Discrimination against people with substance use disorders is a form of discrimination against people who abuse drugs, alcohol, and other substances. In many countries, people with substance use disorders are often blamed for what is often seen as a moral failing but is increasingly being understood as a disease. People with substance use disorders are likely to be stigmatized, whether in society or healthcare. In the process of stigmatization, people with substance use disorders are stereotyped as having a particular set of undesirable traits, in turn causing other individuals to act in a fearful or prejudicial manner toward them.
Background
Drug use discrimination is the unequal treatment people experience because of the drugs they use. People who use or have used illicit drugs may face discrimination in employment, welfare, housing, child custody, and travel,"Roughly 40% of U.S. employees are subjected to drug testing during the hiring process. The rate of employee drug testing has increased 277% since 1987, and drug testing has even expanded to welfare programs in some states." in addition to imprisonment, asset forfeiture, and in some cases forced labor, torture, and execution."Under Iranian Sharia law, certain crimes such as sodomy, rape, theft, fornication, apostasy and consumption of alcohol for the third time are considered to be "claims of God" and therefore have mandatory death sentences." Though often prejudicially stereotyped as deviants and misfits, most drug users are well-adjusted and productive members of society."According to a survey of more than 850 people aged between 16 and 24, and 100 in-depth interviews, drug use is commonplace and consumers tend to be independent, lead active lives, and do not lack self-esteem." Drug prohibitions may have been partly motivated by racism and other prejudice against minorities, and racial disparities have been found to exist in the enforcement and prosecution of drug laws. A 2003 study found that discrimination due to illicit drug use was the most commonly reported type of discrimination among Black and Latino drug users in New York City, two to three times more common than racial discrimination reports. People who use legal drugs such as tobacco and prescription medications may also face discrimination. "Some even prohibit nicotine patches."
Individual factors
The term "addiction" usually correlates with a severe substance use disorder. Addiction is characterized by behaviour that is originally voluntary and reward-seeking that becomes compulsive over time, with a desire to avoid dysphoria or withdrawal rather than to experience the original positive effects associated. A person may become physiologically dependent and/or experience withdrawal. To fund their consumption, people may engage in illicit activities such as prostitution. People who use drugs may not be forthcoming about these practices and may also delay seeking medical treatment for sequelae related to substance use out of fear of stigma or legal consequences.
Clinicians use DSM-V-TR criteria to establish whether a person has a substance use disorder, which may be classified as mild, moderate, or severe. It may also be ruled out, as some people may use substances or may be prescribed controlled substances that have the potential for addiction, but never go on to develop a substance use disorder. Addictive substances include stimulants (caffeine, cocaine, amphetamine, methamphetamine, ephedra, etc.), sedatives/anxiolytics (benzodiazepines, barbiturates, Quaaludes, etc.), opioids (oxycodone, fentanyl, etc.), alcohol, nicotine/tobacco, cannabis, dissociatives (ketamine, nitrous oxide, etc.), certain hallucinogens (especially MDMA), hormones (testosterone), GHB, kratom, GABAergic agents (such as gabapentin), and more.
Institutional basis
Stigma in health care settings is perpetuated by limited education on substance use disorders in many healthcare professions. As a result, medical professionals may be unaware that their beliefs about and practices in treatment for people with substance use disorders are neither evidence-based nor factual. Healthcare professionals may hold biases similar to those of the general U.S. population, who often see substance use disorders as a moral failure rather than a chronic brain disease with psychosocial and genetic factors. Very few providers are certified in addiction treatment; addiction is often thought of as a subspecialty with providers having an initial certification in another specialty area, such as psychiatry. Drug-using patients are often aware of the possibility of poor medical care, "often interpreting physician inconsistency or hospital inefficiency as signs of intentional mistreatment."
Although 1 in 10 people in the United States will meet criteria for a substance use disorder in their lifetime, few will receive treatment. With the increasing number of adults that suffer from an addiction, only a few will receive treatment due to the complexity of health care systems. Most health care systems do not have insurance coverage for addiction recovery and many health care providers have little to no training in treating addiction.Biancarelli, Dea L, Katie B Biello, Ellen Childs, M Drainoni, Peter Salhaney, Alberto Edeza, Matthew J Mimiaga, Richard Saitz, and Angela R Bazzi. "Strategies Used by People Who Inject Drugs to Avoid Stigma in Healthcare Settings." Drug and alcohol dependence 198 (2019): 80–86. Some doctors do not feel comfortable treating addictions, due to their lack of knowledge and training of the topic.Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/ The American Society of Addiction Medicine reports that there are only 3,000 board-certified addiction specialist physicians in the United States while there are nearly 2 million people experiencing opioid addiction.Langabeer, James R, Angela L Stotts, Bentley J Bobrow, Henry E Wang, Kimberly A Chambers, Andrea J Yatsco, Marylou Cardenas-Turanzas, and Tiffany Champagne-Langabeer. "Prevalence and Charges of Opioid-Related Visits to U.S. Emergency Departments." Drug and alcohol dependence 221 (2021): 108568–108568. The limited presence and access to comprehensive care for addiction poses a barrier for recovery for many, particularly those hailing from lower socioeconomic backgrounds.Saloner, Brendan, and Benjamin Le Cook. "Blacks And Hispanics Are Less Likely Than Whites To Complete Addiction Treatment, Largely Due To Socioeconomic Factors." Health Affairs 32, no. 1 (2013): 135–145.
Role of language Language plays a key role in perpetuating or decreasing the stigmatization of people who use drugs. Healthcare provider circles are increasingly shifting towards person-first language to mitigate such stigma. For instance, as opposed to saying "former addict" or "reformed addict", the National Institute on Drug Abuse (NIDA) recommends "person in recovery" or "person who previously used drugs" to separate the problem from the individual. The NIDA similarly discourages the use of words such as "clean" or "dirty" to denote whether or not someone is actively using substances. Moreover, SUD policy reform advocates report language adjacent to SUD can misconstrue associated medical treatment practices which in turn poses barriers to expanded harm reduction efforts from being adopted. An example of this provided in a 2017 executive memorandum from The National Prevention Council was a recommendation to wean usage of "opioid substitution replacement therapy" which many believe falsely alludes that an individual is substituting their addiction for another (i.e. from heroin to methadone) to "opioid agonist therapy". Another term that is losing favor is "abuse", due to its negative connotations and its impact on patient care. Instead, the terms "misuse" for prescribed medications or "use" for illicit substances are used. Similarly, "user" is not used in favor of person-first language, such as "person with a substance use disorder", or "person who uses intravenously".
Drugs and HIV infection Among people who use drugs intravenously, the incidence of HIV and hepatitis C infection is higher than among those who administer drugs through other routes. However, punitive and discriminatory measures against people who use drugs are not able to eliminate either the spread of drug addiction or HIV. A study from the Centers for Disease Control and Prevention’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention found that around 90% of people who choose to inject drugs have missed prior opportunities for HIV testing that were provided. For this reason, annual screening for hepatitis C and HIV is recommended for patients who use drugs. In jurisdictions where harm reduction policies are active, people may use syringe service programs and/or or use substances at safe consumption sites to minimize the risk of infection.
Regional patterns
Africa In Africa, approximately 28 million people use substances. This number is impacted by the rising availability of drugs that can be administered intraveneously such as heroin, cocaine, and methamphetamine. Socio-demographic factors are often primary determinants of the health status of people who use drugs. These factors contribute to an individual's drug use behaviors such as the sharing of needles and the solicitation of sex in exchange for police protection or more drugs. Nutritional status, family support, stigma/discrimination, adherence to medication, and recovery from addiction are also impacted by these socio-demographic factors. Research shows that the majority of people who use drugs transition from the use of non-soluble substances s to substances that can be used intravenously or end up using both simultaneously.
Kenya In Kenya, as with other countries, there is a link between injection-related discrimination, mental health, physical health, and the quality of life for those who inject drugs. The rates of discrimination are linked to higher levels of psychological distress and risky behaviors. Women in Kenya account for 10% of people who use drugs. These women tend to experience typical discrimination faced by people who use drugs in addition to gender-related discrimination. Levels of discrimination are often higher for those that are also HIV positive.
Tanzania The Tanzanian government initiated support for substance-dependence treatment rehabilitation in the late 20th century, with the Ministry of Health and Social Welfare administering the Treatment II center network to oversee this care.United Nations Office on Drugs and Crime. (March 2017). Prevention of Drug Use and Treatment of Drug Use Disorders in Rural Settings. UNODC. Treatment centers and harm reduction efforts in Tanzania have come into conflict with recent discourse from politicians, such as President John Magufuli, who established the nation's war on drugs in early 2017. Calling for the arrest of anyone involved in narcotics, Magufuli's stance is distinct from growing harm reduction pathways established in sub-Saharan Africa in the early 21st century. Tanzania's policing of injection drug use has pushed both consumers and traffickers deeper into the black market, with injection drug users consequently being more likely to be involved in sex work and other illicit trafficking, rather than engage in traditional employment opportunities which risk greater exposure. Populations that exist at this intersection, such as women sex workers who engage in injection drug use, are alienated from using risk reduction interventions due to fear of arrest.