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Reframing Stigma as Social Death: Treating the Whole Patient

Watch and reflect as Ayana Jordan, MD, PhD, discusses how to provide treatment in a way that mitigates stigma for the whole patient.
Then if we look at inequities in the social determinants of health, it gets worse. So SDOH or social determinants of health, this is the definition from the World Health Organization, is defined as inequities in health and avoidable health inequalities that arise because of the circumstances in which people grow, live, work, and age. These conditions in which people live and die are, in turn, shaped by political, social, and economic forces. So when I meet someone for the first time, my treatment plan doesn’t just consist of their substance use disorder. That’s one small part. But if we only focus on the substance use disorder, FAME participants in this liberated space today, we’re never going to move right. What about their legal involvement?
What about access to housing? What about othering? What about racism? What about lack of family support? These need to be on your treatment plan. You can use the social vulnerability tool, that’s what I use with my residents, and thinking about how can you engage with social workers, nonprofit organizations, to
really focus on the social determinants of health so you can improve health outcomes. Because I’m telling you, if you’re so narrowly focused on the substance use disorder itself, you’re not going to have lasting health outcomes that are positive, especially for minoritized populations. It’s important to know that there are different levels of racism. We talked about institutionalized racism, where you have differential access to the goods and services because of how you look, which is a made-up concept called race, personally mediated racism. We talked about this with health professional stigma, that there’s a differential assumption about the abilities, motives, and intent of others based on how they look.
So, people are saying, “Oh, I already know he’s not going to care about or he’s not going to take his medication.” This has been studied in the literature. With physician disrespect, where healthcare providers are less likely to go over the risk benefits and side effect profiles of medications with minoritized populations. And then, this internalized stigma or racism which we see accepted by those stigmatize races, often minority populations in the United States, that accept these negative images about their own intrinsic self-worth. So, they feel like it doesn’t matter. Why would I go to treatment? Why would I go to group? It’s not going to help me anyway.
I want to show you some examples in the media in terms of how regulatory agencies only advertise to white people. And then we’re all surprised when there’s decreased initiation and MAT. This is from the National Alliance of Advocates for Buprenorphine Treatment. This is from “How do you find a buprenorphine provider?” This is if you want to find the Vivitrol provider. I’m a part of AAAP, the American Academy of Addiction Psychiatry, this is what they sent to my inbox. So, what can be done? Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.
That’s why I’m so excited to kick off the FAME series, because we are going to change the trajectory of how we work with patients with substance use disorder who are heavily stigmatized. And we are going to be culturally sophisticated to understand that if you are part of a minority identity, we may need to have a different level of care, not because we’re racist, not because we’re prejudiced. But we know how the impact of structural racism, institutional racism is going to affect your care. One of the things that we can do is first, as someone already said in our liberated space, be intentional with our language.
We have to call in other physicians, we have to call in other colleagues, and challenge what we’re seeing in the media. Become familiar with solutions, including patient-centered language in addiction that promotes recovery and seeks to eliminate stigma. One of the things people say, “Oh, Dr. Jordan, clinic day for me is so busy, Wednesday of my MAT Clinic, I see lots of folks.” And they know they say, “Dr. Jordan, I’m clean, I’m clean. I say I know you’re clean, you’re always clean. I’m not here to say if you’re clean or not. I’m just here to support your recovery goals. Now, do you have a positive urine? Or do you have a negative urine, but clean doesn’t mean anything to me.”
I’m trying to model for them they’re clean, no matter if their urine is negative or positive. How do they see themselves? Part of the thing is we have to recognize our own stigma. Learn more about substance use treatment, do you know the latest techniques? Do you know what are the up-to-date treatment options? You have to speak out against stigma. Make sure that you’re telling your clients or patients that recovery does work, and that you’re referring them to culturally informed treatment options, like the emotional emancipation circle, like the healing circles, you guys need to be up on this. Treat people with dignity. You know, “I’m so glad you’re here. Thank you for coming in. I know it was tough.
I know the bus was late. I know you didn’t have, you know, food, I mean, whatever. But I’m glad you still made it into the clinic.” Think about the whole person. Are we addressing? Or are we, because we don’t have to be social workers, but are we thinking about how are we connecting them to the social needs that they may need to address? Do they have stable housing? Do they have access to a mental health provider? Is that on our treatment planning list so that we can keep up to date with it? I want to transition us from cultural competence to structural competence. Everybody’s worried about cultural competence which is necessary but not sufficient.
Structural competence, which was really invented by Helena Hanson, a black woman, and Jonathan Nestle. They published it in 2014, where they said not just focusing on the person themselves, this is the person, the provider talking back and forth. But moving towards what are the outside factors that influence substance use treatment that we’ve talked about access to healthcare, socioeconomic status, racism, legal status, food access where they live, we can’t think about improving outcomes. If we’re just focused on the one-to-one person, we need to think about all of these structural factors that is practicing structural competency. Another thing I don’t want us to just focus on is AA and NA, that’s not the only answer.
Now, we can’t expect that everybody is going to benefit from AA or NA, and then get mad when they don’t all of a sudden stop using and then kick them out of treatment. Hello, do we need to go back to the patient at the VA that they said we can’t help you?
What are some alternatives to care? Did we think about all the different options of MAT? Or are we so narrowly focused on opioids? Because that’s what the media told us, to just worry about white folks with opioids. I’m not against white people who have opiate use disorder. Now, I’m just saying, can we expand it? We still got to deal with tobacco use disorder, we still got to deal with alcohol use disorder, we still got to deal with methamphetamine use disorder, cocaine use disorder. What about cognitive behavioral therapy? What about dialectical behavioral therapy? What about this stuff? Acamprosate and naltrexone. So, what about backflipping, gabapentin, keppra, all of these things? What about access to harm reduction?
Testing your dope, making sure they have safe needles, making sure they have access to Narcan. We can’t help people if they’re dead. So let us expand our thinking so we’re not perpetuating the stigma that they’re already facing. All right, I’m going to add on this, finally, is everybody’s talking about you know, everybody is cool to be anti-racist. I know the United States just discovered racism last year, but some of us have been doing this work for a long time. One of the things that I’ll say to you all is, when we’re thinking about racial justice, and helping people from minority populations who have addiction, specifically substance use disorder, let’s go beyond anti- racism. Right?
It’s not just the absence of discrimination and inequity, but the presence of deliberate systems and support to achieve and sustain racial equity through proactive and preventative measures. So what supports are we going to be put in place so that we’re not just being against something? But there’s something that we’re substituting for that’s better. What about our language? What about our messaging? What about practicing structural competency? This is the last slide. These are my main takeaways.
One, you have to understand the harmful effects of stigma, and think actively about how you can mitigate it, to recognize how the war on drugs and structural racism has led to inequity in the social determinants of health and how that has further contributed to set stigma amongst people with substance use disorders. I say assess all patients for substance use disorders not based on what you think, or what you feel like somebody with a substance use disorder looks like. Practice structural competency when possible. Really thinking about how can you engage with other systems to address the totality of those factors? And don’t use stigmatizing language. Please, I don’t want to hear you saying abuse now. Don’t call it an addicted baby.
All right, and then consider how minority identities, race, gender, substance use disorder, having multiple medical comorbidities can impact outcome, and how can you optimize your addiction care to be more culturally informed?

Think about the whole person. Are we addressing? Or are we, because we don’t have to be social workers, but are we thinking about how are we connecting them to the social needs that they may need to address? Do they have stable housing? Do they have access to a mental health provider? Is that on our treatment planning list so that we can keep up to date with it? I want to transition us from cultural competence to structural competence. Everybody’s worried about cultural competence which is necessary but not sufficient.

Ayana Jordan, MD, PhD
Associate Residency Program Director, Assistant Professor, and Addiction Psychiatrist, Yale University
As an undergraduate, Ayana Jordan, MD, PhD attended Hampton University, a historically Black university, where she became interested in basic science. After college, Dr. Jordan conducted HIV research at the National Institutes of Health, where she contemplated combining her love for basic science with the clinical sciences. In 2003, Dr. Jordan began an MD, PhD program at Albert Einstein College of Medicine of Yeshiva University in New York City. In medical school, Dr. Jordan became passionate about serving minority populations, specifically within psychiatry. She completed a general adult psychiatric residency at Yale University in 2015, where she served as Program-Wide Chief. During residency, Dr. Jordan became interested in treating patients with substance use disorders, given the intense stigma witnessed from other disciplines. As such, Dr. Jordan completed specialized training in Addiction Psychiatry at Yale. Currently, Dr. Jordan is an associate residency program director, assistant professor, and addiction psychiatrist at Yale University. She is a community-engaged researcher, focused on providing equitable mental health and addiction treatment and preventative services for historically marginalized populations. Her extensive research, educational, and clinical work has focused on increasing access to evidence-based substance use treatment for Black, Latinx, Indigenous, and Persons of Color (BIPOC) both nationally and abroad. Locally, she leads the Faith-based recovery project, Imani Breakthrough (Imani meaning faith in Swahili), held in 8 Black and Latinx churches throughout the state of Connecticut helping Black and Latinx individuals with addiction engage in treatment.
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Understanding the Impact of Stigma on Addiction Treatment

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