A Message from Our Board Chair: Understanding How Stigma Can Impact Patient Care Mar. 23, 2018

A message from our board chair: Understanding How Stigma can Impact Patient Care

Many of us have moved into a new neighbourhood and gradually found our way around the neighbourhood, integrating ourselves quite easily into our new community. For others, it is not as easy. 

Recently, a few of our long-term patients excitedly reported to us that they found a better place to move into after years of being on waitlists. They were particularly happy because the rent was more affordable and the new accommodations offered improved access to amenities, like a kitchen sink.  

However, they still faced significant stress with the move in fitting in with the neighbours and finding a nearby pharmacy where staff “would not look at them funny” as had happened in past lived experiences. 

Patients shared that they were afraid that they would be viewed and looked upon differently because of their disability cheques, mental health issues or previous addictions history.  As a result, even though these patients were moving far away, they chose to inconvenience themselves through long public transit commutes back to our pharmacy for their medications.

While I was happy to continue to care for these patients, I recognized that the toll of having to commute to receive their medications – adding unnecessary stress and increasing risks for drug adherence issues – was not in the best interest of the patient. Patients should not have to go through these additional hoops to receive care in a pharmacy where they feel safe and are treated like a “regular person”. Unfortunately, it only requires one or two lived experiences of being stigmatized for patients to be fearful of how they may be treated.

To help our patients find a new pharmacy in their neighbourhood, we reviewed nearby pharmacies with the patient, often “googling” them together. When a choice was made, with the patient’s permission we transferred prescriptions and gave a verbal history of the patient on the information we had. We also gave the names of the main staff at the new pharmacy to the patients for an easier transition. Having the pharmacist at their existing pharmacy facilitate the introduction to the new pharmacy in their neighbourhood helped give the patients greater confidence that they would be treated with respect and humility.  

How Stigma Impacts Patient Safety

As pharmacy professionals, we are required to always protect and promote the health and well-being of patients and practice respect for patients. I think one of the ways we can achieve this for patients with mental health and substance use disorders is to learn more about stigma, and how it can affect the care patients receive.

According to the Centre for Addiction and Mental Health, stigma involves negative attitudes (prejudice) and negative behaviour (discrimination) toward people with substance use and mental health problems. It includes: 

• Having fixed ideas and judgments—such as thinking that people with substance use and mental health problems are not normal or not like us, that they caused their own problems, or that they can simply get over their problems if they want to
• Fearing and avoiding what we don’t understand—such as excluding people with substance use and mental health problems from regular parts of life (for example, from having a job or a safe place to live)

Stigmatizing language results in discrimination and has a negative impact on patient health. It can create a barrier towards accessing healthcare, and contributes to shame, isolation, risk taking, and overdoses.  Reframing language when talking about people who use drugs or have mental health disorders is key to reducing stigma, increasing trust in healthcare services and saving lives.

Mental health and substance use are diseases just like hypertension or diabetes, but they are often viewed very differently. In particular, substance use disorders are more highly stigmatised than other health conditions as society generally considers drug use to be a “choice” and repeated use to be a result of poor “self-control” in contrast to conditions such as cancer, where society often attributes no blame for the cause or controllability of the disease to the patient. However, current research in addiction medicine demonstrates that developing a substance use disorder is multifactorial, often with a strong biological component. 

Reducing Stigma with Respectful Language

Much of what we can do to help reduce stigma involves recognizing that the language we use matters. Negative, stigmatizing language, whether it is used in healthcare settings, news, or social media, discredits people with substance use disorders and can result in discrimination. 

The Ministry of Mental Health and Additions, the BC Centre on Substance Use, the BC Centre for Disease Control, health authorities and other organizations are all working together to help combat stigma, with a particular focus on its impact on the opioid overdose crisis. 

Recently the Vancouver Canucks hockey team and the Ministry of Mental Health and Addictions joined together on a new campaign that aims to save lives by eliminating stigma: Stop Overdose BC.

I believe pharmacy professionals can also be a part of combating stigma by recognizing how our own attitudes and judgments affect how we think about and behave toward others and learning how to use respectful “person-first” language. 

Here’s four things to do, from the BC Centre for Disease Control, to ensure you are using respectful, non-stigmatizing language with your patients:

1. People-first language. This means referring to a person before describing his or her behaviour or condition. This is important because it acknowledges that a person’s condition, illness or behaviour is not that person’s defining characteristic.  “Person with a cocaine-use disorder” instead of “cocaine user” or “addict.”
2. Use language that reflects the medical nature of substance use disorders. There are a multitude of factors contributing to drug addiction, ranging from personal factors to social, environmental and political ones. Avoid terms that reinforce a belief that addiction is a failure of morals or personality, rather than a medical issue.  “Addictive disease” and “substance use disorder” instead of “abuser” or “junkie.”
3. Use language that promotes recovery. This means healthcare professionals should use language that conveys optimism and supports recovery, and respects the person’s autonomy.  “Opted not to” and “not in agreement with the treatment plan” instead of “unmotivated” or “non-compliant.”
4. Avoid slang and idioms. Slang terms and idioms have negative connotations and a significant level of stigma attached to them. While slang and idioms are rarely used in professional literature, they are also important to avoid when speaking to other colleagues or healthcare professionals.  “Positive” or “negative” when referring to drug tests, instead of “dirty” or “clean.”

Other Helpful Resources

Over the years, I’ve drawn from many different resources around HIV, mental health and addictions that have helped me learn how stigma can affect patient care and how to help to prevent it. 

Resources that may be helpful for you to explore include:

• Government of BC – Reducing Stigma (including stories on combatting stigma and health authority stigma campaigns)
• Provincial Health Services Authority, BC Centre on Substance Use and Toward the Heart – Respectful Language and Stigma Regarding People Who Use Substances
• BC Centre on Substance Use Online Addictions Diploma (available to anyone)
• Sanyas Indigenous Cultural Safety (ICS) Training Courses:
  • Core ICS Training 
  • Core ICS Health Training 
  • Core Mental Health Training 
• Dr. Peter Diaries: AIDs Then and Now 
• Centre for Addiction and Mental Health, Mental Health and Addiction 101 Series - Stigma  
• Mental Health Commission – Stigma and Discrimination

Mona Kwong, RPh

Board Chair, College of Pharmacists of British Columbia 

Mona Kwong is the Board Chair and District 1 (Metropolitan Vancouver) representative for the College of Pharmacists of BC. She also is a part owner and manages a community pharmacy in downtown Vancouver and consults as a clinical pharmacist in a multispecialty collaborative clinic in East Vancouver. 

Mona has served as a faculty member with the UBC Faculty of Pharmaceutical Sciences and continues to educate pharmacists through different workshops and initiatives. She is committed to enabling pharmacists to practice to their fullest extent of their abilities through meaningful collaboration with the pharmacy community and other health care professions.