Three Ways I’ve Witnessed Damaging Stigma Around Opioids Being Taught to Nursing Students

A nurse attends to an infant in the neonatal intensive care unit of the Holtz Children's Hospital at Jackson Memorial Hospital in Miami September 30, 2013. The Obama administration accelerated its push to persuade individual Americans to sign up for the most extensive overhaul of the U.S. healthcare system in 50 years, the Affordable Care Act (commonly referred to as "Obamacare"), even as the program's foes in Congress fought to delay its launch with the threat of a federal government shutdown. The Jackson Health System is the largest in Florida and one of the largest in the U.S.  REUTERS/Joe Skipper (UNITED STATES - Tags: HEALTH) - RTR3FGC6
Apr 07 2016

Three Ways I’ve Witnessed Damaging Stigma Around Opioids Being Taught to Nursing Students

I’m slogging through a master’s in nursing school right now. It’s a place that could be a bastion of radical action to make the world fairer. Instead, it is undergirded by many of the same prejudices as society in general.

Both my personal and working backgrounds—I previously worked in a homeless shelter for queer and trans youth, where my work was rooted in a harm reduction framework—have brought me into close contact with people who use drugs, and the great harms caused to them by the drug war.

This has felt even more pertinent in nursing school over the past 18 months, as I hear first-hand the stigmatizing messages being taught to key health providers from a place of authority. It breaks my heart, but more than that it biases a new generation of nurses. For a profession that prides itself on using evidence-based practices, this is a depressing reality.

The problem is pervasive, but I’ll focus for now on three areas of stigma around opioids:

Opioids for Labor

While being taught about pain management during labor and delivery, my entire class (about 60 future nurses) was reminded, “When you’re giving pain medication, remember that you’re medicating two patients at once. You have to balance the comfort of the mother and the health of the baby; you have to weigh one against the other.”

My professor asserted, with no small degree of emotion, that babies were much smaller than the people bearing them, and would thus be much more strongly affected by a similar opioid dose. We were also told that, although naloxone is kept in delivery rooms, it isn’t often used to correct for opioid-induced respiratory depression immediately post delivery “because its metabolites in the liver of an infant are also central nervous system depressants.” But this isn’t the end of the story.

Later, in the same lecture, she noted that when naloxone is used to enable infants to breathe after parental opioid use, the nursery would be able to manage the side effects. I was left feeling a deep resentment that we were told to withhold pain management for fear of complications that could be managed by a nursery post-partum. Sure, it might not be ideal for a nursery to need to manage those complications, but the parent should be given the relevant information and allowed to make their own choice.

To characterize something manageable as a legitimate reason to withhold pain medication is born from and reinforces drug-war stigma—the idea that opioids are invariably harmful and that there is no way to mitigate any negative impacts of their use.

Opioids and Babies

In the same conversation, we were told that babies born after opioids were used throughout pregnancy would be born dependent and go through horrible withdrawal, and that this is something a parent would be remiss not to protect their unborn child from.

While it’s true that opioid exposure in utero can lead to newborn withdrawal, it’s not some hideous, immutable end-game. It’s actually (again) very manageable—if providers are aware that opioids may, sometimes, be the cause of symptoms such as sleep-wake cycle difficulties or seizures. In fact, it’s managed much as that people who use opioids manage their own withdrawal, by giving things like more opioids and sedatives and slowly titrating down.*

Treatment only becomes possible when providers are made aware of the drug use; the best way to achieve that awareness is through open, destigmatized conversations about drug use. People won’t be honest if they know they are being judged and that treatment will be withheld. It’s not the drugs themselves that cause all the harm here; much of it can be attributed to the ways in which provider stigma structures care.

I cannot count the number of times, even in the last several weeks, that I’ve heard nurses say something to the effect of “I want to make the best decision for the baby.” The best decision for the baby is always to provide pregnant people with the best possible constellation of resources.

Double Standards in Pain Assessments

Relatedly, when I was shadowing a nurse on a post-partum unit the other day, I heard her remark, “I tell people their pain doesn’t need Norco unless they had a C-section.”

There’s no doubt in my mind that this position is rooted in drug-war politics. Opioids are as stigmatized as any other drug; I cannot count the number of times I’ve observed nurses and doctors questioning whether their client really needs it, especially if they know or suspect non-prescription drug use. This skepticism is seldom raised when people are requesting pain medications that don’t also result in euphoria—which suggests that it is simply based in a pervasive, stigma-based disbelief of the patient.

The result is a withholding of medication that is the gold standard for pain. And guess what? I see these judgments exercised disproportionately against patients who are already marginalized: poor people, people of color, and people with mental health diagnoses.

*Kuschel, 2007; Osborn, Jeffery, & Cole, 2005


 

Sources:

Kuschel, C. (2007). Managing drug withdrawal in the newborn infant. In Seminars in fetal and neonatal medicine(Vol. 12, pp. 127–133). Elsevier.

Osborn, D. A., Jeffery, H. E., & Cole, M. J. (2005). Sedatives for opiate withdrawal in newborn infants. Cochrane Database Syst Rev, 3.

Soma Navidson studies and works in health care; she’s rooted in harm reduction and primarily focuses on housing justice, prison abolition, queer and trans liberation, and fighting the drug war. Some of her thoughts on nursing and the medical-industrial complex can be found at her blog: nursingroar.tumblr.com.

  • April Smith

    Great article!