1881 lines
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<title>Stigma: Overcoming a Pervasive Barrier to Optimal Care | National Institute on Alcohol Abuse and Alcoholism (NIAAA)</title>
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<h3>Takeaways</h3>
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<ul>
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<li><strong>Stigma refers to negative beliefs about individuals or groups</strong> based on characteristics that may set them apart from others, such as mental health conditions including alcohol use disorder (AUD).</li>
|
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<li><strong>S</strong><strong>tigma can exacerbate AUD</strong> by contributing to a person’s negative emotional states that drive AUD and by deterring people with AUD from seeking treatment.</li>
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<li><strong>You can reduce stigma and encourage patients to seek AUD treatment</strong> by conveying that AUD is a health condition with effective, evidence-backed treatments that can be delivered on an outpatient basis, preserving patient routines and privacy.</li>
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<p>Stigma refers to negative judgments, avoidance, and discrimination levied against those who are devalued for any number of reasons, including having a mental health condition such as alcohol use disorder (AUD).<sup>1</sup> People with AUD can feel isolated and rejected because they have come to believe that the negative attitudes and false beliefs about AUD they have heard from others<sup>2,3</sup>—or have picked up from society at large—apply to them.<sup>4</sup> Some may even sense stigmatizing attitudes from their healthcare providers, which can compromise their care.<sup>5,6</sup></p>
|
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<p>The consequences of stigma can be severe. It is part of the reason so few people with AUD in the U.S. receive treatment.<sup>4,7–9</sup> Research indicates that the more stigma perceived by a person with AUD, the less likely they are to seek treatment.<sup>4,10</sup> Thus, recognizing and addressing stigma can help remove a barrier to care for people in need.<sup>11,12</sup></p>
|
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<p>Here, we look at signs of AUD-related stigma, factors under the surface that fuel stigma among both patients and providers, and strategies to reduce stigma and encourage more patients to seek treatment.</p>
|
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<h2>How might the effects of stigma show in patients?</h2>
|
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|
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<p>You may not see clear signs of stigma in the exam room, but it could be working under the surface in your patients with AUD. One clue may be when patients acknowledge they have AUD but do not accept a referral to an addiction specialist and say they want to manage their alcohol problems on their own.<sup>7</sup> This go-it-alone attitude could stem from fear of social judgment or professional consequences.</p>
|
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<p>Other clues, which can be harder to detect, are when patients downplay or withhold information about the amount of alcohol they consume or alcohol-related problems, for fear of judgment by the clinician.</p>
|
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|
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<h2>What underlies stigma for patients with AUD?</h2>
|
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|
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<p>In population surveys, several reasons people cite for not seeking treatment for AUD relate to stigma, such as “too embarrassed to discuss it with anyone” and “should be strong enough to handle it alone,”<sup>7</sup> and concern that others might have a negative opinion.<sup>8</sup> Qualitative research digs deeper, finding that patients living with AUD report the following:<sup>13–15</sup></p>
|
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|
||
<ul>
|
||
<li><strong>Shame:</strong> Patients may view AUD and its treatment as shameful, a personal failure, or a blow to self-esteem. Some people with AUD emphasize the importance of keeping up appearances and the need to hide their drinking for fear of being judged. Shame may drive even more drinking via negative reinforcement, that is, drinking to reduce the discomfort of the shame caused by drinking.</li>
|
||
<li><strong>Identity issues:</strong> When people realize they have AUD and need treatment for it, they can face a troubling change in identity. They may internalize society’s negative, stereotypical views of people with AUD. Even when they recognize that the stereotype is at odds with their own situation, the stigma can persist.</li>
|
||
<li><strong>Lack of knowledge about treatment:</strong> People may be aware only of treatment options that may be unappealing to them. These options may include residential treatment, which could interfere with work or home life and be a barrier to confidentiality; the use of an older AUD medication (disulfiram) that causes very unpleasant effects when alcohol is consumed; and a perceived need for lifelong abstinence. They might prefer options that offer more flexibility and autonomy but are unaware that such choices exist (see <a href="#Patient-level_strategies">Patient-level strategies</a> below).</li>
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</ul>
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<p>In short, many patients with AUD see the prospect of treatment itself as potentially stigmatizing. This view understandably leads to a reluctance to seek treatment.</p>
|
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|
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<h2>How might clinicians contribute to a patient’s sense of stigma?</h2>
|
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|
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<p>Stigma may consciously or unconsciously create biases within everyone, even experienced healthcare providers. Although most may hold positive attitudes toward patients with alcohol problems, clinicians may still: </p>
|
||
|
||
<ul>
|
||
<li>shorten visit times with patients with AUD<sup>16</sup></li>
|
||
<li>engage less with and show less empathy for patients with AUD<sup>5,17</sup></li>
|
||
<li>use labeling language such as “alcoholic” instead of “a person with AUD”<sup>5</sup></li>
|
||
</ul>
|
||
|
||
<h2>What misconceptions contribute to stigma in a clinical setting?</h2>
|
||
|
||
<p>In qualitative research into stigma as a barrier to care, some clinicians report false beliefs that patients with AUD:<sup>5,14</sup></p>
|
||
|
||
<ul>
|
||
<li>have chosen their condition</li>
|
||
<li>have complete control over their AUD and could quit if only they were willing to do the work</li>
|
||
<li>have character flaws</li>
|
||
</ul>
|
||
|
||
<p>Conversely, some healthcare professionals might be reluctant to discuss AUD with patients because they are concerned about stigmatizing them.<sup>18</sup></p>
|
||
|
||
<h2>What knowledge about AUD and its treatment may lessen stigma?</h2>
|
||
|
||
<p>The insights below may help counteract some common misconceptions about AUD.</p>
|
||
|
||
<ul>
|
||
<li><strong>There is a misunderstanding that AUD is a choice.</strong> Yes, there is an element of choice when a person first starts drinking. For some people, however, a mix of genetic and environmental factors facilitates a transition, often without full recognition, to increasingly heavier drinking and to AUD (see next bullet). Drinking heavily does not always lead to AUD,<sup>19,20</sup> but when it does, changes in the brain make it difficult for people to control or stop their drinking.<sup>21</sup> If told at this point that their condition is a choice, rather than being offered treatment, patients can feel shame and a lack of self-efficacy, which can lead to more drinking to cope with the negative feelings. (See Core articles on <a href="/health-professionals-communities/core-resource-on-alcohol/neuroscience-brain-addiction-and-recovery">neuroscience</a> and <a href="/health-professionals-communities/core-resource-on-alcohol/alcohol-use-disorder-risk-diagnosis-recovery">AUD</a>.)</li>
|
||
<li><strong>Vulnerability to AUD is influenced by a complex mix of genetic and environmental factors.</strong> About 50% of the risk for developing AUD is due to genetics.<sup>22,23</sup> Other risk factors include trauma, particularly adverse childhood events;<sup>24</sup> mental health conditions such as anxiety and depression;<sup>25,26</sup> stress;<sup>27</sup> exposure to alcohol prenatally;<sup>28,29</sup> drinking in adolescence;<sup>30</sup> and drinking too much, too often, at any age.<sup>31,32</sup> Awareness of contributing factors may promote empathy and reduce stigma. (See Core articles on <a href="/health-professionals-communities/core-resource-on-alcohol/risk-factors-varied-vulnerability-alcohol-related-harm">risk factors</a>.)</li>
|
||
<li><strong>Evidence-based AUD treatment is available, change is possible, and most people recover or markedly improve. </strong>Many healthcare professionals may still believe that treatment options for AUD are limited and that AUD typically persists in severe form for life. However, evidence-based care is available (see Core article on <a href="/health-professionals-communities/core-resource-on-alcohol/recommend-evidence-based-treatment-know-options">treatment</a>), and the majority of people who have AUD recover,<sup>33</sup> often after a few attempts.<sup>34</sup> (See Core article on <a href="/health-professionals-communities/core-resource-on-alcohol/support-recovery-its-marathon-not-sprint">recovery</a>.) Even those who cut back on drinking rather than quit can markedly improve how they feel and function.<sup>35</sup></li>
|
||
<li><strong>The historic separation of AUD treatment from other healthcare has contributed to stigma.</strong> Care for patients with AUD and other substance use disorders traditionally has been separated from medical and mental healthcare. As a result, many healthcare professionals are not trained sufficiently to assess, diagnose, or treat AUD. This sense of AUD being a “different” health issue contributes to stigma.</li>
|
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</ul>
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<h2>What can clinicians do to reduce perceived stigma among patients with AUD?</h2>
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<p>Strategies to reduce stigma can be applied at both the patient level and the practice level.</p>
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<p id="Patient-level_strategies"><em><strong>Patient-level strategies</strong></em></p>
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<li><strong>Explore patients’ understanding of their alcohol use and its consequences before offering a diagnosis of AUD. </strong>(See Core article on <a href="/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods">assessment</a>.) Diagnoses that are made too quickly may be perceived as judgmental.</li>
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<li><strong>Use non-stigmatizing, encouraging language.</strong><sup>36</sup> Use precise, medically-focused language to describe the diagnosis as mild, moderate, or severe “alcohol use disorder” or “AUD,” rather than “alcoholism,” “alcohol abuse,” or other imprecise terms that may imply that the person holds full responsibility for causing or controlling their condition.<sup>37</sup> Use person-first terms such as “people with AUD” rather than “alcoholics” or other slang or idioms. Reinforce that people can and do recover from AUD. (See Core article on <a href="/health-professionals-communities/core-resource-on-alcohol/support-recovery-its-marathon-not-sprint">recovery</a>.) Point to any strengths you may know about your patient.</li>
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<li><strong>Educate patients about AUD and evidence-based treatment. </strong>Help patients understand that AUD is a common medical condition that can happen to anyone. Share that AUD can be mild to severe and that it responds to evidence-based treatments. Note that flexible outpatient options can help protect patients’ daily routines and privacy, that newer medications don’t make people sick if they drink, and that individualized drinking goals can be set on the path to recovery.</li>
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<li><strong>Encourage patient autonomy.</strong> Empower patients by involving them in decisions regarding treatment and providing choices among treatment options and goals. If a patient finds a treatment program to be stigmatizing or raises privacy concerns, recommend switching to an option more conducive to their comfort level.</li>
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<p><em><strong>Practice-level strategies</strong></em></p>
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<li><strong>Normalize addressing patients’ alcohol use in healthcare settings.</strong> Create workflows and systems that incorporate alcohol screening, assessment for AUD, and standard procedures for follow-up. (See Core articles on <a href="/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods">screening and assessment</a> and <a href="/health-professionals-communities/core-resource-on-alcohol/promote-practice-change-take-manageable-steps-toward-better-care">practice change</a>.)</li>
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<li><strong>Educate the whole care team.</strong> Make sure everyone interacting with patients understands that AUD is a medical condition and that they need to avoid stigmatizing language and behaviors. When speaking with your colleagues, model the use of medically accurate, person-first language.</li>
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<li><strong>Consider offering AUD medications in primary care.</strong> Many patients with AUD would prefer to receive initial treatment in a primary care setting.<sup>14</sup> Primary care providers who prescribe AUD medications see this strategy as a potentially effective “foot in the door” to treatment that reduces stigma and other barriers.<sup>5</sup> FDA-approved medications for AUD are non-addicting and no more complicated to prescribe than those for other common medical conditions. See the <a href="/health-professionals-communities/core-resource-on-alcohol/stigma-overcoming-pervasive-barrier-optimal-care#pub-toc6">Resources</a> section below for support in prescribing AUD medications.</li>
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<li><strong>Consider creating an interdisciplinary AUD care team.</strong> Some primary care providers are more comfortable managing the care of patients with AUD if they work collaboratively with therapists for behavioral care and addiction physicians or pharmacists for prescribing support.<sup>5</sup> When healthcare practices support such collaborations, this can enhance the willingness of clinicians to work with and empower their patients with AUD.<sup>16</sup></li>
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<li><strong>Update your referral list to include options that maximize patient privacy.</strong> Use the portal for healthcare professionals on the <a href="https://alcoholtreatment.niaaa.nih.gov/healthcare-professionals">NIAAA Alcohol Treatment Navigator</a> to explore the full range of providers near you, including specialist addiction physicians and therapists who offer lower intensity outpatient choices well-suited for patients with mild to moderate AUD. These options can include flexible outpatient care, including telehealth options, that can preserve autonomy, privacy, and patient routines.</li>
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</ul>
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<p><strong>In closing,</strong> by acknowledging and taking steps to mitigate the stigma your patients with AUD may experience, you can help them overcome this common barrier to getting the treatment they need.</p>
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<h2>Resources</h2>
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<p><strong>Stigma Reduction Resources</strong></p>
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<li><a href="https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/cmece-activities/your-words-matter-terms-to-use-avoid-when-talking-about-addiction-cmece-activity">Words Matter - Terms to Use and Avoid When Talking About Addiction</a>: A CME/CE Activity, National Institute on Drug Abuse, 2021</li>
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<li><a href="https://www.samhsa.gov/sites/default/files/programs_campaigns/02._webcast_1_resources-508.pdf">Resource Guide: Overcoming Stigma, Ending Discrimination</a> [PDF – 874 KB], Substance Abuse and Mental Health Services Administration</li>
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<li><a href="https://www.nap.edu/catalog/23442/ending-discrimination-against-people-with-mental-and-substance-use-disorders">Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change</a>, National Academies of Sciences, Engineering, and Medicine, 2016</li>
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<li><a href="https://solutions.edc.org/resources/words-matter-how-language-choice-can-reduce-stigma">Words Matter: How Language Choice Can Reduce Stigma</a>, Education Development Center with funding from the Substance Abuse and Mental Health Services Administration, 2017</li>
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<p><strong>Making Referrals</strong></p>
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<ul>
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<li><a href="https://alcoholtreatment.niaaa.nih.gov/healthcare-professionals">NIAAA Alcohol Treatment Navigator: Portal for Healthcare Professionals</a></li>
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</ul>
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<p><strong>Alcohol Use Disorder Medication Guides</strong></p>
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<ul>
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<li><a href="https://store.samhsa.gov/product/medication-treatment-alcohol-use-disorder-brief-guide/sma15-4907">Medication for the Treatment of Alcohol Use Disorder: A Brief Guide</a>, NIAAA and the Substance Abuse and Mental Health Services Administration, 2015</li>
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<li><a href="/sites/default/files/Combine_2.pdf">COMBINE Monograph Series Volume 2: Medication Management Treatment Manual</a> [PDF – 1,351 KB], NIAAA, 2004</li>
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<li>Medications for Adults with Alcohol Use Disorder (<a href="https://effectivehealthcare.ahrq.gov/products/alcohol-misuse-drug-therapy/clinician">Provider-facing</a> and <a href="https://effectivehealthcare.ahrq.gov/products/alcohol-misuse-drug-therapy/consumer">Patient-facing</a>), Agency for Healthcare Research and Quality, 2016</li>
|
||
<li>Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder (<a href="https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2017.1750101">Summary</a> and <a href="https://psychiatryonline.org/doi/book/10.1176/appi.books.9781615371969">Full guidelines</a>), The American Psychiatric Association, 2018</li>
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</ul>
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<p><strong>More resources</strong> for a variety of healthcare professionals can be found in the <a href="/health-professionals-communities/core-resource-on-alcohol/additional-links-patient-care">Additional Links for Patient Care</a>.</p>
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<h2>References</h2>
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<li>Lucksted A, Drapalski AL. Self-stigma regarding mental illness: Definition, impact, and relationship to societal stigma. <em>Psychiatr Rehabil J</em>. 2015;38(2):99-102. <a href="https://psycnet.apa.org/fulltext/2015-25297-001.html">doi:10.1037/prj0000152</a></li>
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<li>Schomerus G, Corrigan PW, Klauer T, Kuwert P, Freyberger HJ, Lucht M. Self-stigma in alcohol dependence: Consequences for drinking-refusal self-efficacy. <em>Drug Alcohol Depend</em>. 2011;114(1):12-17. <a href="https://www.sciencedirect.com/science/article/pii/S0376871610003017?via%3Dihub">doi:10.1016/j.drugalcdep.2010.08.013</a></li>
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||
<li>Glass JE, Mowbray OP, Link BG, Kristjansson SD, Bucholz KK. Alcohol stigma and persistence of alcohol and other psychiatric disorders: A modified labeling theory approach. <em>Drug Alcohol Depend</em>. 2013;133(2):685-692. <a href="https://www.sciencedirect.com/science/article/pii/S0376871613003323?via%3Dihub">doi:10.1016/j.drugalcdep.2013.08.016</a></li>
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||
<li>Keyes KM, Hatzenbuehler ML, McLaughlin KA, et al. Stigma and treatment for alcohol disorders in the United States. <em>Am J Epidemiol</em>. 2010;172(12):1364-1372. <a href="https://academic.oup.com/aje/article/172/12/1364/191501?login=true">doi:10.1093/aje/kwq304</a></li>
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||
<li>Williams EC, Achtmeyer CE, Young JP, et al. Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. <em>J Gen Intern Med</em>. 2018;33(3):258-267. <a href="https://link.springer.com/article/10.1007/s11606-017-4202-z">doi:10.1007/s11606-017-4202-z</a></li>
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||
<li>Fortney J, Mukherjee S, Curran G, Fortney S, Han X, Booth BM. Factors associated with perceived stigma for alcohol use and treatment among at-risk drinkers. <em>J Behav Health Serv Res</em>. 2004;31(4):418-429. <a href="https://link.springer.com/article/10.1007/BF02287693">doi:10.1007/BF02287693</a></li>
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<li>Cohen E, Feinn R, Arias A, Kranzler HR. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. <em>Drug Alcohol Depend</em>. 2007;86(2-3):214-221. <a href="https://www.sciencedirect.com/science/article/pii/S0376871606002298?via%3Dihub">doi:10.1016/j.drugalcdep.2006.06.008</a></li>
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||
<li>Receipt of Services for Substance Use and Mental Health Issues among Adults: Results from the 2016 National Survey on Drug Use and Health. Accessed April 5, 2021. <a href="https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR2-2016/NSDUH-DR-FFR2-2016.htm">https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR2-2016/NSDU…</a></li>
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||
<li>Alcohol Treatment in the United States: Prevalence of Past-Year Alcohol Use Treatment. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed January 3, 2024. <a href="https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-treatment-united-states-age-groups-and-demographic-characteristics">https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcoho…</a></li>
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||
<li>Hammarlund R, Crapanzano KA, Luce L, Mulligan L, Ward KM. Review of the effects of self-stigma and perceived social stigma on the treatment-seeking decisions of individuals with drug- and alcohol-use disorders. <em>Subst Abuse Rehabil</em>. 2018;9:115-136.<a href="https://www.dovepress.com/review-of-the-effects-of-self-stigma-and-perceived-social-stigma-on-th-peer-reviewed-fulltext-article-SAR"> doi:10.2147/SAR.S183256</a></li>
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||
<li>Volkow ND, Gordon JA, Koob GF. Choosing appropriate language to reduce the stigma around mental illness and substance use disorders. <em>Neuropsychopharmacology</em>. Published online July 19, 2021:1-3. <a href="https://www.nature.com/articles/s41386-021-01069-4">doi:10.1038/s41386-021-01069-4</a></li>
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<li>Tucker JA, Foushee HR, Simpson CA. Public Perceptions of Substance Abuse and How Problems are Resolved: Implications for Medical and Public Health Services. <em>South Med J</em>. 2008;101(8):786-790. <a href="https://sma.org/southern-medical-journal/article/public-perceptions-of-substance-abuse-and-how-problems-are-resolved-implications-for-medical-and-public-health-services/">doi:10.1097/SMJ.0b013e31817c931c</a></li>
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<li>Wallhed Finn S, Bakshi AS, Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. <em>Subst Use Misuse</em>. 2014;49(6):762-769. <a href="https://www.tandfonline.com/doi/full/10.3109/10826084.2014.891616">doi:10.3109/10826084.2014.891616</a></li>
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<li>Glass JE, Andréasson S, Bradley KA, et al. Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA). <em>Addict Sci Clin Pract</em>. 2017;12(1):14. <a href="https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-017-0079-8">doi:10.1186/s13722-017-0079-8</a></li>
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<li>Cucciare MA, Lewis ET, Hoggatt KJ, et al. Factors Affecting Women’s Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with U.S. Military Veterans. <em>Womens Health Issues Off Publ Jacobs Inst Womens Health</em>. 2016;26(2):232-239. <a href="https://www.sciencedirect.com/science/article/pii/S1049386715001127?via%3Dihub">doi:10.1016/j.whi.2015.07.010</a></li>
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<li>van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. <em>Drug Alcohol Depend</em>. 2013;131(1-2):23-35. <a href="https://www.sciencedirect.com/science/article/pii/S0376871613000677?via%3Dihub">doi:10.1016/j.drugalcdep.2013.02.018</a></li>
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<li>van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Healthcare professionals’ regard towards working with patients with substance use disorders: comparison of primary care, general psychiatry and specialist addiction services. <em>Drug Alcohol Depend</em>. 2014;134:92-98. <a href="https://www.sciencedirect.com/science/article/pii/S0376871613003748?via%3Dihub">doi:10.1016/j.drugalcdep.2013.09.012</a></li>
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<li>Minian N, Noormohamed A, Lingam M, et al. Integrating a brief alcohol intervention with tobacco addiction treatment in primary care: qualitative study of health care practitioner perceptions. <em>Addict Sci Clin Pract</em>. 2021;16(1):17. <a href="https://ascpjournal.biomedcentral.com/articles/10.1186/s13722-021-00225-x">doi:10.1186/s13722-021-00225-x</a></li>
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<li>Dawson DA, Grant BF, Li TK. Quantifying the Risks Associated With Exceeding Recommended Drinking Limits. <em>Alcohol Clin Exp Res</em>. 2005;29(5):902-908. <a href="https://onlinelibrary.wiley.com/doi/abs/10.1097/01.ALC.0000164544.45746.A7">doi:https://doi.org/10.1097/01.ALC.0000164544.45746.A7</a></li>
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<li>Substance Abuse and Mental Health Services Administration. <em>Key Substance Use and Mental Health Indicators in the United States: Results from the 2018 National Survey on Drug Use and Health</em>. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2019:82. <a href="https://www.samhsa.gov/data/">https://www.samhsa.gov/data/</a></li>
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<li>Egervari G, Ciccocioppo R, Jentsch JD, Hurd YL. Shaping vulnerability to addiction - the contribution of behavior, neural circuits and molecular mechanisms. <em>Neurosci Biobehav Rev</em>. 2018;85:117-125. <a href="https://www.sciencedirect.com/science/article/pii/S0149763417300866?via%3Dihub">doi:10.1016/j.neubiorev.2017.05.019</a></li>
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<li>Reilly MT, Noronha A, Goldman D, Koob GF. Genetic studies of alcohol dependence in the context of the addiction cycle. <em>Neuropharmacology</em>. 2017;122:3-21. <a href="https://www.sciencedirect.com/science/article/pii/S0028390817300175?via%3Dihub">doi:10.1016/j.neuropharm.2017.01.017</a></li>
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<li>Tawa EA, Hall SD, Lohoff FW. Overview of the Genetics of Alcohol Use Disorder. <em>Alcohol Alcohol Oxf Oxfs</em>. 2016;51(5):507-514. <a href="https://academic.oup.com/alcalc/article/51/5/507/2237006?login=true">doi:10.1093/alcalc/agw046</a></li>
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<li>Enoch MA. The Role of Early Life Stress as a Predictor for Alcohol and Drug Dependence. <em>Psychopharmacology (Berl)</em>. 2011;214(1):17-31. <a href="https://link.springer.com/article/10.1007/s00213-010-1916-6">doi:10.1007/s00213-010-1916-6</a></li>
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<li>Anker JJ, Kushner MG. Co-Occurring Alcohol Use Disorder and Anxiety: Bridging Psychiatric, Psychological, and Neurobiological Perspectives. <em>Alcohol Res Curr Rev</em>. 2019;40(1). <a href="https://arcr.niaaa.nih.gov/alcohol-use-disorder-and-co-occurring-mental-health-conditions/co-occurring-alcohol-use-disorder-anxiety">doi:10.35946/arcr.v40.1.03</a></li>
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<li>McHugh RK, Weiss RD. Alcohol Use Disorder and Depressive Disorders. <em>Alcohol Res Curr Rev</em>. 2019;40(1). <a href="https://arcr.niaaa.nih.gov/volume/40/1/alcohol-use-disorder-and-depressive-disorders">doi:10.35946/arcr.v40.1.01</a></li>
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<li>Anthenelli RM. Overview: Stress and Alcohol Use Disorders Revisited. <em>Alcohol Res Curr Rev</em>. 2012;34(4):386-390.</li>
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<li>Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O’Malley K, Young JK. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. <em>J Dev Behav Pediatr JDBP</em>. 2004;25(4):228-238. <a href="https://journals.lww.com/jrnldbp/fulltext/2004/08000/risk_factors_for_adverse_life_outcomes_in_fetal.2.aspx">doi:10.1097/00004703-200408000-00002</a></li>
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<li>Baer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult drinking. <em>Arch Gen Psychiatry</em>. 2003;60(4):377-385. <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/207348">doi:10.1001/archpsyc.60.4.377</a></li>
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<li>Hingson RW, Heeren T, Winter MR. Age at drinking onset and alcohol dependence: age at onset, duration, and severity. <em>Arch Pediatr Adolesc Med</em>. 2006;160(7):739-746. <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/205204">doi:10.1001/archpedi.160.7.739</a></li>
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<li>Greenfield TK, Ye Y, Bond J, et al. Risks of Alcohol Use Disorders Related to Drinking Patterns in the U.S. General Population. <em>J Stud Alcohol Drugs</em>. 2014;75(2):319-327. <a href="https://www.jsad.com/doi/10.15288/jsad.2014.75.319">doi:10.15288/jsad.2014.75.319</a></li>
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<li>Dawson DA, Li TK, Grant BF. A Prospective Study of Risk Drinking: At Risk for What? <em>Drug Alcohol Depend</em>. 2008;95(1-2):62-72. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2366117/">doi:10.1016/j.drugalcdep.2007.12.00</a></li>
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<li>Dawson DA, Grant BF, Stinson FS, Chou PS, Huang B, Ruan WJ. Recovery from DSM-IV alcohol dependence: United States, 2001-2002. <em>Addict Abingdon Engl</em>. 2005;100(3):281-292. <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2004.00964.x">doi:10.1111/j.1360-0443.2004.00964.x</a></li>
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<li>Kelly JF, Greene MC, Bergman BG, White WL, Hoeppner BB. How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults. <em>Alcohol Clin Exp Res</em>. 2019;43(7):1533-1544. <a href="https://onlinelibrary.wiley.com/doi/10.1111/acer.14067">doi:10.1111/acer.14067</a></li>
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<li>Witkiewitz K, Falk DE, Litten RZ, et al. Maintenance of World Health Organization Risk Drinking Level Reductions and Posttreatment Functioning Following a Large Alcohol Use Disorder Clinical Trial. <em>Alcohol Clin Exp Res</em>. 2019;43(5):979-987. <a href="https://onlinelibrary.wiley.com/doi/10.1111/acer.14018">doi:10.1111/acer.14018</a></li>
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<li>Broyles LM, Binswanger IA, Jenkins JA, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. <em>Subst Abuse</em>. 2014;35(3):217-221. <a href="https://journals.sagepub.com/doi/10.1080/08897077.2014.930372">doi:10.1080/08897077.2014.930372</a></li>
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<li>Kelly JF, Saitz R, Wakeman S. Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an “Addiction-ary.” <em>Alcohol Treat Q</em>. 2016;34(1):116-123. <a href="https://www.tandfonline.com/doi/full/10.1080/07347324.2016.1113103">doi:10.1080/07347324.2016.1113103</a></li>
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|
||
<li><strong>Physician Assistants</strong></li>
|
||
<li><strong>Nurses</strong></li>
|
||
<li><strong>Pharmacists</strong></li>
|
||
</ul>
|
||
|
||
<p>To earn <strong>AMA, AAPA, ANCC, ACPE</strong>, or <strong>ABIM MOC</strong> credit, review this article, then use the link below to log into or create a CME University account. Answer 3 out of 4 questions correctly on the post-test to earn 0.75 credits.</p>
|
||
|
||
<div class="credit-button">
|
||
<div class="button button-primary"><a href="https://www.cmeuniversity.com/course/take/122800"><span class="no-ext">Complete the CME/CE Post-Test</span><br>
|
||
for Topic 4</a></div>
|
||
</div>
|
||
</div>
|
||
|
||
<div class="pub-highlighted credit-wrapper">
|
||
<p>These professionals can earn <strong>1.5 credits </strong>for reading <strong>a pair of articles</strong> as indicated below:</p>
|
||
|
||
<ul>
|
||
<li><strong>Licensed Psychologists </strong>(and others who can earn APA credit)</li>
|
||
<li><strong>Social Workers</strong></li>
|
||
</ul>
|
||
|
||
<p>To earn<strong> APA or ASWB </strong>credit, review this article and <a href="/health-professionals-communities/core-resource-on-alcohol/neuroscience-brain-addiction-and-recovery">Topic 3—Neuroscience: The Brain in Addiction and Recovery</a>, then use the link below to log into or create a CME University account. Answer 7 out of 10 questions correctly on the combined post-test to earn 1.5 credits.</p>
|
||
|
||
<div class="credit-button">
|
||
<div class="button button-primary"><a href="https://www.cmeuniversity.com/course/take/125427"><span class="no-ext">APA or ASWB Credit Only:<br>
|
||
Complete the Combined CE Post-Test</span><br>
|
||
for Topics 3 & 4</a></div>
|
||
</div>
|
||
</div>
|
||
|
||
<p>Released on 5/6/2022<br>
|
||
Expires on 5/10/2025</p>
|
||
|
||
<h3>Learning Objectives</h3>
|
||
|
||
<p>After completing this activity, the participant should be better able to:</p>
|
||
|
||
<ul>
|
||
<li>List factors that contribute to stigma associated with alcohol use disorder (AUD).</li>
|
||
<li>Describe the relationship between stigma associated with AUD and likelihood of seeking treatment.</li>
|
||
<li>Develop patient-centered strategies to overcome stigma as a barrier to treatment of AUD.</li>
|
||
</ul>
|
||
|
||
<h3>Contributors</h3>
|
||
|
||
<p>Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.</p>
|
||
|
||
<h4>NIAAA Writers and Content Contributors</h4>
|
||
|
||
<p><strong>Raye Z. Litten, PhD</strong><br>
|
||
Editor and Content Advisor for the Core Resource on Alcohol,<br>
|
||
Director, Division of Treatment and Recovery, NIAAA</p>
|
||
|
||
<p><strong>Laura E. Kwako, PhD</strong><br>
|
||
Editor and Content Advisor for the Core Resource on Alcohol,<br>
|
||
Health Scientist Administrator,<br>
|
||
Division of Treatment and Recovery, NIAAA</p>
|
||
|
||
<p><strong>Maureen B. Gardner</strong><br>
|
||
Project Manager, Co-Lead Technical Editor, and<br>
|
||
Writer for the Core Resource on Alcohol,<br>
|
||
Division of Treatment and Recovery, NIAAA</p>
|
||
|
||
<h4>External Reviewers</h4>
|
||
|
||
<p><strong>H. Westley Clark, MD, JD, MPH</strong><br>
|
||
Dean's Executive Professor of Public Health,<br>
|
||
Santa Clara University, Santa Clara, CA</p>
|
||
|
||
<p><strong>Hector Colon-Rivera MD, MRO</strong><br>
|
||
Medical Director of Asociacion<br>
|
||
Puertorriquenos En Marcha, Inc;<br>
|
||
Attending at University of Pittsburgh Medical<br>
|
||
Center, Philadelphia, PA</p>
|
||
|
||
<p><strong>Joseph Edwin Glass, PhD, MSW </strong><br>
|
||
Associate Investigator Kaiser Permanente,<br>
|
||
Washington Health Research Institute,<br>
|
||
Seattle, WA</p>
|
||
|
||
<p><strong>Shelly F. Greenfield, MD, MPH</strong><br>
|
||
Chief Academic Officer and Professor of<br>
|
||
Psychiatry, McLean Hospital/Harvard Medical<br>
|
||
School, Belmont, MA</p>
|
||
|
||
<p><strong>John F. Kelly, PhD, ABPP</strong><br>
|
||
Elizabeth R. Spallin Professor of Psychiatry in<br>
|
||
Addiction Medicine, Harvard Medical School;<br>
|
||
Director, MGH Recovery Research Institute,<br>
|
||
Massachusetts General Hospital, Boston, MA</p>
|
||
|
||
<p><strong>Richard Saitz, MD, MPH </strong>(Deceased)<br>
|
||
Professor of Medicine and Professor and<br>
|
||
Chair of Community Health Sciences,<br>
|
||
Boston University School of Medicine, Boston</p>
|
||
|
||
<p><strong>Emily C. Williams, PhD, MPH</strong><br>
|
||
Professor of Health Systems and Population<br>
|
||
Health, University of Washington;<br>
|
||
VA Puget Sound Health Services Research,<br>
|
||
Seattle, WA</p>
|
||
|
||
<h4>NIAAA Reviewers</h4>
|
||
|
||
<p><strong>George F. Koob, PhD</strong><br>
|
||
Director, NIAAA</p>
|
||
|
||
<p><strong>Patricia Powell, PhD</strong><br>
|
||
Deputy Director, NIAAA</p>
|
||
|
||
<p><strong>Nancy Diazgranados, MD, MS, DFAPA</strong><br>
|
||
Deputy Clinical Director, NIAAA</p>
|
||
|
||
<p><strong>Lorenzo Leggio, MD, PhD</strong><br>
|
||
NIDA/NIAAA Senior Clinical Investigator and Section Chief;<br>
|
||
NIDA Branch Chief;<br>
|
||
NIDA Deputy Scientific Director;<br>
|
||
Senior Medical Advisor to the NIAAA Director</p>
|
||
|
||
<p><strong>Falk W. Lohoff, MD</strong><br>
|
||
Lasker Clinical Research Scholar;<br>
|
||
Chief, Section on Clinical Genomics and Experimental Therapeutics, NIAAA</p>
|
||
|
||
<p><strong>Aaron White, PhD</strong><br>
|
||
Senior Scientific Advisor to<br>
|
||
the NIAAA Director, NIAAA</p>
|
||
|
||
<h4>Editorial Team</h4>
|
||
|
||
<h5>NIAAA</h5>
|
||
|
||
<p><strong>Raye Z. Litten, PhD</strong><br>
|
||
Editor and Content Advisor for the Core Resource on Alcohol,<br>
|
||
Director, Division of Treatment and Recovery, NIAAA</p>
|
||
|
||
<p><strong>Laura E. Kwako, PhD</strong><br>
|
||
Editor and Content Advisor for the Core Resource on Alcohol,<br>
|
||
Health Scientist Administrator,<br>
|
||
Division of Treatment and Recovery, NIAAA</p>
|
||
|
||
<p><strong>Maureen B. Gardner</strong><br>
|
||
Project Manager, Co-Lead Technical Editor, and<br>
|
||
Writer for the Core Resource on Alcohol,<br>
|
||
Division of Treatment and Recovery, NIAAA</p>
|
||
|
||
<h5>Contractor Support</h5>
|
||
|
||
<p><strong>Elyssa Warner, PhD</strong><br>
|
||
Co-Lead Technical Editor,<br>
|
||
Ripple Effect</p>
|
||
|
||
<p><strong>Daria Turner, MPH</strong><br>
|
||
Reference and Resource Analyst,<br>
|
||
Ripple Effect</p>
|
||
|
||
<p>To learn more about CME/CE credit offered as well as disclosures, <a href="/health-professionals-communities/core-resource-on-alcohol/cmece-general-information">visit our CME/CE General Information page</a>. You may also <a href="/health-professionals-communities/core-resource-on-alcohol/contributors">click here to learn more about contributors</a>.</p>
|
||
</div>
|
||
</div>
|
||
<div class="revised-date">
|
||
Last Revised <time datetime="2025-01-06T12:00:00Z">01/06/2025</time>
|
||
|
||
</div>
|
||
</article>
|
||
|
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</div>
|
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</li>
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<li class="usa-sidenav__item">
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<a href="/health-professionals-communities/core-resource-on-alcohol/mental-health-issues-alcohol-use-disorder-and-common-co-occurring-conditions" class="link" data-drupal-link-system-path="node/12961">Mental Health Issues</a>
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</li>
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<li class="usa-sidenav__item last">
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<a href="/health-professionals-communities/core-resource-on-alcohol/alcohol-use-disorder-risk-diagnosis-recovery" class="link" data-drupal-link-system-path="node/12966">Alcohol Use Disorder</a>
|
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</li>
|
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</ul>
|
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</li>
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|
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|
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|
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<li class="usa-sidenav__item expanded dropdown">
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<span class="nolink">Strategies for Prevention and Treatment</span>
|
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<ul class="usa-sidenav__sublist">
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<li class="usa-sidenav__item first">
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<a href="/health-professionals-communities/core-resource-on-alcohol/screen-and-assess-use-quick-effective-methods" class="link" data-drupal-link-system-path="node/12996">Screen and Assess</a>
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</li>
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<li class="usa-sidenav__item">
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<a href="/health-professionals-communities/core-resource-on-alcohol/conduct-brief-intervention-build-motivation-and-plan-change" class="link" data-drupal-link-system-path="node/12926">Conduct a Brief Intervention</a>
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</li>
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<li class="usa-sidenav__item">
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<a href="/health-professionals-communities/core-resource-on-alcohol/recommend-evidence-based-treatment-know-options" class="link" data-drupal-link-system-path="node/12921">Recommend Evidence-Based Treatment</a>
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</li>
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<li class="usa-sidenav__item">
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<a href="/health-professionals-communities/core-resource-on-alcohol/make-referrals-connect-patients-alcohol-treatment-meets-their-needs" class="link" data-drupal-link-system-path="node/12916">Make Referrals</a>
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</li>
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<li class="usa-sidenav__item last">
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<a href="/health-professionals-communities/core-resource-on-alcohol/support-recovery-its-marathon-not-sprint" class="link" data-drupal-link-system-path="node/12911">Support Recovery</a>
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</li>
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</ul>
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</li>
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<li class="usa-sidenav__item expanded dropdown last">
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<span class="nolink">Pulling It All Together</span>
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<ul class="usa-sidenav__sublist">
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<a href="/health-professionals-communities/core-resource-on-alcohol/promote-practice-change-take-manageable-steps-toward-better-care" class="link" data-drupal-link-system-path="node/12906">Promote Practice Change</a>
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</li>
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<li class="usa-sidenav__item last">
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<a href="/health-professionals-communities/core-resource-on-alcohol/how-apply-core-resource-alcohol-clinical-practice" class="link" data-drupal-link-system-path="node/14091">How to Apply The Core Resource on Alcohol in Clinical Practice</a>
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</li>
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<li><a href="/health-professionals-communities/core-resource-on-alcohol/about-core-resource-alcohol">About the Core Resource on Alcohol</a></li>
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<li><a href="/health-professionals-communities/core-resource-on-alcohol/cmece-general-information">Free CME and CE Credits – General Information</a></li>
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<li><a href="/health-professionals-communities/core-resource-on-alcohol/additional-links-patient-care">Additional Links for Patient Care</a></li>
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<p style="margin-right:-0.8rem;">For comments about the content, please contact us at <a href="mailto:NIAAACoreResource@nih.gov"><strong>NIAAACoreResource@nih.gov</strong></a></p>
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<p>For questions about CME/CE certification, please contact the Postgraduate Institute for Medicine (PIM) at <a href="mailto:inquiries@pimed.com"><strong>inquiries@pimed.com</strong></a></p>
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