This year’s hit medical TV drama, The Pitt, is a worthy successor to those previous fan favorites, ER and Grey’s Anatomy. From its first dramatic moments, we experience a chaotic 15-hour shift in a Pittsburgh emergency room. The doctors, nurses and other medical staff do their best to serve a diverse clientele, regardless of medical diagnosis. Meanwhile the hospital administration is breathing down their necks to increase patient satisfaction scores.
Even those in medicine describe the show, which just received several Emmy awards, as realistic. But one area where it doesn’t match my real-life experiences is how medical providers treat people with substance use disorder, and the stigma that lies therein.
The Pitt immediately transported me back to my own medical trauma with my son Alex. We spent years trying to save Alex, first from anorexia, and then again from addiction. Alex died from a heroin overdose in May 2015. He was 25.
Over a period of years he resided in multiple ERs, hospitals, rehabs and sober living homes, in New Jersey, Connecticut and Florida. At pivotal times, medical providers could have helped him, and we are thankful for those who did.
Where we hoped for empathic support, we found doctors and nurses chastising Alex for his “bad choices” and “lack of will power.”
But more often, they failed him. Where we expected caring attention, there was judgment. Where we hoped for empathic support, we found doctors and nurses chastising Alex for his “bad choices” and “lack of will power.”
“First do no harm” was not the mandate. Stigma came first. We learned firsthand the effects of what I call treatment trauma.
Why did Alex end up an overdose statistic? We never gave up on him, but felt increasingly helpless as we watched him circle the drain of death.
Alex wasn’t alone. The Centers for Disease Control and Prevention reported that 49,293 people died of overdose during the 12 months prior to that terrible May 2015. Back then most deaths involved heroin. But with fentanyl on the rise, the rolling 12-month total of overdose fatalities reached its peak eight years later, with 111,466 deaths reported in June 2023.
It’s useful to examine whether stigma-induced treatment trauma in addiction medicine differs from experiences around other conditions. Our first traumatic medical experience arrived when Alex was hospitalized with an eating disorder at 12 years of age.
Then, The Pitt was our reality. Our pediatrician, and the pediatric cardiologist we consulted, were alarmed by Alex’s low heart rate. When he refused to eat, we took him to the ER, where a multidisciplinary team—pediatrician, dietician, psychiatrist, endocrinologist, social worker and many nurses—worked successfully to address his medical needs. They worried with us that if Alex had a heart attack, they wouldn’t be able to bring him back. And just like Dr. Robby in The Pitt, the ER workers were brilliant, effective and compassionate. Alex was stabilized and transferred to an eating disorder unit, where medical providers literally saved his life.
Opioid-involved overdoses were bound to be among the medical crises The Pitt profiled. When 18-year-old college student Nick died after ingesting fentanyl-laced “Xanax,” the doctors and nurses worked with his parents as they struggled to understand how their son could be alive and healthy one day, and gone the next. The staff assembled an “honor walk” as Nick’s parents left the ER to donate their son’s organs. Among those who also overdosed but survived that day were an acquaintance of Nick’s who used from the same batch, and a successful businessman, in town to celebrate his daughter’s wedding.
At the facilities Alex resided in, he was simply an “addict.”
What struck me in all three scenarios was the lack of stigma directed at those who ingested illicit drugs. The caring practitioners viewed themselves as responsible for helping people who use drugs. They even recognized substance use as reflecting societal factors, and not merely individual choice.
Like Nick, Alex had many protective privileges. He was upper middle-class and white; educated, with a BS in biology, a minor in computer science and honors in Latin. He was in a graduate program in science and business when he died. He also had a community of self-described best friends, and parents who loved him. He hadn’t been abused, and suffered none of the usual traumas health care providers use to account for drug use. But despite his privilege, Alex ended up isolated and alone. And at the facilities he resided in, he was simply an “addict.”
In searching for answers, I was unable to find satisfactory explanations for why addiction devastated our family. Common and contrasting arguments hold either that people with substance use disorder choose to keep using drugs of their own volition, or else that they suffer from a brain disease that renders them powerless.
I view both these explanations as reductive and personalistic. As a sociologist, I know that individual choice occurs within social contexts that include precursor conditions such as psychological issues (eg, anxiety, depression, trauma), or socioeconomic issues (eg, unemployment, poverty, incarceration, racism). Amid a widespread crisis,we need to move beyond personalistic to systemic responses.
Medical provider stigma is among those systemic factors generating treatment trauma that in Alex’s case accelerated his downward spiral. Since the brilliant work of Erving Goffman, sociologists have described stigmatization as the process whereby the mark of stigma affects the lives of those affected. This progression is social because it occurs through interactions with people of different status and power. While stigma operates in multiple institutions, its role in medical care is especially pronounced, insidious and devastating.
Alex resided in many medical facilities, and in nearly all of them he encountered stigma, sometimes mundane and other times stark. Stigma affected us as well; sociologists call that courtesy stigma.
Sadly, it was often doctors, nurses and other medical professionals who berated, shamed and labeled Alex. It happened in the many ERs and detoxes where Alex recovered from overdoses, and in the rehabs he attended. More than once, I overheard nurses lecturing him about his “choices.” I mostly pretended not to hear, but the stigma stuck.
Alex’s psychiatrist described him as being “a drug addict without much insight, who may either be a psychopath or a pseudo-psychopath.”
The most egregious stigma Alex encountered was at a well-known psychiatric facility. Given its programs on mental health, substance use and eating disorders, the hospital seemed perfect. In addition to Alex’s substance use, the anorexia he’d struggled with as a preteen had re-emerged with a vengeance, and this time included bulimia.
As his medical heir, I had full access to medical information from nearly every facility in which Alex resided, including notes from admissions interviews, facilitators of groups and residence staff. I saw progress notes and assessments from Alex’s psychiatrists, social workers and other medical staff.
Alex’s medical records provide the truth of what he experienced during his short month in the psychiatric facility, in the exact words of his medical providers. I watched his frustration build over the course of his treatment.
Within the first week, his psychiatrist reported on Alex’s “drug-seeking behavior,” “lack of engagement,” and “denial.” Alex also had a run-in with his social worker; he asked to switch to someone else, a request that was denied.
By the beginning of his second week, Alex’s psychiatrist described him as being “a drug addict without much insight, who may either be a psychopath or a pseudo-psychopath. He may also be developing a subtle psychotic illness, possibly due to his drug use … I hope there is more substance to him than that. I hope he is salvageable.”
Five days later, the psychiatrist described how he lectured Alex to stop “acting like a drug addict,” be less needy, tolerate discomfort and start being “nice,” along with a little name-calling (“sociopath”) thrown in for good measure.
It was clear that before the program was half over, Alex’s medical providers had already given up on him. Once he clashed with his social worker and psychiatrist, his progress stalled. It’s useful to point out that the labels his psychiatrist used are not in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the gold standard for psychiatric diagnoses. Nonetheless, those labels stuck.
Is it too much to have wanted Alex to have medical staff like those at The Pitt? If he had, he might be alive today.
The trained professionals charged with Alex’s care resorted to blaming him, labeling him and then writing him off. The psychiatrist’s early view that “he may not be able to gain very much from this program” became a self-fulfilling prophecy. This psychiatric hospital provided a substance use program inflexibly wedded to 12-step methods applied in cookie-cutter fashion—a case of nonrecovery in action. This program failed him, just like every other one. Perhaps not surprisingly, two days after returning home, Alex began using drugs again.
Another example of treatment stigma occurred during Alex’s stay at a Florida ER a few weeks before he died. After leaving his last sober house, Alex walked to an urgent care facility where he received prescriptions for 90 Xanax and 30 Ambien tablets. He washed many of those down with alcohol from a nearby liquor store and wound up incoherent and delirious at the local ER.
Getting prescribed that boatload of medicines was ethically problematic enough. But once he arrived at the ER, he found judgment, not compassion.
It’s understandable that medical providers who deal daily with overdoses must be jaded and weary. But the staff complained about having to care for him. They wanted him to leave so the bed could be used for “someone who needed it.” One of his nurses said, “I’m tired of being his babysitter, I will not give him more food.”
Is it too much to have wanted Alex to have medical staff like those at The Pitt? If he had, he might be alive today.
Perhaps it’s not surprising that medical providers stigmatize. After all, they are like the rest of us, so they often make moral judgments when they should be making prognoses and decisions based on science. It’s not that the providers who cared for Alex were bad people. Perhaps unwittingly, they relied on culturally induced assumptions of personal responsibility instead of their scientific knowledge.
Learning what happened to Alex and so many others can help medical providers develop effective strategies to reduce treatment trauma.
What would substance use treatment without stigma look like? If writers of hit TV shows can imagine it, our medical institutions should be able to do so as well.
One important goal of public health strategies is to ensure that clinical education and practice consciously recognize and reduce harmful stigma. We must mandate and fund standardized addiction and stigma training for all medical providers. Would-be providers need to know that these disorders are treatable, and that harm reduction strategies work.
In clinical settings, reducing overdose requires wider use of evidence-based medications for opioid use disorders (MOUD). Currently only one in five patients with opioid use disorder receive MOUD. We need to think creatively about how to better use powerful tools like buprenorphine. Along with greater access to treatment services, we need community harm reduction efforts, with increased naloxone, drug checking and overdose prevention centers, to reduce the risks and stigma associated with drug use. Among other locations, harm reduction services should be embedded within hospital emergency departments.
Because there are multiple roads to addiction, there must be multiple paths to recovery. Abstinence programs work for some, but not for all. Alternative approaches must be widely researched and made available through insurance.
We must steer a course toward public health policies and practices based in compassion and empathy. Unfortunately, these aspirations face fierce headwinds from the Trump administration.
Lack of insurance limits treatment, as does the absence of insurance parity. People with opioid use disorders should have equal access to physical and mental health/substance use treatment, as federal law requires. That necessitates enforcing the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) through stricter oversight and penalties for providers who fail to comply. And ultimately, of course, we need to move toward universal health care.
We must steer a course toward public health policies and practices based in compassion and empathy. By February 2025, the annual number of overdose deaths had dropped to 76,298—a fall many experts attribute to a limited but meaningful shift from criminal-legal responses to drug use, to those rooted in public health.
By decriminalizing and regulating drugs, and by providing resources and treatment without judgment, we could much more rapidly reduce the risk and harm associated with drug use. When research shows that harm reduction is effective in preventing overdose deaths, why would we continue to resort to punitive approaches?
Finally, along with people who use drugs, their families and loved ones are also made to suffer in the current environment. But families and other networks serve as critically important support mechanisms. Their efforts must be supported.
Unfortunately, these aspirations face fierce headwinds from the Trump administration, which has, among other things, cut Medicaid, decreased grants to state and county health departments, reduced SAMHSA staff and closed offices, eliminated the only nationwide survey on substance use and mental health, and ramped up the drug war.
They aim to eliminate harm reduction itself. SAMHSA’s recent dear colleague letter and strategic priorities explicitly refuse funding for harm reduction and safe consumption efforts, strategies that have unequivocally proven successful in saving lives.
Robert F. Kennedy Jr., the current Health and Human Services (HHS) secretary and self-described “addict,” is critical of much of the recent research on mental health and substance use disorders. He supports deep and ongoing cuts for his agency. To treat addiction, Kennedy argues for wellness farms, where clients will be “re-parented” with no treatment medicines and no medical providers. Even antidepressants would be unavailable.
Policymakers cannot languish in such outdated fantasies of fixing individual choice. Policies that address systemic issues and make drug use safer are already saving lives. Those policies must remain our lodestar.
Top photograph (cropped) by Jacob Windham via Wikimedia Commons/Creative Commons 2.0. Inset photographs courtesy of Patricia A. Roos.
