. Substance using individuals are dangerous and unpredictable
  2. Decision making capability of patients with SUD is grossly impaired
  3. Individuals with SUD are consistently rated as substantially more to be blamed for their condition than individuals with other psychiatric disorders
  4. Patients with SUD can “pull themselves together” without treatment
  5. Individuals with SUD are perceived more immoral than those with depression, diabetes, or schizophrenia.[10]


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.”[7] 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:

  1. Treatment coercion: Indicated by the willingness to impose treatment or policies that limit treatment opportunities such as financial reimbursement for treatment
  2. mposing restrictions: Indicated by the willingness to restrict people with addiction from taking responsible roles in society
  3. 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
  4. Decreased feelings, tolerance, benevolence, and support toward community-based care
  5. Increased familiarity with substance users is associated with increased avoidance and decreased intention to engage in help promoting behavior.[11]


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 Top


Public stigma toward substance use is shown to decline with age.[12] Higher perceived stigma toward substance use is associated with lower levels of education, married, and currently employed status.[13] Female substance users experience a higher social stigma than their male counterparts.[14] 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.[8] 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.[15] Finally, patients who use drugs suffer from more severe public stigma than those with other mental/physical disabilities.[10]


  Stigma and Substance Use in the Indian Context Top


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.[16] 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.[17] Perceived stigma among opioid users was found to be associated significantly with an inferior quality of life.[18] 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.[19] Even the stigma was perceived by the substance users and their family members alike.[20] 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.[21] 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 Top


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].
Table 1: Scales to measure stigma among substance users

Click here to view



  Interventions to Reduce Stigma Related to Substance Use Disorders Top


Evidence-based programs that can mitigate societal-level stigma toward those with SUDs are needed.[22],[23],[24],[25] These crucial interventions need to be kept in mind while devising and implementing programs for reducing stigma.

  1. 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
  2. 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
  3. Removal of legislative and administrative barriers that reinforce stigmatization toward people with substance use
  4. Supporting and promotion of self-help and voluntary organizations as the medium for reintegration to society in the patients of substance dependence
  5. 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
  6. Facilitating and support grassroots efforts to build the capacity of the recovery community, which discusses drug dependence, treatment, and recovery
  7. Promoting the dignity of people in treatment and recovery, encouraging respect for their rights as in other illnesses
  8. 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
  9. 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.[26]


  Conclusion Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, NMHS collaborators group. National Mental Health Survey of India, 2015-16: Prevalence, patterns and outcomes. Bengaluru, National Institute of Mental Health and Neuro Sciences, NIMHANS Publication No. 129, 2016.  Back to cited text no. 1
    
2.
Semple SJ, Grant I, Patterson TL. Utilization of drug treatment programs by methamphetamine users: The role of social stigma. Am J Addict 2005;14:367-80.  Back to cited text no. 2
    
3.
SAMHSA. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Ser H-48, HHS Publ No 14-4863. Vol. 14. Rockville, MD: Subst Abus Mental Health Service Adm 2014. p. 1-143.  Back to cited text no. 3
    
4.
Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the public stigma of mental illness: A meta-analysis of outcome studies. Psychiatr Serv 2012;63:963-73.  Back to cited text no. 4
    
5.
Corrigan P. How stigma interferes with mental health care. Am Psychol 2004;59:614-25.  Back to cited text no. 5
    
6.
Mojtabai R, Chen LY, Kaufmann CN, Crum RM. Comparing barriers to mental health treatment and substance use disorder treatment among individuals with comorbid major depression and substance use disorders. J Subst Abuse Treat 2014;46:268-73.  Back to cited text no. 6
    
7.
Kulesza M, Larimer ME, Rao D. Substance Use Related Stigma: What we Know and the Way Forward. J Addict Behav Ther Rehabil 2013;2:782.  Back to cited text no. 7
    
8.
Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend 2007;88:188-96.  Back to cited text no. 8
    
9.
McNeil R, Guirguis-Younger M. Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons: Perceptions of health and social services professionals. Palliat Med 2012;26:350-9.  Back to cited text no. 9
    
10.
Yang LH, Wong LY, Grivel MM, Hasin DS. Stigma and substance use disorders: An international phenomenon. Curr Opin Psychiatry 2017;30:378-88.  Back to cited text no. 10
    
11.
Green S, Davis C, Karshmer E, Marsh P, Straight B. Living stigma: The impact of labeling, stereotyping, separation, status loss, and discrimination in the lives of individuals with disabilities and their families. Sociol Inq 2005;75:197-215.  Back to cited text no. 11
    
12.
Adlaf EM, Hamilton HA, Wu F, Noh S. Adolescent stigma towards drug addiction: Effects of age and drug use behaviour. Addict Behav 2009;34:360-4.  Back to cited text no. 12
    
13.
Keyes KM, Hatzenbuehler ML, McLaughlin KA, Link B, Olfson M, Grant BF, et al. Stigma and treatment for alcohol disorders in the United States. Am J Epidemiol 2010;172:1364-72.  Back to cited text no. 13
    
14.
Malik K, Benegal V, Murthy P, Chand P, Arun K, Suman LN. Clinical audit of women with substance use disorders: Findings and implications. Indian J Psychol Med 2015;37:195-200.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997;38:177-90.  Back to cited text no. 15
    
16.
Gyawali S, Sarkar S, Balhara YPS, Kumar S, Patil V, Singh S. Perceived stigma and its correlates among treatment seeking alcohol and opioid users at a tertiary care centre in India. Asian J Psychiatr 2018;37:34-7.  Back to cited text no. 16
    
17.
Mattoo SK, Sarkar S, Gupta S, Nebhinani N, Parakh P, Basu D. Stigma towards substance use: Comparing treatment seeking alcohol and opioid dependent men. Int J Ment Health Addict 2015;13:73-81.  Back to cited text no. 17
    
18.
Singh S, Kumar S, Sarkar S, Balhara YP. Quality of life and its relationship with perceived stigma among opioid use disorder patients: An exploratory study. Indian J Psychol Med 2018;40:556-61.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Sarkar S, Balhara YPS, Kumar S, Saini V, Kamran A, Patil V, et al. Internalized stigma among patients with substance use disorders at a tertiary care center in India. J Ethn Subst Abuse 2019;18:345-58.  Back to cited text no. 19
    
20.
Mattoo SK, Sarkar S, Nebhinani N, Gupta S, Parakh P, Basu D. How do Indian substance users perceive stigma towards substance use Vis-A-Vis their family members? J Ethn Subst Abuse 2015;14:223-31.  Back to cited text no. 20
    
21.
Gupta P, Panda U, Parmar A, Bhad R. Internalized stigma and its correlates among treatment seeking opium users in India: A cross-sectional observational study. Asian J Psychiatr 2019;39:86-90.  Back to cited text no. 21
    
22.
Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy 2010;21:202-7.  Back to cited text no. 22
    
23.
Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies – Republished article. Behav Ther 2016;47:869-85.  Back to cited text no. 23
    
24.
Luoma JB, Kohlenberg BS, Hayes SC, Bunting K, Rye AK. Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addict Res Theory 2008;16:149-65.  Back to cited text no. 24
    
25.
Committee on the Science of Changing Behavioral Health Social Norms; Board on Behavioral, Cognitive, and Sensory Sciences; Division of Behavioral and Social Sciences and Education; NASEM. Research strategies. In: Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change; 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK384915/[Last accessed on 2019 Dec 17].  Back to cited text no. 25
    
26.
Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: A systematic review. Addiction 2012;107:39-50.  Back to cited text no. 26
    



 
 
    Tables

  [Table 1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Nature and Impac...
Variables Relate...
Stigma and Subst...
Measures of Stig...
Interventions to...
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1879    
    Printed38    
    Emailed0    
    PDF Downloaded172    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]