Experiences of stigma in hospitals with addiction consultation services: A qualitative analysis of patients’ and hospital-based providers’ perspectives

Abstract

Background

Addiction consultation services (ACS) provide evidence-based treatment to hospitalized patients with substance use disorders (SUD). Expansion of hospital-based addiction care may help to counteract the stigma that patients with SUD experience within the health care system. Stigma is among the most impactful barriers to seeking care and adhering to medical advice among people with SUD. We aimed to understand how the presence of an ACS affected patients’ and hospital-based providers’ experiences with stigma in the hospital setting.

Methods

We conducted a qualitative study utilizing focus groups and key informant interviews with hospital-based providers (hospitalists and hospital-based nurses, social workers, pharmacists). We also conducted key informant interviews with patients who received care from an ACS during their hospitalization. An interprofessional team coded and analyzed transcripts using a thematic analysis approach to identify emergent themes.

Results

Sixty-two hospital-based providers participated in six focus groups or eight interviews. Twenty patients participated in interviews. Four themes emerged relating to the experiences of stigma reported by hospital-based providers and hospitalized patients with SUD: (1) past experiences in the health care system propagate a cycle of stigmatization between hospital-based providers and patients; (2) documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among hospital-based providers resulting in anticipated stigma among patients; (3) the presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative; (4) ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among patients with SUD.

Conclusions

An ACS can facilitate destigmatization of hospitalized patients with SUD by incorporating evidence-based SUD treatment into routine hospital care, by providing and modeling compassionate care, and by reframing addiction as a chronic condition to be treated alongside other medical conditions. Future reductions of stigma in hospital settings may result from promoting greater use of evidence-based treatment for SUD and expanded education for health care providers on the use of non-stigmatizing language and medical terminology when documenting SUD in the medical chart.

1. Introduction

People with substance use disorders (SUD) have high rates of comorbidities that require frequent medical care and hospitalization (Gryczynski et al., 2016; Schranz et al., 2019; Walker & Druss, 2017). Social stigma toward people with SUD is pervasive within health care and is a barrier to treatment engagement (Carusone et al., 2019; van Boekel et al., 2013). Patients and health care providers report experiencing, or bearing witness to, stigma when receiving or delivering health care services, which reduces the likelihood that people will seek SUD treatment (Hall et al., 2021; Wakeman & Rich, 2018). In health care settings, interactions between patients and providers are affected by many types of stigma, including public, enacted, perceived, anticipated, and internalized stigma (Earnshaw & Quinn, 2012; Paquette et al., 2018).

Public stigma is represented by negative beliefs and stereotypes associated with a subset of the population (Corrigan et al., 2011). Previous research demonstrates that the public views people with SUD as being more dangerous and worthy of blame than people with mental illness (Angermeyer & Dietrich, 2006; Corrigan et al., 2009). Public stigma contributes to enacted stigma, the discrimination or mistreatment of people in a stigmatized group as a direct result of their association with that group (Luoma et al., 2007; Paquette et al., 2018). For members of a stigmatized group, perceived stigma is the subjective interpretation of stigma in their interactions with institutions or other individuals (Livingston & Boyd, 2010). Often, repeated experiences of discrimination and perceived stigma result in anticipated stigma, the expectation of future negative treatment, and internalized stigma, the belief that one possesses negative traits due to their membership in a stigmatized group (Earnshaw & Quinn, 2012). Internalized stigma contributes to increased perceived stigma, low self-esteem and self-efficacy, reduced health care utilization, and lower quality of life (Earnshaw & Quinn, 2012; Livingston & Boyd, 2010). In health care settings, interventions aimed at addressing the negative impact of stigma on patients with SUD should address both the transmission of stigma between health care providers and patients and patients’ internalization of previous stigmatizing health care experiences.

To reduce the impact of enacted and internalized stigma on the health care experience and overall health of people with SUD, providers should address the root contributors to stigma. The Health Stigma and Discrimination Framework suggests that many perceived contributors to health-related stigmas exist, including fear, lack of awareness, social judgment, blame, stereotypes, and prejudice (Stangl et al., 2019). For patients with SUD, these perceptions manifest as the conceptualization of addiction as a choice, the isolation of addiction treatment from routine medical care, the use of negative language to describe substance use or a person with an SUD, and the punitive nature of institutions’ policies for people with SUD (Olsen & Sharfstein, 2014; Wakeman & Rich, 2018). Previous research demonstrates that hospitalized patients with SUD often leave the hospital prior to treatment completion, delay seeking necessary care, and perceive that they are being punished for substance use through inadequate treatment of withdrawal or pain symptoms (Carusone et al., 2019; McNeil et al., 2014). Recent studies suggest that the presence of dedicated, hospital-based addiction-trained providers may reduce stigma experienced by hospitalized adults with SUD, because the services address and reduce some contributors to SUD stigma (Bearnot et al., 2019; Livingston et al., 2012).

Addiction consultation services (ACS) are interdisciplinary, hospital-based consultation services that provide hospitalized patients with addiction treatment concurrent with other medical care and facilitate linkage to community-based addiction treatment following hospital discharge (Englander et al., 2018). Two qualitative studies that evaluated the impact of an ACS found that the ACS reframed their hospital staff’s understanding of SUD and improved their satisfaction with caring for patients with SUD (Callister et al., 2021; Englander et al., 2018). The primary responsibility of an ACS is the medical management of SUD with an emphasis on clinical education and culture change in hospitals to reduce the stigma experienced by people who use drugs (Priest & McCarty, 2019).

In this study, we aimed to extend the literature by qualitatively exploring how the presence of an ACS influenced hospital-based providers’ perceptions of caring for hospitalized adults with SUD. We sought to understand how patients with SUD experience, anticipate, or internalize stigma in hospitals that employ a weekday ACS. We integrated these perspectives to explore how interprofessional and patient-provider interactions transmit stigma and how these interactions are experienced by individuals working or receiving care in hospitals with an ACS.

2. Methods

2.1. Study design

We conducted a qualitative study based on a thematic analysis using focus groups and key informant interviews (Braun & Clarke, 2012; Gilchrist, 1992; Krueger, 2014; Marshall & Rossman, 2014). Participants included hospitalists and hospital-based nurses, social workers, and pharmacists, henceforth described as hospital-based providers. We also included people who received care from an ACS during their hospitalization. The Colorado Multiple Institutional Review Board approved the study (Protocol # 19-0336). Study staff obtained informed consent from all study participants.

2.2. Setting, participants, and recruitment

We recruited hospital-based providers working in a safety-net hospital or a university hospital in metropolitan Denver, Colorado. Both hospitals employ a weekday ACS. We used a purposeful sampling strategy to recruit hospital-based providers who routinely care for hospitalized adults with SUD. Division leaders and hospital administrators invited study participation via email solicitation. Recruitment flyers were also placed in work areas to increase awareness and interest. Patients who received SUD treatment from the ACS during hospitalization were eligible for study participation. We contacted patients following hospital discharge or during a subsequent rehospitalization. All patient participants were English-speaking and between the ages of 25 and 65 years old. We excluded patients who were too medically ill to participate.

2.3. Data collection

2.3.1. Focus groups with hospital-based providers

We conducted focus groups with hospital-based providers to understand barriers and facilitators of providing treatment to hospitalized patients with SUD. We organized focus groups into three professional groups to facilitate dynamic conversation: hospitalists, pharmacists, and nurses with social workers. We combined nurses and social workers to ensure adequate participant numbers necessary to create a group dynamic during busy nurse clinical shifts. We anticipated that professional groupings would allow for a rich understanding of the “the attitudes, behaviors, opinions, or perceptions of the participants on the topic of discussion” as it related to their professional experience (Hennink, 2007; Liamputtong, 2011).

We developed and iteratively refined a focus group guide specific to each professional group. Guide development was informed by two theoretical frameworks: the Knowledge, Attitudes, and Practices Framework, which is used to identify barriers to physician adherence to practice guidelines; and the Donabedian Framework for the Evaluation of the Quality of Care, which is used to identify structures, processes, and outcomes of care provided by health care organization (Cabana et al., 1999; Donabedian, 1966). Guide development was also informed by a literature review exploring hospital-based providers clinical practice when caring for patients with opioid use disorder (OUD), and their perceptions of caring for this patient population (Calcaterra et al., 2020; Callister et al., 2021; Wakeman et al., 2017; Wakeman et al., 2016). Focus group guides included questions about the hospital-based provider’s comfort and knowledge, and their attitudes and beliefs about caring for patients with SUD. We inquired about their perception of job-specific roles and responsibilities when caring for people with SUD, and their perception of institutional support to provide optimal resources or training to care for patients with SUD.

An experienced qualitative researcher (SL) moderated the focus groups, while KH served as co-moderator for all focus groups. Neither had a prior relationship with participants. SLC, CC, and JH assisted in co-moderating at least one focus group. SLC and CC provide clinical care on the ACS but were not present for focus groups with providers at their institution. The study held sessions in a hospital conference room and lasted approximately one hour, with lunch provided as compensation for participation. We anticipated that some nurses would have scheduling conflicts for focus group participation due to busy clinical duties. In this case, we invited nurses to participate in key informant interviews conducted over the telephone outside of clinical shifts. The study provided gift cards as compensation. SLC and SL conducted nurse interviews, which lasted approximately 45 minutes.

2.3.2. Key informant interviews with patients

We used a semi-structured approach to conduct key informant interviews with patients who received care from the ACS during hospitalization (Galletta, 2013; Marshall & Rossman, 2014). The interview guide aimed to elicit information regarding the patient’s perception of their hospitalization and their experiences with the primary team and the ACS, the discharge process, and treatment linkage following discharge. The guide was informed by a literature review regarding patients’ perspectives of addiction treatment (Finlay et al., 2020; Rawson et al., 2019; Snow et al., 2019; Velez et al., 2017). We iteratively refined the interview guide as subsequent interviews revealed new topics of interest. SLC and CC conducted patient interviews but they were not involved in the patient’s care at the time of the interview. Study staff informed patients that their participation would be confidential and would not affect their medical care. Study staff conducted interviews over the telephone or in-person in the participant’s hospital room and they lasted approximately 45 minutes. All participants received a gift card for compensation. The study used a purposeful recruitment strategy and concluded after reaching data saturation in which no novel concepts were introduced by participants (Marshall, 1996; O’Reilly & Parker, 2012).

De-identified audio recordings were transcribed and study staff transferred them to ATLAS.ti (Version 8; Scientific Software Development GmH, Berlin, Germany) for data management.

2.4. Data analysis

We used an iterative team-based process guided by a thematic analysis, using a mixed deductive and inductive approach to examine, discuss, and interpret transcripts (Braun & Clarke, 2012; Fereday & Muir-Cochrane, 2006). The study first used a deductive approach to identify predetermined codes based on literature, prior knowledge, theoretical models, and the interview guides. As transcripts were coded, the team employed an inductive approach to identify unanticipated concepts that emerged from the data and were relevant to the research question (Fereday & Muir-Cochrane, 2006). SLC, SL, CC, and KH conducted the coding. The team initially independently coded three focus group transcripts. They then met to review and reconcile any discrepancies, while ensuring codes were precisely defined and consistently applied. We repeated this process for patient transcripts. At least two team members coded each transcript. Throughout coding and analysis, the team met frequently to discuss and refine codes, and preliminary and final themes until we reached a consensus.

3. Results

3.1. Participants’ characteristics

From November 2019 to February 2020, we conducted six focus groups and eight interviews with 62 hospital-based providers, including 20 hospitalists, 18 pharmacists, 13 nurses, and 11 social workers (Table 1). From February 2020 to December 2020, we conducted 20 patient interviews. All patients reported previous or active opioid use, with some patients reporting use of alcohol (n = 2) or methamphetamines (n = 11) with opioid use (Table 1). Four themes emerged relating to the experiences of stigma reported by hospital-based providers and patients with SUD who received care from an ACS (Table 2). Two emergent themes describe the experiences of stigma that persist despite the presence of an ACS: (1) past experiences and interactions in the health care system propagate a cycle of stigmatization between hospital-based providers and patients and (2) documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among providers, resulting in anticipated stigma among patients. Two additional themes characterize the role of the ACS in addressing some aspects of SUD stigma: (3) the presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative and (4) ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among hospitalized patients with SUD.

Table 1:

Participant Characteristics, n (%)

Healthcare Provider Participants (n=62)*
Gender
Female	46 (75)
Male	16 (25)
Professional role
Hospitalist	20 (32)
Pharmacist	18 (29)
Nurse	13 (21)
Social Worker	11 (18)
Years working in current role
≤ 5	20 (33)
6 – 10	17 (28)
11 – 15	16 (26)
≥ 15	8 (13)
Patient Participants (n=20)
Gender
Female	7 (35)
Male	13 (65)
Race/ethnicity
White, non-Hispanic	15 (75)
Hispanic	5 (25)
Reported substance(s) used**
Opioids alone	7 (35)
Opioids and methamphetamines	11 (55)
Opioids and alcohol	2 (10)

^*n=63 participants, one participant did not complete a survey

^**Based on self-report. Cannabis not included because it is legal for use among people 18 years or older in Colorado; no reported regular use of cocaine or benzodiazepines.

Table 2:

Emergent Themes and Additional Representative Quotations

Theme	Respondent	Quotation
Past healthcare experiences propagate a cycle of stigmatization	Nurse Interview #7	I had a woman who was in the hospital six weeks for receiving IV antibiotics for endocarditis. She made me feel unsafe. She brought visitors in who would bring paraphernalia in to her. We would catch her with it.
	Patient Interview #20	When they [doctors] came in and looked at my arm, they weren’t concerned about if it hurt whenever they yank the packing out. They’re not the ones shootin’ heroin, so they’re not the ones that put myself in this position. They’re treating me like an addict.
Documentation in medical charts perpetuates stigma	Nurse/Social Worker Focus Group 2	I've had some experiences where you look at the chart at delivery, and it's clear that they've had substance use history, it's on their problem list, but I can't find documentation of a UA…I feel like the OB team really shies away from getting any kind of evidence because they're afraid of having an intense conversation because they're afraid they're gonna lose the rapport and the patient's not gonna get care, and we're gonna lose them completely. They'd rather see them for OB care than not see them at all.
	Patient Interview #2	…Before, I felt really ashamed taking [suboxone or buprenorphine] and stuff like that ‘cause, usually—I don’t know. People always assume that you’re a heroin addict, so people always make me ashamed to take it.
The ACS reduce stigma by expanding the use of evidenced-based treatment and reframing SUD narrative	Pharmacist Focus Group 2	We still should be seeing a lot of [patients with SUD] in other systems [that don’t employ ACS], but I don't really feel the same drive. Lifting the stigma, really encouraging patients need to be treated appropriately, getting them into therapy. I didn't feel like it was the same level of attention given to it [as at hospital with ACS].
	Physician Focus Group 1	I think what made me feel most comfortable was—not so much the X-waiver and online training but—I think shadowing [addiction trained physician] on the wards and seeing how [addiction trained physician] talks to these patients, and how [addiction trained physician] approaches them and initiates the medications, I think got me a lot more comfortable.
The ACS combats stigma by promoting self-worth, self-efficacy, and mutual respect	Patient Interview #8	[ACS was] definitely not judgmental and very helpful. They made me feel very secure and better about the whole situation.
	Patient Interview #3	They [the ACS] were patient with me and…made me feel like I had a voice instead of forcing me to do something that I didn't want to. They respected my decisions and talked to me about my consequences and respected me when I said ‘no’. I loved that. They were just all so nice.

3.2. Emergent themes

3.2.1. Past experiences and interactions in the health care system propagate a cycle of stigmatization between hospital-based providers and patients.

Both hospital-based providers and patients with SUD perceived a mutual mistrust that propagated negative stereotypes. Hospital-based providers described distressing patient interactions that influenced how they cared for, and interacted with, hospitalized patients with SUD. These negative experiences likely contributed to enacted stigma in subsequent patient interactions. One nurse recalled her experience with a patient who overdosed in the hospital:

I discovered my patient was using heroin in the hospital. I was pretty naive. In hindsight I feel like I should have realized, he [patient] had frequent visitors and we weren’t searching them. There were plenty of reasons to suspect contraband. That leaves me with a bad taste in my mouth.

Nurse Interview #1

Another nurse described her experience caring for patients in opioid withdrawal: “We are like their punching board. We’re with them all of the time, so the aggression comes out on us.” Patients recalled previous negative health care experiences that shaped their current hospital experience. Negative experiences ranged from having misunderstandings with medical staff to being physically restrained. One frequently hospitalized patient described feeling deceived by her medical team who prescribed opioids in the hospital for acute pain. When she realized she was physically dependent on opioids and was experiencing opioid withdrawal, she felt betrayed:

Why would they [physicians] give me something that I was gonna get addicted to and take it away cold turkey? Then they look at me funny and tell me horrible things [about myself]? I don't understand why people do that [patient crying].

Patient Interview #3

Past negative health care experiences influenced how patients perceived the intentions and actions of hospital-based providers during their hospitalization. One patient initially believed her doctors dismissed her reports of intolerable pain because she used heroin. Later, she realized she was critically ill and her doctors saved her life. She said, “I felt like they were jerks to me because I was a heroin addict, but it really was that they didn’t know what was wrong with me.”

3.2.2. Documentation in medical charts unintentionally or intentionally perpetuates enacted stigma among providers, resulting in anticipated stigma among patients.

Hospital-based providers cited instances in which they read information in the patient’s medical chart that labeled patients as “drug users” who were “likely to have behavioral issues”. These negative descriptions influenced how they approached patients, even before meeting them in person. One nurse described her initial thoughts when reviewing the medical chart of a patient with documented OUD:

Immediate things I worry about, is this patient going to request their narcotic more often? Is this patient going to provide an unrealistic report of pain to us? Is this patient going to get something on the side from friend or family delivered here? Is this patient going to have a behavioral issue?

Nurse Interview #2

Reported examples of medical chart documentation that perpetuated enacted stigma included physician or nursing notes describing an “against medical advice” discharge or a methadone o buprenorphine prescription:

I do feel like it's a thing in the hospital where [nurses] are judgmental. When they see methadone or Suboxone (in medication list), there are certain nurses who are just like, “I don’t want to deal with that patient.”

Nurse and Social Worker Focus Group #1

Patients, from their perspective, were sensitive to being misrepresented in the medical chart. Inaccurate documentation about the quantity of substance used or the reason for substance use were highlighted by patients as a source of frustration, which they felt impacted their medical treatment. One patient described his reaction when he reviewed his medical chart:

One thing that teed me is they wrote down that I said I was drinking a lot more than I was. They said three pints a day, and I said two half-pints a day. That’s a big difference. I saw it [in] my notes online, on the app.

Patient Interview #2

Another patient described being labeled as an “addict” when she was prescribed buprenorphine for chronic pain. The label made her feel “ashamed” and she stopped taking the medication to avoid repeating the negative interactions she had when seeking help in the emergency department and hospital for uncontrolled pain:

It [label in chart] made me not wanna be on pain medicine and made me feel like maybe I was addicted and I didn’t know, that it wasn’t just that my body was dependent, maybe that I was addicted and trying to get pain medicine. They [the doctors] made me just feel really awful about myself.

Patient Interview #15

Some hospital-based providers were aware that documentation propagating stigma was prevalent in the medical record and could affect a patient’s health care interactions. One nurse shared her interaction with a patient who was prescribed naloxone at hospital discharge:

I had a young patient who saw that she had been prescribed Narcan at home. She said, “do you think that I’m an addict?” Just that this was some sort of accusation… There is so much stigma around addiction and I think that even something like a naloxone prescription can be thought of as an accusation.

Nurse and Social Worker Focus Group #2

One hospitalist described her awareness about how the use of stigmatizing language in the medical record could impact patient care:

Having more knowledge makes me realize how much stigma there is in our healthcare system. Seeing other consultants write notes about your patient and make decisions based on their substance use disorder, you’re like, “That’s actually pretty judgmental.

Hospitalist Focus Group #1

3.2.3. The presence of an ACS reduces enacted stigma among hospital-based providers through expanding the use of evidenced-based SUD treatment and reframing the SUD narrative

With the expansion of the ACS, and greater use of methadone and buprenorphine, hospital-based providers learned about different approaches to care for hospitalized patients experiencing opioid withdrawal. This expansion challenged existing stigma around these medications. A pharmacist described this initial discomfort, stating, “when we started inducing people on buprenorphine, pharmacists were petrified to verify buprenorphine [even though] we kill more people with saline every year than we do buprenorphine.” One hospitalist described how the ACS reframed her interactions with patients with OUD:

Before [the ACS], you’re already frustrated before you even meet the patient. That’s not a good starting place. Internally, you’re just like, “I really hope you don’t use [heroin] in your room. I hope that this discussion we’re gonna have on opioids is not gonna be as bad as I think it’s going to be…“And you never give the patient the benefit of the doubt. It’s the opposite of how the ACS approaches patients.”

Hospitalist Focus Group #1

Following the implementation of the ACS, hospital-based providers perceived that patients’ needs were being addressed by the ACS, which led to a change in the nature of their interactions with patients and increased work satisfaction. One nurse stated:

I think they [ACS] makes things better…sometimes I feel manipulated, it can be confrontational, or I am walking on eggshells to avoid a confrontation [with a patient]. It was generally not a good rapport with many of these patients. Now [with the ACS], I feel like we’re actively addressing [their SUD], it feels better.

Nurse Interview #1

Greater use of methadone and buprenorphine to manage opioid withdrawal improved communication between patients and hospital-based providers, which contributed to their hopefulness for a patient’s recovery.

I think being able to get treatments going [for opioid withdrawal] and see patients feel gratitude and relief with a good plan leaving is better. I've been able to sit with people before they're ready to go and hear their story. There is more openness and optimism about what's gonna happen. It goes back to greater satisfaction that you're doing something that's worthwhile, you're doing something that matters.

Hospitalist Focus Group #2

By expanding hospital-based treatment for SUD, ACS team members modeled patient-centered care. One hospitalist described his transition from providing reactive care to advocating for his patients with SUD.

They [the ACS] reframed my thinking about these patients. Now I think, “How can I advocate for this patient” instead of “How can I keep things steady, “How can I put out fires?”…So, it’s just a very different view in which to care for them [patients with SUD]. I try to I incorporate that practice, especially in my teaching to residents…

Hospitalist Focus Group #1

3.2.4. ACS team members combat the effects of internalized stigma by promoting feelings of self-worth, self-efficacy, and mutual respect among patients with SUD

Hospitalized patients with SUD generally described positive interactions with ACS team members in contrast to previous health care interactions, especially regarding stigma and judgement. Only one patient interviewed discussed having interactions with ACS team members that made him feel judged and like he was being treated “like a three-year-old”. Other patients discussed being treated like a “regular patient” as their substance use was addressed as one aspect of their overall medical care. One patient stated that the ACS physician “wouldn’t judge me. She would talk me through it…‘You got this. Don’t feel down. You got this.’ That made me feel good about that.” In contrast, when discussing other members of her hospital team, she said, “[they] make me feel like I’m a drug addict.” Patients described their interactions with the ACS as promoting feelings of self-worth and self-efficacy.

They [the ACS] made me feel like I was worth more, like there was still hope, that there's still a window open that I can actually survive and get out the situation if I wanted to.

Patient Interview #10

Hospital-based providers noticed increased self-efficacy among patients with SUD who were treated by the ACS. One social worker described her experience watching patients with OUD progress during their hospitalization:

[When ACS starts] methadone or Suboxone and [patients] really want to take a stab at it, they get enrolled and they feel better, they're not withdrawing, they're not angry and grumpy anymore… they start to get some hope for the future of like, “okay, maybe I will be able to stay away.”

Nurse and Social Worker Focus Group #1

Patients also perceived that ACS team members approached them with compassion and genuine interest in how they were being treated in the hospital. One patient stated:

They [ACS] always came in with a level of compassion and care. Not just about me and not just about my addiction, but about anything medical or mental or anything I had going on. They [ACS] had a very huge level of compassion and care, they [ACS], seemed to radiate it.

Patient Interview #6.

4. Discussion

Our findings demonstrate that patients’ and hospital-based providers’ past negative health care encounters propagate a cycle of stigmatization in the hospital setting. An ethnographic study published by Merrill et al identified the roles that physician inconsistency, confusion about how to address SUD, and fear of manipulation play in increasing patients’ perceived stigma and distrust of the medical system (Merrill et al., 2002). Two decades later, our participants reported experiencing a similar cycle in which stigma is perpetuated by past instances of mistreatment, misunderstanding, and mutual mistrust of hospital-based providers and patients. Although most patients in our study reported having positive interactions with the ACS, both providers and patients perceived that patients with SUD experience mistreatment and stigma by non-ACS providers. One reported limitation of an ACS is that it may shift efforts to learn how to best communicate and care for hospitalized patients with SUD away from general hospital staff, leaving knowledge gaps for many providers (Englander et al., 2018). Our findings suggest that, like basic knowledge of how to provide evidence-based treatment for SUD, tools for how to build rapport and have nonstigmatizing interactions with patients with SUD cannot be utilized only by members of the ACS. Ideally, education to reduce negative and stigmatizing interactions should be integrated into the clinical practice of all providers who interface with patients to reduce stigma in the hospital setting. Despite the perpetuation of stigma in some aspects of hospitalization, we found evidence that the ACS plays an important role in mitigating stigma in the hospital by providing evidence-based SUD treatment and modeling compassionate care. Englander et al. also identified that, among providers, practice changes and compassionate care were perceived to reduce enacted stigma by hospital-based providers toward people who use substances (Englander et al., 2018). Our study builds on this work by highlighting how patients benefit from the perceived reduction in enacted stigma and the promotion of self-worth, self-efficacy, and mutual respect practiced by the ACS. Our study also elucidated the specific aspects of the ACS that may contribute to its role in reducing enacted stigma among hospital-based providers. The presence of the ACS normalized the use of evidence-based treatment for SUD, and hospitalists recognized the benefits of using methadone or buprenorphine to manage opioid withdrawal among their patients. The resolution of patients’ opioid withdrawal symptoms was facilitated by improved patient-provider communication, which had previously been challenging to achieve. To promote better interactions between patients with SUD and health care personnel, education about evidence-based treatment for SUD should be provided to a broader range of health care workers starting earlier in their careers.

Our findings revealed that many patients with SUD had negative past health care experiences that left them feeling frustrated and mistrusting of their medical team. Stigmatizing and negative experiences in the hospital, such as difficult patient-provider interactions or poorly controlled withdrawal symptoms, contribute to detrimental patient outcomes, including receipt of incomplete medical treatment or in-hospital overdoses (Calcaterra et al., 2016; Fanucchi et al., 2018; Velez et al., 2017). People who internalize or anticipate stigma within health care settings are more likely to mistrust their health care providers and treatments, have lower self-worth and efficacy, and engage in higher risk health behaviors compared to people who do not exhibit internalized stigma (Cama et al., 2016; Earnshaw & Quinn, 2012; Livingston & Boyd, 2010). In our study, patients who received care from the ACS reported greater feelings related to respect, self-worth, and suggested an increase in self-efficacy for their recovery. Positive and encouraging interactions between patients and ACS providers may contribute to treatment engagement following hospital discharge. Provision of hospital-based addiction treatment is associated with reduced rehospitalization and increased post-discharge treatment engagement, which benefits both patients and health care systems alike (Englander et al., 2019; Wakeman et al., 2020).

Our results indicate that patients’ anticipation and perceptions of stigma are influenced by an awareness that documentation in their medical charts affects their care and interactions with the medical team. Previous studies characterized the role of medical charts in transmitting stigma with a tendency for providers to “treat the chart” rather than the patient (Flanagan et al., 2009). Patients with negative connotations or stigmatizing language in their charts are more likely to be treated negatively by health care providers (Goddu et al., 2018). In April 2021, federal rules implemented in the 21^st Century Cures Act specified that most clinical notes in the medical record must be made freely available to patients (Federal Rules Mandating Open Notes, 2021). Ideally, this change will benefit patients’ understanding and knowledge of their diagnosis and will promote adherence to treatment recommendations (Blease et al., 2021; Sarabu et al., 2021). Health care systems should consider educating their medical staff to eliminate the use of stigmatizing language when documenting patient encounters and writing notes in medical charts. Evidence supports the benefits of using person-first language to describe people who use substances to reduce experienced stigma (Pivovarova & Stein, 2019; Wogen & Restrepo, 2020). Hospital-based providers should document an SUD diagnosis in the medical record by using medical language included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Diagnostic and statistical manual of mental disorders : DSM-5, 2013) and avoid colloquial words and phrases to describe a medical condition.

We interviewed hospitalists, nurses, social workers, and pharmacists for this study. Notably, many of the conversations regarding experience of stigma were generated by hospital-based providers involved directly in bedside care during hospitalization. Because the pharmacist has limited patient-provider contact, our results revealed that pharmacists’ experiences and perceptions of stigma were more limited than the hospitalists, nurses, and social workers included in this study. Experiences related to stigma brought up among pharmacists were often related to institutional procedures and uncertainty around the legality of prescribing and dispensing methadone for withdrawal prevention or treatment continuation based on historical hospital specific rules and restrictions. Increasingly, however, pharmacists are aware that patients with OUD who are hospitalized for a medical reason, i.e., endocarditis, abscess, osteomyelitis, and who are also experiencing opioid withdrawal, can legally be treated with methadone, even if they are not enrolled in a methadone program, for the duration of their hospitalization (Title 21 Code of Federal Regulations, 1999). With the expansion of ACS, and literature clarifying these laws, more patients will receive methadone for opioid withdrawal prevention (Noska et al., 2015; Pytell et al., 2020).

4.1. Limitations

This study has several limitations. First, the generalizability of our findings is limited given the nature of qualitative research. Additionally, as participation was voluntary, those who chose to participate may represent a subset who were more interested in discussing treatment of patients with SUD due to previous personal or professional experience. Therefore, our results may not reflect experiences from all hospital-based providers.

Our patient sample was recruited from a single institution; thus, it may represent a limited subset of all patients with SUD. Although patient interviewers were not members of participants’ medical team at the time of interview, they may have previously provided medical care to participants, which represents a potential source of bias where patients may have been more likely to participate and offer positive responses to interviewers. To mitigate this, we assured patients that their participation was voluntary, anonymous, and would not impact future aspects of their medical care.

Our study included two sites in the same general geographic location. As many of the experiences discussed are influenced by regional factors like community resources and health care policy, our findings may not be generalizable to all settings. As is true of all qualitative research, results may be influenced by investigators’ perspectives during data collection and analysis. To reduce the impact of potential bias, the research team employed strategies like team-based, iterative analysis and reflexive discussion.

4.2. Conclusions

Expanding access to in-hospital addiction experts, provision of evidence-based medications to treat SUD, and greater use of person-first and medical language to describe SUD in the medical chart would likely reduce stigmatizing interactions in the hospital setting. Further research should help us to understand how the federal open note mandate will affect medical chart documentation, treatment uptake and recovery, and the perception of stigma and mistrust that people with SUD experience during health care encounters.

Highlights:

• Stigma it is a barrier to medical and addiction treatment for patients with substance use disorders.

• Hospital-based addiction consultation services can act as interventions to reduce stigma.

• Past experiences and medical charts perpetuate stigma in patients and hospital-based providers.