Public Health Response to Substance Use Stigma
Stigma is a set of negative attitudes, beliefs, and practices directed towards specific individuals or groups. Stigma impacts health and wellbeing as it can lead to shame, isolation, and reluctance to seek assistance for issues associated with substance use. Stigmatized individuals are less likely to seek treatment, recovery, or other wraparound services due to fear of discrimination and previous negative experiences in these settings. This underutilization can lead to delayed diagnoses, treatment, and worsening health conditions. Additionally, stigma can also affect the quality of care itself, as medical professionals, first responders, or other service providers may hold stigmatized views that impact their interactions with people who use drugs. Apart from its impact on physical health and willingness to seek treatment and services, stigma can also lead to worsening mental health, social isolation, and barriers to employment(i)
In the context of substance use and overdose, it is hard to overstate the impact of stigma. By some measures, people who use drugs experience more stigma than any other group(ii) Stigma toward drug use is deeply seated in our culture and impacts every level of the overdose crisis and the public response to it. This environment fosters a general lack of empathy toward people who use drugs and erects deeply rooted barriers toward a compassionate and effective response to the ongoing crisis.
While the manner in which stigma is expressed is varied and there are a number of ways the phenomenon can be categorized, it can be helpful to divide the sources of stigma into three major categories(iii):
- Community stigma: the negative, attitudes, and beliefs are directed at individuals or groups in their own communities.
- Structural stigma: where these negative attitudes and practices manifest within specific systems. This is especially relevant in systems that commonly interact with people who use drugs, such as medical or criminal/legal settings.
- Internalized stigma: where individuals anticipate or endorse these negative attitudes and practices about themselves and/or their peers.
Action to mitigate stigma in all three domains is an imperative step towards developing person-focused overdose prevention and response policies and practices. This webpage will serve as a resource hub on this issue, providing information, resources, and tools for local health departments (LHDs) and their partners seeking to better understand and respond to stigma in their communities.
NACCHO, in collaboration with Dr. Lawrence Yang from Stigma Lab LLC, developed five toolkits to help local health departments assess stigma within their community. Four of the toolkits focus on a key population and include validated scales that can be used to develop a stigma assessment. An additional toolkit is available with information on data collection and analysis. The toolkits are available here:
Each toolkit also contains a template assessment that can be easily adapted and distributed within local communities. The template stigma assessments are also included here:
NACCHO has worked with local health departments and their partners throughout the U.S. on projects that assess, address, and reduce substance use-related stigma. These projects include:
- Substance Use Stigma Assessment and Response (SSAR)
- Implementing Overdose Prevention Strategies at the Local Level (IOPSLL)
Community Health Program
Francis Higgins
Senior Program Analyst, Overdose Prevention
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Community Health Program
Madeline Masog
Program Analyst, Overdose Prevention
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Community Health Program
Emily Winkelstein
Director, Overdose Prevention
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(i) Kulesza M, Ramsey S, Brown R, Larimer M. Stigma among Individuals with Substance Use Disorders: Does it Predict Substance Use, and Does it Diminish with Treatment? J Addict Behav Ther Rehabil. 2014 Jan 15;3(1):1000115. doi: 10.4172/2324-9005.1000115. PMID: 25635257; PMCID: PMC4307942.
(ii) Room, R., Rehm, J., Trotter II, R. T., Paglia, A., & Üstün, T. B. (2001). Cross-cultural views on stigma, valuation, parity, and societal values towards disability. In Disability and culture : universalism and diversity (pp. 247–297).
(iii) Department of Health, W. S. (n.d.). Stigma. Washington State Department of Health.