The Incidence and Disparities in Use of Stigmatizing Language in Clinical Notes for Patients With Substance Use Disorder

Abstract

Objective: The language used to describe people with substance use disorder impacts stigma and influences clinical decision making. This study evaluates the presence of stigmatizing language (SL) in clinical notes and detects patient-and provider-level differences. Methods: All free-text notes generated in a large health system for patients with substance-related diagnoses between December 2020 and November 2021 were included. A natural language processing algorithm using the National Institute on Drug Abuse's "Words Matter" list was developed to identify use of SL in context. Results: There were 546,309 notes for 30,391 patients, of which 100,792 (18.4%) contained SL. A total of 18,727 patients (61.6%) had at least one note with SL. The most common SLs used were "abuse" and "substance abuse." Nurses were least likely to use SL (4.1%) while physician assistants were most likely (46.9%). Male patients were more likely than female patients to have SL in their notes (adjusted odds ratio [aOR], 1.17; 95% confidence internal [CI], 1.11-1.23), younger patients aged 18 to 24 were less likely to have SL than patients 45 to 54 years (aOR, 0.55; 95% CI, 0.50-0.61), Asian patients were less likely to have SL than White patients (aOR, 0.45; 95% CI, 0.36-0.56), and Hispanic patients were less likely to have SL than non-Hispanic patients (aOR, 0.88; 95% CI, 0.80-0.98). Conclusions:The majority of patients with substance-related diagnoses had at least one note containing SL. There were also several patient characteristic disparities associated with patients having SL in their notes. The work suggests that more clinician interventions about use of SL are needed.

Use of nonstigmatizing language is associated with improved outcomes in hospitalized people who inject drugs

“…In another large national online survey of members of the lay public, individuals described as “drug addict[s]” had higher ratings of negative affect and personal responsibility than those described as having OUD 11 . Additionally, a recent cross‐sectional study of more than 30,000 patients with substance‐related diagnoses demonstrated that 18.4% of notes contained stigmatizing language, and 61.6% of patients had at least one note with stigmatizing language 12 …”

“…11 Additionally, a recent crosssectional study of more than 30,000 patients with substance-related diagnoses demonstrated that 18.4% of notes contained stigmatizing language, and 61.6% of patients had at least one note with stigmatizing language. 12 Optimal language is a constantly moving target, but current best practices call for the use of person-centered language, for example, using the term "person with opioid use disorder" rather than "opioid addict." 13 Under the title "Words Matter," the National Institute on Drug Abuse (NIDA) has released specific guidelines concerning preferred language when discussing the evaluation and treatment of persons with a substance use disorder.…”

A qualitative analysis of stigmatizing language in birth admission clinical notes

“…No studies to date have explicitly examined stigmatizing language use in the electronic health record (EHR) related to these marginalized populations. There is an emerging area of study, however, examining stigmatizing language use in the care of people with substance use disorders (Weiner et al, 2023).…”

The Power of Language in Hospital Care for Pregnant and Birthing People

“…Demographic disparities in stigmatizing language use have been identified in the EHRs of Black and Latinx people in oncology, 17 the emergency department, internal medicine, [18][19][20] and substance use care. 21 These studies used qualitative and machine learning methods to identify categories of stigmatizing language such as stereotyping (highlighting unsophisticated terms, eg, "states the wound 'busted open'" 22 ), disapproval (eg, "patient adamantly declined weekly testing"), and questioning a person's credibility (eg, "patient claims she is having abdominal pain"). Recent research has begun to qualitatively examine stigmatizing language in the EHR in pregnancy and birth settings.…”