The number of fatal drug overdoses in Philadelphia has been growing in recent years, with about 1,215 deaths in both 2017 and 2020. And preliminary figures for 2021 show an increase in fatalities from the previous year, putting the city on track potentially to have as many as 1,250 deaths once all the data is tallied.
As fatalities have continued to rise, the focus has intensified on medication for opioid use disorder (MOUD); the Food and Drug Administration has approved three drugs—methadone, naloxone, and buprenorphine—to treat OUD. The Pew Charitable Trusts hosted a couple of gatherings with experts to help frame the issues around the use of MOUD. The first meeting in May was a virtual panel discussion with health system leaders in the Philadelphia region to discuss new opportunities and looming challenges around using MOUD, especially buprenorphine. One of the main themes that emerged was the role that stigma plays in creating barriers to providing—and accessing—this lifesaving treatment.
December's panel further explored insights into the barriers that stigma presents as well as opportunities to help overcome them. Panelists included Nicole O'Donnell, a certified recovery specialist at the University of Pennsylvania Health System; Rachel Haroz, division head of toxicology and addiction medicine at Cooper University Healthcare; and Hector Colon-Rivera, medical director of Asociación Puertorriqueños en Marcha, which serves the city's Latino residents. The discussion was moderated by Priya Mammen, an emergency physician and public health consultant who has served as an adviser to Pew. Alene Kennedy-Hendricks, a professor at Johns Hopkins University, kicked off the session by presenting research on the role that stigma plays in the health care system. The event, featured in the accompanying video, explored several key issues:
Stigma surrounding OUD is pervasive throughout the health care system—including among health care providers.
Research from Alene Kennedy-Hendricks showed that, among key health professional groups such as primary care physicians, there are high levels of stigma toward people with OUD. Her work suggests that stigma manifests in both the lack of OUD and MOUD in medical school curricula and the development of often punitive policies targeting people with OUD. Kennedy-Hendricks pointed out that "among clinicians, higher levels of stigma are associated with lower levels of interest in working with patients with opioid use disorder." (Go to 14.55 in the video.)
Stigma extends beyond those providing medical treatment to include other systems that patients rely on.
Hector Colon-Rivera explained how stigma around OUD exists within the health care system, but also in other systems that patients rely on, including pharmacies, insurance, housing, transportation, and others—all of which can create additional barriers to getting treatment. (Go to 29:03 in the video.)
Nicole O'Donnell, a peer counselor, said that stigma can even be found in the recovery community, especially in abstinence-based self-help programs, through attitudes that don't support evidence-based treatment. "I see a lot of people not accessing care because they're afraid they're going to be judged inside the recovery community," O'Donnell said. (Go to 44.37 in the video.)
Stigma discourages people seeking OUD treatment—which can have grave consequences.
Panelists relayed examples in which people seeking treatment for OUD faced punitive measures, shaming, complicated administrative requirements, and long wait times. This treatment is often rooted in a mistrust of people with OUD, and is markedly different from the treatment of people with other diseases. Some populations, including women, pregnant people, and trans people, often face additional stigma.
Priya Mammen noted the pitfalls of a "one-size-fits-all" approach to OUD treatment and singled out populations particularly affected by stigma. She noted that this group often includes women, "particularly women who are pregnant or parenting. The amount of shame and hate that's put on them is tremendous. I think within the medical system, we don't help that, and it keeps people further from us. It's a tremendous disparity." (Go to 46:13 in the video.)
Nicole O'Donnell talked about how stigma can contribute to health care trauma when people don't trust hospitals or providers. She relayed an account in which, after she reversed a patient's overdose, he said, "I would rather die than go to the hospital," because of his concern about how he would be treated. Or, worse, that he wouldn't be offered treatment. (Go to 1:19:10 in the video.)
Systemic stigma creates barriers for providers treating OUD.
Providers treating OUD often face challenges rooted in stigma as well. Some may be able to offer immediate services to their patients, but can experience barriers and rejection when referring patients to additional care and services. Providers are also required to complete additional training and licensing to treat OUD, which creates hurdles that don't exist when treating other conditions.
Rachel Haroz reflected on how stigma affects providers who are trying to connect their patients to care and additional services. "I realized that this entire field of addiction, and especially opioid use disorder, lived outside of medicine. It didn't even exist inside of medicine. It had its own home somewhere far down the street in a corner somewhere and people that weren't willing to talk about it or deal with it." (Go to 27:51 in the video.)
Hector Colon-Rivera talked about the stigma around prescribing buprenorphine for OUD that has roots in fear that helps shape policies, and how the same stigma does not exist for other medications, or even for buprenorphine when prescribed for something other than OUD, such as pain management. (Go to 48:31 in the video.)
Stigma is ingrained in processes and systems—including limited education in the field. Low-barrier access to treatment, streamlined referrals, partnerships and coordination, and positive reinforcement can support systems change and a change in culture.
Rachel Haroz talked about her practice's approach to lowering barriers to waivering, prescribing, and referral is designed to empower physicians treating OUD. She pointed out that low-barrier access is an important aspect of her practice. "Every afternoon we have [a] walk-in clinic. You can just walk in. I did a walk-in clinic yesterday, and I had 25 people register in the first 17 minutes. So, it is so needed. It doesn't come without difficulty. We've had to step up and step up and step up to meet these needs. But I think it's worth it … we need to meet the patient where they're at, which is not in a structured, predictable environment." (Go to 35:15 in the video.)
Sophie Bryan is a senior manager and Marcelo Fernandez-Vina is an officer with The Pew Charitable Trusts' Philadelphia research and policy initiative.