Taking Action Summit: Addressing the Stigma of Substance Use Disorders
Thank you for joining this session: Addressing the Stigma of Substance Use Disorders. My name is Michele Herrmann, and I would like to welcome participants who are joining through the virtual platform. And those of you who are joining us here at Eastman School of Music. It is my absolute pleasure to introduce your speaker today, an Assistant Professor in the University of Rochester, Department of Psychiatry and Research Investigator at the Department of Veteran Affairs- Center of Excellence for Suicide Prevention.
Dr. Lisham Ashrafioun's focus is on mitigating suicide and overdose risk among individuals with chronic pain and or substance use disorders through psychosocial interventions and empowering strategies to increase engagement and evidence-based treatments. His current work includes using national survey and administrative medical record data to characterize risk in patients with SUD who experience chronic pain and to identify interventions to optimize treatment for these patients. Funding for his work recently has been provided by the VA and the National Institutes of Health.
At the end of the presentation, we will have a Q and A period for both in person and virtual attendees. For the virtual attendees, please use the chat option. Dr. Ashrafioun.
So I'm Lisham Ashrafioun and to everyone on Zoom, thank you for attending. I'm also, I'm psyched that people were able to attend in person as well. So, Rochester's my current home, of course, but I also grew up here and in case people haven't realized, you know, Rochester isn't exactly Maui. So I love it when people have an excuse to come here and visit, because I love Rochester.
So again, I'm Assistant Professor of Psychiatry at the University of Rochester and a researcher at the VA Center of Excellence for Suicide Prevention. And really, I'm gonna kind of kick things off today by providing maybe more of an overview on stigma of people with substance use disorders. So I'm a clinical psychologist by training, and since 2005, I've been conducting research to understand addiction initially in animal models, which led me to a position where I was focused more on helping people who were dealing with chronic pain, who were, who had a co-occurring addiction to their prescription opioids.
And then more recently, my line of work has been more focused on increasing connection and treatment engagement among individuals with substance use disorders, which I, which to me are sort of innerably tied with stigma. And then just sort of on a personal level, I've recently lost some family members to drugs and alcohol. And so this is something that's both professionally and personally meaningful to me. So I feel like I have sort of a, you know, a larger duty to tackle this issue.
So this is of course, you know, our fantastic acknowledgements and disclosures page. So we have an absolutely amazing and hardworking team who's really dedicated to the work that we're doing. So, Kim Chiaramonte, Tedra Cobb, Gloria Baciewicz, Michelle Lawrence, Charmaine Wheatley, among a host of other people, really instrumental in getting this project off the ground and continuing in this work. And we've also met some truly amazing people along the way.
And so I just want to take a second to acknowledge, you know, their willingness to share their stories of substance use and recovery. And then also the communities who opened their doors and really were willing to help us address stigma in their community. And this project, of course, is funded by HRSA and I have no conflicts of interest to disclose. So just to orient everyone and frankly, me too, so I don't go completely off the rails here, I'll start with a broad overview on what stigma is, including types of stigma.
I'll go through some of the consequences of stigma, and I'll talk about some of the evidence based approaches to stigma. And then I'll also include the approach that we've taken as part of this HRSA grant to help address both provider and community stigma. And I hope to end this talk by answering questions of course, but also having, you know, maybe more of a discussion as well. So, you know, I'm kind of curious about what others have tried, what seems to work, what are some of the challenges, how people have overcome these challenges.
I think we have a huge opportunity to really pool together our resources in terms of expertise and experiences and successes and challenges. So people with substance use disorders are among the most highly stigmatized individuals. And actually many providers prefer that individuals with substance use disorders are sort of solely treated by addiction specialists. And so there's already like some social distancing from- Social distancing, it's taken on such a different definition nowadays, but, (Lisham laughs) stigma had it initially, right?
So providers have sort of socially distanced themselves from individuals with substance use disorders. And so the National Academy of Sciences defines it as a complex combination of attitudes, beliefs, behaviors, and structures that interact at different levels of society. And they manifest themselves in prejudicial attitudes about and discriminatory practices against individuals with substance use disorders. And so, just sort of based on this definition, you can tell that there are essentially multiple layers of stigma.
And so broadly we can think of these as structural stigma, public stigma, and self stigma. So I want to dig into some of these types of stigma in a bit more detail. And before I do, I want everyone to just kind of take a second, embrace yourself because I got some, you know, amazing animations coming up. And so I just wanna be, I want everyone to be prepared for them.
So, structural stigma occurs at the institutional level where beliefs about substance use disorders are encoded into cultural norms, laws and institutions, like healthcare and the legal systems. See, that took me like 45 minutes to do. (Lisham laughs) From the criminal justice perspective, there we go. From the criminal justice perspective, substance use disorders are often treated as a criminal issue instead of a health concern.
And so you might see harsher sentences that sort of reinforce the idea that people with substance use disorders are unwanted or undeserving of treatment. From a healthcare perspective, examples include, you know, things like limited access to evidence-based treatments, lack of funding, low quality of care. And then, within structural stigma, you also see stigma that's held by providers. And so in some instances, this can lead to suboptimal care patterns that extend to maintaining overly rigid and nonbeneficent care policies, lacking respect for patient autonomy and deploying punitive care terminations in response to policy violations or positive urine drug screens.
And so many providers, you know, can express little interest in providing evidence based medications or treatments. And then for those that do, many don't do it up to capacity. And so this provider distancing leads to a huge gap in treatment access and availability. And then patients are often stereotyped as difficult or dangerous.
There's just two more slides of these animations. (Lisham laughs) I know you're disappointed. So public stigma are the negative attitudes and beliefs and behaviors at the community level. And then this is, you know, again, often driven by stereotypes such as, you know, perceived dangerousness, perceived moral failings, you know, they're liars who can't be trusted.
And stigmas also undermine the wider distribution of treatment and programming, like overdose education, naloxone distribution in the community. And so concerns about moral hazard and sort of, you know, this not in my backyard mentality tend to come up here. You know, people with substance use disorders are perceived as having, you know, complete control over their condition and therefore are more likely to be completely blamed without an understanding of why the person is using substances and how substance use disorders work. And ultimately, this leads to fracturing ties between the individual and the community.
And then within public stigma, there's also something called courtesy stigma. And so courtesy stigma has been used to describe the type of stigma that family members and friends may experience just because of their affiliation with a person experiencing a substance use disorder. And it's just, to me, it's just sort of awful to think about, you know, for instance, a parent sort of wrapping their head around a premature death of their kid and having to worry about how they're gonna be treated in the community because their kid, you know, because their kid lost their life to drugs or alcohol.
And so you know, oftentimes the community might have this experience of like, oh, well, you know, the parents must have done something wrong. And then the parents can kind of come around and adopt these same beliefs as well. And then I also wanna mention too, that this can occur for providers as well. And so healthcare workers who provide treatment to individuals with substance use disorders may often be judged by others in the community, including other providers.
And then self stigma occurs at the individual level. As a person, as people with substance use disorders become more aware of public stigma and of related discriminatory practices, the distancing and messages that they receive from friends and family, they can internalize the perceived stigma and then apply it to themselves. And oftentimes this comes with shame, low self-esteem, low self-efficacy, or confidence in their ability. And it also serves as a potent barrier to treatment engagement.
And so you can think of maybe some of these thoughts that might be commonly experienced by people with substance use disorders. So like, you know, why try? I'm just an addict. No one cares about me.
I've had people with opioid use disorders who I've worked with that have concealed their participation in some of our studies from their spouse because they don't want people to know that they're getting help even. And so, you know, they're hiding things from the people who are supposed to be in their social support network. And then another issue is that the treatments themselves are stigmatized as well. You know, maybe this mentality that, you know, people should be able to do it themselves completely on their own without any help of medications or, you know, having, talking with someone to help them through the difficulties.
And then underlying each of these layers of stigma is language to describe individuals with substance use disorders and substance use. And this of course was discussed a little bit, you know, yesterday, but words and phrases might be used in the media or institutions, community and also, you know, people with substance use disorders that ultimately perpetuate stigma, disparage individuals with substance use disorders and imply that a person is their substance use disorder. So words like addict and substance user, clean, dirty, abuse, are examples of this. And then there's of course, some huge consequences of stigma.
It's been called a fundamental hindrance of the opioid crisis as there's a wide range of impacts that stigma can have. So, you know, I've hinted at this, but it's a huge barrier to treatment engagement of course. There might be less availability and access to treatment because of lack of funding, or again, this not in my backyard mentality of treatments and programs because, you know, for instance, the community might fear that individuals with substance use disorders are dangerous. Again, there might be fewer providers delivering treatments or providing medications that might be helpful because not wanting to deal with, you know, the headaches of treating someone with a substance use disorder.
And then at the individual level might be, you know, due to fear of reaction from friends and family, their place of employment, it might also be the result of their previous experience dealing with the healthcare system and feeling rejected or treated poorly. For those who do attend treatment, it can often damage their view of the healthcare system. And people often rate greater dissatisfaction with treatment. There's poor communication with providers and they're less likely to complete treatment, again, often because they feel like they're being treated less empathically and their needs are often not met.
And then of course, this isn't just necessarily limited to seeking care for addiction treatment either. So people might be declined from treatment or will avoid seeking medical treatment because of stigma as well. So, you know, a person comes to mind who we worked with, who had GI issues that were so severe that he wouldn't eat. And using heroin was the, he was using heroin for pain relief so that he could eat.
And he wouldn't go to the doctor because of stigma and he wouldn't go until he was off drugs. Now you can see how this would be difficult if he's using it to be able to eat. So it, you know, it's not just something that interferes with seeking substance use disorder treatment. It's just, it can even be about seeking out basic medical treatment as well.
And then the criminalization of substance using behaviors exacerbates stigma and produces exclusionary processes that deepen the marginalization of people with substance use disorders. So these types of policies relate to, these types of policies and related decision making, not only reinforce the ways in which people with substance use disorders are treated by others, but it also, you know, again, implicitly classifies people with substance use disorders as being unworthy of investment and undeserving of treatment. And so it's, you know, part of this is also driven, you know, huge health inequities for communities of color who are disproportionately affected by this distinction of who's considered a patient versus a criminal.
And then stigma comes back to affect clinical outcomes of course. And so we see, you know, poor health outcomes, psychological distress, poor quality of life, you know, can impact housing and employment opportunities. And then of course, you know, there's a return to use or continued use. And so unfortunately you might also get this sort of self-fulfilling prophecy that might just kind of reinforce the beliefs from the community and providers.
And then another important adverse clinical outcome is isolation, which I want to just touch quickly. It's sort of, you know, this old pal of substance use that's, you know, I feel like it's received a little bit more attention. And my work is really centered around loneliness and social isolation among individuals with substance use disorders more recently. And I view stigma as, you know, of course, a very important contributor to this.
It really can drive people into hiding and they feel like there's nowhere to turn, you know, their ties with friends and family might feel severed and they feel like they have nowhere to turn in the community and even the healthcare system. So, for example, there was one study that found that over two thirds of the sample reported feeling lonely, at least sometimes, among individuals receiving methadone for opioid use disorders. So it's a, you know, at least in this sample is very, very common. And then there's been some research showing that loneliness and difficult meeting friends who are abstinent is commonly cited as reasons for craving among individuals who are using heroin.
And it's also often cited as a strong motivator of heroin use. It's also associated with, again, this more severe clinical profile. So among individuals with substance use disorders, loneliness is associated with suicide attempts, more mood disorder symptoms, non-suicidal self injury, and poor quality of life and life satisfaction. We did an analysis of national survey data.
We found that difficulties participating in social activities were of course more common among individuals with opioid use disorders, compared to those without. And then within our, you know, we just looked within individuals with opioid use disorders, and we found that those that reported difficulties participating in social activities compared to those who did not, they had a higher likelihood of reporting past year suicidal ideation and suicide attempts. And then again, studies among individuals receiving methadone for past heroin use reported that loneliness was associat- They found that loneliness was associated with worse sleep and greater pain severity, which are of course are important precipitants of relapse.
And then qualitative research has also underscored that some individuals with opioid use disorders indicate that they lack purpose in life. And that's largely driven by a sense of loneliness, often because they're pushed to the fringe, they feel like they're pushed to the fringes of society due to stigma. And then it all, loneliness and social isolation, of course, is, you know, associated with social support and treatment seeking. So there's been some longitudinal research that's revealed that the greatest reduction in heroin use was not just in people who were married, but those who were reporting close personal relationships with their partner.
Treatment retention is associated with a perception of strong social support from one's family. So, you know, maybe there's not that same stigmatizing attitudes and behaviors that's coming from their family and that, you know, seems to support recovery. And then just a couple other notes about loneliness. We find that it tends to be higher earlier in recovery and it predicts shorter length of stay in treatment.
So just kind of sum up all that, like, you know, reducing stigma can play an important role in substance use disorders, of course, for numerous reasons, including the individual with the substance use disorder feeling like they're not going through this alone because they've been able to maybe maintain some of their close relationships. So much of what I was just talking about is also experienced in rural communities, but it can come at sort of an amplified level. So this may occur because of close knit relationships and relatively small communities. There's often multiple or overlapping relationships with providers and patients that heightens concerns about boundary violations, breaches of confidentiality and privacy issues.
And then the availability of treatment may be more scarce and there's fewer resources for recovery. And this has been found to increase, you know, potentially more discrimination in courts, the workplace and healthcare facilities, maybe due to a lack of understanding or knowledge about substance use disorders. And then there's a strong sense of, oftentimes in some rural communities, there's a strong sense of self-efficacy. And so there's this mentality of like, well, you know, you should be able to handle this on your own.
You just need to pull yourself up by your bootstraps. And unfortunately, we know that this isn't the case for most people. All right, so I feel like that was a really, really depressing first half of the talk. (Lisham laughs) As I was going through, I'm like, oh, man, this is brutal.
So I just wanna stop and take a deep breath. And so I again, I've kind of painted this picture of doom and gloom, but I'm gonna try to end this on a higher note and talk about some of the reasons why there might be some hope. And so, fortunately, there are some evidence based treatments to address stigma, and I'll go through them at the individual community and institutional levels. So in terms of self stigma, group based acceptance and commitment therapies significantly reduced shame, internalized stigma among individuals with substance use disorders.
So acceptance and commitment therapy or ACT, focuses on accepting experiences rather than avoiding them and engaging in more value driven behavior while still experiencing those aversive negative emotions, sensations and thoughts. And so a person might, you know, hold feelings of hopelessness and anxiety, but they wanna improve. So they reach out to people who still care about them because they wanna connect or maybe they wanna get back to work. And so in spite of having, holding those negative thoughts and emotions, they just sort of accept them and still move towards their values.
The employment skills training among individuals with substance use disorders was shown to improve participants' view of society and feeling socially alienated. And then my mentor has utilized a one session telehealth intervention that's targeted treatment beliefs that are acting as barriers to treatment. And many of the most common ones that she's found are the stigmatizing beliefs. And she's found that the intervention has increased treatment engagement among individuals with mental health and substance use concerns.
And these are people who are treatment naive, so they have not even been to treatment, at all. So basically it's based on this idea that many times we have these beliefs that are unhelpful or inaccurate, and we believe them to be true, a hundred percent true, a hundred percent of the time. And so by breaking down these thoughts, we might be able to kind of come up with more helpful alternatives and maybe more accurate in some ways, which can promote help seeking. And so she's currently implementing this with a number of rural VAs.
And then I'm also working on a study where we're trying to get people who are using prescription opioids for chronic pain who continue to have functional impairment for their chronic pain to, you know, increase their engagement in non-pharmacological pain treatments in order to potentially reduce their opioid use and, you know, increase their functioning. I kind of hinted at this, but I didn't say it specifically, but we're also currently working on an intervention to address social isolation through encouraging people to go out and seek positive social interactions. And we do this by addressing, you know, again, some of these unhelpful beliefs that are acting as barriers to social interaction.
And I wouldn't necessarily call this an evidence based strategy just yet, but we hope that it will become one soon. And again, the sole focus of the intervention isn't on stigma, but it really, it does address some of these self stigmatizing beliefs. And then there's several strategies to consider for public stigma or addressing it at the community level. We find that didactic fact sheets just don't really seem to be sufficient, but when having educational pamphlets that communicate positive depictions about people with substance use disorders, it can significantly reduce stigmatizing attitudes among the general public towards people using heroin and people with an alcohol use disorder.
And so some of the educational components often include, that addiction can happen to anyone, educating people about the effects of drugs on the brain, that there are options for recovery and that recovery is possible, and that a return to use is not uncommon as it's sort of a part of recovery for many. There's been some research showing that brief motivational interviewing, which involves strategies to resolve ambivalence and increased motivation through eliciting change talk. So one study delivered it to members of the community and found that it decreased stigmatizing attitudes towards people with alcohol use disorders.
And while the evidence to date might be kind of a little underwhelming in terms of marketing campaigns, marketing campaigns can be useful as well. And so this wouldn't be something like simply providing general information and education, but rather tailoring it, tailoring materials to maximize appeal and the potential for, to change behaviors, again, by doing this tailored targeting. Particularly in the specific community. And then there's also been quite a push in terms of getting people, you know, again, to recognize the use of certain language to describe substance use and people experiencing substance use disorders.
Like I've noticed there's been a lot of papers among some of the peer review journals that have specifically said, like, you know, we really have to, as a scientific community, we really have to avoid using substance user, substance abuser, things like that. And it's, I mean, it's not funny, but like it's, when, you know, as I was starting adopting this into my own writing, sometimes it feels a little bit awkward to like, say people with substance use disorders in a paper over and over again. But ultimately, you know, is it worth, you know, that shorthand given the potential damaging outcomes as a result?
So for structural stigma, there might be some broader scale levels of addressing stigma. And this might be just sort of like advocating for policy changes within a healthcare system for example. Changes to the legal system or broad federal, state or local regulation. Or it really could just be advocating for additional funding or increased access and availability of treatments.
So there was a study that was completed among police officers and they utilized an instructive and interactive crisis intervention skills training program, excuse me. And it reduced officer's desire to maintain social distance from people with alcohol use disorders, and people with cocaine- excuse me, and people with cocaine use disorders. There's a number of strategies that have targeted healthcare or future healthcare providers as well. So drug and alcohol education paired with clinical experiences for medical students revealed some effects on the dislike towards people with alcohol use disorder and people with opioid use disorders.
The findings with like discomfort were a little bit mixed, but there was a significant increase in the sense of responsibility of helping these individuals. So it shows some promise in addressing some of that social distancing that some providers may feel. And again, we see ACT here. So they have used this with substance use disorder counselors, and they found that it's decreased stigmatizing attitudes.
And even at the three month follow up. And again, exposing medical students to prenatal clinics that specialize in working with pregnant women with substance use disorders increased comfort levels. And then there was also an effect on judgemental feelings towards pregnant women who were using substances, incorporating reflection techniques into psychiatry, postgraduates training, enhanced understanding with lived experience of people with substance use disorders and improved clinical skills for working with people who have these conditions. There was a recent study that was just completed among healthcare providers, where providers were exposed to varying combinations of a narrative vignette that communicated the importance of using non-stigmatizing language from the perspective of a person with an OUD and a clinician or a healthcare administrator.
And then there was a visual campaign on either the harm of stigmatizing language and another focused on effectiveness of medications of opioid use disorders. And when exposed to the visual campaign and the narrative vignette from this perspective of the person with a opioid use disorder, providers were significantly less likely to report stigmatizing attitudes and they had a higher warmth rating compared to other exposures. And then just a couple things about the field overall. There's certainly a lot we don't know about the longer term effects of these types of strategies.
You know, are the effects maintained over time? There's really just a few studies that have looked at, you know, beyond the point of, you know, right before the training compared to right after. And as you can tell much of the outcomes I described are on attitudes and related constructs, and there's much less on, you know, actual behavior. So our referrals being made to treatment, does it actually change, you know, in terms of like community and, you know, provider stigma interventions?
Does it actually change how the person with substance use disorder feels and how they're being treated? And so overall, some of the most important components of evidence based approaches to reducing provider and community stigma is through some education, positive depictions, and also contact or exposure to people with lived experience, particularly, you know, for those who are achieving successful outcomes in recovery. And so I just want to take a little bit of time to go through the approach that we've taken for one of our projects on this HRSA grant in attempting to tackle provider and community stigma.
And so our goal was to raise awareness in stigma, lived experience of people with opioid use disorders, and highlighting that recovery is possible. And so we developed this suite of instructional materials that have centered around artwork depicting the lived experience of someone with opioid use disorder who's in stable recovery. And this has entailed installing artworks, in high artwork in on high traffic areas in the community, and also conducting workshops to further disseminate information, discuss materials, and allow for opportunities to reflect on the materials. So I'm sure you've seen some of this artwork, you know, throughout the summit venue.
And so the University of Rochester has an artist in residence who had been doing similar work to address HIV and mental health stigma. And she ultimately meets with and almost performs like an interview and for this study of people from eastern Kentucky who are in recovery from opioid use disorders. And they just sort of talked about their story. And again, the portraits are an attempt to help sort of humanize people with opioid use disorders through telling their story.
And these portraits are completed and they're actually put up in the communities that they live in. And so, there were eight portraits that were installed in Kentucky, three in Knott County, and five at the Mountain Arts Center in Floyd County. And portraits were created of people in recovery and also of, as well as community advocates, such as like the mayor of one of the towns. And these photographs from the portrait session, so these are photographs from the portrait session and the text that combines the experience of the person with facts about opioid use disorders, opioid overdoses, and the impact of stigma on people like those who've sat for the portraits.
And so these were prominently displayed in highly traffic public areas. And again, you know, it gives people a chance to have some like contact or exposure through their story of lived experience along with some education to further contextualize their story within the larger crisis. And then on the left part of this slide, there's a still image from a video of a portrait session of someone from Knott County. We included documentary footage with the artwork to further contextualize the artwork.
And so portions of these are played at community conversations, and these workshops are designed to inform providers and the community members on stigma and its consequences through instruction and also discussion and reflection on the lived experience of people who sat for the portraits. And then we ask participants of these conversations to think about substance use disorders at a deeper level to help dispel myths, understand consequences of stigma, see individuals with substance use disorders as people, to see that there's the potential to recover from substance use disorders. And there's actually some evidence based strategies that, you know, are based on evidence.
So Tedra Cobb facilitates these conversations, she's absolutely remarkable at it. I think the most recent count is 15 community conversations in Maryland that have been done across Maryland, Kentucky, Maine, Ohio, Oklahoma. And I think actually one was just completed yesterday as well. And then she also does a train the trainer, there's a train the trainer curriculum that was developed to help disseminate these workshops and further address provider and community stigma more broadly.
And so with that, I just wanna, you know, again, thank you for attending and you know, feel free to send me an email or talk to me after if there's anything you wanna discuss further. And in the meantime, it looks like we have about 15 minutes to answer questions and hopefully have maybe more of a discussion to find out what others are doing, you know, in the community or in healthcare facilities.
Anybody in the crowd have any questions for the presentation? (audience applauds) - [Audience Member One]
Thank you very much. That was very helpful and informational. And the only, I have a lot of questions probably, but the one that sticks out the most is, one of the approaches that you all take, and you mentioned it's not evidence based yet, is encouraging individuals to go out into the community and seek those positive experiences. And I didn't know if you had any information on what type of positive experiences have shown to, you know, be something that a person's actually went out or groups have went out and done and followed through with.
Whether that's going to churches or certain groups, 12 step meetings, or if there's another element in there that might be helpful. Especially in rural communities that may not have a lot of opportunities for group settings and.
Yeah, yeah, that's a great question. So ultimately, you know, fortunately the approach that we take is very patient centered. And so, sometime like fortunately for us, they have, you know, they're the experts in themselves and the communities and their family members and all that. And so, typically they've been able to generate a range of different things themselves.
And we tend to not, you know, provide examples for them. And sometimes it starts small, sometimes it's like, you know, I haven't talked to my son in a long time or like, or they would get a text from someone and they don't respond because they're afraid of messing up or, you know, oh, well they don't really want to talk to me, even though the evidence is showing since they're texting them, like, okay, well maybe they do want to talk to me if they're texting me. Other times there's been people who just don't really get out of bed much. And so, you know, we just try to help them to kind of get up and, you know, even get to the grocery store where there's even an opportunity to interact with someone.
So it's kind of a range from, you know, small things for some people to, you know, engaging people, engaging with people at maybe a more intimate level than what they've been used to recently. And so we work with their cognitive barriers that may have some evidence that are true. There's not really a lot for me to go out and do. But we kind of work with them and figure out what are some of the things that they can do, whether it's getting to church, whether it's going to a local concert or something like that.
But I'd be interested too, if you have any ideas, because we've had, so our studies with people with opioid use disorders, many of whom also have chronic pain that's debilitating and they live in rural communities, so the transportation issues just aren't there. So I'm willing to hear some ideas as well, if you have any. Not right this second, but just in general.
We have a virtual question that's come in. I'm just gonna come over here. What employment skills, trainings, do you recommend for healthcare professionals to reduce stigma?
So, like the approach that we've taken, you know, again, it doesn't necessarily have to be artwork. We just used artwork as our vehicle to disseminate the information of, you know, to paint people, as people with substance use disorders as people. And that there's opportunities to help them and that they can recover and, you know, that it won't necessarily take, or maybe there's an initial investment of time, but over time it might provide, you know, they might have more time to help some of their patients because the person with, you know, the substance use disorder is feeling heard and they're actually getting the help that they need.
So ultimately, you know, it's about sort of providing education to providing education that, you know, recovery is possible and that there's evidence based treatments for it. You know, help the providers like, you know, see the people with substance use disorders as people through exposing them to a lived experience. And then ultimately sometimes it's just, you know, working, working with them more, you know. Providers are people too.
And so they have these built up cognitive barriers that I've talked about. And so, you can work with the providers to help dispel some of the myths about working with people with substance use disorders. Just to list some examples.
Any other questions in the crowd here?
- [Audience Member Two]
And you did a great job of identifying the three different types of self, structural and public. And so I was just kind of wondering with the work that your team has been doing, do you have more data in any one of those three areas from the work that you know, that you've done over the years?
So we actually haven't look- we should have but we haven't looked too closely at the data yet, but we do have data at least before and after the workshops that are put sent out in the community. So we'll have to take a closer look at that. And then we're also considering strategies to again, look at potential, you know, longer term outcomes and also some of the behaviors as well that I was referring to. But we haven't gotten there yet.
But just like anecdotally, like, you know, it seems, there seems to be movement there.
We have another one online. You mentioned the evidence for marketing campaigns to address public stigma is underwhelming. Are you aware of marketing or communication campaigns that have been effective at reducing stigma?
Yeah, there are some that have helped. I can't recall like what some of the specific campaigns are. But again, they sort of hit on those same themes of having engaging materials that focus on, you know, the lived experience of the individual, recoveries possible, that, you know, there's huge impacts on the brain with substance use disorders, to kind of dispel some of the myths and educate people that things are out there. There is a hu- like a massive national institute on drug abuse study that just started a little bit ago, so I'm kind of curious about how that will turn out.
And then I'm also working on, it's a VA study, but one of the people on our teams has her PhD in communications and she's really focusing in on developing messaging, public health messaging for people who have, who are using opioids and have had a recent overdose or suicide attempt and figuring out like, you know, how much of a balance do we have on, you know, focusing on the mental health side. You know, some kind of combination with substance use and mental health or just focusing on the substance use and what should the messages look like. And just some preliminary data that we found is that un- It seems like the ones that are, you know, sort of the messaging that's, you know, kind of, it's kind of depressing, you know, the talk about like the pain that they're experiencing, seem to be the messages that the veterans seem to respond the most to.
And the ones that are focused on the substance use versus the suicide aspect seem to be more powerful. But that's preliminary.
Anybody else had a question?
- [Audience Member Three]
So my question is more about, I don't know, I guess trauma informed care and how that plays into, you know, the research and, because my thing with it is, is that, and what I've learned after being in recovery for 17 years is that for me it was never about the drugs. It was about what happened before the drugs. Because I could remember at eight years old looking in the mirror and saying, I hate you, I wish you would die. I did the same thing at 40.
You know what I mean? And drugs didn't have anything to do with it either time. And so, you know, my focus and my question, not really a question, I guess more of a comment, but it's, you know, with implementing trauma informed care, first I love what you said about letting an individual choose what path they want to take. Because sometimes I feel like we're in, you know, we're put into a treatment center or we're put into a criminal justice system and we're told where to go.
You go here, this works for them, so it's gonna work for you. And what I've seen personally is some people do that and it works for a while, and then all of a sudden the drugs ain't working. This lifestyle I'm living ain't working. And the only option left is, you know, suicide attempts.
And so, you know, I really, I really think, I like your approach to folks on the individual and the art and the education piece of it. Because that's, for me, that's where the sense of purpose and fulfillment came from when I was able to actually be who I truly am and not what everybody told me I was. And express myself in a way that helps me and helps others. And so I'll stop at this cause I know other people have questions, but one thing I'm also noticing is that we use the word recovery a lot and recovery is so different for each individual.
Because, you know, you could ask a room full of people in recovery, what are you recovering? What are you recovering from? What are you trying to get back? You know?
And you're gonna get different answers from everybody. And so, we focus so much on that word recovery, like it's a destination or something or something that is a lifestyle.
- [Audience Member Three]
But also for some of us, we're recovering who we were before the pain and before people hurt us.
- [Audience Member Three]
You know what I mean? So there's so many approaches and I just love what you're doing here and thank you.
Great, yeah, thanks for sharing. And just, you know, one of the, you know, I just recall before I was here is at the, I think I mentioned this yesterday, I was at the VA Ann Arbor here. And like, it was great there in some senses because there was, you know, a PTSD clinic, there was a mental health clinic, there was a substance use disorder clinic. We were all in the same hall, but we, we were still so siloed and so, the people with, you know, if you had any hint of substance use, things changed.
But initially when I was there, if there was any hint of substance use and for the PTSD clinic, you know, you'd get sent over to the sub clinic. But I think there, you know, my hope is that there's, you know, there's more of a shift of being able to address a lot of the underlying mental health issues and some of the trauma that people have experienced in order to tackle both the substance use and also the pain that's underneath all of it to begin with. So, you know, for instance, I did notice that there are, you know, the substance use disorder groups that were available there, they typically, they targeted, you know, for instance, depression and substance use, you know, over time there was PTSD and substance use, sleep and substance use, pain and substance use.
And so people are, were able to kind of pick up skills to be able to address one, address the other, and address the interaction between the two.
I wonder, has your group done any work on looking at leveraging technology as a way of helping people connect and sort of address that isolation and the stigma? I know there's lots of online resources available for people and ways for people to connect. And just wondered if you had any opinions on that?
Yeah. Yeah, I feel like in some ways like the people in healthcare and research are like so behind on some of these things, including myself, even though I find, you know, I consider myself more of a tech savvy person. I still like can't wrap my head around how to pull it off and stuff like that. But I think that there is some momentum here.
Like there's some people that I'm working with who, there's something called ecological momentary interventions where, you know, you collect information and then you know, face-to-face or telehealth session where they're identif- I'm big on like cognitive behavioral therapy. So that's my go-to. I talk about beliefs and thoughts all the time. So they'll talk about some of their thoughts in the session and then they'll, you know, when they go home, you know, of course you know they're not being seen for a week.
There's plenty of time to do all sorts of things. Many times people don't necessarily do their homework of course in at home assignments. And so, you know, a quick assessment will be shot out through a text assessing like how they're feeling, if they're feeling lonely or depressed or anxious. And then if they report, you know, a certain level, pass a certain threshold, then a subsequent text will be sent out that identifies maybe some of the thoughts that they were, that had gone through their, that they had talked about in the session.
And then also what some of those alternative more helpful thoughts were. And so that way they're sort of getting it in the moment. Another thing that seems to be on the rise are just sort of like dashboard tools within the medical record system. So like the VA has a bunch where they have every single person in the entire healthcare system who has either an opioid use disorder or on prescription opioids for pain, or even people who are recently discontinued from opioids cuz we find that they're at increased risk of suicide and overdose as well.
And basically, the provider can kind of look through that chart, which is populated through the medical records system. The VA's mass-, you know it's the largest healthcare system in the country. So it pulls together all these resources and it just puts it up on this nice screen where the provider can see, you know, the risk mitigation strategies that have been employed and then also what they could use, why they might be at higher risk. They stratify the risk and things like that.
So I think those are probably the two most that I'm most knowledgeable about I guess. Like, you know, this much. (Lisham laughs) - [Michelle]
So very often providers are faced with implementing services within a community that does not share their vision, especially when that community stakeholders heavily rely on the criminal justice system for employment. Are you able to provide an example of how a provider was able to create a partnership with community stakeholders within these types of communities?
I'm sure they are out there. I don't know if I can specifically, I don't, Gloria you, sorry to pull you in, but I feel like you might know more than me. But I'm sure there are examples of it, but I don't. (Gloria responds away from the microphone) Oh yeah, that's- (Lisham laughs) That's true.
Yeah that's true. Like being able to establish some kind of champion within the healthcare setting and finding that champion within the community. I think there's opportunities to help address it.
- [Audience Member Four]
Had one more question and kind of go off of that as well. I like what you said coming from a former mental health agency that was separated with SUD here, PTSD here, and not holistically treating a person. I believe a lot of that has been implemented because of insurance. (audience member four laughs) So I didn't know if there was any, any plans or if you all have been successful in any way to get policy change implemented or you know, anything in that direction.
Because I think that that's a huge part to tackle when it comes to stigma and just being able to actually treat a person holistically and getting rid of those barriers.
Yeah, I personally have not. I don't, Gloria have you, the healthcare policy? (Gloria responds away from the microphone) Yeah. I'm a novice, yeah.
So I was telling Li that I have seen some change over the years because I'm older and it's been an amazing amount of change really. When I started in the system in 1986, we had in New York State one organization to control regulations about drugs and one about alcohol and, you know, the counselors from one sort of regulatory body did not get along with the other ones. They would say that they were doing something very, very different. And now in most states we have the alcohol and the drug side united.
So also when I started this whole thing about treatment of co-occurring disorders within substance use disorder clinics was not liked at all by these agencies. But now we're to the point where most of these agencies really favor it and even are beginning to try to regulate it or to say that, you know, it has a place in substance use disorder treatment. So I'm very pleased with that part. I think we don't have the full answer yet as to how to treat people holistically.
But you know, there's been a lot of work done on that. It's been great, really.
And we are at time right now. So thank you Dr. Ashrafioun for your presentation and if there were any questions in the chat that we did not get to, (audience applauds) please email UR Medicine's Recovery email on the virtual platform. Thank you.
Lisham Ashrafioun, PhD
Assistant Professor of Psychiatry, University of Rochester School of Medicine and Dentistry