Hilary Drake is a medical student in the Class of 2021 at the University of British Columbia
On my first day in a new family practice, my preceptor asked me to take a history from a patient who had listed their “reason for visit” as a sore throat. I stood in the hallway and made a mental checklist of questions to ask and observations to make. Have they had any sick contacts? Does their voice sound hoarse?
When I opened the door and asked them if they could tell me what brought them in today, they responded as expected: “My throat is sore.” When I asked what they thought might be causing the pain, they unwrapped a scarf from their neck and stated, “I think it’s because the noose didn’t work.” At that point they started crying.
They had tried to come in before. They had recognized their pain and wanted to reach out for help, but they were unable to out of fear that their physician would not believe the pain if they could not see it.
That was the day that I learned how stigma can kill someone.
I have seen the effects of stigma over and over. As a medical student, I have heard the voices of patients who did not see a doctor in a timely manner because they were scared to be judged. I have seen a patient who previously struggled with a substance use disorder, but upon beginning treatment for Post-Traumatic Stress Disorder, was able to begin the process of achieving sustained abstinence. I can’t forget a patient who was coming in for a refill for their selective serotonin reuptake inhibitor whose parents had found out she took a pill for depression and were upset that she was not able to be happy on her own.
Many of my friends and family have mental health diagnoses. Like many of the patients I see, they also believe they are not worth the help physicians have failed to provide them. I have learned to listen to my friends as they describe sitting in an examination room or an emergency waiting room, their hearts pounding as a panic attack washes through their body, only to receive medical care several hours later. I have friends who have switched from one physician to another trying to find a doctor who believes that they have depression. I have seen a doctor tell someone I love that, in order to help them, they need to stop using a drug they had quit using years ago. Underneath these labels and diagnoses are my friends, my family, and people who I want to do better for.
A recent review of illicit drug overdoses in British Columbia examined the circumstances of over 1800 people who died of an illicit drug overdose between January 1st, 2016 and July 31st, 2017. The review panel found that most deaths occurred among people using drugs alone.
Building on these results, Interior Health in British Columbia launched Use Safe, an engagement campaign aimed at examining the needs of individuals who use illicit substances alone. During the campaign — which I participated in as a summer research student — we heard from people who use drugs alone as well as from their friends and families, many of whom had lost their loved ones to overdose, in addition to front-line service and medical providers. Engagement was done through one-on-one interviews, focus groups, and online surveys between February and May of 2018.
The Use Safe campaign confirmed what we already knew: that stigma and judgement are killing people. Individuals who use drugs alone struggle not only with externalized stigma, but also internalized stigma. They fear what might happen if they disclose their drug use because they may lose things they care deeply about (e.g., kids, jobs, partners, or housing). They hate themselves and the drug they use. The community voiced that more education is needed so people will stop believing that providing care to this population is done so at a cost to other health issues.
In a nutshell, shame and stigma are major contributors to why so many people use and die alone.
Underlying many individuals’ drug use are untreated health conditions. One participant noted, “Drugs are the outcome, but not the initiator.” For many, their underlying ailment is a mental health condition. Without adequate community supports for mental health, many people turn to drugs. Mental health impacts not only those that use alone; it stretches into their families and can lead to depression and even suicide over the pain of losing their loved one. First responders, front-line staff, and members of the medical community are not immune either. The stress of the opioid crisis is traumatizing to many, and there are not enough resources to support them — particularly in smaller towns in B.C.
I have also heard from patients whose lives were saved by physicians who treated them with compassion, respect, and empathy.
As a medical student, these skills can feel overemphasized at times. However, having had the opportunity to exercise them, I have learnt that these proficiencies truly make a difference.
We need more conversations. We need to change the way we address stigma. We need to make healthcare more accessible. We need to stop putting Band-Aids on broken brains, and instead strive to fix the underlying wiring and biochemistry. I still see patients with metaphorical nooses around their necks.
This needs to change. I want this to change. I believe it can, if we learn how to listen to patients and treat all patients without labels and judgement — but learning how to do this must become a priority.
Empathy, education, and exposure to people with mental health and substance use disorders are key tools we can utilize to make this change (1). These can make a difference in how we, as medical professionals, interact with individuals who use substances.
Think about how you can incorporate these into your life. Do you know someone who may have first-hand experience with perceived stigma from a health care professional? Listen to their story. Does your medical school’s curriculum include mental health and addiction? Advocate for them to be included. Are there any electives in addiction medicine you can take or physicians you can shadow? Go for it. Your actions now may change the actions of your patients and save their lives.
- van Boekel L, Brouwers E, van Weeghel J, Garretsen H. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug Alcohol Depend. 2013;131(1-2):23-35. doi:10.1016/j.drugalcdep.2013.02.018
Note: The patients depicted here are fictitious.
Bravo, Hilary. Your willingness to see with your heart, and to engage in real conversations with patients is such a breath of fresh air. You are still very much in the minority. I sincerely hope that your generation of new medical professionals will change the culture of otherness and detachment that seems to pervade the world of medicine in general and psychiatry in particular. It is a tough road you have chose to travel. Surround yourself with excellent mentors and like-minded peers. You will need that support system to live by your principles. Bon courage, Hilary.