Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review

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Abstract

Background

Healthcare professionals are crucial in the identification and accessibility to treatment for people with substance use disorders. Our objective was to assess health professionals’ attitudes towards patients with substance use disorders and examine the consequences of these attitudes on healthcare delivery for these patients in Western countries.

Methods

Pubmed, PsycINFO and Embase were systematically searched for articles published between 2000 and 2011. Studies evaluating health professionals’ attitudes towards patients with substance use disorders and consequences of negative attitudes were included. An inclusion criterion was that studies addressed alcohol or illicit drug abuse. Reviews, commentaries and letters were excluded, as were studies originating from non-Western countries.

Results

The search process yielded 1562 citations. After selection and quality assessment, 28 studies were included. Health professionals generally had a negative attitude towards patients with substance use disorders. They perceived violence, manipulation, and poor motivation as impeding factors in the healthcare delivery for these patients. Health professionals also lacked adequate education, training and support structures in working with this patient group. Negative attitudes of health professionals diminished patients’ feelings of empowerment and subsequent treatment outcomes. Health professionals are less involved and have a more task-oriented approach in the delivery of healthcare, resulting in less personal engagement and diminished empathy.

Conclusions

This review indicates that negative attitudes of health professionals towards patients with substance use disorders are common and contribute to suboptimal health care for these patients. However, few studies have evaluated the consequences of health professionals’ negative attitudes towards patients with substance use disorders.

Introduction

Although alcohol use is socially accepted in Western societies, substance use is a major public health problem. In Europe, 11.8% of all deaths in the age group 15–64 years are attributed to alcohol-related causes (World Health Organization, 2012) and, worldwide, 4% of the causes of death are attributable to alcohol and illicit drug use (World Health Organization, 2009). Furthermore, alcohol and illicit drug use accounts for 5.4% of the global burden of disease (World Health Organization, 2010). Substance use problems are also a risk factor for other societal problems, such as absenteeism at work, accidents, and loss of productivity (World Health Organization, 2003, World Health Organization, 2011). Although treatment enhances the likelihood to recover (Dawson et al., 2006), only 24.1% of people with lifetime alcohol dependence ever seek treatment (Hasin et al., 2007). Additionally, only 14.7% of people with a substance dependence received professional help in the past year (Grella et al., 2009). Patients do not often disclose or admit having a substance use problem (Substance Abuse and Mental Health Services Administration, 2011). Since the majority of patients with substance use problems seek treatment in the first place for other problems (such as headaches), health professionals play a crucial role in the identification of these problems and the accessibility to treatment (Mersy, 2003, Muhrer, 2010).

Stigmatizing attitudes of health professionals towards people with substance use problems may negatively affect healthcare delivery and could result in treatment avoidance or interruption during relapse (Ball et al., 2006, Eaton, 2004, Neale et al., 2008). Previous studies demonstrate the negative effects of stigma experiences among people in treatment for substance use disorders on recovery and feelings of self-efficacy (Luoma et al., 2007, Schomerus et al., 2011). Negative attitudes of health professionals towards patients with an alcohol or other drug addiction are known to lead to poor communication between professional and patient, diminished therapeutic alliance, and misattribution of physical illness symptoms to substance use problems, also referred to as diagnostic overshadowing (Palmer et al., 2009, Thornicroft et al., 2007). As known from stigma research in general, factors that could mitigate stigmatizing attitudes are attribution beliefs and knowledge of and experience with a stigmatized condition (Corrigan et al., 2003, Corrigan et al., 2001b, Penn et al., 1994, Weiner et al., 1988). These factors may influence health professionals’ attitudes towards patients with substance use disorders. Thus, overall the attitudes of health professionals have the potential to influence the diagnosis, treatment, and rehabilitation of substance use disorders.

Attitudes of health professionals towards patients with substance use disorders have been investigated among different disciplines and settings (Au, 2006, Moodley-Kunnie, 1988). A literature review of nurse's attitudes towards substance misusing patients revealed greater acceptance of these patients although a minority of nurses still regard these patients as immoral and unlikely to recover (Howard and Chung, 2000). However, no overview of recent evidence and findings is available about studies investigating attitudes of different health professionals towards patients with substance use disorders. Therefore, the primary aim of this systematic review is to assess health professionals’ attitudes towards patients with substance use problems in Western countries. Secondary aims are to describe which factors cause negative attitudes of health professionals towards these patients, and examine the impact of these negative attitudes on healthcare delivery.

Section snippets

Search strategy

The databases of Pubmed, Psycinfo, and Embase were systematically searched for articles published in English or Dutch between January 2000 and November 2011. These three databases were selected to cover biomedical literature from Pubmed as well as psychological literature from Psycinfo. Embase was chosen to broaden the search results to European journals since Pubmed mainly includes American journals. The particular time span was chosen since the aim was to assess recent evidence and findings

Search results

The search process yielded 1562 potentially relevant citations. After the first selection phase, 420 citations were included. Abstracts of these remaining citations were judged by two independent reviewers of which 55 citations proceeded to the next phase. In this phase, full texts of the remaining citations were examined leading to the final inclusion of 28 studies which met the inclusion criteria. Because all these studies fulfilled the quality criteria as defined by the quality indicators of

Discussion

We present an overview of recent evidence regarding attitudes of health professionals towards patients with substance use disorders. Most evidence indicated that health professionals generally have lowered regard, less motivation and feelings of dissatisfaction when working with this patient group (Ford et al., 2008, Gilchrist et al., 2011, McLaughlin et al., 2006, Rao et al., 2009). This was sometimes explained by the perception of health professionals that these patients are potentially

Role of funding source

Nothing declared.

Contributors

L. van Boekel performed the searches, selected the papers, extracted data, and constructed the tables. E. Brouwers, J. van Weeghel and H. Garretsen selected the papers and extracted data. All authors interpreted the findings L.C. van Boekel and were involved in the production and revisions of the manuscript.

Conflict of interest

No conflict declared.

Acknowledgements

None.

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