A new national study from Columbia University Mailman School of Public Health, with colleagues at the University of Miami Miller School of Medicine, University of Chicago, National Opinion Research Center, and Emory University finds that stigma toward patients with substance use disorders (SUD) remains widespread among U.S. healthcare providers—and varies significantly across types of substances. The findings are published in the journal Addiction.
The study is the first national analysis to compare provider stigma across opioid (OUD), stimulant, and alcohol use disorders (AUD) with other chronic but often-stigmatized conditions like depression, HIV, and Type II diabetes. Researchers also assessed how stigma influences whether providers screen for SUD, offer referrals, or deliver treatment.
"While we've made progress in expanding access to evidence-based SUD treatment, stigma remains a profound barrier—often embedded in the clinical encounter itself," said Carrigan Parish, DMD, PhD, assistant professor in the Department of Sociomedical Sciences at Columbia Mailman School of Public Health. "Our findings show that many providers still feel uncomfortable treating patients with substance use disorders and that hesitancy leads directly to missed opportunities for care. In particular, emergency departments often serve as the first—and sometimes only—point of care for people with substance use disorders. We need to leverage those moments, not miss them."
The study, conducted from October 2020 to October 2022, surveyed 1,081 primary care providers (PCPs), 600 emergency medicine providers (EMPs), and 627 dentists using a nationally representative random sample licensed from the American Medical and Dental Associations. Participants rated their agreement with 11 standardized stigma statements and reported their screening, referral, and treatment practices for six conditions: three SUDs (opioids, stimulants, alcohol) and three comparison medical conditions (Type II diabetes, depression, HIV).
Key findings:
- Stigma score toward stimulant use disorders was highest (36.3 points, followed by OUD (35.6 points) and AUD (32 points).
- For comparison, stigma scores were far lower for depression (26.2 points, HIV (25.8 points), and Type II diabetes (23.2 points), where providers also reported higher levels of compassion and treatment.
- More than 30 percent of providers said they prefer not to work with patients with OUD or stimulant use disorders—compared to just 2 percent for diabetes, and 9 percent for both HIV and depression.
- Emergency medicine physicians (EMPs) expressed the highest levels of stigma toward SUD, yet were also the most active in providing clinical care:
- 28.4 percent reported providing drug use treatment
- 27.2 percent prescribed medications for opioid use disorder (MOUD) compared to just 12 percent and 10 percent of primary care physicians (PCPs) for drug use treatment and prescribing medications, respectively.
- Dentists reported the lowest stigma levels toward all queried conditions—which may be due to greater clinical and moral distance from SUD treatment and viewing SUD-related practices as outside their scope of practice
- Stigma scores did not significantly differ by provider race, age, gender, region, or rurality, indicating that these attitudes span the healthcare workforce
"Overall, providers were less likely to feel they could effectively help patients with stimulant or opioid use disorders. In fact, 22 percent of providers said, 'there is little I can do to help patients like this'—a response we almost never saw for other conditions," said Daniel Feaster, PhD and professor of Biostatistics and one of the lead investigators at University of Miami.
"This isn't just a matter of attitude—it's about access. If a provider doubts treatment efficacy or holds stigmatizing beliefs, they're less likely to screen or refer a patient. That becomes a system failure."
The study also highlighted key institutional barriers that may reinforce stigma, including:
- Time constraints
- Lack of training
- Limited referral resources
- Discomfort discussing SUD with patients
- Legal concerns
- Minimal privacy in clinical settings
Senior author Lisa R. Metsch, professor of Sociomedical Sciences at Columbia Mailman School and Dean of the School of General Studies at Columbia University added, "We heard over and over that providers feel unequipped or unsupported to treat SUD—despite being on the frontlines. That's especially true in primary care settings, where time pressures and limited resources are a daily challenge." Metsch also added, "Notably, the majority of health providers agreed that insurance plans should cover patients with SUD at the same degree as they cover patients with other health conditions."
Dentists, although typically less involved in treating SUD, are well-positioned to recognize oral signs of substance use and refer patients to appropriate care—but they, too, face gaps in training and systemic support.
"Going forward, we should strive to be more cognizant of the many treatment and provider roles we have distinguished in this study. By unpacking all the variations, we can start to build smarter interventions—tailored by specialty, setting, and substance," said Parish.
Other co-authors are Viviana E. Horigian, University of Miami Miller School of Medicine; Harold A. Pollack, University of Chicago School of Social Work; Xiaoming Wang and Petra Jacobs, National Institute of Drug Abuse; Christina Drymon and Elizabeth Allen, National Opinion Research Center; Carlos del Rio, Emory University School of Medicine; and Margaret R. Pereyra and Lauren Gooden, Columbia Mailman School.
The study was supported by the National Institute on Drug Abuse Treatment Clinical Trials Network, grant 5UG1DA013720-23.
Columbia University Mailman School of Public Health
