Reducing the stigma of substance use disorder (SUD) in vet med

By Kristen Green Seymour, AAHA Copywriter - 9/23/2023

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Phil Richmond, DVM, CAPP, CPHSA, CCFP, is on a mission to reduce the stigmatization of substance use disorders (SUDs).

It’s a topic that’s come up in the veterinary community as of late, thanks to a new requirement by the US Drug Enforcement Agency (DEA) for providers in human medicine to complete a one-time, eight-hour training on the treatment and management of patients with opioid or other SUDs. Veterinarians are exempt, but many received notifications anyway.

And it begged the question—should the veterinary community receive more training in SUDs?

Richmond believes so, and that’s both a personal and a professional opinion.

Phil’s story

“I’d graduated in ’06, so in 2008 I was a relatively new veterinarian. I’m working maybe 70 or 80 hours a week. I’m working on my days off, then I’m trying to pick up emergency shifts, working every Saturday, that sort of thing,” he said, noting that his job didn’t ask this of him. “That was self-imposed burnout.”

And he dealt with that burnout in the only way he knew how.

“From the time I was 15, the tool I had in my toolbox was alcohol—to address that screw in my chest that would tighten up, the impostor syndrome, the perfectionism, those types of things,” he said.

And it worked—until it didn’t anymore.

How SUDs show up in healthcare

“We know that, at some point in their career, 10 to 15% of medical professionals are going to meet criteria for alcohol or substance misuse,” said Richmond.

And according to a 2022 self-reported survey, one out of seven physicians reported they were either drinking or taking substances while at work.

While there’s far more research on this regarding healthcare providers in the realm of human medicine than veterinary medicine, the fact is that veterinary professionals share similar knowledge of and access to various prescription drugs. (Take xylazine, for example.)

Clearly, SUDs among health care professionals are common. What Richmond wants to know is, “Why the stigma?” While the stigma around mental health as a whole is changing for the better, the stigmatization of alcohol use and substance use disorder remains strong, even amongst healthcare professionals, largely due to a lack of public understanding about the root causes.

Addiction and adverse childhood experiences (ACEs)

Researchers have found a very close connection between adverse childhood experiences (ACEs) and chronic health problems, mental illness, and substance use problems in adolescence and adulthood.

The assessment called the ACEs test uses 10 questions about a person’s experiences under the age of 18 to determine ACEs. They include things like whether anyone in the home verbally, physically, or sexually abused them; whether they had enough food to eat or enough money; had a parent with mental illness or substance use disorder; or experienced parental separation or household members being incarcerated.

“If we have four or more of those, we’re 7–10 times more likely to have an alcohol or substance use disorder,” Richmond said. “We’re seven times more likely to have ADHD; six times more likely to have depression; six times more likely to have generalized anxiety disorder; and 32 times more likely to attempt to take our own life.”

In considering these ACEs, Richmond said that it’s important to consider the way the trauma is framed. “Instead of asking, ‘What’s wrong with you?’ can we instead ask, “What happened to you?’” he suggested. “Giving that person grace and understanding that the behavior may be a result of something hugely traumatic and impactful that that individual had no say in as a child that affects their life moving forward.”

This is something he knows from experience.

“My dad likely had bipolar disorder, he had alcohol use disorder, and there was violence in our home,” he said. “I will also say that my father did the best he could with the tools he had; he didn’t get the opportunities I had to recover.”

Today, Richmond knows how fortunate he was to have access to help, but back in 2008, that was far from the case.

Not exactly news

Is this connection news to you? It shouldn’t be.

“This big study came out in 1999 and was sponsored by the CDC and Kaiser,” Richmond said, “but just now is this connection being taught in medical schools. And that’s amazing, because in veterinary medicine, if we have anything that creates a 7–10 times higher risk, we’re all over that!”

“In fact, the CDC epidemiologists say they’ve never seen something so correlated with disease [as] childhood trauma,” he said.

The researchers found that 64% of US adults reported at least one ACE before their 18th birthday; 12.4% of Americans have four or more of those ACEs.

Richmond is one of them, scoring six out of 10 on the ACEs test.

Barriers to seeking treatment

By 2008, when he was fully experiencing burnout, he was drinking every night. “I was in this challenging spot. So why didn’t I ask for help when I knew, in my mind, I couldn’t stop? Because I couldn’t ask for help. I couldn’t show weakness,” he said.

If he’d had cancer, or diabetes, or any number of diseases, he knows he would’ve sought treatment immediately.

“But this?” he recalled thinking, “If I have this, it’s a moral failure. It’s weakness.”

Plus, there was the very real fear of having his license revoked.

“When I did the licensing exam for the state of Florida to become a veterinarian, there were specific questions asked, like, ‘Are you addicted to alcohol or narcotics?’” he recalled. “I know why they were asking that. It’s a fitness-to-practice question.” But, Richmond said, the language around those questions matters.

With the way those questions were worded, he said, “There’s no way in hell we’re ever going to answer honestly!”

Why we lie about drug and alcohol use

A 2017 Mayo Clinic study backs that up; nearly 40% of physicians in states with questions about mental health on their licensure applications reported that, due to concerns about repercussions to their medical licensure, they’d be reluctant to seek formal medical care for treatment of a mental health condition.

“They found that in states where physicians had those types of questions around mental illness, they were 40% less likely to seek treatment. And the only difference was just that those questions were on the licensing exam.”

Richmond has since worked with a group to have that language stricken from the application in Florida, but that didn’t help him back in 2008, when he was scared out of his mind, wondering how he’d get through the day, let alone the next 30 years.

“Thank goodness my colleagues recognized what was going on with me,” he said, “and the difference was that they knew what resources were available.”

Helping each other get help

Specifically, a veterinarian he’d worked with in vet school knew about programs (like those found through the Federation of State Physician Health Programs) that protect veterinarians and their licenses.

“It’s an illness, you know?” he said. “If I can get treated, I will be OK.”

Being referred to a program saved his life, Richmond said. “I got into treatment, I got into 12-step recovery, and I learned a bunch of tools that helped me love veterinary medicine again. And about five or six years ago, I got more active on a state and national level.”

Treatment and a monitoring program have been shown to be incredibly successful in physicians, he added: “78% of physicians have no return to alcohol or substance use during five-year contract; 72% return to practice,” he said.

“These are fantastic numbers with regard to treatment of a chronic condition: Diabetes and hypertension, for example, do not have treatment success numbers like this.”

Words matter when talking about SUDs

Not everyone is in the position to work like Richmond to influence policy makers and fight for change at state and national levels, but we can all pay attention to the language we use.

“What we know is those words matter,” Richmond said.

The Substance Abuse and Mental Health Services Administration (SAMHSA) explains that the language used to discuss SUDs—especially by healthcare providers—can either increase or decrease SUD stigma.

Stigmatizing language often stems from two factors, according to SAMHSA: perceived control that a person has over the condition, and perceived fault of the person for acquiring the condition. This is why, with a disease we know a person has little to no control over, such as pneumonia or cancer, we’re unlikely to attach stigma to the person or the disease.

With other conditions like SUDs or mental health conditions, people mistakenly believe these are within an individual’s control—and judgment becomes stronger when an illegal substance is part of the equation.

How language impacts treatment

With this in mind, it’s easy to see why avoiding words like addict, alcoholic, or substance abuser makes a difference: These words put a sense of blame on the person, whereas using language that recognizes an SUD as a medical condition creates a sense of compassion. And, while blame leads to a punitive measures, compassion invites therapeutic solutions.

It can feel risky to acknowledge you have a problem and ask for help—especially if it’s not clear what the consequences will be.

Richmond has seen zero-tolerance policies that say, if something happens that’s alcohol-related, the individual will be fired—there’s no second chance and no offer of treatment.

“We can’t force someone to get help,” he said, but when he sees language like that, he urges the decisionmakers to reconsider.

“One of the hallmark signs of addiction is that we’re defensive,” he said. “But why are we defensive? Because of the stigmatization, because of the punitive nature of treating the condition.”

Removing that stigma doesn’t only provide more space for those affected to seek help, but for their colleagues to speak up.

“We have a lot of data from human medicine, and 95% of physicians agree that they have an ethical obligation to intervene,” he said. In some states, veterinarians also have a legal duty to report.

“As far as physicians go, 95% agreed that they have an ethical obligation, but only two-thirds of them potentially would intervene appropriately,” Richmond said. And that’s just in a hypothetical situation.

“The thing is, once we actually see people affected at work, that is essentially the end stage,” he said. “With professionals—and I can relate to this 100%—the job is the last thing we hold onto. Our relationships have gone by the wayside. Self-care has gone by the wayside.”

For those who wonder why people with SUDs don’t just stop, Richmond offers some helpful insight.

“No one in that situation is picking up a drink for the first time and going to work. They didn’t just all of a sudden make that decision,” he said.

“In the brain of an individual with SUD, the frontal cortex gets bypassed, he explained. “There isn’t rational thinking—the reward center hijacks the thought process and it’s just overwhelming.”

As for simply stopping, he added, “Most of us have thought 1,000 times, ‘Yes, I’m going to! With every fiber of my being, I’m going to stop.’ But we can’t do it by ourselves.”

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