Fighting the Stigma of Substance Use Disorder
An Interview with Dr. Carolyn Warner-Greer
Written by Kristina Nussbaum
YWCA Northeast Indiana had the privilege of chatting with Dr. Carolyn Warner-Greer about the stigma associated with addiction. Dr. Warner-Greer, medical director at Bowen Recovery Center and a physician in their outpatient offices, works with patients that have substance use disorder.
Addiction is clinically referred to as substance use disorder. According to DSM-5, a substance use disorder (SUD) involves patterns of symptoms caused by using a substance that an individual continues taking despite its negative effects. Based on decades of research, DSM-5 points out 11 criteria that can arise from substance misuse.
Why is Substance Use Disorder (SUD) Classified as a disease?
There has been a great deal of skepticism in the community as to whether SUD is a disease or merely a choice combined with a lack of willpower. Dr. Warner-Greer explains that psychiatry uses criteria to diagnose illnesses or diseases. For example, to diagnose an individual with a depressive disorder, there are very specific criteria used. The same is true for generalized anxiety and other mental health disorders. “I don't think anyone would ever argue that those (referring to depression and anxiety) aren't medical conditions,” says Dr. Warner-Greer.
Criteria used to diagnose substance use disorder include using a substance longer than planned, consuming larger amounts than planned, and being unable to cut down or stop using. Substance use disorder also has a negative impact on relationships and life activities, so other criteria that can identify SUD includes losing interest in or failing to participate in family events, work, parenting, or other responsibilities or hobbies that were previously important to the person.
One difference between someone who uses a substance versus someone who could be diagnosed as having substance use disorder is when the individual has cravings and a growing tolerance to the substance, resulting in having to take more to get the same effect and experiencing withdrawal symptoms if they try to cut back.
As with other medical conditions, substance use disorder responds well to a combination of interventions and medicines. Clinical interventions can include individual and group therapy and living in a supportive housing environment. Education for both the patient and their family is also important. For example, if a 10-year-old was diagnosed with diabetes, the child’s family would receive education about managing the disease. The same is necessary for the family of someone diagnosed with substance use disorder.
To summarize, the criteria and diagnosis for substance use disorder is handled similarly to other medical diseases, and like other medical diseases, interventions and treatment are also needed to manage the disease and help someone live in recovery.
Why do some people get addicted to a substance, while others do not?
“If I took 10 people and exposed them all to a substance, let's say opiates, statistically 8 out of 10 would have a negative response, like nausea, itching, or sedation. These same people would say ‘no thanks’ and prefer some other form of pain relief, such as Tylenol. They also would be able to easily stop when the reason they are taking the medication has resolved,” says Dr. Warner-Greer.
Dr. Warner-Greer goes on to explain that statistically two people will have a different experience than the norm. “With opioids, people typically feel tired because the drug can act like a depressant, but people with a substance use disorder will experience a sense of euphoria or ease, and when the legitimate reasons for using the opioid are gone, they will want to continue using the drug as it affects the brain’s pleasure center.”
The brain has a pleasure center where everything that is pleasurable to us, such as eating, sex, holding a brand new baby, or being around family, causes an increase in endorphins. Opioids do that too. When people experience that sense of euphoria from a substance, their brains, at the most primitive level, want to continue to feel that way.
People with substance use disorder will go to great lengths to satisfy their primitive brain, that inner craving, because that part of the brain is telling them that they will not be okay and that they cannot function or survive without the substance. “The people around them, and even themselves, won’t understand why the higher order of their brains (their upbringing, values, etc.) cannot overcome the primitive cravings. They know that taking Grandmother’s medicine is wrong, but their most primitive brain tells them that it is necessary,” Dr. Warner-Greer explains.
What are some interventions and are medications beneficial?
When someone is affected by a psychiatric illness, whether it be a mood disorder, a thought disorder, or substance use disorder, Dr. Warner-Greer says she looks at interventions that will improve the patient’s quality of life, improve their social relationships, and help them become a contributing member of society.
“I would never argue with the principles of a 12-step program like Alcoholics Anonymous or Narcotics Anonymous as they have been around for many years, and the camaraderie of a recovery fellowship can be very valuable; however, for some people, incorporating medicines in their treatment plan benefits them,” Dr. Warner-Greer says. “We collect evidence that demonstrates the effectiveness of medicine, but we are still fighting a stigma. Before medicines were widely used, medicine was often seen as replacing one substance for another. And some people in long-term recovery would say ‘I didn’t need that medicine, so why should they?’ To be perfectly honest, that is the opinion I had 15 years ago. The way I flipped it around is they're already dependent on that medicine, so we're not creating a problem. That ship sailed a long time ago from whatever exposure they had. What I'm doing is improving their quality of life and definitely reducing the likelihood of death, which doesn't just affect that person but also affects everybody who has a connection with them.”
Substance use disorder is not an issue that affects only individuals. “The overdose epidemic has harmed families, communities, and definitely has harmed individuals, so anything we can do, that we know from a scientific standpoint will improve quality of life and longevity of life, we should do.”
“I had a wise mentor who asked me why I would want to withhold something that was going to improve a patient’s life just because it wasn't available 10 years ago,” Dr. Warner-Greer explains. “That wisdom made perfect sense to me.”
Medicines are not just for people dealing with an opioid-related disorder but can also be effective in addressing tobacco and alcohol use. Dr. Warner-Greer shares that medicines to address tobacco and alcohol use have been around for a long time. “Tobacco and alcohol, which are the two most devastating substances in our community, will rob lives and disrupt families and communities much more than opioids or stimulants or marijuana ever will, but because they're legal they don't get quite the attention.” Dr. Warner-Greer went on to state, “And in my office, these conditions get attention because I don't want someone to stop using heroin to only die of lung cancer when they are 50 years old because I never address their tobacco use.”
What is one thing you would like to change about the stigma of substance use disorder?
Per Dr. Warner-Greer, one of the reasons that people don't get treatment for very curable illnesses, such as mental illness or substance use disorder, is that for both there is a stigma associated with seeking treatment. Dr. Warner-Greer admits she still can have stigma-influenced thoughts, even when working all day, every day with patients impacted by mental illness and substance use disorder. “I always go back to what a mentor told me a long time ago. When people are doing things that seem like they're causing more problems, know that inside their head that's not what's going on. They are not intentionally causing more problems because nobody wants to live that life. Most likely, the pain that's associated with not using substances is so great that they are picking the lesser of two horrible situations. I try as hard as I can to sit in the pain that my patients have undergone, and I don't think I, or anyone, could ever really understand another person’s pain or trauma, but I do understand that substance use often is only because it's too hard to be without substances at that moment.”
Dr. Warner-Greer seeks not only to provide medical care to her patients but also makes it a priority to understand their trauma. She also says it is important to accept where they are at that moment. “We try to do everything we can to improve the social determinants of health and applaud any positive change.”
She is frequently asked, “Why would you expect anything outside of abstinence?” Her response includes, “If someone came to see me a year ago and they were using fentanyl five times a day and now they're using it once a week, that is a huge and positive change. Now, will their drug test come back negative? Probably not, but they are still alive. That's positive. We need to look at things outside of objective drug tests and, instead, say, “you have developed a relationship with your family again” or “you are parenting your children and going to work.” In the minds of my patients, they believe they are making progress and achieving stability, and that is given praise. I know that if I was working really hard on something and someone came up to me and said, “well it’s not finished so it's worthless,” that would probably not help me stay fastidious towards my goal.”
The words we use also can contribute to stigma or lessen a stigma. We don’t want to label people by their disease, just like we wouldn’t for other medical illnesses. We need to stop using words like “addict” and “unclean.” Instead, we need to say “a person with substance use disorder” or “someone who has a positive (or negative) drug test.”
“I ask people to work to change their language, and then watch the change that comes from that,” Dr. Warner-Greer says. “But, we also need to offer grace with those that are striving to change their language, learn, and adopt new vocabulary.”
For further information on this topic, YWCA Northeast Indiana suggests listening to Dr. Carolyn Warner-Greer's TedX talk “Shaming the Sick: Substance Use and Stigma”.