Moving beyond stigma in health care: Canada’s opioid crisis

For people with opioid use disorder, getting the care they need can be fraught with hidden challenges, especially when it comes to the stigma surrounding pain management and medication.

To bring awareness to this stigma, a team from Subject Matter Health Research Lab has produced a short, animated video entitled Beyond Stigma: Treating Pain in Opioid Use Disorder.

“Stigma is a major barrier to patients with opioid use disorder receiving access to high-quality care. It’s more than attitude, it’s entrenched in every aspect of how we provide care. It’s in the system – the programs, routines, setups,” says Dr. Abhimanyu Sud, one of the project leads, as well as an Assistant Professor at the University of Toronto’s Department of Family & Community Medicine (DFCM).

Dr. Sud is also a community-based physician with a focused practice in chronic pain management who was recently appointed the Humber River Hospital Research Chair in Primary Care & Population Health Systems.  

The video, funded by Health Canada, is part of a larger education program aiming to improve opioid disorder care and pain management in primary care settings. It’s meant for family physicians, nurse practitioners, pharmacists and other providers.

This is a timely initiative given the worsening opioid crisis in Canada, caused in part by COVID-19 and the strain it has placed on the health system. Reduced access to care, services and medication means many more overdoses. “The number of people with opioid use disorder who are dying has gone through the roof during COVID,” says Dr. Sud.

Those with opioid use disorder and other addictions often feel judged when discussing pain and the need for pain management with care providers.

“It may be assumed they will use their medication for recreational purposes, when they are in fact suffering and have significant, untreated pain,” explains Dr. Sud.

For the video, the team chose a broken arm – a visibly painful injury. But for those with internal injuries or less obvious causes of pain, these conversations can be even more difficult.

Due to the skepticism and confusion that people who use opioids face, a normal prescription medication may be delayed or denied altogether at various stages, by doctors, pharmacists, nurses and others. In the video, the stigma is physically represented by a dark cloud hovering around the main character, which everyone sees and reacts negatively to.

“If the health system makes it difficult for these patients to access prescribed drugs, they may turn to buying them on the street,” Dr. Sud says. Even though it’s risky and unregulated, patients who are turned away at doctor’s offices and pharmacies often don’t have any other choice.

To address this, opioid use disorder needs to be better understood by health providers, says Dr. Sud. “Knowing how to ask the right questions, such as how long they’ve been on methadone, recognizing that patients perceive pain differently and being prepared to have respectful conversations are all helpful.”

There should also be better synchronization between parts of the health system to ensure the patient receives compassionate, well-coordinated, quality care, he adds.

Dr. Kirsten Dixon, a DFCM graduate and a family physician with the Centre for Addiction and Mental Health (CAMH), has a shelter-based practice working with people experiencing mental illness, substance use disorders and homelessness. Dr. Dixon was the project lead who developed the script and worked with animator Lily Fang to create the visual representation of a patient’s experience of stigma.

“Our video is meant to be easy to understand and accessible by many groups. It sends the message: We need to be extremely careful when assessing patients’ pain and shouldn’t make snap judgements about whether it’s legitimate,” she says.

Dr. Dixon adds that it’s not just individuals, but also a bigger, system-wide problem. “We want to encourage better access to better education on these issues and help change the current environment,” she says.

The team hopes that the video will encourage care providers to be more aware of the system’s built-in stigma, and their own.

For Sean LeBlanc, a project consultant with lived experience of opioid use disorder, the video is a positive step. “At the end of the video, it shows what non-stigmatized care looks like. That’s what we all want.”

It means providing the same high quality of care regardless of the patient’s medical history and doing your best to maintain a neutral expression, tone of voice and body-language, LeBlanc says.

“No one deserves to be stigmatized by others. There’s enough self-stigmatization going on.”

LeBlanc says the video helps the drug using community feel more understood and connected to others. “We’ve been hit hard these last few years. People who use drugs have felt forgotten during COVID. Watching this video could save people’s lives.”

While opioid use disorder needs more attention in health research and policy, Dr. Sud hopes the program will help address some of the stigma felt by patients with opioid use disorder. 

“We have all the tools – but why aren’t we using them for opioid use disorder yet? Stigma is the answer. It’s time to start addressing this stigma so patients get the compassionate care they deserve.”

To watch the video, and to find out more information about the project and opioid use disorder, visit the Subject Matter website.