Stigma toward SUDs comes from many sources including society, individuals living with SUDs themselves, their families, and healthcare professionals (6). Many factors can play a role in perpetuating this stigma, especially the longstanding societal view of addiction as a personal or moral failure (6, 7). In different societies and cultures, it is not uncommon for the community to label individuals with SUDs as worthless, weak, dangerous, criminals, incapable of holding jobs or forming families, and having deliberately chosen addiction. Some specific stereotypes faced by individuals with SUDs can be related to disadvantaged and vulnerable populations, such as those living in poverty or homelessness, minorities, and those who allow “peer pressure” to influence their drug use (8). In Nepal, individuals with a history of SUD continue to be perceived as lacking moral values, despite undergoing treatment, which can lead to relapse (9). One systematic thematic analysis of Indian newspaper articles explored online media’s attitudes and perceptions toward individuals with SUDs. Results showed that many articles propagated public stigma by using stigmatizing language, identifying people who use drugs with negative and unwanted qualities (10). Similarly, the media in New Zealand had often used terms such as “meth head” and “drug addict” when discussing individuals with SUDs (11). In Italy, schools, universities, and media outlets rarely convey the medical aspects of addictions, and SUDs are typically perceived as vices rather than diseases. Along the same lines, addiction treatment centers tend to be isolated and external to the general hospital setting (12, 13). Criminalizing drug use further fosters public stigma toward individuals with SUDs, through social and economic marginalization. Criminalization also diverts attention from the medical and public health models of addiction to a moral and punitive model. In India, for instance, this translates in the latest Narcotic Drugs and Psychotropic Substances policy limiting the access to evidence-based treatment, such as opioid agonist maintenance treatment and harm reduction strategies, by imposing restrictions on the duration and settings of treatment (14). Similarly, in Nepal, current laws remain harsh and add to the perception that individuals with SUDs are criminals who should be referred to the criminal justice system (15).

Individuals with SUDs and their family members experience significant internalized and affiliate stigma. Across cultures, internalized stigma is correlated with poorer quality of life (16) and delay in seeking treatment (17), especially in the initial stages of the illness (18). The Arab, Iranian, and Indian societies are collectivistic societies where family plays an essential role in fostering support and individuals’ decision-making. Hence, if one family member is affected by a SUD, others would attempt to provide support. However, families would also try hard to shield the affected member from the neighborhood and society to avoid stigma, which can lead to delays in treatment. In general, affiliate stigma tends to prevent families from providing the necessary medical support to their loved ones (19).

Healthcare professionals also hold negative perceptions and implicit biases toward individuals with SUDs. One study among primary care providers in New Zealand found that people who misuse prescription medications can be often stigmatized and offered limited harm reduction interventions (20). A systematic review of studies conducted in Western countries found that negative attitudes of healthcare professionals toward individuals with SUDs are common and contribute to suboptimal care (5). The general attitude of healthcare providers toward people with lived experience of mental illness is not positive in Iran, and attitudes toward those living with SUDs seem to be worse (21, 22). In many countries, including the Arab world and India, little enthusiasm is noted among psychiatry trainees to take up addiction psychiatry as a career option. Minimal exposure during residency, non-availability of evidence-based treatments and limited awareness about them, and significant public stigma might contribute to this. For similar reasons, practicing psychiatrists are sometimes uncomfortable with treating individuals with SUDs and are reluctant to initiate medications, perceiving this population as “challenging” and “difficult”.

Stigma is a negative driver for recovery from addiction. As previously mentioned, individuals who are stigmatized are less willing to engage in or seek medical treatment. Moreover, they may have to deal with associated fear, anger, isolation, trauma, or comorbid mental health disorders. This leads to care avoidance, self-directed early hospital discharge, and hesitance to call medical help or accept transport to a hospital after an overdose, all secondary to the fear of stigma and legal consequences (4). Stigma also impacts treatment availability, with a noted scarcity in the workforce that caters to the needs of individuals with SUDs, insufficiency in the number of treatment centers and available interventions, and limited support groups. Along the same lines, research into the treatment of addictions tends to be less prioritized than that of other mental illnesses. The stigmatizing language used to describe substance use behaviors, individuals with SUDs, and substance use treatment also creates other types of barriers for individuals who are on the road to recovery and re-integration into society, including at the level of their general healthcare, housing, employment, and insurance policies.

In many parts of the world, this translates into inappropriate and potentially hazardous treatment methodologies. For instance, in India, some privately owned rehabilitation centers deliver unethical and punitive treatments that lack evidence- and right-based medical approaches (23). In Iran, families can push their relatives with SUDs for involuntary admissions to “Campus”, which represents mandatory residence places that fail to provide proper treatment. In Nepal, people with SUDs have been traditionally treated out of health systems, in shoddy rehabilitation centers run by people with no experience and no standardized treatment protocol (15). In the Arab world, drug use can still be seen as a form of breakdown, possession by an evil spirit, or shortcoming of individual religious faith; and people may pursue a religious healer instead of a professional mental health practitioner to address this problem (24). But even when individuals seek professional help from psychiatrists or other allied medical health professionals, they can certainly be subject to inaccurate treatment approaches, highlighting the need for improving the awareness of the different stakeholders about the available evidence-based interventions.