Drug Addiction Stigma in the Context of Methadone Maintenance Therapy: An Investigation into Understudied Sources of Stigma

"In their mind, they always felt less than": The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention

INTRODUCTION

A substantial, national need exists for culturally acceptable, accessible opioid use disorder (OUD) treatment. Medication for opioid use disorder (MOUD) is regarded as effective in treating OUD; however, retention in MOUD programs remains low nationally. One known barrier to MOUD retention is stigma, particularly within ethno-racial minority communities. Peer recovery specialists (PRSs), individuals with shared experience in substance use and recovery, may be particularly well suited to support patients in MOUD treatment, and may have capacity to play a key role in decreasing stigma-related barriers to MOUD retention.

METHODS

This study used qualitative methods to solicit feedback on how patients receiving methadone treatment (MT) experience stigma (i.e., toward substance use [SU] and MT). Study staff also gathered information regarding how a PRS role may reduce stigma and improve retention in care, including barriers and facilitators to the PRS role shifting stigma. Study staff conducted semi-structured qualitative interviews and focus groups (N = 32) with staff and patients receiving MT at an opioid treatment program as well as PRSs in Baltimore.

RESULTS

Participants identified experiences of internalized, as well as enacted and anticipated, MT and SU stigma, and described these as barriers to treatment. Participants also identified opportunities for PRSs to shift stigma-related barriers for patients receiving MT through unique aspects of the PRS role, such as their shared lived experience.

CONCLUSIONS

Reducing stigma surrounding SUD and MT is critical for improving MOUD outcomes, and future research may consider how the PRS role can support this effort.

Adapting the Health Stigma and Discrimination Framework to understand the association between stigma and sleep deficiency: A systematic review

OBJECTIVE

Sleep deficiency and sleep disorders disproportionally affect socially disadvantaged and marginalized individuals and groups. Recent evidence suggests that stigma, a social process characterized by labeling, stereotyping, and prejudice, is associated with sleep characteristics.

PURPOSE

Guided by the Health Stigma and Discrimination Framework, the purpose of this systematic review is to describe associations between dimensions of stigma and sleep deficiency and to identify future directions for research.

METHODS

We searched the OVIDPsycINFO, OVIDEMASE, OVIDMEDLINE, and CINAHL databases for empirical research studies that reported relationships between the 3 dimensions of stigma-internalized, perceived, and anticipated-and characteristics of sleep deficiency-duration, continuity/efficiency, timing, alertness/sleepiness, quality, and disorders.

RESULTS

Of 1717 articles, 15 met our inclusion criteria. The most frequently assessed dimensions of stigma were internalized and perceived stigma. Characteristics of sleep deficiency were measured by self-report and included sleep quality, duration, trouble sleeping, and insomnia symptoms. We found consistent evidence that stigma, whether internalized, perceived, or anticipated, is associated with self-reported characteristics of sleep deficiency.

CONCLUSIONS

This evidence base can be further strengthened with prospective studies that incorporate both multidimensional measures of stigma and objective measures of sleep characteristics. We outline research implications that can clarify underlying mechanisms and more precisely define the relationships between stigma and sleep and inform interventions to address stigma, improve sleep, and reduce the health inequities that disproportionately affect individuals from socially disadvantaged and marginalized groups.

Cohort profile: the Kyrgyzstan InterSectional Stigma (KISS) injection drug use cohort study

BACKGROUND

In Kyrgyzstan and other Eastern European and Central Asian countries, injection drug use and HIV-related intersectional stigma undermines HIV prevention efforts, fueling a rapidly expanding HIV epidemic. The Kyrgyzstan InterSectional Stigma (KISS) Injection Drug Use Cohort is the first study designed to assess the impact of drug use, methadone maintenance treatment (MMT) and HIV stigma experiences among people who inject drugs (PWID) on HIV prevention service utilization.

METHODS

Adult PWID were recruited from Bishkek city and the surrounding rural Chuy Oblast region in northern Kyrgyzstan via modified time location sampling and snowball sampling. All participants completed a baseline rapid HIV test and interviewer-administered survey. A subsample of participants were prospectively followed for three months and surveyed to establish retention rates for future work in the region. Internal reliability of three parallel stigma measures (drug use, MMT, HIV) was evaluated. Descriptive statistics characterize baseline experiences across these three stigma types and HIV prevention service utilization, and assess differences in these experiences by urbanicity.

RESULTS

The KISS cohort (N = 279, 50.5% Bishkek, 49.5% Chuy Oblast) was mostly male (75.3%), ethnically Russian (53.8%), median age was 40 years old (IQR 35-46). Of the 204 eligible participants, 84.9% were surveyed at month 3. At baseline, 23.6% had a seropositive rapid HIV test. HIV prevention service utilization did not differ by urbanicity. Overall, we found 65.9% ever utilized syringe service programs in the past 6 months, 8.2% were utilizing MMT, and 60.8% met HIV testing guidelines. No participants reported PrEP use, but 18.5% had heard of PrEP. On average participants reported moderate levels of drug use (mean [M] = 3.25; α = 0.80), MMT (M = 3.24; α = 0.80), and HIV stigma (M = 2.94; α = 0.80). Anticipated drug use stigma from healthcare workers and internalized drug use stigma were significantly higher among PWID from Bishkek (p < 0.05), while internalized HIV stigma among PWID living with HIV was significantly greater among PWID from Chuy Oblast (p = 0.03).

CONCLUSION

The KISS cohort documents moderate levels of HIV-related intersectional stigma and suboptimal engagement in HIV prevention services among PWID in Kyrgyzstan. Future work will aim identify priority stigma reduction intervention targets to optimize HIV prevention efforts in the region.

Integrating time into stigma and health research

Stigma changes over time: it waxes and wanes through history, is manifested within humans who develop over time and is tied to statuses (such as attributes, illnesses and identities) that have varying courses. Despite the inherent fluidity of stigma, theories, research and interventions typically treat associations between stigma and health as stagnant. Consequently, the literature provides little insight into when experiences of stigma are most harmful to health and when stigma interventions should be implemented. In this Perspective, we argue that integrating time into stigma research can accelerate progress towards understanding and intervening in associations between stigma and health inequities. We situate time in relation to key concepts in stigma research, identify three timescales that are relevant for understanding stigma (historical context, human development and status course), and outline a time-based research agenda to improve scientists’ ability to understand and address stigma to improve health.

Associations between stigma and health are typically treated as stagnant. In this Perspective, Earnshaw et al. argue that considering stigma in relation to historical, human development and status course timescales can advance progress in understanding and addressing stigma to improve health.

Lessons from the First Wave of COVID-19 for Improved Medications for Opioid Use Disorder (MOUD) Treatment: Benefits of Easier Access, Extended Take Homes, and New Delivery Modalities

Background Medications for Opioid Use Disorder (MOUD) are associated with important public health benefits. Program changes implemented in response to COVID-19 hold promise as ongoing strategies to improve MOUD treatment. Methods: MOUD patients on buprenorphine or methadone, providers, government regulators, and persons who use drugs not in MOUD were recruited in the Northeast region of the United States between June and October of 2020 via advertisements, fliers, and word of mouth. Semi-structured qualitative interviews were conducted. Interviews were professionally transcribed and thematically coded by two independent coders. Results: We conducted interviews with 13 people currently on buprenorphine, 11 currently on methadone, 3 previously on buprenorphine, 4 previously on methadone, and 6 who used drugs but had never been on MOUD. In addition, we interviewed MOUD providers, clinic staff, and government officials at agencies that regulate MOUD. Most participants found increased take-home doses, home medication delivery, and telehealth implemented during COVID-19 to be favorable, reporting that these program changes reduced travel time to clinics, facilitated retention in care, and reduced stigma associated with clinic attendance. However, some participants reported negative consequences of COVID-19, most notably, decreased access to basic resources, such as food, clothing, and harm reduction materials that had previously been distributed at some MOUD clinics. Conclusion: Access to and retention in MOUD can be lifesaving for persons using drugs. COVID-19-impelled program changes, including increased take-home doses, home medication delivery, and telehealth generally improved participants' experiences with MOUD. Making these permanent could improve retention in care.

Injection and Non-Injection Drug Use Among Adults with Diagnosed HIV in the United States, 2015-2018

Understanding behavioral characteristics and health outcomes of people with HIV (PWH) who inject drugs and PWH who use drugs, but do not inject, can help inform public health interventions and improve HIV clinical outcomes. However, recent, nationally representative estimates are lacking. We used 2015-2018 Medical Monitoring Project data to examine health outcome differences among adults with diagnosed HIV who injected drugs or who only used non-injection drugs in the past year. Data were obtained from participant interviews and medical record abstraction. We reported weighted percentages and prevalence ratios with predicted marginal means to assess differences between groups (P < 0.05). PWH who injected drugs were more likely to engage in high-risk sex; experience depression and anxiety symptoms, homelessness, and incarceration; and have lower levels of care retention, antiretroviral therapy adherence, and viral suppression. Tailored, comprehensive interventions are critical for improving outcomes among PWH who use drugs, particularly among those who inject drugs.

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

Measuring Stigma Towards People with Opioid Use Problems: Exploratory and Confirmatory Factor Analysis of the Opening Minds Provider Attitudes Towards Opioid-Use Scale (OM-PATOS)

Many countries are experiencing an ongoing opioid crisis characterized by high rates of opioid use problems, overdose, poisoning, and death. Stigma has been identified as a central problem for seeking and receiving quality services from health providers and first respondents. The Mental Health Commission of Canada developed a scale that could be used to measure stigma in this population, as no such scale currently exists. This paper provides the results of psychometric testing of this new scale, known as the Opening Minds Provider Attitudes Towards Opioid-Use Scale (OM-PATOS), using exploratory (EFA) and confirmatory (CFA) factor analysis. EFA findings showed a 15 item 2-factor solution, with subscales of ‘attitudes’ (6 items) and ‘behaviours/motivation to help’ (9 items). The confirmatory factor analysis provided some preliminary confirmation of the factor structure suggested by the exploratory analyses, but further research with larger samples is needed to fully confirm the factor structure. Overall, results support the use of the 15-item scale with health professionals and first responders, with factors used for descriptive value rather than as calculated subscales until further research can be completed.

Opioid Use Stigma: An Examination of Student Attitudes on Harm Reduction Strategies

Understanding how the public views harm reduction strategies may help inform researchers on how to reduce related stigma and barriers to help-seeking. The current study explored whether stigma towards those who use opioids was affected by gender and type of harm reduction strategy used. Undergraduate students (N = 328) were randomly assigned to read one of six vignettes varying by gender and the type of harm reduction strategy: no harm reduction, opioid agonist therapy (OAT), or safe consumption sites (SCSs). Results demonstrated that participants were less stigmatizing towards the character who engaged in OAT compared to the character with no harm reduction. There was also a pattern demonstrating that SCSs may be perceived more negatively than OAT, although these differences only met conventional significance, not adjusted/corrected alphas. There were no significant effects for gender. Qualitative results revealed that participants held misconceptions about harm reduction. Implications and future directions are discussed.

Attitudes toward Medication for Opioid Use Disorder among Substance Use Treatment Providers

Background: Provider attitudes can be a powerful reinforcer of stigma toward medication for opioid use disorder (MOUD). This study examines attitudes toward MOUD among substance use treatment providers and identifies personal and professional characteristics associated with more positive attitudes. Methods: Treatment providers (N = 570) working at publicly-funded substance use programs in Michigan self-administered a web-based survey (November 2020 through July 2021), reporting their socio-demographics, professional experience, and attitudes toward MOUD. Linear regression was used to identify factors associated with general attitudes toward MOUD and three logistic regression models were calculated to identify factors associated with perceptions of each medication. Results: Half of providers considered methadone an effective treatment (53.0%); 62.9% considered buprenorphine effective, and 70.3% considered naltrexone effective. Receipt of training (B = 1.433, p = .009) and serving pregnant women or women with children (B = 1.662, p < .001) were associated with more positive attitudes toward MOUD. Providers with advanced degrees were more likely to consider methadone (OR = 2.264, p = .006), buprenorphine (OR = 2.192, p = .009), and naltrexone (OR = 2.310, p = .011) effective. Rural providers were more likely to consider naltrexone effective (OR = 2.708, p = .003). Providers working with criminal legal populations were more likely to consider buprenorphine (OR = 2.948, p = .041) and naltrexone (OR = 4.108, p = .010) effective, but not methadone. Conclusion: Treatment providers' attitudes remain poorly aligned with the evidence base. Increased efforts are needed to address attitudes toward MOUD among the specialized treatment workforce.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention’s women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women’s focus; and consider providing same-day PrEP.

Patient-centered HCV care via telemedicine for individuals on medication for opioid use disorder: Telemedicine for Evaluation, Adherence and Medication for Hepatitis C (TEAM-C)

BACKGROUND

Telemedicine has the potential to increase healthcare access especially for vulnerable populations. Telemedicine for Evaluation, Adherence, and Medication for Hepatitis C (TEAM-C) is comparing telemedicine access to specialty medical care to usual care for management of hepatitis C virus (HCV) infection among persons with opioid use disorder (PWOUD). PWOUD have the highest hepatitis C virus (HCV) prevalence and incidence, yet they infrequently receive HCV care. The study objectives are to compare access to specialty care via telemedicine to offsite specialty referral (usual care) on 1) treatment initiation, completion, and sustained virological response, 2) patient satisfaction with health care delivery, and 3) HCV reinfection after successful HCV cure.

METHODS

TEAM-C is a multi-site, non-blinded, randomized pragmatic clinical trial conducted at 12 opioid treatment programs (OTP) throughout New York State that utilizes the stepped-wedge design. The unit of randomization is the OTP with a total sample size of 624 participants. HCV-infected PWOUD were treated via telemedicine or referral. Telemedicine encounters are conducted onsite in the OTP with co-administration of direct acting antivirals for HCV with medications for opioid use disorder. The primary outcome is undetectable HCV RNA obtained 12 weeks post-treatment cessation. We also follow participants for two years to assess for reinfection.

CONCLUSIONS

The study utilizes a rigorous study design to evaluate the effectiveness and implementation of virtual treatment for HCV integrated into behavioral treatment. We demonstrate the feasibility, engagement principles and lessons learned from the initial prospective randomized trial of telemedicine targeted to a vulnerable population.

LGBTQ Student Health: A Mixed-Methods Study of Unmet Needs in Massachusetts Schools

BACKGROUND

Lesbian, gay, bisexual, transgender, and queer and questioning (LGBTQ) youth experience poor physical and mental health outcomes relative to their non-LGBTQ peers. School health professionals (SHPs), such as school nurses, play a key role in addressing LGBTQ student health needs. However, few studies examine school health needs of LGBTQ students from both the youth and SHP perspective.

METHODS

From August 2017 to July 2018, 28 LGBTQ youth and 19 SHPs (N = 47) in Massachusetts participated in online focus groups and a brief survey on school health needs and experiences. Qualitative themes were coded using Rapid Qualitative Inquiry principles and NVIVO.

RESULTS

Both LGBTQ students and SHPs identified an urgent need for inclusive sexual education and mental health services. LGBTQ students raised access to safer bathrooms, information, and guidance on gender transitioning, and access to safe spaces as school-based needs. Missing from SHPs' perspectives, students also discussed sexual violence/harassment of transgender students and racism impacting youth of color.

CONCLUSIONS

LGBTQ students, especially transgender students and LGBTQ youth of color, have unmet health needs that need to be addressed. Recognizing these needs is the first step towards inclusive health services and support for all students in schools. Next, interventions to increase the capacity of SHPs to address LGBTQ student health are necessary.

Perceived healthcare stigma among patients in opioid substitution treatment: a qualitative study

Background

People with substance use disorders (SUD) including patients in opioid substitution treatment (OST) are subject to stigma, and have generally poor health and barriers towards seeking healthcare. Experience of stigma might negatively affect healthcare seeking, but this topic is sparsely investigated. The aim of this study was to explore OST patients’ past and present experiences of substance use stigma in healthcare settings, in order to provide insight into the challenges that people with opioid use disorder may face when using health services, and the strategies they use to cope with them.

Methods

Six focus groups with 23 OST patients were moderated by OST staff, and conducted with a questioning route focusing on health literacy. Experiences associated with stigma and its consequences that were spontaneously brought up by participants were assessed in a secondary analysis using a thematic approach.

Results

Experiences of stigma from a wide range of healthcare settings were reported. Medical records and patients’ oral information regarding substance use, OST medication or hepatitis C infection were identified as circumstances bringing unwanted attention to the SUD. Participants reported various forms of poor treatment, believed to reflect views of people with SUD as morally culpable, intimidating, curious, untrustworthy and less valuable than other patients, sometimes with tangible effects on the quality of healthcare. Stigma in healthcare settings affected healthcare seeking behaviors, and could result in patients concealing their OST status or substance use history.

Conclusion

This study highlights several aspects of perceived healthcare stigma that can shed light on difficulties that OST patients might experience when navigating the healthcare system. The results implicate a need to investigate attitudes towards OST patients, and the aptitude to deal with patients with SUD, among healthcare professionals, as well as a need for interventions addressing knowledge deficits and issues tied to values and patient reception among healthcare staff.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00417-3.

Tracing the affordances of long-acting injectable depot buprenorphine: A qualitative study of patients' experiences in Australia

BACKGROUND

Long-acting injectable depot buprenorphine is an important new treatment option for the management of opioid dependence, delivering therapeutic doses in weekly or monthly formulations. Depot buprenorphine aims to overcome challenges associated with traditional opioid agonist therapy (OAT), including: poor patient adherence; inconvenience of regular attendance for dosing; and, risk of non-medical use of takeaway doses. However, little is known about patients' experiences of depot buprenorphine. This qualitative study aimed to explore patients' experiences of the practical and social affordances of depot buprenorphine.

METHODS

Participants were recruited from sites in Sydney, regional New South Wales, and Melbourne, Victoria, Australia. Thirty participants (16 men, 14 women; mean age 47.3 years) participated in semi-structured interviews. Participants had histories of both heroin and prescription opioid use, and previous OAT including daily dosing of buprenorphine and methadone.

FINDINGS

Depot buprenorphine afforded positive benefits for many participants, including: opportunities to avoid stigma experienced at pharmacies/clinics; time to engage in activities (e.g., travel, work) by releasing participants from previous OAT treatment regimens; and, cost savings by not having to pay pharmacy fees associated with daily dosing. However, for some participants, moving to depot buprenorphine: disrupted engagements with important social/practical supports available at pharmacies/clinics; constrained their control over dosing; and, constrained their ability to generate income via the sale of takeaway doses.

CONCLUSIONS

While generally experienced as affording benefits, depot buprenorphine can have differing social and practical impacts. Clinicians should monitor patients receiving depot buprenorphine to reduce the risk of unintended consequences including disruption to clinical supports.

Qualitative characterizations of misinformed disclosure reactions to medications for opioid use disorders and their consequences

INTRODUCTION

Methadone and buprenorphine/naloxone medications are among the most effective treatment options for opioid use disorders, yet many people remain misinformed about their benefits and hold negative perceptions about the use of medications to treat opioid use disorders. Such perceptions, especially negative perceptions based on misinformation, may be especially harmful or stigmatizing within the context of disclosure (i.e., telling another about one's opioid use disorder history or treatment), inhibiting important recovery outcomes and sources of social support.

METHODS

Therefore, using the Disclosure Process Model as a framework, the current study seeks to characterize and compare participants' perceptions of stigmatizing reactions to their disclosures of MOUD use that stem from misinformation about methadone or buprenorphine/naloxone. Participants included people who are actively receiving MOUD as treatment.

RESULTS

Results suggest that participants (N = 52) receiving both types of medications experienced similar stigmatizing reactions to disclosures. Participants also reported treatment consequences of misinformed reactions to their disclosure, such as dropping out of support groups (e.g., Narcotics Anonymous) or prematurely ending their medication use. Further, the paper provides participants' recommendations for avoiding or managing misinformed disclosure reactions.

CONCLUSIONS

Short-term intervention efforts may promote strategies to manage misinformation, equipping individuals to respond to misinformation surrounding their medication use. Long-term interventions may target misinformation about methadone and buprenorphine/naloxone medications to increase health literacy, reduce stigma, and combat cultural ambivalence within communities, as well as promote recovery among people receiving medications for opioid use disorder.

Factors associated with obtaining employment among opioid use disorder patients enrolled in a therapeutic workplace intervention

BACKGROUND

Unemployment is a common problem among adults who have substance use disorder that often persists during treatment and recovery. We identified patient characteristics that were associated with obtaining employment among unemployed adults in opioid use disorder treatment.

METHODS

This analysis used data from participants (N = 91) who were enrolled in a randomized controlled trial evaluating the effectiveness of a therapeutic workplace in promoting drug abstinence and employment. After a 3-month training period (Phase 1), participants were randomly assigned to a study group and could work for 12 months with an employment specialist who assisted participants in obtaining employment (Phase 2). A logistic regression model was used to identify patient characteristics that were associated with obtaining employment.

RESULTS

Of the 91 participants, 39 (42.9 %) obtained employment. Compared to participants who did not obtain employment, participants who obtained employment worked more days in the therapeutic workplace during the training period (Phase 1) [OR (95 % CI) = 1.072 (1.015-1.132), p = .014], provided more opiate- and cocaine-negative urine samples while seeking employment [OR (95 % CI) = 1.015 (1.002-1.027), p = .025], and reported not usually being unemployed at study intake [OR (95 % CI) = 0.229 (0.080-0.652), p = .007].

CONCLUSIONS

Our analyses suggest that among unemployed adults in opioid use disorder treatment, those with the lowest rates of therapeutic workplace attendance, lowest rates of drug abstinence while seeking employment, and relatively long histories of unemployment are the least likely to obtain employment. These relations are potentially addressable at a practical level, and future research could build on these findings to improve the effectiveness of employment-based interventions.

Changing Nurse Practitioner Students' Attitudes and Beliefs About Caring for Those With Opioid Use Disorders

PURPOSE

Nurse practitioners (NPs) are in a unique position to address the problem of opioid use disorders (OUDs) because they provide a large percentage of primary care services (Agency for Healthcare Research and Quality, 2014). This study aimed to increase doctoral NP students' beliefs/attitudes about their ability to care for and about individuals with OUDs through a multifaceted educational approach, guided by social cognitive theory.

METHODS

Researchers used a quasi-experimental pre/post design. Five doctoral students attended lectures and 16 hours of direct clinical exposure to individuals with OUDs at a medication-assisted treatment center. The 22-item Drug and Drug Problems Perception Questionnaire examined students' attitudes toward individuals with OUDs before and after receiving this multifaceted education. Students completed reflective writings. Descriptive statistics and effect sizes were computed, and reflective writings were reviewed.

RESULTS

Changes in Drug and Drug Problems Perception Questionnaire scores before and after intervention showed a fairly large effect size. This suggests that the intervention may have clinical significance for practice and is likely to attain statistical significance with a larger sample size. Greatest changes occurred in students' perceptions of role adequacy and self-esteem scores, indicative of higher self-efficacy. Measured score increases correspond to increases in confidence, knowledge, and skills to therapeutically engage with this population.

CONCLUSION

Doctoral NP students had more positive attitudes and beliefs about individuals with OUDs after the multifaceted intervention. Enhancement of self-esteem and adequacy in the caregiver role for this population were promising signals that education can reduce stigma. Further study is warranted with a larger and more diverse sample.

Rural-Urban Differences in Physician Bias Toward Patients With Opioid Use Disorder

OBJECTIVE

Effective treatments for opioid use disorder exist, but rural areas of the United States have a shortage of services offering such treatments. Physician bias toward patients with opioid use disorder can also limit care access, but no studies have assessed whether physician bias is a more acute barrier in rural compared with urban communities.

METHODS

In total, 408 board-certified physicians in Ohio, a state with a high rate of opioid overdoses, completed an online survey examining perspectives on clinical care for patients who misuse opioids. Respondents with missing county-level data were excluded, leaving a total sample of 274. The authors used t tests to determine rural-urban differences in bias, key predictors of bias, and availability of opioid services. Multivariable regression modeling was used to estimate rural-urban differences in bias independent of key bias predictors.

RESULTS

Physicians in rural areas (N=37) reported higher levels of bias toward patients with opioid use disorder than did their urban counterparts (N=237). This difference remained statistically significant even after accounting for known bias predictors and physician specialty. Physicians specializing in addiction medicine reported lower bias than did physicians not working in this specialty.

CONCLUSIONS

Given existing disparities in harm reduction and addiction treatment services in rural areas, increased physician bias in counties lacking these services suggests that rural patients with opioid use disorder face numerous challenges to finding effective treatment. Bias reduction interventions should target health care professionals in rural communities where such efforts may have the most pronounced impact on improving health care access.

Municipal police support for harm reduction services in officer-led referrals of people who inject drugs in Tijuana, Mexico

BACKGROUND

Police constitute a structural determinant of health and HIV risk of people who inject drugs (PWID), and negative encounters with law enforcement present significant barriers to PWID access to harm reduction services. Conversely, police may facilitate access via officer-led referrals, potentiating prevention of HIV, overdose, and drug-related harms. We aimed to identify police characteristics associated with support for officer-led referrals to addiction treatment services and syringe service programs (SSP). We hypothesized that officers who believe harm reduction services are contradictory to policing priorities in terms of safety and crime reduction will be less likely to support police referrals.

METHODS

Between January and June 2018, police officers (n = 305) in Tijuana, Mexico, completed self-administered surveys about referrals to harm reduction services during the 24-month follow-up visit as part of the SHIELD police training and longitudinal cohort study. Log-binomial regression was used to estimate adjusted prevalence ratios and model policing characteristics and attitudes related to officers' support for including addiction treatment and SSP in referrals.

RESULTS

Respondents were primarily male (89%), patrol officers (86%) with a median age of 38 years (IQR 33-43). Overall, 89% endorsed referral to addiction services, whereas 53% endorsed SSP as acceptable targets of referrals. Officers endorsing addiction services were less likely to be assigned to high drug use districts (adjusted prevalence ratio [APR] = 0.50, 95% CI 0.24, 1.08) and more likely to agree that methadone programs reduce crime (APR = 4.66, 95% CI 2.05, 9.18) than officers who did not support addiction services. Officers endorsing SSPs were younger (adjusted prevalence ratio [APR] = 0.96 95% CI 0.93, 0.98), less likely to be assigned to high drug use districts (APR = 0.50, 95% CI 0.29, 0.87), more likely to believe that methadone programs reduce crime (APR = 2.43, 95% CI 1.30, 4.55), and less likely to believe that SSPs increase risk of needlestick injury for police (APR = 0.44, 0.27, 0.71).

CONCLUSIONS

Beliefs related to the occupational impact of harm reduction services in terms of officer safety and crime reduction are associated with support for referral to related harm reduction services. Efforts to deflect PWID from carceral systems toward harm reduction by frontline police should include measures to improve officer knowledge and attitudes about harm reduction services as they relate to occupational safety and law enforcement priorities.

TRIAL REGISTRATION

NCT02444403.

The intersection of gender and drug use-related stigma: A mixed methods systematic review and synthesis of the literature

BACKGROUND

Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma?

METHODS

Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma.

RESULTS

Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma.

CONCLUSION

The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.

Undergraduate health profession students attitudes toward illicit substance users in Jordan

BACKGROUND

The use of illicit substances is a critical international issue that must be addressed by healthcare systems worldwide. Today, the problem of illicit substance use is increasingly becoming a burden on healthcare systems in both developed and developing countries. The aims of this study were: (1) to describe the attitudes of health major undergraduate students (the study participants) toward illicit substance users; (2) to describe the discriminatory behaviors among the study participants toward illicit substance users; and (3) to examine the relationship between the attitudes and the actual discriminatory behaviors of the study participants.

METHOD

A cross-sectional descriptive design was used to investigate the attitudes and behaviors of health professional undergraduate students enrolled at university in Jordan.

RESULTS

Students who were younger and identified as female were generally more positive toward illicit substance users versus those students who were older and identified as male.

CONCLUSION

The findings of this study supported the literature that students who were younger and identified as female were generally more positive toward illicit substance users versus those students who were older and identified as male. It is therefore important to determine whether the type of courses in health majors available for undergraduate students affects their attitudes toward illicit substance users.

How urban and rural built environments influence the health attitudes and behaviors of people who use drugs

Research suggests that the built environment is associated with drug use. However, there is limited scholarship focusing on specific features of the built environment that influence drug use behaviors, experiences, and patterns and how risk factors for drug use are placed in distinctive urban and rural settings. Applying Neely and Samura's conceptual theory that describes space as contested, fluid and historical, interactional and relational, and defined by inequality and difference, we assessed data from semi-structured qualitative interviews conducted between 2019 and 2020 with consumers at syringe exchange programs (SEPs) in an urban location (New York City) and a rural location (southern Illinois). We aimed to contextualize how drug use manifests in each space. In total, 65 individuals, including 59 people who use drugs (PWUD) and six professionals who worked with PWUD, were interviewed. Findings illustrate that, in both the urban and rural setting, the built environment regulates the drug use milieu by mediating social reproduction, namely the degree of agency PWUD exert to acquire and use drugs where they desire. Processes of "stigma zoning," defined as socio-spatial policing of boundaries of behavior deemed undesirable or deviant, impacted PWUD's socio-geographic mobility, social conditions, and resource access, and modulated PWUD's broader capacity and self-efficacy. Similar patterns of drug use, according to social and economic inequities chiefly related to housing instability, were further observed in both settings.

Conceptualizing stigma in contexts of pregnancy and opioid misuse: A qualitative study with women and healthcare providers in Ohio

BACKGROUND

Women with histories of opioid misuse face drug-related stigma, which can be amplified during pregnancy. While women are often blamed for their drug use and urged to change, the social contexts that create and reinforce stigma are largely unchallenged. Drawing on a multidimensional model of stigma, we examine how stigma manifested across women's pregnancy journeys to shape access and quality of care.

METHODS

We triangulate in-depth interviews with 28 women with histories of opioid misuse who were pregnant or recently gave birth and 18 healthcare providers in Ohio. Thematic analysis examined how stigma operates across contexts of care.

RESULTS

Providers represented physicians, nurses, social workers, counselors, and healthcare administrators. Among 28 women, average age was 30 (range: 22-41) and 79 % were White. Most women used prenatal medication-assisted treatment (MAT), including Suboxone (n = 19) or methadone (n = 8), and 15 were pregnant. Evidence of stigma emerged across healthcare contexts. Structural stigma encoded barriers to care in insurance practices and punitive drug treatment, while enacted stigma manifested as mistreatment and judgment from providers. Unpredictability of an infant diagnosis of neonatal abstinence syndrome (NAS), even when women were "doing everything right" by using MAT, perpetuated anticipated stigma from fear of loss of custody and internalized stigma among women who felt guilty about the diagnosis. Providers recognized the harmful effects of these stigmas and many actively addressed it.

CONCLUSIONS

We recommend harm reduction approaches to address the multiplicity of stigmas that women navigate in opioid misuse and pregnancy to improve healthcare experiences.

A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs

OBJECTIVE

Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence-based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients' perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post-opioid overdose period.

METHODS

We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural).

RESULTS

The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self-reported lifetime opioid overdoses. Eight themes were identified as influencing participants' consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs.

CONCLUSIONS

Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED-based research evaluating a patient-oriented approach to engage patients after opioid overdose.

Facilitating engagement of persons with opioid use disorder in treatment for hepatitis C virus infection via telemedicine: Stories of onsite case managers

Although hepatitis C virus (HCV) infection has high prevalence and incidence in persons with opioid use disorder (PWOUD), their engagement in HCV care has been limited due to a variety of factors. In an ongoing multisite study at 12 opioid treatment programs (OTPs) throughout New York State (NYS), we have been evaluating telemedicine accompanied by onsite administration of direct acting antiviral (DAA) medications compared with usual care including offsite referral to a liver specialist for HCV management. Each site has a case manager (CM) who is responsible for all study-related activities including participant recruitment, facilitating telemedicine interactions, retention in care, and data collection. Our overall objective is to analyze CM experiences of clients' stories and events to understand how the telemedicine model facilitates HCV treatment. Hermeneutic phenomenology was used to interpret and to explicate common meanings and shared practices of the phenomena of case management, and a focus group with CMs was conducted to reinforce and expand on key themes identified from the CMs' stories. We identified three themes: (1) building trust, (2) identification of multiple competing priorities, and (3) development of personalized care approaches. Our results illustrate that trust is a fundamental pillar on which the telemedicine system can be based. Participants' experiences at the OTP can reinforce trust. Understanding the specific competing priorities and routinizing dedicated personalized approaches to overcome them are key to increasing participation in HCV care among PWOUD.

Stigma in the News: The Representation and Trivialization of Stigma in U.S. News Publications

Stigma represents an important social issue, one rooted in communication. The present study used a quantitative content analysis to examine the representation of the term stigma in one national and six regional news publications in the United States between 2000 and 2018. In the 1,524 stories examined, journalists explicitly defined stigma once. Stigma was discussed in relation to serious, often dehumanized conditions such as schizophrenia, substance abuse, and HIV/AIDS. However, journalists and news sources frequently trivialized stigma by referencing it in relation to bad football teams, food, motor vehicles, and other objects that do not experience the full impact of stigma: stereotypes, prejudice, and discrimination.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

"We'll be able to take care of ourselves" - A qualitative study of client attitudes toward implementing buprenorphine treatment at syringe services programs

BACKGROUND

Syringe services programs (SSPs) complement substance use disorder treatment in providing services that improve the health of people who use drugs (PWUD). Buprenorphine treatment is an effective underutilized opioid use disorder treatment. Regulations allow buprenorphine prescribing from office-based settings, potentially including SSPs although few studies have examined this approach. Our objective was to assess the attitudes among PWUD toward the potential introduction of buprenorphine treatment in an SSP. Methods: In this qualitative study, we recruited 34 participants who were enrolled at a New York City-based SSP to participate in one of seven focus group sessions. The focus group facilitators prompted participants to share their thoughts in five domains: attitudes toward (1) medical clinics; (2) harm reduction in general; (3) SSP-based buprenorphine treatment; (4) potential challenges of SSP-based treatment; and (5) logistical considerations of an SSP-based buprenorphine treatment program. Four researchers analyzed focus group transcripts using thematic analysis. Results: Of the 34 participants, most were white (68%), over the age of 40 years old (56%), and had previously tried buprenorphine (89%). Common themes were: 1) The SSP is a supportive community for people who use drugs; 2) Participants felt less stigmatized at the SSP than in general medical settings; 3) Offering buprenorphine treatment could change the SSP's culture; and 4) SSP participants receiving buprenorphine may be tempted to divert their medication. Participants offered suggestions for a slow intentional introduction of buprenorphine treatment at the SSP including structured appointments, training medical providers in harm reduction, and program eligibility criteria. Conclusion: Overall, participants expressed enthusiasm for onsite buprenorphine treatment at SSPs. Research on SSP-based buprenorphine treatment should investigate standard buprenorphine treatment outcomes but also any effects on the program itself and medication diversion. Implementation should consider cultural and environmental aspects of the SSP and consult program staff and participants.

Effectiveness of psychosocial interventions for reducing parental substance misuse

BACKGROUND

Parental substance use is a substantial public health and safeguarding concern. There have been a number of trials of interventions relating to substance-using parents that have sought to address this risk factor, with potential outcomes for parent and child.

OBJECTIVES

To assess the effectiveness of psychosocial interventions in reducing parental substance use (alcohol and/or illicit drugs, excluding tobacco).

SEARCH METHODS

We searched the following databases from their inception to July 2020: the Cochrane Drugs and Alcohol Group Specialised Register; CENTRAL; MEDLINE; Embase; PsycINFO; CINAHL; Applied Social Science (ASSIA); Sociological Abstracts; Social Science Citation Index (SSCI), Scopus, ClinicalTrials.gov, WHO ICTRP, and TRoPHI. We also searched key journals and the reference lists of included papers and contacted authors publishing in the field.

SELECTION CRITERIA

We included data from trials of complex psychosocial interventions targeting substance use in parents of children under the age of 21 years. Studies were only included if they had a minimum follow-up period of six months from the start of the intervention and compared psychosocial interventions to comparison conditions. The primary outcome of this review was a reduction in the frequency of parental substance use.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 22 unique studies with a total of 2274 participants (mean age of parents ranged from 26.3 to 40.9 years), examining 24 experimental interventions. The majority of studies intervened with mothers only (n = 16; 73%). Heroin, cocaine, and alcohol were the most commonly reported substances used by participants. The interventions targeted either parenting only (n = 13; 59%); drug and alcohol use only (n = 5; 23%); or integrated interventions which addressed both (n = 6; 27%). Half of the studies (n = 11; 50%) compared the experimental intervention to usual treatment. Other comparison groups were minimal intervention, attention controls, and alternative intervention. Eight of the included studies reported data relating to our primary outcome at 6- and/or 12-month follow-up and were included in a meta-analysis. We investigated intervention effectiveness separately for alcohol and drugs. Studies were found to be mostly at low or unclear risk for all 'Risk of bias' domains except blinding of participants and personnel and outcome assessment.  We found moderate-quality evidence that psychosocial interventions are probably more effective at reducing the frequency of parental alcohol misuse than comparison conditions at 6-month (mean difference (MD) -0.32, 95% confidence interval (CI) -0.51 to -0.13; 6 studies, 475 participants) and 12-month follow-up (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.03; 4 studies, 366 participants). We found a significant reduction in frequency of use at 12 months only (SMD -0.21, 95% CI -0.41 to -0.01; 6 studies, 514 participants, moderate-quality evidence). We examined the effect of the intervention type. We found low-quality evidence that psychosocial interventions targeting substance use only may not reduce the frequency of alcohol (6 months: SMD -0.35, 95% CI -0.86 to 0.16; 2 studies, 89 participants and 12 months: SMD -0.09, 95% CI -0.86 to 0.61; 1 study, 34 participants) or drug use (6 months: SMD 0.01, 95% CI -0.42 to 0.44; 2 studies; 87 participants and 12 months: SMD -0.08, 95% CI -0.81 to 0.65; 1 study, 32 participants). A parenting intervention only, without an adjunctive substance use component, may not reduce frequency of alcohol misuse (6 months: SMD -0.21, 95% CI -0.46 to 0.04, 3 studies; 273 participants, low-quality evidence and 12 months: SMD -0.11, 95% CI -0.64 to 0.41; 2 studies; 219 participants, very low-quality evidence) or frequency of drug use  (6 months: SMD 0.10, 95% CI -0.11 to 0.30; 4 studies; 407 participants, moderate-quality evidence and 12 months: SMD -0.13, 95% CI -0.52 to 0.26; 3 studies; 351 participants, very low-quality evidence). Parents receiving integrated interventions which combined both parenting- and substance use-targeted components may reduce alcohol misuse with a small effect size (6 months: SMD -0.56, 95% CI -0.96 to -0.16 and 12 months: SMD -0.42, 95% CI -0.82 to -0.03; 2 studies, 113 participants) and drug use (6 months: SMD -0.39, 95% CI -0.75 to -0.03 and 12 months: SMD -0.43, 95% CI -0.80 to -0.07; 2 studies, 131 participants). However, this evidence was of low quality. Psychosocial interventions in which the child was present in the sessions were not effective in reducing the frequency of parental alcohol or drug use, whilst interventions that did not involve children in any of the sessions were found to reduce frequency of alcohol misuse (6 months: SMD -0.47, 95% CI -0.76 to -0.18; 3 studies, 202 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use at 12-month follow-up (SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). The quality of this evidence was low. Interventions appeared to be more often beneficial for fathers than for mothers. We found low- to very low-quality evidence of a reduction in frequency of alcohol misuse for mothers at six months only (SMD -0.27, 95% CI -0.50 to -0.04; 4 studies, 328 participants), whilst in fathers there was a reduction in frequency of alcohol misuse (6 months: SMD -0.43, 95% CI -0.78 to -0.09; 2 studies, 147 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use (6 months: SMD -0.31, 95% CI -0.66 to 0.04; 2 studies, 141 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that psychosocial interventions probably reduce the frequency at which parents use alcohol and drugs. Integrated psychosocial interventions which combine parenting skills interventions with a substance use component may show the most promise. Whilst it appears that mothers may benefit less than fathers from intervention, caution is advised in the interpretation of this evidence, as the interventions provided to mothers alone typically did not address their substance use and other related needs. We found low-quality evidence from few studies that interventions involving children are not beneficial.

A qualitative study of a publicly funded pharmacy-dispensed naloxone program

AIMS

To characterize the experiences of individuals accessing pharmacy-based naloxone and relate these experiences to the risk environments and discourses in which they are embedded.

METHODS

We conducted a qualitative study using in-depth interviews of 37 adults aged 18 years and over who had accessed pharmacy-dispensed naloxone. Participants were recruited from across Ontario, Canada, and comprised individuals taking opioids for chronic pain, those taking opioids for reasons other than chronic pain, and individuals acquiring naloxone to act as bystanders in an opioid overdose setting. We drew upon risk environment theory to interpret participants' accounts.

RESULTS

Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing pharmacy-dispensed naloxone: 'intersection of naloxone narrative with pharmacy environment', 'individual risk environment and pharmacy-dispensed naloxone uptake', 'safe spaces: creating an enabling environment for pharmacy-dispensed naloxone', 'individuation: becoming a first responder' and 'beyond naloxone: the macro risk environment'. Specifically, participants described how judgement and stereotyping associated with the broader naloxone narrative can be amplified in the space of the pharmacy, leading to fears of reprisals and strategies to mitigate social risk. In addition, the social construction of naloxone as a drug for 'problematic' opioid use and a lack of pharmacist awareness regarding the risk environments in which opioid use occurs was perceived to limit opportunities for optimizing naloxone distribution and training. Finally, participants described approaches that could create enabling environments in the space of the pharmacy while remaining cognizant of the structural changes required in the macro risk environments of people who take opioids.

CONCLUSIONS

Despite increasing the availability of naloxone, participants characterized several social and environmental factors that could limit the accessibility of the drug from pharmacies. Strategies to address these factors could create enabling environments within pharmacies that optimize the reach and impact of pharmacy-dispensed naloxone.

How to be self-reliant in a stigmatising context? Challenges facing people who inject drugs in Vietnam

BACKGROUND

Stigma works to reinforce dominant social values. The meaning of stigma is therefore not static but dependant on the regime in power. Taking into account the significant socioeconomic changes that took place in Vietnam over the last thirty years, this study explores the meaning of stigma directed at Vietnamese people who inject drugs in different social spheres.

METHODS

This qualitative study was conducted as part of an evaluation of a peer outreach program that distributes harm-reduction supplies and information, and provides treatment referral assistance to people who inject drugs in Haiphong, Vietnam. We conducted ethnographic field observations with peer outreach workers, home visits, and 54 in-depth interviews with participants in 2017 and 2018. Grounded theory led our theoretical sampling and analysis.

RESULTS

Stigma towards people who inject drugs seems to centre on the ability to be self-reliant rather than on drug-using behaviours. Participants described how their families and neighbours expressed expectations that they should manage their substance use issues by themselves, without considering the barriers they face in the job market. Participants interpret stigma directed at them in terms of poverty rather than drug use. As a result, they sometimes engage in illegal income-generating activities to pursue financial autonomy and to regain their social status.

CONCLUSION

People who inject drugs were struggling to conform to social expectations of self-reliance with limited support to realise it. Effective interventions must consider the many facets and challenges individuals encounter in their daily lives.

What aspects of their child's primary care do mothers value? A qualitative analysis of perspectives of women in treatment for opioid use disorder

BACKGROUND

Preventive paediatric healthcare is essential for infant and child health. Current research, however, suggests that the delivery of routine well child care (WCC) for children affected by maternal opioid use disorder (OUD) could be improved. How mothers perceive interactions with healthcare providers may help identify ways to modify the experience of WCC, which could ultimately improve healthcare utilization, patient satisfaction and clinical outcomes. The objective of this qualitative study was to assess perceptions of WCC among mothers in treatment for OUD.

METHODS

Four focus group sessions of 4-8 participants each (N = 22) were conducted. All study participants were receiving comprehensive behavioural and physical health support and care plus pharmacotherapy for OUD from a single outpatient treatment centre. Focus groups were semi-structured, with a standardized set of open-ended questions and follow-up prompts to engage participants in a fluid discussion. Participants were asked to identify and discuss important aspects of their youngest child's WCC and what they liked and disliked about their child's WCC. Grounded theory analysis was used to identify themes.

RESULTS

Several aspects of WCC were identified as important to the mothers. Main themes identified included (1) mother-provider relationship, (2) communication with healthcare team and (3) support for mother's OUD treatment. Participants discussed their desire to be heard and understood and wanted the entire healthcare team and clinic staff to see them as mothers first and foremost, not merely as individuals with OUD.

CONCLUSION

Future attempts to refine care may consider healthcare models that highlight open communication and personalized care and offer strong support and ongoing encouragement for the mother's OUD treatment and recovery process.

Attitudes Toward Organ Donation for Persons Who Have a Substance Use Disorder Relative to Other Health Conditions

Background: Increases in opioid-related overdose and death have led to increases in the number of organs available for donation and transplant, however persons who have a substance use disorder (SUD) may be disadvantaged relative to other health conditions with regard to receiving an organ for transplant. Objective: This study aimed to evaluate perceptions regarding acceptability and priority for organ donation vs. a control condition (resuscitation) for hypothetical persons with nine target health conditions including a substance use disorder, among persons recruited as part of an online survey. Methods: Respondents (N = 285; male = 172, female = 113) recruited from Amazon Mechanical Turk rated acceptability and priority that hypothetical persons representing nine target health conditions expected to influence transplant success (including a SUD) receive an organ transplant and resuscitation via a survey hosted by Qualtrics. Primary outcomes of stigma ratings and priority ranking of persons as a function of the hypothetical target health condition were analyzed using Repeated Measures Analyses of Variance and Bonferroni-corrected t-tests. Demographic information was presented descriptively for all respondents. Results: Ratings for acceptability and priority for persons who had a SUD were generally lower than ratings for other conditions for both organ for transplant and resuscitation, though respondents reported less stigma toward resuscitation, F ₍₈₎ = 22.35, p <0.001 overall. Respondents were least supportive of persons who smoked cigarettes receiving an organ, p's < 0.001. Priority rankings favored persons who were young or had a history of heart disease. Multivariable models determined that target health condition, F ₍₈₎ = 33.64, p < 0.001, was a better and more consistent predictor of response than demographic variables that were examined. Conclusions: Data suggest that general perception of acceptability and priority ranking for receipt of life-saving interventions was lower for persons who have a SUD relative to other clinically-relevant health conditions. Research to examine this effect among persons working in the donation system are warranted and efforts to reduce stigma toward persons who have a SUD should be continued.

Stigma Surrounding the Use of Medically Assisted Treatment for Opioid Use Disorder

This study sought to determine whether certain factors influenced public stigma toward the use of medication to treat opioid use disorders (MOUD). Method: In a series of 3 studies using between-subjects designs, hypothetical MOUD patients matched in age and educational status with the participants were varied in systematic ways to determine whether certain factors influenced stigmatizing views of the patients. Results: Study 1 (n = 142) determined that stigma levels were elevated for hypothetical patients receiving agonist medication for OUD compared to other medications or no medication at all. Study 2 (n = 144) found that hypothetical patients receiving opioid agonist medication for either heroin or pain pills were equally stigmatized and stigmatized more than hypothetical patients on nicotine agonist medication. Study 3 (n = 151) showed that stigmatizing attitudes did not change as a result of enhanced treatment services for hypothetical MOUD patients (i.e. therapy as a supplement to medication). Conclusions/Importance: Results indicate that patients receiving agonist medication for an OUD may be the target of public stigma. Public education on the efficacy of agonist medications for OUD is urgently needed to help reduce such stigma, which may facilitate treatment delivery, treatment adherence, and treatment success.

Intervention Stigma toward Medications for Opioid Use Disorder: A Systematic Review

Medications for opioid use disorder (MOUD) are evidence-based treatments, yet can be controversial among some populations. This study provides a systematic review of prejudice and discrimination toward MOUD, a form of "intervention stigma," or stigma associated with a particular medical treatment. A systematic search strategy was used in PsychInfo and PubMed to identify studies published between 1998 and 2018. Studies that empirically examined stigma toward MOUD were included if the manuscript was of moderate or high quality. Studies were analyzed using thematic synthesis. The search yielded 972 studies, of which 28 were included. Most studies utilized qualitative methods to examine intervention stigma toward methadone or buprenorphine, with one including naltrexone. Studies demonstrated that intervention stigma among healthcare providers was influenced by lack of training and abstinent treatment preferences. Providers equated MOUD with illicit substance use and at times refused to care for MOUD patients. Stigma among peer patients seeking treatment was also influenced by abstinent treatment preferences, and among the general public stigma was influenced by lack of MOUD knowledge. Intervention stigma was also driven at the policy level by high regulation of methadone, which fueled diversion and hindered social functioning among patients. Few studies indicated how to reduce intervention stigma toward MOUD. Intervention stigma affects both provision and perceptions of methadone and buprenorphine, decreasing access and utilization of MOUD. Future research should further develop and test MOUD stigma reduction interventions in a variety of social contexts to improve access to care and reduce patient barriers.

A qualitative investigation of addiction counselors' perceptions and experiences implementing an open-access model for treating opioid use disorder

OBJECTIVE

To examine addiction counselors' perceptions and experiences of implementing an open-access model for methadone maintenance treatment (MMT), in which the program rapidly enrolled prospective patients, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Between 2006, when the treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the study site grew from 1431 to 4500.

METHODS

Participants were 31 addiction counselors employed at a treatment organization that implemented an open-access model to scale up MMT. We examined counselors' perceptions and experiences of working in programs that employed this model, using individual semi-structured interviews, which an interdisciplinary team audiotaped, transcribed, and systematically coded using grounded theory. The team reviewed themes and reconciled disagreements (rater agreement was 98%). We describe themes that more than 10% of participants reported.

RESULTS

Counselors described perceived advantages of the open-access model for clients (e.g., "individualized to client needs"), clinicians (e.g., "fewer demands"), and the community (e.g., "crime reduced"). Counselors also described perceived disadvantages of the open-access model for clinicians (e.g., "uneven workload") and clients (e.g., "need for more intensive services for some clients"), as well as program-level concerns (e.g., "perceived lack of structure").

CONCLUSIONS

Counselors who work in opioid treatment programs that use an open-access framework described multiple benefits to themselves, their clients, and the public; they also outlined disadvantages for themselves and clients, which research should further explore and address to facilitate MMT scale up.

Stigma and substance use disorders: A clinical, research, and advocacy agenda

The United States is currently experiencing an opioid epidemic, with deaths due to opioid overdoses persisting in many communities. This epidemic is the latest wave in a series of global substance use-related public health crises. As a fundamental cause of health inequities, stigma leads to the development of substance use disorders (SUDs), undermines SUD treatment efforts, and drives persistent disparities within these crises. Given their expertise in mental and behavioral health, psychologists are uniquely positioned to play a frontline role in addressing SUD stigma. The goal of this paper is to set an agenda for psychologists to address SUD stigma through clinical care, research, and advocacy. To set the stage for this agenda, key concepts are introduced related to stigma and SUDs, and evidence is reviewed regarding associations between stigma and substance use-related outcomes. As clinicians, psychologists have opportunities to promote resilience to stigma to prevent the development of SUDs, and leverage acceptance and mindfulness approaches to reduce internalized stigma among people with SUDs. As researchers, psychologists can clarify the experiences and impacts of stigma among people with SUDs over time and adapt the stigma-reduction toolbox to address SUD stigma. As advocates, psychologists can call for changes in structural stigma such as policies that criminalize people with SUDs, protest the intentional use of SUD stigma, and adopt stigma-free language in professional and social settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Community-led Priority Setting for Opioid Use Disorder in Pregnancy and Parenting

OBJECTIVES

To engage community members with opioid use disorder (OUD) and case managers working with pregnant and parenting individuals with OUD in a priority setting process to identify the key priorities for research, policy, and care improvement during pregnancy, birth, and postpartum.

METHODS

We conducted focus groups across Washington State with pregnant and parenting people with OUD and with case managers working with this community as part of research priority setting using the validated Research Prioritization by Affected Communities protocol. Priorities for research, policy, and service improvement were developed during each focus group by the participants.

RESULTS

Three focus groups with pregnant and parenting people with OUD and 2 focus groups with case managers were conducted (total N = 24 and 16, respectively). Both prioritized topics such as stigma and bias, housing, access to treatment, and steps toward successful recovery. The community and case manager groups shared similar, complementary strategies for each priority, with differences reflecting their perspectives in relation to OUD.

CONCLUSIONS

Community-engaged priority setting among those with OUD was an effective and meaningful way to guide future research, policy, and care improvement efforts.

A Community-Based Investigation of Stigma Toward Individuals Receiving Methadone Maintenance Treatment in China: A Randomized Case Vignette Study

Background: Even though methadone maintenance treatment (MMT) is effective and widely recommended, it is widely misunderstood and stigmatized. This study aimed to explore people's attitudes and beliefs toward MMT, and stigmatization of MMT patients in China. Methods: This randomized, vignette-based study enrolled 1,066 household respondents (552 males and 514 females, response rate is 88.83%, 86.00% in vignette 1 and 91.66% in vignette 2) from two communities in China. Respondents initially completed questionnaires on sociodemographic characteristics and their knowledge about methadone and MMT. They were then randomly assigned to vignette 1 (described a patient receiving MMT) or vignette 2 (described a patient receiving amlodipine treatment). The labeling, stereotyping, and social distance toward the individual described in the vignettes were evaluated. Results: In these two vignettes, respondents showed a significantly higher level of stigma and discrimination toward the patient receiving MMT than the patient receiving amlodipine treatment. Approximately 60% of respondents believed that methadone is a type of addictive drug and that participating in MMT is a way to get high. Over 60% of respondents labeled the heroin-dependent patient who is receiving MMT as an addict even though the patient has not used heroin for several years; about 80% of them believed that the patient has undesirable characteristics and expressed a strong desire for social distance. Conclusions: People's misunderstanding of MMT, and stigmatization of MMT patients were very common among populations in the communities in China. To maximize MMT patients benefiting from MMT programs, more efforts are needed to minimize the impact of MMT-related stigma.

Breaching Trust: A Qualitative Study of Healthcare Experiences of People Who Use Drugs in a Rural Setting

Background: Increased drug use has disproportionately impacted rural areas across the U.S. People who use drugs are at risk of overdose and other medical complications, including infectious diseases. Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, particularly in rural settings where resources may be limited. Methods: We conducted 20 semi-structured interviews with people who use drugs, including 17 who inject drugs, in rural southern Illinois between June 2018 and February 2019. Interviews were analyzed using a modified grounded theory approach where themes are coded and organized as they emerge from the data. Results: Participants reported breaches of trust by healthcare providers, often involving law enforcement and Emergency Medical Services, that dissuaded them from accessing medical care. Participants described experiences of mistreatment in emergency departments, with one account of forced catheterization. They further recounted disclosures of protected health information by healthcare providers, including communicating drug test results to law enforcement and sharing details of counseling sessions with community members without consent. Participants also described a hesitancy common among people who use drugs to call emergency medical services for an overdose due to fear of arrest. Conclusion: Breaches of trust by healthcare providers in rural communities discouraged people who use drugs from accessing medical care until absolutely necessary, if at all. These experiences may worsen healthcare outcomes and further stigmatize this marginalized community. Structural changes including reforming and clarifying law enforcement's role in Emergency Departments as well as instituting diversion policies during arrests may help rebuild trust in these communities. Other possible areas for intervention include stigma training and harm reduction education for emergency medicine providers, as well as developing and implementing referral systems between Emergency Departments and local harm reduction providers and medically assisted drug treatment programs.

A mixed methods study exploring methadone treatment disclosure and perceptions of reproductive health care among women ages 18-44 years, Los Angeles, CA

INTRODUCTION

Opioid use disorder (OUD) and methadone treatment are increasing among women ages 18-44 years old, a population with unique healthcare needs. Despite this increase, there is little research on the healthcare experiences of women with OUD, particularly experiences with reproductive healthcare.

METHODS

We designed a sequential, mixed-methods study in three Los Angeles methadone clinics. In the first phase, we conducted in-depth interviews with women in methadone treatment (n = 22) (September-December 2016). After thematic coding and analysis, we designed and administered a survey to understand patterns in women's experiences and reproductive health knowledge, attitudes, and behavior (n = 50) (January-April 2018). We conducted descriptive statistics, then integrated the quantitative and qualitative findings to contextualize and understand perceptions and experiences with healthcare providers among women in methadone treatment.

RESULTS

We found that women experienced and anticipated that providers would treat them poorly when they disclosed that they were in methadone treatment for OUD. Women's actual experiences with disclosure, shared in in-depth interviews, varied by whether they had disclosed their status intentionally or inadvertently. Approximately one-third (37%) of survey respondents thought a healthcare provider would scold them if they became pregnant; however, all who had been pregnant in the past while on methadone (n = 11) reported disclosing methadone treatment during pregnancy to their provider. Under a quarter of all women (22%) said having a healthy pregnancy while on methadone was likely or very likely. These perceptions were reinforced by negative experiences with providers, or, in many cases, women in the survey reported that they had never discussed the recommendations for a healthy pregnancy while on methadone with a healthcare provider.

DISCUSSION

Women experience and anticipate experiencing negative interactions with their healthcare providers if and when they disclose their methadone treatment. These perceptions and experiences impact subsequent treatment seeking and disclosure. The majority of women did not discuss pregnancy with healthcare providers. To improve quality of care, healthcare providers can provide a safe space for women to disclose methadone treatment through nonjudgmental communication that intentionally alleviates stigma. Additionally, healthcare providers should understand medical guidelines and laws/policies around methadone during pregnancy and communicate this understanding to all patients who may wish to become pregnant or who are at risk for unintended pregnancy.

Exclusion and hospitality: the subtle dynamics of stigma in healthcare access for people emerging from alcohol and other drug treatment

This article explores the role of drug use-related stigma in constraining access to healthcare services. Drawing on interviews with 20 people conducted shortly after leaving an Australian alcohol and other drug withdrawal management unit, the article explores their willingness and ability to access primary care, hospital and further services. It finds repeated descriptions of feeling ignored and shamed during efforts to access care, with some descriptions relating to subtle signs of disapproval or condemnation, and others to being ignored or dismissed. Some accounts additionally emphasise unwelcoming atmospheres, and exclusion by omission of signals of welcome and encouragement. The article goes on to consider, for the first time in this field, contemporary notions of welcome and hospitality as outlined within the cosmopolitanism tradition, asking whether they offer insights into how healthcare may become more accessible for people who regularly experience stigmatisation. In concluding, the article considers the need to think further about forms of exclusion that occur when social and individual histories of stigma are not institutionally recognised, and measures to counter these histories are not actively adopted.

Sexual health services in community pharmacy for women on opioid substitution treatment: a qualitative study

BACKGROUND

Women on opioid substitution treatment (WOST) are at heightened risk for the sexual transmission of sexually transmitted infections and blood-borne viruses. This study aimed to explore the opportunities to promote their sexual health in community pharmacies in UK.

METHODS

Semi-structured interviews were conducted with 20 WOST and 14 community pharmacists (CPs). A focus group was run with three CPs. Participants were recruited in drug services and a service for sex workers (WOST), and in CP. Data collection took place between October 2016 and September 2017. Data were analyzed using Framework Analysis and directed Content Analysis.

RESULTS

CPs could play a role in promoting sexual health among WOST. Sexual health screening, treatment and condom supply were suggested as potential ways of delivering pharmacy-based sexual health services. These services should be actively offered to WOST, delivered in a private space and free of cost. We identified several challenges to overcome in order to design and implement sexual health services for WOST in community pharmacies.

CONCLUSIONS

This study highlights the potentially key role CPs can have promoting sexual health and addressing health inequities among WOST. Improvements in pharmacists' training are required in order to address stigma towards WOST, and promote trust and positive rapport. Structural changes are also needed to broaden the services available for this group of women and improve their access to healthcare.

"They look at us like junkies": influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City

BACKGROUND

People who inject drugs (PWID) are a medically and socially vulnerable population with a high incidence of overdose, mental illness, and infections like HIV and hepatitis C. Existing literature describes social and economic correlations to increased health risk, including stigma. Injection drug use stigma has been identified as a major contributor to healthcare disparities for PWID. However, data on this topic, particularly in terms of the interface between enacted, anticipated, and internalized stigma, is still limited. To fill this gap, we examined perspectives from PWID whose stigmatizing experiences impacted their views of the healthcare system and syringe service programs (SSPs) and influenced their decisions regarding future medical care.

METHODS

Semi-structured interviews conducted with 32 self-identified PWID in New York City. Interviews were audio recorded and transcribed. Interview transcripts were coded using a grounded theory approach by three trained coders and key themes were identified as they emerged.

RESULTS

A total of 25 participants (78.1%) reported at least one instance of stigma related to healthcare system engagement. Twenty-three participants (71.9%) reported some form of enacted stigma with healthcare, 19 participants (59.4%) described anticipated stigma with healthcare, and 20 participants (62.5%) reported positive experiences at SSPs. Participants attributed healthcare stigma to their drug injection use status and overwhelmingly felt distrustful of, and frustrated with, medical providers and other healthcare staff at hospitals and local clinics. PWID did not report internalized stigma, in part due to the availability of non-stigmatizing medical care at SSPs.

CONCLUSIONS

Stigmatizing experiences of PWID in formal healthcare settings contributed to negative attitudes toward seeking healthcare in the future. Many participants describe SSPs as accessible sites to receive high-quality medical care, which may curb the manifestation of internalized stigma derived from negative experiences in the broader healthcare system. Our findings align with those reported in the literature and reveal the potentially important role of SSPs. With the goal of limiting stigmatizing interactions and their consequences on PWID health, we recommend that future research include explorations of mechanisms by which PWID make decisions in stigmatizing healthcare settings, as well as improving medical care availability at SSPs.

Navigating the Intersection Between Persistent Pain and the Opioid Crisis: Population Health Perspectives for Physical Therapy

The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapist practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts could provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as providing actionable suggestions for physical therapists to help develop and implement upstream interventions that could reduce the impact of OUD in their communities.