Well, welcome everybody to our workshop, Words That Wound, Examining the Stigma of Addiction. I apologize we're getting started a few minutes late just due to technical difficulties but all is now squared away. I am Alona Balasanova and I will introduce the rest of our illustrious panelists who will be joining us for this presentation. We're going to dive right in. We do not have any disclosures. So our speakers, so myself, I'm going to introduce everybody one by one. I am the current president of the Nebraska Psychiatric Society. I'm also the director of addiction psychiatry education at the University of Nebraska Medical Center in Omaha where I also co-direct our addiction psychiatry clinical service in the hospital. We have Dr. Daryl Shorter who is an associate professor at Baylor College of Medicine. He's also the medical director of addiction services at Menninger Clinic and the director of the Addiction Psychiatry Fellowship Program. We have Dr. Patrice Harris who was the 174th president of the American Medical Association and also the first black woman president of the American Association. She is past trustee also of the American Psychiatric Association, adjunct professor both at Emory and at Morehouse School of Medicine, and strategic advisor for Columbia University as well as co-founder and CEO of E-Med. Of course, Dr. Ayanna Jordan who also is past trustee of the American Psychiatric Association. She is medical director of Project REACH, which you will learn a bit about during this presentation. She's also the associate professor of psychiatry at the Grossman New York University School of Medicine, as well as in the Department of Population Health and in psychiatry. She's also assistant professor of psychiatry at Yale. Our objectives today are to describe stigma and its relationship with substance use disorder. We'll talk about how stigma affects patient care as it relates to substance use disorder, and we'll review the changing landscape of terminology which informs how we talk about patients with substance use. We'll also have a very fun interactive activity about identifying stigmatizing terminology and then appropriate alternatives. So, we'll jump right into addiction. Let's first define our terms. Now, of course, we all know the DSM-5 criteria, the 11 criteria we use to diagnose substance use disorders. But looking at it a little bit more globally, what is truly the definition of what an addiction is? It is a chronic brain disease that has the potential for both recurrence and remission, and it is associated with uncontrolled or compulsive use of one or more substances. It is also considered to be the most severe form of substance use disorder. Now, these definitions come from the US Surgeon General in the Facing Addiction in America report that came out in 2016. So, the major tenets, then, are that it's chronic, right? It's a chronic brain disease. It is not acute. And it has this potential for long-term remission, which we know many patients who have many years of remission. But again, the risk for recurrence and return to use is always there. And this idea of uncontrolled use despite negative consequences is something that, at times, society at large fails to truly recognize, because how many times have you heard even our colleagues sometimes say, you know, oh, that person should just clean up their act and, you know, stop using? Well, the fact of the matter is, despite their best intentions, their brain's been hijacked, and they really can't stop using without additional assistance, right? Willpower alone isn't going to work through this one. So, then, what is substance use disorder? Again, we know the DSM criteria, but how do we define it in a more global sense? So, it is a medical illness caused by repeated misuse of a substance that develops gradually over time. So, using a substance one time does not mean you have a substance use disorder. Using substances at all does not mean you have a substance use disorder. It just means you use substances. And after this recurrent use, then, it can lead to brain changes. Now, the brain changes involve several neurocircuitry areas, including the prefrontal cortex, the most important of which, of course, is our executive decision-making center, the basal ganglia, and the extended amygdala. And these changes, particularly with the executive decision-making, really cause problems with self-control, right? The ability to inhibit one's behaviors and decision-making. So, you're not making the best decisions for you. Now, what is substance misuse? I did mention that repeated misuse of a substance can cause a substance use disorder. So, substance misuse is the use of a substance, any substance, in a way that can bring harm to yourself or those around you. So, an example I like to use is alcohol. You know, it's legal for if you're 21 and above. And if you choose to drink alcohol and you're 21 and above, and you go to a restaurant and you have a glass of wine with dinner, that's substance use, right? It's socially sanctioned, it's legal, it's perfectly acceptable. But if you have too many glasses of wine and you get behind the wheel of a car, well, now that's substance misuse, because now you are putting yourself at risk and you're putting other people at risk as well. So, the continuum is substance use, which can lead to substance misuse, which over time repeatedly can cause a substance use disorder, the most severe of which culminates with an addiction. And then what about this idea of dependence, right? Yesterday, we had a workshop on benzodiazepines in which a prominent part was how do you help those with chronic benzodiazepine dependence? That is physiological dependence, that is not a use disorder, because those are very different things. And so, dependence is an ordinary biological consequence of taking certain medications, not just benzodiazepines, but for weeks or years, and your body adapts to that. And after repeated exposure to the medication, your body learns to live with that medication. So, opioids, SSRIs even, beta blockers can cause this as well. And now these adaptations are distinctly different than those that result in addiction, right? Those neurocircuitry changes that we talked about a little bit earlier. That really specifically refers to the loss of control over these urges to take the drug even at the expense of negative consequences. So, dependence really is a function of your physiology and has nothing to do with a substance use disorder, so you may have dependence as part of your substance use disorder. So, perhaps equally or maybe even more important than what addiction is, let's talk about what it's not. It is not a moral failing. It is not a character deficit. It is not just bad behavior. It's also not poor decision-making, although that could be a symptom. And most of all, it is not a voluntary choice. You know, once I heard this remark, I think at a conference where, you know, if you ask kindergartners to raise their hand and say, what would you like to be when you grow up? You'll hear firefighter or police officer. Nobody says, I want to be addicted to drugs, right? Nobody's going to wish for that, and so it's not a choice. It's something that happens as a consequence of a variety of biopsychosocial reasons, but it is not a voluntary choice. And so, the language of addiction really matters, right? I'm preaching to the choir, but I think it's important that we make it very clear that, you know, language is the fabric of our communities. It is how we interact socially. It's how we develop relationships with one another. So, the language that we use to describe those with substance use disorders is critically important, not just amongst ourselves, but amongst our interactions with other colleagues, with the media, with other entities where we can either dispel or promote stigma. So, the words that we choose matter, right? We should be saying what we talked about in the continuum, substance use disorder, substance misuse, substance use addiction, a person with a substance use disorder. Of course, using that person-first language is critical because we all have our shared humanity, right? We're people first, and then we can be afflicted with a disease. We are not our disease. And not saying things like substance abuse, which is what we've heard for so long and sometimes is still taught, unfortunately. We certainly don't want to hear replacement therapy, which connotes this idea that we're replacing one addiction for another when nothing could be further from the truth. And of course, labeling people as alcoholics or drug abusers or addicts, right? As clinicians, that's not appropriate terminology for us to be using. Part of the reason, other than simply to be respectful, is that there's this idea of unconscious bias, that as human beings, we all have unconscious bias. And we've learned over time with research that when we use certain terms, our unconscious bias kicks in. And this is not just for the average person. This is even for highly trained professionals in healthcare. So, this was a little out of order. But language impacts patient care. So, there's these vignettes that we, this was some of John Kelly's work out of McLean, where he had mental health clinicians look at these two vignettes. So, they got one or the other. And it is the same vignette, as you notice, but in one, Mr. Williams is described as a substance abuser. And in the other, Mr. Williams is described as having a substance use disorder. And then the individuals were asked a series of questions after reading these vignettes. And what was found was quite striking, when the clinical scenario is the same. So, what they found was that the attitudes that people had and that implicit behavior, when the implicit bias would really drive their behavior. So, the individuals who had the vignette that called him a substance abuser were more likely to assign blame to him for his disease. They were also more likely to agree with the need for punishment of the patient. And they viewed Mr. Williams, when he was a substance abuser, as less deserving of care than if he was described as a person with a substance use disorder. Right, and that's quite telling. And in part, what this does is show us the stigma behind the stigma behind the language, right? So, what is stigma then? Attitudes, beliefs, behaviors, and structures that interact at different levels of society and manifest in prejudicial attitudes about, and discriminatory practices against people. And again, this can happen inadvertently. It can happen without our knowledge. But we can be inadvertently stigmatizing patients. It's an overarching term that really refers to all three components, right? So, we have the knowledge when you're just not aware. You have the attitudes that you have and the deeply held values you may have, and then the behavior that is the outcome of that. So, we'll go through this here. So, this was another study that looked at hospitalists at Massachusetts General Hospital and looked at attitudes and clinical practices of those taking care of patients who were admitted to the medical floors with substance use disorders. Amongst them, 38% felt that substance use disorder was somehow different than other chronic diseases because the person who uses drugs is making a choice. 14% felt that medication treatment using opioid agonists is simply replacing one addiction for another, right? Certainly what the term replacement therapy seems to connote. And 12% thought that somebody using drugs was committing a crime and deserves to be punished. Now, this is physicians that are saying this about patients. And I always like to think of diabetes, which is one of the most common chronic diseases, right? Much like addiction. And if somebody has diabetes and a poorly controlled hemoglobin A1C and they're eating a piece of cake, right? Like, are you really going to think that they're committing a crime and deserve to be punished? It's not something that would even enter our consciousness. And yet, this is what our colleagues feel when they think about the patients with substance use disorders. So not only does this hurt our patients, but it actually hurts ourselves. So we know burnout, systemic abuse, there's a variety of ways that people have described this phenomenon where clinicians develop compassion fatigue. And we know that in general, healthcare providers have pretty negative attitudes towards patients with substance use. They sometimes find them more challenging to treat or more difficult, or they simply just don't want anything to do with it. And we know that these attitudes are then linked with lower engagement with our patients. So the less we engage with them, the lower our therapeutic alliance is. And ultimately, the lower our empathy is. And we know that reduced empathy with our patients is one of the signs of burnout, which of course then leads to poor patient outcomes as well as poor clinician outcomes. I'm not sure why the headings are not coming up, but there are headings to all of these slides. So the technical difficulties. In any case, so healthcare stigma. So that includes physician misinformation and bias is a significant driver of negative health outcomes, right? And that misinformation can be something as simple as thinking naltrexone is a controlled substance, right? I mean, these are conversations that I have with our primary care colleagues that don't want anything to do with naltrexone because they seem to be confusing it with buprenorphine. But even then, why would they not wanna do that, right? I mean, it leads to a lot of questions. So healthcare providers may hold these biased views, right? That these individuals are too complex. I mean, how many times have we heard that I don't want those patients in my waiting room? I've heard that countless times. When you try to get to the bottom of who are those patients exactly? What does that mean? And so there's several ways we can reduce stigma and the rest of our talk, we'll talk quite a bit about that. One way that we have found with trainees in particular, so this was what we did with our third year medical students in our psychiatry clerkship at the University of Nebraska. We had them attend an Alcoholics Anonymous meeting, an open meeting that was open to the public. And we gave them a series of prompts to write a reflective essay after the experience, asking them what they felt when they went there. What were their preconceived notions? Were they confirmed? Were they disconfirmed? And what we found was that attending this meeting truly reduced stigma, because the students saw people who look like themselves. They saw people they never imagined could suffer from a substance use disorder that were doing very well in their recovery. And that's not something they ever conceptualized before. So this is just one opportunity with our trainees to dispel stigma. Another opportunity is through experiential learning. So this was another study that we did with our consult service, our addiction psychiatry consult service. We serve as one of the sites for the third year psychiatry clerkship. So we're one of the few places where you can have your core psychiatry experience on an addiction psychiatry service. And through that experience, we did the medical condition regard scale with our students before they began and after they finished. And the condition in question was substance use disorder. And so what we found was that they actually improved quite a bit in their feelings towards patients with substance use disorders, their desire to work with patients with these disorders. I mean, and some of the questions were along the lines of, you know, getting up in the middle of the night on call for these patients is something that I would be willing to do, for example. And those numbers simply shot up from having had this experience. So again, stigmatizing language is not unique to people with substance use disorders. We hear things all the time about somebody being wheelchair bound, as opposed to using a wheelchair for mobility. There's a variety of ways in which this impacts all of us and our patients. And it's important that we recognize the context of what's happening, the culture around us, and how that plays a role. And now I will hand it off to Dr. Shorter. Thank you. Thank you. Good afternoon, everyone. Thank you so much for being here. I have the honor of introducing Dr. Harris, as well as some videos that she will be commenting on. Dr. Harris spearheaded the AMA's efforts to end the opioid epidemic and served as chair of the AMA Opioid Task Force, as well as a chair of the panel now called the AMA Substance Use and Pain Care Task Force. During her presidency, Dr. Harris led this task force, which worked across every state to eliminate barriers to treatment, provide patients with access to affordable non-opioid pain care, and fight the stigma faced by those with substance use disorders. And so, in this first video, this will be a video of Dr. Harris discussing the current state of the opioid, of the overdose epidemic. So, this is the part where I tap dance a little bit, while we figure out if... So, Dr. Harris is going to riff now a little bit, so this just got very interesting, but she has faced the AMA House of Delegates before, so I'm sure she's ready for this crowd, so thank you so much, Dr. Harris, we appreciate you even more now than we did before. So good afternoon, everyone, and so sorry you are not able to see those wonderful videos, but you can, in your spare time, go to YouTube and click on these wonderful links, and, you know, flexibility, I always say, is my middle name, so I will try to bring to life some of the points that I made in the videos, and I think the biggest point and where I want to start with is the opportunity I had as president of the AMA. For those of you who don't know, the official job description of the president of the AMA is to be the spokesperson, and I want to go back and share a little bit of how we got there, how I got there, and why it's so important, and what an opportunity, but the key take-home message I would say to you is each of you will have opportunities. Some will be large opportunities like I had as president of the AMA. Some will be small opportunities in conference rooms and committees and the PTA and those types of organizations, and it's important, Alona described us as the choir, and we are the choir in this room, so glad you're here, but we have a lot of folks who are the non-choir, and so it is important still today that we do what we can, again, not adding to our list of things to do. We have a lot to do, but from time to time, I would urge us all to be laser-focused on stigma. I was recently at a meeting, and a psychiatrist said we should stop focusing on stigma. We should focus on X, Y, and Z, and by the way, he was right. We need to focus on X, Y, and Z, but stigma is still prevalent, particularly when it comes to substance use disorders, so it was about 1997 and a little bit of history about the AMA. For years, the AMA was really a state-based organization, so if you think about Congress, everyone has representatives that are related to the population or based on the population. You have a certain number of representatives for every X number of citizens, and then we all as a state have two senators, so the AMA was like that when it came to the state medical societies. I live in Georgia. I belong to the Medical Association of Georgia. You did get that proportional representation, but when it came to the specialties, you only had two, and over the years, policy changed, and the specialties were able to have proportionate representation, and so psychiatry went from two to seven, and I was one of those newly appointed delegates when we expanded our delegation, and we sat in a conference room and said, let's assess the current state of conversation around psychiatry, mental health, substance use disorders, and where we need to go, and we, of course, as probably no surprise to this in this room regarding policy and how the discussions were held or not even held at the AMA, we knew we needed to improve, so our goal was to have a psychiatrist on every council, every committee, leadership, and someday have a psychiatrist be president of the AMA, so 20 years and a lot of hard work and working with the specialty societies and psychiatrists across this country, I was elected. I will say, though, that we've had others, Dr. Jeremy Lazarus. You may know him, psychiatrist from Colorado. He was president a couple years before me, but he came from the state, right, so it didn't count as we teased him, you know, and seriously, the reason why is, again, we were just not represented when it came to policy and conversations, and so we've been able to successfully expand. If again you needed to sleep and you wanted to look at the policy handbook, we just left the AMA meeting, but so many policies around mental health and care and burnout, and again, not just coming from the delegation, from the medical students and all the other delegations, and I think that speaks to the influence over the years, and I will say that when I was elected president, one of the things that I said I wanted to do was elevate the conversation. I think in my inaugural address, the Dr. Prom, elevate the conversation, and so in 2015, the AMA had been on the board since 2011, but the conversations around the opioid use disorder, recall 2014 or actually pre-2015, the narrative was very narrow and very shallow. The language was stigmatizing and the opportunities were limited, so the AMA Board of Trustees established the Substance Abuse Task Force, so I am sufficiently embarrassed, but that was the first name, and I'm going to give myself a little bit of grace and say we were just running at full speed trying to address this issue, right? Prince had unfortunately just passed away, and I'm sure if you recall, this whole opioid epidemic was all the doctor's fault, and if they would just stop prescribing, and then there was a rash of bills being passed that limited opioids, you know, just these blood force laws that were being passed, and so hence, we said we've got to do something about it as physicians, we have to lead and own this, so the task force was born, but I will say that soon after that, not soon enough, so I'm going to give myself grace, but I'm a little bit embarrassed, we did change it to the Opioid Task Force, and as you can see now, it's opioid and pain care, and that's because as you all know, a lot of synergy between those two issues, and we had the Opioid Task Force, we've been pretty successful, and then we had the Pain Care Task Force, they were working on issues, and when I left, I chaired the task force from 2015 to 2021, they decided to combine, but again, the opportunities were to expand the narrative, to prevent some of these very ineffective blood force pieces of legislation that again, not only didn't help, but sometimes harmed patients, particularly those patients in pain, and they were what I call feel-good legislation, so we formed the task force, eventually got the name right, and so some of the videos that you again, can watch at your leisure, were me talking about the importance of using the right language and addressing stigma, we called out stigma, and so that was very important, so again, through my experience, here are some take-home lessons that I'll end with, one is if you ever get a chance, if you get asked to speak before media, get a media opportunity, please take it, now you might want to get a little bit of training, but listen, you are the experts, you can be on TV and use the appropriate language, right, because there are so many people not using the appropriate language, how many times have we seen, and again, we know our media, if it bleeds, it leads, how many times have you seen either a photo or a video of two parents in the car, passed out with the children in the back, right, plenty of those, and those are true stories, they happen, but we did some media training with reporters and said, how about you share stories of people who are on buprenorphine, and the success stories, or any other treatment, right, it doesn't have to be medications for addiction treatment, but the point is, share good stories, and so you all can, again, not only use appropriate language in these media opportunities, but share the stories of your patients, of course not using names, but of who are, you know, in recovery, and successfully being treated, the media tends to share more of those stories now, but that's an opportunity, and something that I was able to do. You heard Alona talk about dependency, even among our colleagues, and we know, and so in your clinics, if you're in a multidisciplinary clinic, or when you are around other colleagues, we have to get them to appreciate the difference between dependency, right, and substance use disorders, and substance misuse, so that is something that I would ask you to please elevate, because physicians are worried about prescribing, and again, we want to expand the use of buprenorphine, and they are afraid, again, you heard that replacement, and so we can help with that, and we can talk about physiologic dependence, which is not the same as substance misuse, and that goes with SSRIs, and also medications used to treat addiction. The other point you would have seen on these videos is we should make assumptions, and we probably don't in this room, that our colleagues know better, and a story that I tell, and this is an unfortunate story, I'll tell two, one related to substance use disorders and one not, but we were just at the AMA meeting, was it in June? We meet twice a year, June, November, we just had the one in Orlando, but again, we've come a long way, and there's progress, and great policy being debated on the floor, right, great policy, but then one of our colleagues got up to actually speak to the policy, which we wanted to, but used the term drunkard, and used it once, and of course we all over in the psychiatry section council were cringing, but you know, you try to give grace, but he used it a couple more times, and I think somebody else got up and said drunk, you know, something, another term that was very stigmatizing, so all of us were looking at one another, so me being the past president, I have no more races to run, so I get to go to the mic and stand up and say things, and not worry about a future election, right, we want Alona to rise, so I said, let me take this on, so that is the privilege of having no more races to run, right, and I went to the mic, and at the AMA, past presidents use their ability, we can go to the mic, you have to be privileged and all that to go to the mic at the AMA, pretty serious, but past presidents have the privilege, and I went to the mic and said, listen, we have come a long way, colleagues, but this is a point of information, here are the terms we use and here are the terms we don't use and guess what I got applause. That wouldn't have happened about 15 or 20 years ago when we first went to the house. So that's again progress in our in our profession but also shows just how far we have to come. How many of you have been in this is a non substance use disorder issue how many of you have ever been in a meeting and someone described something someone as schizophrenic not a person with schizophrenia but let's say and by the way I've been watching HGTV lately to not watch the news and I'm so I'm addicted to I am really to to house hunters and a guy they were looking for a place that a touch of modern this is the international but some charm right and he walked into this place that had I think of the Scottish charm I think they were in Edinburgh Scottish charm but the kitchen was modern and he said this feels schizophrenic to me and I cringe but we hear that all the time and by the way I've heard that in boardrooms and I always raise my hand gently because it's not too embarrassed to call in and sometimes I will pull the person to the side and say later but if it keeps happening and so that's an opportunity just an example of an opportunity where we can either pull our colleagues to the side at one-on-one or but sometimes I call it calling in you gotta raise your hand and just say it out loud so that everybody can hear this but you of course can do that giving them grace and so I would say opportunities are going to come our way professionally and just maybe again at the at the PTO meeting so please let's continue to take these opportunities to reduce the language that folks are using that further stigmatizes our patients but also again gets into policy and just in some ways many ways are harmful to our patients so thank you all for your time hello hello hello I am so excited to be here and really talk about stigma I appreciate dr. Harris and really thinking about using opportunities right and taking advantage of opportunities to address stigma and one of the words or ways that I love to think about stigma is really of this concept related to social death because I think we talk about stigma so much that the stigma in stigma itself is kind of minimized so there is a global mental health physician dr. Kleinman he said stigma really does equal social death and thinking about how there are many people that continue to die within our field because of social death there is no opportunity for them to get help and if they want help the stakes are so high because they don't want to be labeled an addict so this still matters and I do think we have to think about what opportunity we have to really confront stigma so let me try to go forward in this vein one of the things that I thought was really important was making sure that people who are not white could see themselves in care right wanting to be cared for by physicians that look like their mothers look like their fathers their parents their sisters and their brothers and so one of the things that was so awesome early in my career is I was able to come to the triple AP conference but I looked around similar to my flight from New York City to Fort Myers and I was like everybody's white like this is scary to me I don't feel safe right I don't feel like I belong and so one of the things that we were able to do through SAMHSA was write a grant and the goals of the grant were simple I wanted to come to a triple AP conference and have more non-white doctors period and so we wrote this grant back in 2017 it got funded in 2018 we're going into our sixth year I'm so happy we just got funded for five more years yay but the point of the grant and it's called recognizing and eliminating disparities and addiction through culturally informed health care was granted to triple AP I'm the medical director was to increase the number of addiction specialists from historically excluded backgrounds that was number one but number two for all of us regardless of how we're racialized or what our ethnic makeup is is to better take care of people from historically excluded backgrounds with addiction so that's reach thinking about opportunity this was one opportunity to address stigma not just through calling people in which I love that language I do that all the time through publicity but also changing right the face of addiction psychiatry I just want you to see that we have been really successful over the year and recruiting people so if you see a non-white physician here they're probably from reach and if they're not from reach they probably know about reach or they probably trained in reach or they're probably a mentor so I'm really happy in terms of the history of what we've been able to do and we want to keep on going so I'm just really happy in terms of the addiction psychiatry fellows medicine fellows but also we have medical students physician associates advanced nurse practitioners that are a part of the program this is I always take credit for the people who came through reach whether it was the inaugural program or now I say once a reach scholar always a reach scholar if you become famous I will take the credit so Dr. Fabiola Arbelo-Cruz is now assistant professor at Yale and she's just amazing but I wanted to read some of her narrative directly about the program she said I've been involved with the reach program for many years I started as a scholar and cohort two that was second year I am now a mentor the reach program has impacted my work professionally and personally in many ways it has provided me with the network of addiction medicine mentors and peers second both scholars and mentors are provided wellness sessions which teaches how to prioritize self-care I want to pause there for a second because I think one of the things that was mentioned in the introduction was how empathy really does help with burnout and if we no longer have empathy that all also negatively impact our patients but also ourselves so one of the things in addressing stigma or social death that I want to remind us collectively in this room is centering wellness not in terms of just getting massages and a pedicure although I plan to do both but really thinking about self-preservation how do you do work that really fuels your heart your soul and being able to take advantage of these opportunities to call in people and I do think a form of self self-care and really thinking about how do we discuss our patients publicly in ways that help our profession so self care addressing stigma really as a way for us to take care of ourselves this is another reach scholar dr. Justin Morales he's actually interviewing right now for addiction psychiatry fellowships but it says for me reach has gone above and beyond not only are we getting culturally competent knowledge which is going to be even more important in this political climate but thinking about professional development and making sure you don't have to be from a historically excluded background in order to mentor our young people who are interested in in addressing addiction how can you mentor them give them opportunities when I first met dr. Morales he wasn't the strongest writer but now he is publishing in all types of journals in terms of best taking care of our patients so thinking about what can you do to really shape right the next generation of addiction leaders I want to end with Terrence he just celebrated his birthday I love his Instagram stories he said Beyonce and birthday I couldn't think of a better duo I'm like me either he said being black queer non-binary doctor reach has truly been a home for me so we think about of course our patients are stigmatized because they have substance use disorders right but what about our black transgender non-binary patients who misuse cocaine like where is their representation who are they going to come to to get help right if we're able to develop doctors that can treat the least amongst us in the social fabric we collectively all do well so I love his point of view in terms of addressing stigma just through representation of who he is and he really does get to see lots of folks who would never come to someone like me all right so I think what I'm going to do is stop because I am so excited about this next part our group activity we're in real time we're able to take some real-life case scenarios and collectively go through them so I'm going to turn it over to our chair I always say I wish you could run my life because you're so amazing she's so organized and gets us to where we need to do but she's going to pass out the actual group activity and then we'll provide some directions about what we what we want to do and we hope you stick around because it's really good for us to go through look at these and figure out how would we address stigma in that way okay thank you so for our small group activity we're going to ask that you all kind of group up in small groups of four four to five people so here's a naturally forming group of five right here I don't want to direct it too much I will if left to my own devices I certainly will direct it and in your small group you're just going to take some time to read through the vignette and then rewrite it with non stigmatizing language so in the first one you're going to rewrite the consult request with non using non stigmatizing language and then well once we will give them about 20 minutes or so 10 and 10 so we'll do 10 for the first one oh okay so there's so it's front and back so you can take a look at both of them and at the halfway mark we'll discuss the first one and then we'll read it right the second one and then we'll discuss the second one So in the next five minutes if you can switch to the second vignette, and then we will review all of them together yeah Yeah, yeah, so you still got a little bit of time to work on the first one But in about five minutes switch to that whichever is the second. Thanks These are not buttons. These are buttons. Okay, we can reconvene as a large group now. So we're just going to go around and ask people to share how it is that you have changed vignette number one, the consult request to use non-stigmatizing language. So in this first one, I'll go ahead and read it. Mr. S is a 37-year-old homeless man who presents to the ED expressing suicidal thoughts. You are asked to consult on his plan of care. The consult request you receive for the patient states Mr. S is a frequent flyer. He's an addict with methamphetamine abuse. You can talk to him, but no matter what plans we give him, he's always back. That's the way it is with junkies. You know how it goes. It's pretty hopeless. He comes in manipulating us with threats of suicide, and then he leaves AMA instead of going to detox or rehab. His urines are always dirty when he arrives. Let's clear him for suicide, and we will send him back out to the street as usual. It's too bad he doesn't have more willpower. Most of the time, he just wants a sandwich, and even though he is covered with track marks and abscesses, he won't accept any treatment and lies about what he has been doing between showing up at the ED. Yes? We've only got to this one. Okay. Well, so then you better for sure participate in this one. Mr. S is a 37-year-old man who lives in a house with a woman and a teenager. You are asked to consult on his plan of care. The consult request you receive for the patient states Mr. S is a frequent flyer. You can talk to him, but no matter what plans we give him, he's always back. That's the way it is with junkies. We wanted to get the actual specificity of the number of visits in a certain time frame, so we just have like X visits to ED in past X amount of time. He is a person with methamphetamine use disorder, which is a chronic medical condition. He has been seen frequently for, okay, I think threats of suicide with self-directed discharge. He has declined medically supervised withdrawal management and residential treatment. His toxicology screens are positive upon arrival. After comprehensive safety assessment and recommend use of motivational interviewing, he may have food insecurity and may request nourishment. He shows signs of injection drug use and may need treatment for abscesses. Patient may be an unreliable reporter of his activities between admissions. Pretty good. Pretty good. Well done. All right. Thank you. I actually have a question about this. So I heard online or was looking at kind of a talk about using the word homeless versus unhoused. And I think I read something like maybe it's not completely appropriate to use unhoused as an alternative to homeless because they kind of are describing two different situations where like for example if someone is their lease ended and they're looking for a new place to live they're just like between living situations that would probably be a more accurate way of using the word unhoused because again it's like a less stigmatized term describing their situation. But if someone is like chronically like on the streets like they have not had a stable place to live for like years and years maybe using a term like homeless is a more accurate way of like depicting their living situation. I guess like what are your thoughts on that kind of rhetoric? I don't know if I can hear you, I'll come up here. Just in case you can't hear me. So me personally I really like to use action terms. I don't like to label. So even you know unhoused, homeless, those are labels. So the way that I usually describe it is that it is a person experiencing homelessness. So something that's transient, right? Not necessarily static. So that's how I personally describe it but there's many different various ways. Yeah, so I really liked what the first group had described in their rewriting. One thing I would just kind of add that we had been looking at is in kind of, I mean, a big chunk of this we were like, opinion, X, just kind of unnecessary, this is not medical. But in looking at the, you know, him leaving before treatment referrals were made or not engaging in treatment referrals is that significant barriers exist to treatment engagement and maybe identifying what those are for this patient that they've seen in the past because that would help. So the struggle of the patient is something that is missing in these words so whenever we we were using words like patient is struggling with and that can be Very impactful on the receiving doctor if we can because we try to help Especially when there is a struggle So if in words that choose struggle, I think we had that Not just diagnosis and label for that Might I throw a question out To the group around use of the term patient Now I have been pretty dogmatic. So again admitting my own bias I am a physician and I take care of patients, but we've gone through the consumer and and other terms and Happy to understand that and talk about that But I read something recently that I hadn't thought about was we have to be careful because the payors Are now sort of using that if you don't use patient almost as a an excuse or a reason not to treat substance use disorder as a medical disorder, which I think that it is but I Throw in this question out to the panelists or anyone in the audience about using the term patient So the question is about whether or not to call someone a patient with a substance use disorder what your thoughts are I use patients, but what? Do others think? This is kind of controversial in terms of like I work with a lot of advocacy groups people who Actively use substances and are not interested in getting treatment at all. They feel like there's the over a medicalization of Substance use period and definitely would not identify as such Then there are other Health professions who are like social workers and things like that. They say, you know, it's clients Your clinician I'm like, no, I'm a physician I love working with other clinicians. So in my own writing I'll say physicians and other health care providers taking care of patient slash client like It's a larger question of like it's an existential question like are you trying to get rid of the physician part I've already have My own stigma because it's like psychiatrists always gets confused with psychologists. So all that to say and I Legitimately hate fighting with insurance companies. I will say patient. I do think it legitimizes people who are getting help with a medical condition that like many other medical conditions including diabetes hypertension is exacerbated by Social determinants we should take on patients. I have trainees that are like, dr. Jordan. No, we're gonna call it. Mr Person this and that I'm like you got it, but I think that It's an ongoing discussion, but I really am curious what folks say, yeah, please The mobile microphone stand, okay Thank you. Hi, I'm Daniela Rokossovic. This is my favorite question ever. I have a lot of thoughts and feelings about it. So the word provider Actually makes me break in hives, okay because You know, my hairstylist is a provider. She provides a service. I'm a physician and I Took Hippocratic Oath and I think that the relationship with a physician and patient is one of the oldest and most sacred Relationships that should be honored as it is. So yes, I'm going to use the word doctor physician Always and forever. My patients are my patients. They're not my clients. They're not consumers. They're not receivers of My product I Mean it is ridiculous and so reductionistic that I appreciate you you're raising concern about it Yeah, please. Thank you. I I Respect the amount of work that I've put in to get where I am and to have MD after my name but I work with a lot of a PR ends that have to treat the same patients and I feel the need to elevate them so that somebody doesn't just walk all over them and say well They're not a doctor and they have no authority to make any diagnosis or to make any treatment decisions. So You know, I guess in the community we can argue, you know the validity of Physician versus other providers and I again respect that very much but in terms of the patient care that I need to do Elevating other people in my departments to an equal status is important And so that's where it generates for my personal department and I'm not making a generalized statement Thank you This will be our last because we want to get last comment about I think we as psychiatrists a little bit too sensitive To our patients if all doctors are changing their name from physician to provider I'm game if we're changing all patients across all Specialties to clients. I'm game. I think we exclusively Minimize ourselves and our importance and our patients we want It's it can't be like we are the only ones who are dealing with the stigma and also being victims of it. So Thank you for that point of things for sure. Okay vignette number two We didn't solve it, but you know, we at least we're talking about it Yeah, it's not unconscious. So what one of the groups that has not gone yet like to share we won't read it Oh Sorry, yep, sorry. Thank you Did anybody get to vignette to who wants to reword and yet to Okay, so we'll take a partial answer. This will be, so you got a C to start with, okay. Just teasing. Alright, you guys have to help me here, okay? Okay, so Miss B is a 25-year-old pregnant woman with past history of benzodiazepine and opioid use disorder who presents to the outpatient psych clinic for the first time. We did kind of break it down into the presentation and the formulation. Biologically, the patient has demonstrated dependence upon opioids and benzos in the past. Psychologically, there's concern for a potential Cluster B disorder in addition to the substance use disorder. Socially, patient has faced or been involved with CPS due to concern for her children's safety. And that's just something to keep in mind as she's being treated. I think that's kind of what we've got. That's pretty good, actually. That's a creative approach using biopsychosocial formulation to describe this patient. Yeah, no, I appreciate that way of thinking through the case. This is the first time actually having someone do the BPS. It's hers just rewriting it, so kudos for that. What is really kind of struck me with this case is the line around, I mean there's a lot of stigmatizing language in here, but really like her oldest child was taken from her as appropriate given that she would not have ever been able to care for the baby. Like what? How are you making all these assumptions? I mean this is a note. These are things that are written by physicians and other providers. But the point being and this is some of the work that my lab and others have done, we have, there's so much stigma and bias in terms of who gets referred to CPS, who gets reported, who doesn't. We know that black women are more likely to get reported than white women. So I think that I just want to say that that was particularly unnerving and really thinking about how do you rewrite this? How do you think and how do we have to really work use our opportunities even in our language to communicate what is happening to the best of our ability without assumption. And then I just do not like when people are putting things in quotes, like borderline, like just reserve that for literally what the patient said. Right? You don't have to, I'm hurting. Like that is what needs to go in quotes. Not whatever you think, but what did the patient say? Yeah. Others. I would love to hear. Please. I was curious, taking a little bit of a step back from the exercise, I think a lot of the stigma is about setting standards and bringing the unconscious to awareness. But I'm wondering if in a lot of the terminology we're getting away from the root, which might be pain, anger, trauma, and look about our colleagues that either have been unable to process a lot of the trauma and counter-transference in the work that they do as well as people in their places of origin, at home or otherwise in society. And think about, can we work out getting people the help that they need with trauma and getting people the well-being work that they can get better at processing all that they're dealing with in a very taxing profession. Just so I understand, you mean like the providers? I would agree with that. So I think learning to write more effectively with less stigmatizing language is the first step, but the next several steps are how do you write in an empathic way that the other people on your team can hold on to that and get a sense of not just the symptoms and the emotions, but what are the coping strategies and how do you facilitate resilience. No, I think I hear that and so, and I'll pass it on to the other panelists, but I think it's a and both not either or, right, and walking and chewing gum at the same time. Yes, and I think we have to even just get to the point where people are able to effectively communicate because we're not even there yet, and at the same time deal with lack of empathy, burnout, the stressors of the system itself. Well, I just think it's a, I'm so sorry, it's a both and, but I would start with, you know, what we could do, you know, I even hate the term low-hanging fruit, and I think it's educating and bringing some of the unconscious to awareness and how you do that at your place of business will be different, and then the only, and I agree with because most of us, you know, all of us were traumatized with COVID, right, so there's a lot of that. My only, and so I agree with that, of course, as a psychiatrist, we want that. I do want to make sure that when we talk about solutions, we include that and language and making sure the system does not contribute to burnout because, you know, when we first started to have the conversations about burnout, specifically about physicians, it was physician heal thyself, you know, get more sleep, eat right, and meditate, right, and so, and I will just give the AMA props, we pushed back on that. We said burnout is administrative burden and all of these other things, and so don't expect for the problem to be solved with physicians sort of eating right and getting more sleep. The system has to take ownership of that, so again, it's and, and, and. As a kind of ongoing from that point, I think as a liaison to the service that's consulting you, you have to figure out how to address this kind of behavior in a consult request, you know, what's the appropriate way to address that clinician. Yeah, I just had a, I mean, both of those vignettes were very cringy. I'll just kind of put that out there, but I think as a group, we've all seen that type of speech come up or that type of writing come up in, in consults. One thing that, that does bother me a lot, and I, we haven't really talked about this yet, but there's a, I think there's a general perception with our, not only with our non-addiction psychiatry colleagues, but with our non-addiction medical colleagues, that substance use disorders do have a poor prognosis, and I know it's a relapsing, remitting disease, but I've actually always seen a lot of hope for this population. I tell the residents that, that train with me that, you know, at least within, in the mental health field, addiction is kind of the, the one disorder that can really achieve full sustained remission, where individuals can go back to their pre-morbid level of functioning 100%, you know, and I guess my question is, how do we get that perception, which I think is a very big misperception from the rest of our colleagues out there, so that people, you know, have, instead of the sort of fatalistic view of addiction, as it's untreatable, it's never-ending, they're never going to get better, to really help our colleagues to understand that, you know, that there is a lot of hope for these patients. Yeah, no, yes, oh, can you hear me? Yes, this is not, it doesn't feel that way. I appreciate that so much, and that's so much of what some, my work has focused on, particularly with trainees, and how do we instill that message of hope, right? What you're describing is spreading hope and, and educating people that recovery is not only possible, it's probable, right? I mean, that's what's going to happen if you get the care that you need, and I think exposure and ongoing conversations about that are really critical, as well as role models, right? Each and every one of us in this room can serve as positive role models, not only for trainees, but for our colleagues, right? And so setting an example, not only through our language, but through our behaviors, through the ways that we describe these patients, and the hope that we describe, we see every time that we treat them. I just want to add, real quick, that one of the challenges we've been having in our academic medical center and in our department is that we are struggling to find preceptors for medical students, much because of the burnout that's been mentioned, and the administrative burden, and now you want me to fill out an evaluation every two weeks, and I'm supposed to take a new student every two weeks, and I just can't do that. But the reality is that we really need addiction psychiatric providers, sorry. Don't, don't explode. Don't do it. Addiction psychiatrists, physicians, we need those people, yikes, to take on students, even though it's tough, and it's hard, and it could potentially add to burnout, because they're the ones that can really provide the kind of hope that you're talking about, because by the time they get to residency, it may be too late. We have to start earlier, we have to start upstream when it comes to exposing students to, to this type of hope that we, that we can convey. The other thing is, like, what are the other opportunities that are available in your medical setting to provide that type of mentorship and perspective to people, and are we doing all that we can to take advantage of that? I'm sorry, go. Thank you. So with regard to this second case that we've discussed, I used to run a hospital-based treatment program for pregnant women. Every last one of those women was there because they wanted the benefits of recovery for their babies. Not one could recognize that she herself deserved all of those benefits, but they did recover, they did get better, and they had good lives. I think every woman having a, or every person having a baby in America today is anxious, or ought to be, just because of how poorly we treat pregnant people and parenting new parents in this country compared to other developed nations. In response to the question, how do we spread the word, we talk up our stories. We talk about the people who are recovering, the successes that we see, especially the successes of, in marginalized people who may otherwise be disrespected all over the place. People don't know what a great field addiction psychiatry is unless we share those stories. In my rural community, rural remote, not quite frontier medicine, in our critical access hospitals in our rural county, they're allergic to addictions. They're also allergic to mental health, and they refuse to seek consultation. But every opportunity we have, my husband and I talk with them about the benefits of recovery and how people get well. In the treatment center where we work, if we have to send somebody to the hospital for emergency care, it's a crapshoot. They may be badly disrespected. The thing they fear most is, quote, being treated like an addict. Well, nobody wants to be disrespected in any way. We know that that disrespect keeps people from getting the care we need, so we need to talk about the joys of doing the work. And it's too hard to do alone. We really need teams to do this, because there are times when we get that awful phone call, I regret to inform you. And it does happen that our patients die, but this is a life-or-death issue. And the good news is, many people live because of the work we do with them, and they have good quality of life as a result. I would just like to amplify the comment that you made, Ayanna, that I think people can not only recover, but I think they often come out of this process wonderful people. I think they make progress that outshines much of the rest of the population. And I think that we could be responsible and helpful for that to happen. And it's not just that they recover. I think they often grow in enormously productive ways as a result of that experience, and that we could help that. Thank you so much, Dr. Enner. And thank you to everybody. What a wonderful note to end on, a note of positivity and hope. Thank you, everybody, for attending and participating. Well, we're still around in case you wanted to. Thank you.

addiction stigma

Alona Balasanova

destigmatizing language

addiction psychiatry

Dr. Daryl Shorter

Dr. Patrice Harris

Dr. Ayana Jordan

Project REACH

culturally informed healthcare

media reform

policy reform

person-first language

subconscious biases

compassionate care

chronic medical condition

stigmatizing language

Dr. Alona Balasanova

unconscious bias

healthcare burnout

recovery success stories

opioid epidemic

REACH program

diversity in addiction specialists

positive narratives