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Date: December 26, 2024

Reference: Steinhauser S et al. Emergency department staff compassion is associated with lower fear of enacted stigma among patients with opioid use disorder. AEM December 2024

Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus.

Case: You and your resident physician have been working hard all day taking care of patients, saving lives, and making a difference. You hear your resident groan. You ask her what’s the matter, and she says: “I just picked up a patient with the chief complaint ‘abdominal pain,’ thinking it would be a simple, bread-and-butter workup, but the patient is on methadone. I don’t feel like dealing with this at the end of my shift.” Your resident looks up at you intently, looking for answers and hoping for wisdom. You wonder what you can say to help motivate your resident the right way and bring your patient back to the center of the encounter.

Background: Opioid Use Disorder (OUD) represents a profound public health challenge, impacting millions of individuals worldwide. Defined as a chronic, relapsing condition characterized by a compulsive urge to use opioids despite harmful consequences, OUD transcends demographic boundaries, affecting individuals across all socioeconomic strata and geographies.

In the United States alone, the burden is staggering: over six million individuals were estimated to have OUD in 2022. Emergency departments (EDs) are often the first point of contact for patients experiencing opioid-related crises, ranging from overdose to withdrawal. This positions EDs as critical spaces for intervention, offering a chance to initiate treatment, provide education, and connect patients with long-term resources.

Despite this, patients with OUD frequently encounter stigma in healthcare settings, including the ED. Stigma in this context refers to the devaluation and discriminatory attitudes directed at individuals due to their condition. Such attitudes can manifest in subtle ways—disparaging comments, undertreatment of pain, or reluctance to initiate evidence-based treatments like medication-assisted therapy (MAT). This stigma not only undermines the patient-provider relationship but also discourages individuals from seeking care, perpetuating cycles of harm and disengagement.

The stigma associated with OUD in emergency settings is multifaceted, rooted in misconceptions about addiction as a moral failing rather than a medical condition. Education and empathy-focused interventions have shown promise in mitigating these biases. By fostering an environment of compassion and understanding, healthcare professionals can significantly enhance the quality of care for these patients and potentially reduce the fear of stigma, as suggested by emerging research.

Clinical Question: What is the prevalence of the fear of enacted stigma among patients who present to the ED with OUD, and is experiencing greater compassion from the ED staff associated with lowering this fear?

Reference: Steinhauser S et al. Emergency department staff compassion is associated with lower fear of enacted stigma among patients with opioid use disorder. AEM December 2024

  • Population: Adult patients with diagnosed OUD presenting to an academic ED between February and August 2023.
    • Exclusions: Patients unable to consent, non-English speakers, prisoners, acutely psychotic patients, critically ill patients, those suffering from dementia and those without a definitive diagnosis of OUD.
  • Intervention: NA
  • Comparison: NA
  • Primary Outcome: The level of fear of enacted stigma, measured via the 9-item subscale of the Substance Abuse Self-Stigma Scale. The subscale consists of items rated on a 5-point Likert scale. Scores range from 9 to 45, with higher scores indicating greater fear of enacted stigma.
  • Type of Study: Survey-based, observational.

This is an SGEMHOP, and we are pleased to have the lead author, Savannah Steinhauser, on the show. Savannah is a 4th-year medical student at Cooper Medical School in Camden, NJ and is applying to internal medicine for residency. She has experience working with people with OUD both during clinical rotations at Cooper Hospital and with clients with the organization she founded called CMSRU Outreach Alliance. It organizes weekly outreaches on the streets in Camden.

Authors’ Conclusions: “Among ED patients with OUD, fear of enacted stigma is common. Patient experience of compassion from ED staff is associated with lower fear of enacted stigma. Future research is warranted to test if interventions aimed at increasing compassion from ED staff reduce patient fear of enacted stigma among patients with OUD.”

Quality Checklist for Observational Studies:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? No
  4. Was the exposure accurately measured to minimize bias? NA
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Unsure
  7. Was the follow-up of subjects complete enough? NA 
  8. How precise are the results? Fairly precise and 95% Confidence Intervals were provided
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study: Supported by the Camden Coalition
  13. Conflicts of Interest: “CWJ has no competing interests related to this work, though he has been an investigator on studies funded by AstraZeneca, Vapotherm, Abbott, and Ophirex. ST has co-authored two books on compassion. He donates his book proceeds to the Cooper Foundation and has received payments for speaking engagements related to the books.”

Results: The study cohort consisted of 116 individuals. The median age was 42 years, 36% were female and 60% white/Caucasian. Over half (59%) reported IV opioid use, 85% gave a history of polysubstance use and 57% were current or prior methadone users.

Key Result: Increased compassion correlated with a lower fear of enacted stigma.

  • Primary Outcome: Score on the Substance Abuse Self-Stigma Scale.
    • The median score was 23, with an interquartile range (IQR) of 16–31. This indicates a moderate-to-high level of perceived stigma.
    • Nearly all participants (97%) reported some degree of enacted stigma (score >10).
    • Patient experience of greater ED compassion was independently associated with a lower fear of enacted stigma, β = −0.66 (95% CI −1.03 to −0.29)
    • This suggests that every 1-point increase in the 5-item compassion measure score is associated with a 0.66-point decrease in the fear of enacted stigma score.

We asked Savannah five nerdy questions. Listen to the SGEM podcast to hear her responses.

1. Single-Site: A single-centred study inherently limits generalizability because it focuses on a specific population, environment, and practices. The study center often reflects the demographics, socioeconomics, and cultural factors unique to the study location. In addition, practices at that ED may differ significantly from those at other institutions. 

2. Convenience Sample: Data was collected between 2 pm and 9 pm from February to August. The patients included in the study may not fully represent the broader population of individuals with OUD who visit EDs. We recognize convenience samples are common in ED research, but it does introduce selection bias. Would the results be different if patients were recruited 24/7/365? 

3. Exclusions: Three of the groups that were excluded from the cohort were non-English speakers, prisoners, and acutely psychotic patients. These groups also can have a stigma attached to them. How do you think including these people would have impacted the results of your study? 

4. Response Bias: Several types of response bias could have played a role in this study. These include social desirability bias (participants may underreport experiences or feelings perceived as socially undesirable), recall bias (patients may misremember or distort events, particularly if their ED visit was emotionally charged, leading to inaccurate reporting of either stigma or compassion), and acquiescence bias (some participants might consistently agree with survey items regardless of their actual beliefs, especially if they find the questions ambiguous or wish to avoid conflict). 

5. Hawthorne Effect: Were the ED staff aware of this study? If ED staff knew their interactions with patients were being evaluated for compassion and its impact on stigma, they might have consciously or unconsciously provided more compassionate care. This could inflate the observed levels of compassion reported by patients, potentially skewing the results. 

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusion.

SGEM Bottom Line: There is fear of enacted stigma amongst patients with OUD. Increasing compassion seems to decrease fear of enacted stigma amongst OUD patients, particularly the ones who are presenting to the ED primarily for an OUD-related complaint.

Case Resolution: You look at the resident, smile, and validate their feelings. They are human and can have feelings across the entire spectrum of emotions, but it’s important to take note of these feelings and how they may impact their patient care. You encourage them to read the new study that was just published on how patients with a history of opioid use disorder commonly have a fear of enacted stigma, especially the patients who are presenting for OUD-related complaints. This study also suggests increased compassion amongst the ED care team can decrease this fear. You encourage the residents to tap into the empathetic side of their humanity when caring for patients to help navigate their feelings. The resident takes a deep breath, says thank you for the information and perspective, and proceeds to take excellent care of the patient before signing them out to the overnight team!

Dr. Suchi Datta

Clinical Application: The next time you and your team are caring for an OUD patient in the ED, reflect on how they may fear enacted stigma and how being more compassionate can help decrease this fear.

What Do I Tell the Patient? Not much. However, you discuss with the resident, other colleagues and staff how patients with OUD are fearful of being subjected to enacted stigma by the ED staff. You remind them that the ED is a light in the house of medicine, with an ever-shining ray of hope, always open to help all, particularly the more vulnerable and hopefully without judgement. By being more authentically compassionate, we can decrease the fear of enacted stigma amongst our patients who have battled the opioid crisis.

Keener Kontest: Last week’s winner was Brian Caldwell. He knew the first IO site was the sternum. Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.

SGEMHOP: Now it is your turn, SGEMers. What do you think of this episode on OUD? Tweet your comments using #SGEMHOP. What questions do you have for Savannah and her team, ask them on the SGEM blog. The best social media feedback will be published in AEM.

Other SGEM Episodes on Opioids:

  • SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department)
  • SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain
  • SGEM#241: Wake Me Up Before You Go, Go – Using the HOUR Rule
  • SGEM#374: Bad Habits – Medications for Opioid Use Disorder in the Emergency Department
  • SGEM#407: Here We Go Test Strips for Fentanyl
  • SGEM#453: I Can’t Go For That – No, No Narcan for Out-of-Hospital Cardiac Arrests

REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.