Written by Elizabeth Cairns, Mobilize Recovery Special Projects and Michael Masiowski, MD, reviewed by Code Recover Clinician Advisors, August 2026

Dr. Mike Masiowski talks about stigma toward OUD patients, and how working with peers helps humanize people with SUD

Stigma is not merely a social issue; it is a significant clinical barrier that directly impacts patient outcomes and mortality rates. In the Emergency Department, stigma typically manifests in three forms:

Clinician stigma (all clinical staff) – Attitude of disapproval expressed through language, tone, decisions and care provided. A systematic review of health professionals' attitudes toward patients with substance use disorders found that negative attitudes are common and are associated with diminished empathy, lower personal engagement in care, and poorer treatment outcomes. (source) Clinician-enacted stigma can result in patient mistrust and disengagement from care.

This form of stigma can appear as labeling patients as "drug-seeking," or "frequent fliers," displaying less empathy, or ignoring efficacy of available treatments. It can also lead to diagnostic overshadowing, in which all symptoms are attributed to the patient's substance use and underlying conditions are not considered or treated.

Patient stigma – Internalized shame leads to feelings of worthlessness and ultimately disengagement from treatment. In its most extreme form, patients can believe they are undeserving of care.

Structural stigma – Institutional policies, cultural norms, and resource allocation decisions that reflect beliefs that people with addiction are less treatable or less deserving of care. Some examples of this form of stigma include restrictive visitation rules specifically for OUD patients, sub-optimal pain management protocols, restrictive methadone dispensing regulations, or the now-discontinued x-waiver requirement for buprenorphine.

To improve outcomes, the ED must move toward a culture that treats OUD with the same professional urgency and medical rigor as any other life-threatening chronic condition or disease.

Combatting stigma

Person-centered language

A primary tool for dismantling stigma is the intentional use of person-centered language. This is not a matter of etiquette. In a randomized study of 516 clinicians — most of them doctoral-level — participants who read a case vignette describing a "substance abuser" were significantly more likely to judge the person as personally culpable and to endorse punitive rather than therapeutic measures than those who read an identical vignette describing a "person with a substance use disorder." (source) The only variable was the term.

Providers should replace stigmatizing terms like "addict," "abuser," or "frequent flyer" with "person with opioid use disorder." Similarly, clinical documentation should shift from "clean" or "dirty" toxicology results to "positive" or "negative," and from "relapse" to "recurrence of use" or "return to use." (source) These shifts move the focus from a perceived moral failing to a clinical manifestation of a chronic disease, reducing the shame that often leads patients to leave the ED against medical advice.

Understanding OUD as a Chronic Medical Condition

Many clinicians lack specific training on OUD and may misunderstand it as a moral failure and/or a case of poor life choices, and disregard the physiological basis of the disease. It is imperative that clinicians understand that OUD is a chronic, treatable brain disease. This understanding is essential for reducing both provider bias and patient self-stigma. When the clinical team views OUD through the lens of neurobiology rather than behavior, the focus shifts toward evidence-based stabilization (like buprenorphine induction) and long-term management. Providing a supportive, non-judgmental environment in the ED signals to the patient that the care team is invested in their health and well-being.

Integrating Peers with Lived Experience

Finally, the integration of peers with lived experience serves as a powerful antidote to institutional stigma. By working alongside peers, ED clinicians see the success stories of recovery that are often invisible when only treating patients in acute distress from their substance use. This integration of peers is known as contact-based intervention, where exposure to people in recovery may correct the distortion that recovery is rare, since clinicians disproportionately encounter patients during active use rather than in recovery. Across 79 stigma-reduction studies involving more than 38,000 participants, contact-based approaches produced attitude changes roughly twice the size of those achieved by education alone. (source)

Additionally, seeing peers model compassion and interpersonal connection with OUD patients is humanizing and uplifting. Their success with patients can help clinicians believe that recovery is possible.