In a piece published in JAMA that discussed last year’s film Beautiful Boy, Dr. Abigail Zuger endorsed the sentiment of a former patient: “never trust an addict” (Zuger 2019). For a healthcare provider to hold and promote this opinion is stigmatizing, misleading, and harmful. Patients with substance use disorder regularly experience perceived and enacted stigma in healthcare settings, and thus are resistant to sharing the truth about their drug use (Paquette 2018). Stigma is a common reason that people who use drugs do not seek or maintain treatment (Bozinoff 2018). Providers are, in return, perturbed that their patients aren’t forthcoming, creating a cycle of distrust that passes from patient to provider and back again.
Just a few issues later, JAMA published an opinion piece titled “Why Physicians Should Trust in Patients” (Grob 2019). The article highlights the advantages of patients contributing to their own care plan, and shares evidence that trusting patients improves diagnostic accuracy, patient outcomes, and potentially prevents physician burnout. The authors also point out that trust and respect are particularly tenuous among vulnerable patient populations and suggest that presuming trust in each patient can mitigate some disparities in outcomes. That both Dr. Zuger’s commentary and this thoughtful piece on trust were published in the same journal in a matter of weeks accentuates the “othering” of patients with substance use disorder, who are assumed to be untrustworthy despite the evidence that trust promotes better patient outcomes.
Expecting an untruthful patient predisposes physicians to neglect patients’ needs. In the film Beautiful Boy, Nic is at times untruthful because he is an intelligent young adult and has enough foresight to protect himself from shame, and his father from heartache, by lying about his drug use. However, he also tells the truth in powerful ways, such as the moment where he apologizes to his dad and admits that he feels horrible about himself. I recently had the privilege of hearing Nic speak about his experiences along with his father, David Scheff, who authored the book Beautiful Boy is based on, at the American Society of Addiction Medicine Annual Conference. Scheff commented on the stigma that people who use drugs face: “We make someone who is addicted feel worse when they already feel badly about themselves and are already in pain.” This sentiment is magnified when stigma is encountered in healthcare with providers who are expected to be unbiased in their healing.
Addressing the stigma of substance use disorder will require a multipronged effort and structural changes, such as integration of SUD services into primary care settings (Beletsky 2018). Educating providers on how to treat SUD can improve physician preparedness and thus attitudes toward patients who use drugs, job satisfaction, and likelihood of prescribing lifechanging medications such as naloxone (Wakeman 2017). Although many progressive initiatives are being established and evaluated across the country, physicians have the power to make positive change immediately by trusting their patients. Presuming trust can lead to better health outcomes, decreased physician burnout, and a better physician-patient relationship for patients who often need it the most (Grob 2019).
- Zuger A. Addiction 101, in Technicolor. JAMA. 2019 Jan 22;321(3):228-229. doi:10.1001/jama.2018.19480.
- Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: Health services experiences among people who inject drugs. Int J Drug Policy. 2018 Jul;57:104-110. doi:10.1016/j.drugpo.2018.04.004.
- Bozinoff N, Anderson BJ, Bailey GL, Stein MD. Correlates of Stigma Severity Among Persons Seeking Opioid Detoxification. J Addict Med. 2018 Jan/Feb;12(1):19-23. doi: 10.1097/ADM.0000000000000355.
- Grob R, Darien G, Meyers D. Why Physicians Should Trust in Patients. JAMA. 2019 Mar 22. doi: 10.1001/jama.2019.1500. [Epub ahead of print]
- Beletsky L. Using Choice Architecture to Integrate Substance Use Services withPrimary Care: Commentary on Donohue et al. J Addict Med. 2018 Feb;12(1):1-3. doi:10.1097/ADM.0000000000000367.
- Wakeman SE, Pham-Kanter G, Donelan K. Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists. Subst Abus. 2016 Oct-Dec;37(4):635-641.