Stigma inhibits action
Beth Macy's book Raising Lazarus covers the past three years of evolution in the substance use crisis, including the expanded rate of overdoses particularly in rural areas, the profound impacts of the pandemic and grassroots achievements in new treatment approaches, including harm reduction. It starts where her best-seller Dopesick (since adapted by Netflix) leaves off. While it focuses on the opioid crisis, and I feel confident in extrapolating many of the ideas to policy in alcoholism treatment as well.
Digesting her book has given me insight into Pete's situation, and how I failed to help.
I am a product of early 80's addiction treatment policy. I learned a mindset early, while I was a 15-year-old bystander to my mother's recovery, learning from clinicians during "family week", and those lessons were enhanced by co-dependency readings for the rest of the decade. Fear, stigma and a "there's nothing I can do to help" hopelessness built on the emotional pain and hurt of my experience to create the basis of my mindset. I am of the time, but it is time for change; in fact, it is well past time for change.
Macy, among others, writes that blaming or overpunishing addicts distracts from the very-real addictiveness of the alcohol or drugs. It fails to acknowledge our medical culture's vigorous marketing and overprescribing of gateway drugs and resulting drug company profits (p. 72), or the pervasive, subversive marketing and profits of alcohol conglomerates. The power of these substances, in particular after long-duration use, goes unrecognized. Our broken health care system often can't treat substance use disorder with the medicines proven effective, due to legal or policy barriers, or it doesn't want to. It often fails to sufficiently acknowledge the complicating role untreated mental health conditions play in substance use disorder, or untreated physical ailments and pain. Another key component related to that- the unavailability of mental health services. U.S. history highlights the Reagan Administration's gutting of services through changes to the Community and Mental Health Act, from which we are still trying to recover; the gutting led to more people on the streets seeking and finding self-medication (p. 85) without other avenues of aid. Practicalities also weigh in, like paying for health care. The U.S. health care system costs twice as much as other rich countries with fewer deaths of depair(p.70, Case and Deaton, 2021).
Demonstrating stigma within the medical establishment, a study published in the New England Journal of Medicine surveyed doctors to find 2/3 of respondents believe addicted people are "dangerous". That can't be good for the addicted individual's health care. I understand that fear, though, because I'd long been afraid of my brother. Afraid of his outbursts, his interest in guns, his suicidal expressions, his neediness and sometimes disordered thinking. I, too, had trouble seeing those symptoms as cries for help, instead felt threatened. It was a natural initial response, one I can now see beyond. We all need to get past the fear. Education is key to evolving to next-generation thinking.
Stigma exacerbates substance use by encouraging substance users to hide from the world in shame; it, in turn, fuels their drive for relief from substances.
"Drug-addicted people often react to stigma by excluding themselves from public life...drugs feel good when the actual world doesn't." (pp. 3-4)
Pete had been slowly, progressively isolating himself from family and friends for over a decade. The isolation makes things worse, as the individual's struggles go unseen while they suffer loneliness and emotional pain, pain often self-treated with substances.
Pete's situation at the end of his life stacked the deck against even an attempt at a recovery. There were so many cards in that deck:
Having worked at lower-wage hourly work for several years, he'd been unemployed for the better part of two years and had exhausted options for employment, having recently been fired from a new, under-$10-per-hour job. He had been suffering from an untreated, painful, dangerous health condition for months, one that was affecting his work and exacerbated by it. Prior to taking this job, he'd been going through a lengthy process to apply for Medicaid, submitting paperwork repeatedly to justify basic access to badly needed healthcare for someone without an income - without success. No doubt he was feeling depressed and frustrated, even hopeless, evident in his Facebook posts that by this point regularly frightened his friends and family.
Five years prior he'd had access to some weeks of outpatient recovery and mental health services resulting from DUI convictions, but nowhere near enough. He'd been told at one time that there was no sense continuing mental health treatment unless the drinking stopped, contrary to harm reduction strategy that would have kept him in the system as long as possible to build trust and statistically enhance outcomes. Pete had spent a few years in unstable housing situations, and carried many bad memories and feelings from that time. He was male and within the age range of most Minnesota deaths by alcohol, both risk factors. He suffered trauma in his childhood and likely had untreated mental health conditions that he was self-medicating as a basis of his compulsive alcohol use. And, he was under the influence of a lot of vodka, with years worth of affect in addition to the fresh doses on a given day, so it is likely he wasn't thinking clearly or logically. This is the common situation, that multiple factors build upon each other to create a specific, difficult-to-solve situation; it is easy to see that an individual's chances against such a stacked deck would be small, and greatly, greatly enhanced with outside help.
I see in each one of Pete's deck of cards a layer of stigma that gave his employers, social services representatives, his loved ones, and himself hesitation in taking action. Stigma prevents change and investment in solutions and promote hopelessness. There is still a tide of political and social will against people suffering substance use disorder, against seeing them worthy of investment. If addicted people "do this to themselves" and are "lacking willpower", then it absolves our culture and our institutions - US! - from helping them. In order to change mindsets and then policy, people - family members, substance users, doctors and medical staff included - have to believe that substance use disorder requires medical treatment like any disease and is treatable, sticking to that belief even after the repeated heartbreaks it causes those trying to help. The hope is in the recent grassroots programs of recent years with proven effectiveness, based in respect and comprehensive, wrap-around medical social services. My next post will dip into those programs, as reported by Mx. Macy.
