At the conclusion of the activity, participants will be able to complete the following:
- Identify the breadth and scope of the opioid crisis in New Jersey.
- Recognize the impact of implicit or explicit bias in the management of patients with opioid use disorder (OUD).
- Discuss how the language we use stigmatizes patients with opioid use disorder (OUD).
- Identify one’s own implicit biases.
- Describe the steps to mitigate biases in management of opioid use disorder.
In order to obtain AMA PRA Category 1 Credit ™, participants are required to adhere to the following:
- Review the learning objectives at the beginning of the CME article. If these objectives match your individual learning needs, read the article carefully. The estimated time to complete the educational activity is one hour.
- After reflecting on the contents of the article, demonstrate your understanding by answering the post-test questions in the online form at www.surveymonkey.com/r/CMESummer2020. These questions have been designed to provide a useful link between the CME article and your everyday practice. The entire form must be completed, including the evaluation section. The post-test cannot be processed if any sections are incomplete. If you are unable to complete the online form, you may request a hard copy by contacting Alysiana Bagwell at 888-355-5551 or ABagwell@mdanj.com.
- If a passing score of 80% or more is achieved, a CME certificate awarding AMA PRA Category 1 Credit™ and the test answer key will be mailed to you within 4 weeks. Individuals who fail to attain a passing score will be notified and offered the opportunity to reread the article and submit a new post-test.
- All post-tests must be submitted between October 8, 2020, and October 1, 2021. Submissions received after September 1, 2021, will not be processed.
Authors: Sophia Chen, DO, MPH, Christin Traba, MD, MPH, Maria Soto-Greene, MD, MSHPE, & Sangeeta Lamba, MD, MSHPE, Rutgers New Jersey Medical School, Newark, NJ.
Article Content Last Updated: This content was updated as of July 18, 2020.
Accreditation Statement: HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. This enduring article has been planned and implemented in accordance with the accreditation requirements and policies of the Medical Society of New Jersey (MSNJ) and Health Research Education and Trust of New Jersey (HRET) in joint providership with MDAdvantage Insurance Company. HRET is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians.
AMA Credit Designation Statement: HRET designates this enduring activity for 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Disclosure: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, there are no relevant financial relationships to disclose. No commercial funding has been accepted for the activity. This article was peer-reviewed in accordance with the MDAdvisor Guidelines for Peer Review.
The Opioid Crisis in New Jersey
The opioid crisis has affected people of all ages and of every race and ethnicity across the nation, including newborns affected by neonatal abstinence syndrome (NAS), teenagers with increased access to synthetic opioids and elderly individuals with prescription opioid use disorder. The impact of opioid use disorder is far reaching and goes beyond the individual with the disorder. It also affects families, significant others and the healthcare system. Factors contributing to the burden of opioid use disorder include physicians prescribing opioids for non-cancer pain, diversion of prescription opioids and the recent emergence of synthetic opioids.1 The six-fold rise in the last decade in opioid-related deaths led to the U.S. Department of Health and Human Services to declare the opioid epidemic a public health emergency.2,3
To address this public health crisis, the White House proposed expansion of access to treatment and community prevention strategies, including naloxone distribution to prevent escalating opioid-related deaths. A fact sheet released by the Obama administration in 2015 informed the healthcare community that “there is a clear imperative to educate and train health professionals to be knowledgeable, empathetic, and engaged to meet the growing treatment needs of this patient population.”4
“In the State of New Jersey, there were approximately 2,000 opioid-related deaths in 2017, a rate of 22.0 deaths per 100,000 (5–6 deaths per day) compared to the national rate of 14.6 deaths per 100,000.”
In the State of New Jersey, there were approximately 2,000 opioid-related deaths in 2017, a rate of 22.0 deaths per 100,000 (5–6 deaths per day) compared to the national rate of 14.6 deaths per 100,000. Of these deaths, 69 percent (1,358) were identified as white non-Hispanic, 17 percent (338) black non-Hispanic and 12 percent (245) Hispanic.5 Although New Jersey providers write, on average, fewer opioid prescriptions per every 100 persons compared to the national rate (44.2 versus 58.7), the number of opioid-related overdose deaths continues to rise.
A recommended treatment approach for opioid use disorder includes the use of medication-assisted treatment (MAT) that combines counseling and behavioral therapies with the use of medications, such as buprenorphine. As of 2019, in New Jersey 183 facilities provide MAT. Every county has at least one facility able to provide MAT; the majority have three or more providers. However, although these facilities exist, the demand exceeds the services offered, and the vast majority of persons (87 percent in New Jersey) with opioid use disorder are not receiving MAT at this time.6 Challenges that may affect access to services include insurance reimbursement and transportation issues, as well as other social determinants of health. It is important for all healthcare providers to understand that in addition to these known challenges, stigmatization and implicit and explicit biases may also impact access to services for opioid use disorders.
Similar to the social stigma surrounding mental illness, there is a stigma attached to substance misuse disorders, including opioid use. This stigmatization often prevents a patient from seeking care. Many people view substance misuse disorder as a moral weakness; as a result, people facing these issues are often plagued with shame. They feel isolated and alone, and are less likely to seek treatment for fear of being labeled. These societal views may shape the values and beliefs of healthcare professionals, leading to patient stereotyping. To provide the best care for patients affected by opioid use disorder, healthcare professionals should be aware of their own implicit and explicit biases and seek ways to mitigate them.
Understanding Implicit Bias
Social psychologists first coined the term implicit bias in the 1900s; since then, variations of the definitions have been used. The Kirwan Institute and the American Association of Medical Colleges define implicit (unconscious) bias as “attitudes or stereotypes that are outside our awareness and affect our understanding, our interactions, and our decisions.”7
We all harbor implicit associations—both positive and negative—about other people based on characteristics such as race, ethnicity, gender, age, social class and appearance. Scientists have identified that our brain is set up to recognize patterns and create shortcuts to process the overwhelming load of sensory information so we can function effectively. A bias is one such shortcut to process external information. Implicit biases exist in all of us, even in those who are explicitly committed to being fair and impartial, such as doctors, teachers and judges. These implicit associations may be biased against one’s own identified group and may not necessarily align with an individual’s declared beliefs or what that person may explicitly endorse. For example, a female physician who strongly believes in advancement for women in science may also harbor an implicit bias that favors men in science. These associations may influence our feelings and attitudes and result in involuntary discriminatory practices, especially in demanding circumstances.7
“Implicit biases exist in all of us, even in those who are explicitly committed to being fair and impartial, such as doctors, teachers and judges.”
Most of the time, these brain shortcuts and associations increase efficiency, but they also make us prone to errors. Many studies have shown the impact of stereotyping on patient care resulting in negative healthcare outcomes. Examples include physicians not taking chest pain in a woman seriously or not offering the same treatment options for the same diagnosis in black patients versus white patients. Stereotyping leads to healthcare disparities, especially in marginalized and vulnerable groups, such as persons of color and those with disabilities, mental illness or substance use disorders. Implicit bias is often perpetuated by many factors, such as personal upbringing and experiences, societal norms, social surroundings and quite often, even the language we use to describe our patients.
The good news is that our brain can unlearn these associations through awareness and making the implicit more explicit. This can be accomplished by becoming self-aware and engaging in deliberate practice. The Implicit Association Test (IAT) offered through Project Implicit at Harvard is one tool that may uncover a person’s implicit attitudes and beliefs for topics such as race, gender, weight, disabilities, etc.8
The following sections discuss small but significant changes healthcare professionals can make through the proper choice of words and by engaging in deliberate practice that sets the tone of respect for all.
The language used to describe patients with addictions generally has an attached stigma that can perpetuate stereotypes. Examples of words that have negative connotations include junkie, alcoholic, abuser or addict. The word junkman was shortened to junkie and originated in the 1920s when people stole scrap metal or “junk” to help finance their substance use. These words automatically stigmatize the patient as a problem and prevent us from seeing the person behind the label. The National Alliance of Advocates for Buprenorphine Treatment asserts, “The labels make no distinction between the person and the disease. They imply a permanency to the condition leaving no room for change in status.”9
AVOID These Words
USE These Words Instead
|User, junkie, abuser, addict||Persons with substance use or substance-related disorder|
|Opioid abuse||Opioid use disorder|
|Clean, dirty (referring to drug test results)||Substance free, negative, positive|
|Habit, drug habit||Substance use disorder, alcohol and drug disease or disorder, addiction disorder|
|Replacement or substitution therapy||Medication-assisted treatment|
AVOID These Words
|User, junkie, abuser, addict|
|Clean, dirty (referring to drug test results)|
|Habit, drug habit|
|Replacement or substitution therapy|
USE These Words Instead
|Persons with substance use or substance-related disorder|
|Opioid use disorder|
|Substance free, negative, positive|
|Substance use disorder, alcohol and drug disease or disorder, addiction disorder|
In addition to spoken words, medical documentation can have an impact on how patients are perceived. Patients with many visits to primary care clinics and emergency departments are often described in the electronic medical record as “frequent flyers.” An airplane icon in various colors may identify a patient to indicate degree of utilization, which can have unintended consequences.10 Healthcare professionals may then automatically assume that this is a problem patient and dismiss their stated complaints. As a result of this implicit bias, different populations may receive different and often lower-quality medical care leading to higher morbidity and mortality from illnesses such as cardiovascular disease.11 Using proper terms, such as opioid use disorder as opposed to opioid abuser, establishes a culture of respect.
Moving from Self-awareness to Explicit Interventions
Recognizing implicit bias in yourself, as well as in others, is essential for providing optimal patient care. It is critical to acknowledge opioid use disorder as a disease like any other chronic illness with physical components, such as diabetes. This helps to shift the focus from the behavior of a person to the disease. However, this is only the first step to move us from awareness to action. Programs such as CHARGE2 and INTERRUPT, described in this article, can help healthcare professionals mitigate bias.12
CHARGE2 allows one not only to assess personal bias but also to model behaviors that set the tone and expectations for others as well.12
- C – Change your context: Is another perspective possible?
- Be open minded about the patient’s story; listen actively with curiosity instead of judgment.
- H – Be Honest with yourself: Acknowledge and be aware
- Don’t make or be afraid to correct assumptions (say, “oops”).
- A – Avoid blaming yourself: Know that you can do something about it
- R – Realize when you need to slow down
- We use shortcuts when we are pressed for time; sometimes, allowing that moment to slow down may help reframe our perspective.
- G – Get to know people you perceive as different from you
- E – Engage: Remember why you are doing this
- Believe in the philosophy that people can and do recover. Don’t give up recognizing that each person has a right to fail.
- E – Empower patients (and peers)
- Set meaningful short-term goals with the patient. Step up to intervene if you witness bias.
INTERRUPT provides “a toolkit of options to address microaggressions and biases when witnessed or experienced.”12,13 This allows physicians to feel empowered to intervene when they witness bias toward patients. The toolkit encourages physicians to be curious and nonjudgmental with their colleagues to allow for a respectful dialogue.
- I – Inquire: Leverage curiosity
- “I am curious. What makes you think that …”
- N – Non-threatening: Respectful tone, focus on the person
- “It would be helpful for me to understand if you told me why….”
- T – Take responsibility: Apologize, acknowledge
- “Oops, I am sorry – I meant to say …. not opioid addict.”
- E – Empower: Ask questions that will make a difference
- “What could we do differently to help?”
- RR – Redirect and Reframe
- “Let’s shift…”
- “What would happen if we shift the focus?” (i.e., connect her to a buprenorphine clinic?)
- U – Use impact questions
- “What if we considered the impact this has on … (i.e., our society, our learners, the family, us etc.)”
- P – Paraphrase
- “It sounds like you think that … (i.e., the patient can fix this issue without help).”
- T – Teach by using “I” phrases
- “I felt X… (e., uncomfortable, worried, bothered) when Y happened, and it impacted me because… (i.e., I think…, I feel…we should respect, …not judge… etc.).”
Addressing the opioid epidemic requires a multi-faceted approach that goes beyond educating healthcare providers and creating treatment approaches or plans for patients. It is essential to recognize that our biases, both explicit and implicit, against patients with opioid use disorders may prevent us from providing optimal care. Taking steps to mitigate these implicit biases through deliberative practice is at the core of improving healthcare outcomes and reducing mortality in the increasing number of individuals affected by the opioid crisis.