Using Science to Battle Stigma in Addressing the Opioid Epidemic: Opioid Agonist Therapy Saves Lives

Individual, interpersonal, and neighborhood measures associated with opioid use stigma: Evidence from a nationally representative survey

Despite growing awareness of opioid use disorder (OUD), fatal overdoses and downstream health conditions (e. g., hepatitis C and HIV) continue to rise in some populations. Various interrelated structural forces, together with social and economic determinants, contribute to this ongoing crisis; among these, access to medications for opioid use disorder (MOUD) and stigma towards people with OUD remain understudied. We combined data on methadone, buprenorphine, and naltrexone providers from SAMHSA’s 2019 directory, additional naltrexone providers from Vivitrol’s location finder service, with a nationally representative survey called “The AmeriSpeak survey on stigma toward people with OUD.” Integrating the social-ecological framework, we focus on individual characteristics, personal and family members’ experience with OUD, and spatial access to MOUD at the community level. We use nationally representative survey data from 3008 respondents who completed their survey in 2020. Recognizing that stigma is a multifaceted construct, we also examine how the process varies for different types of stigma, specifically perceived dangerousness and untrustworthiness, as well as social distancing measures under different scenarios. We found a significant association between stigma and spatial access to MOUD — more resources are related to weaker stigma. Respondents had a stronger stigma towards people experiencing current OUD (versus past OUD), and they were more concerned about OUD if the person would marry into their family (versus being their coworkers). Additionally, respondents’ age, sex, education, and personal experience with OUD were also associated with their stigma, and the association can vary depending on the specific type of stigma. Overall, stigma towards people with OUD was associated with both personal experiences and environmental measures.

Jail-based treatment for opioid use disorder in the era of bail reform: a qualitative study of barriers and facilitators to implementation of a state-wide medication treatment initiative

Background

Until recently, few carceral facilities offered medications for opioid use disorder (MOUD). Although more facilities are adopting MOUD, much remains to be learned about addressing implementation challenges related to expansion of MOUD in carceral settings and linkage to care upon re-entry. This is particularly important in jails, where individuals cycle rapidly in and out of these facilities, especially in jurisdictions beginning to implement bail reform laws (i.e., laws that remove the requirement to pay bail for most individuals). Increasing access to MOUD in these settings is a key unexplored challenge.

Methods

In this qualitative study, we interviewed staff from county jails across New Jersey, a state that has implemented state-wide efforts to increase capacity for MOUD treatment in jails. We analyzed themes related to current practices used to engage individuals in MOUD while in jail and upon re-entry; major challenges to delivering MOUD and re-entry services, particularly under bail reform conditions; and innovative strategies to facilitate delivery of these services.

Results

Jail staff from 11 New Jersey county jails participated in a baseline survey and an in-depth qualitative interview from January–September 2020. Responses revealed that practices for delivering MOUD varied substantially across jails. Primary challenges included jails’ limited resources and highly regulated operations, the chaotic nature of short jail stays, and concerns regarding limited MOUD and resources in the community. Still, jail staff identified multiple facilitators and creative solutions for delivering MOUD in the face of these obstacles, including opportunities brought on by the COVID-19 pandemic.

Conclusions

Despite challenges to the delivery of MOUD, states can make concerted and sustained efforts to support opioid addiction treatment in jails. Increased use of evidence-based clinical guidelines, greater investment in resources, and increased partnerships with health and social service providers can greatly improve reach of treatment and save lives.

Supplementary information

The online version contains supplementary material available at 10.1186/s13722-022-00313-6.

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

Health professionals' attitudes toward medications for opioid use disorder

BACKGROUND

Research has shown that medications, especially opioid agonist treatments, are an effective way to treat opioid use disorder (OUD); however, negative attitudes held by health professionals contribute to their underutilization. Methods: A 23-year review of studies that examined health professionals' attitudes toward medications for OUD (MOUD) was conducted to describe the current state of knowledge and to inform future research and interventions. Results: Studies examined attitudes toward the use of methadone, buprenorphine, and naltrexone among various types of health professionals: prescribers, non-prescribing clinicians, pharmacists, and administrators. The characteristics and findings of the included studies were reviewed and synthesized. Findings indicate that attitudes toward MOUD affect access and utilization by influencing prescribing practices, referrals, and adoption within programs. Exposure, knowledge, and treatment orientation were found to be important factors related to attitudes toward MOUD across multiple studies of various types of health professionals. Conclusions: To increase access and utilization, continued efforts are needed to increase positive attitudes toward MOUD among various types of health professionals. Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers.

Exploring first responders' perceptions of medication for addiction treatment: Does stigma influence attitudes?

Researchers have suggested that provider-based stigma of persons who suffer from opioid use disorder (OUD) in the criminal justice system serves as a barrier to fully implementing harm reduction strategies, such as the use of naloxone and medication for addiction treatment (MAT). While scholars have begun to explore the relationships between stigma and first responders' attitudes toward naloxone, little work has been done to assess first responders' attitudes toward other forms of harm reduction, including MAT. The goal of the current exploratory study was to help fill this gap in the literature by assessing first responders' (N = 282) attitudes toward MAT, as well as the correlates of these attitudes. The study specifically focused on examining the relationship between provider-based stigma and attitudes toward MAT. Results show that, in the aggregate, first responders held slightly negative attitudes toward the use of MAT. Moreover, the study found that certain dimensions of stigma (i.e., dangerousness and fatalism) to exhibit a negative relationship with attitudes toward MAT, while support for the disease model of addiction was associated with positive perceptions. Policy implications based on these findings are discussed within.

A Critical Review of the Social and Behavioral Contributions to the Overdose Epidemic

More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present trends in opioid overdose rates during this period and discuss how the proliferation of opioid prescribing to treat chronic pain, changes in the heroin and illegally manufactured opioid synthetics markets, and social factors, including deindustrialization and concentrated poverty, contributed to the rise of the overdose epidemic. We also examine how current policies implemented to address the overdose epidemic may have contributed to reducing prescription opioid overdoses but increased overdoses involving illegal opioids. Finally, we identify new directions for research to understand the causes and solutions to this critical public health problem, including research on heterogeneous policy effects across social groups, effective approaches to reduce overdoses of illegal opioids, and the role of social contexts in shaping policy implementation and impact.

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.

Adolescent-Serving Addiction Treatment Facilities in the United States and the Availability of Medications for Opioid Use Disorder

PURPOSE

Adolescents with opioid use disorder are less likely than adults to receive medications for opioid use disorder (MOUD), yet we know little about facilities that provide addiction treatment for adolescents. We sought to describe adolescent-serving addiction treatment facilities in the U.S. and examine associations between facility characteristics and offering MOUD, leading to informed recommendations to improve treatment access.

METHODS

This cross-sectional study used the 2017 National Survey of Substance Abuse Treatment Services. Facilities were classified by whether they offered a specialized adolescent program. Covariates included facility ownership, hospital affiliation, insurance/payments, government grants, accreditation/licensure, location, levels of care, and provision of MOUD. Descriptive statistics and logistic regression compared adolescent-serving versus adult-focused facilities and identified characteristics associated with offering maintenance MOUD.

RESULTS

Among 13,585 addiction treatment facilities in the U.S., 3,537 (26.0%) offered adolescent programs. Adolescent-serving facilities were half as likely to offer maintenance MOUD as adult-focused facilities (odds ratio, .53; 95% confidence interval, .49-.58), which was offered at 23.1% (816) of adolescent-serving versus 35.9% (3,612) of adult-focused facilities. Among adolescent-serving facilities, characteristics associated with increased unadjusted odds of offering maintenance MOUD were nonprofit status, hospital affiliation, accepting insurance (particularly, private insurance), accreditation, Northeastern location, or offering inpatient services.

CONCLUSIONS

The one-quarter of U.S. addiction treatment facilities that serve adolescents are half as likely to provide MOUD as adult-focused facilities, which may explain why adolescents are less likely than adults to receive MOUD. Strategies to increase adolescent access to MOUD may consider insurance reforms/incentives, facility accreditation, and geographically targeted funding.

Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services

BACKGROUND AND AIMS

Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non-medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non-medication treatments in specialty care settings.

DESIGN

Retrospective cohort study using state-wide treatment data linked to death records. Survival analysis was used to analyze data in a time-to-event framework.

SETTING

Services delivered by 757 providers in publicly funded out-patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016.

PARTICIPANTS

A total of 48 274 adults admitted to out-patient specialty treatment programs in 2015-16 for primary diagnosis of opioid use disorder.

MEASUREMENTS

Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non-medication treatments and time following non-medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral.

FINDINGS

The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non-medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08-0.40]. Periods after discharge from non-medication treatment (aHR = 5.45, 95% CI = 2.80-9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10-11.02) had similar and substantially elevated risks compared with periods in non-medication treatments.

CONCLUSIONS

Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non-medication treatments during care but not after treatment is discontinued.

The United States opioid epidemic

The United States opioid epidemic is a nationwide public health crisis. Initially driven by increased consumption and availability of pharmaceutical opioids, an increasing number of opioid overdoses are now related to heroin and illicitly manufactured fentanyl and fentanyl analogs. Addressing this epidemic requires addressing the stigma associated with opioid use disorders and its treatment, improving access to efficacious treatment options, specifically methadone and buprenorphine, and reducing opioid overdose fatalities with distribution of the opioid antagonist and overdose reversal agent naloxone.

Managing the stigma of opioid use

Substance use stigma makes it difficult to reframe the opioid crisis as a public health issue and has been a barrier to accessing life-saving treatments. Interventions using people that convey recovery stories are promising practices. Groups that may benefit from targeted stigma reduction interventions include opioid users (to combat shame and blame), at-risk youth, first responders, dispensary personal, media, and healthcare professionals. The evidence supporting antistigma interventions is thin, with little Canadian research. Research is needed to establish the effectiveness of substance-related stigma reduction strategies. Health leaders should examine their own responsibilities to lead the public health debate, reduce opioid-related stigma, and actively engage members of the community of those with lived experience to become partners in these activities.

Ethical and clinical safety considerations in the design of an effectiveness trial: A comparison of buprenorphine versus naltrexone treatment for opioid dependence

We examine ethical challenges encountered in the design of an effectiveness trial (CTN-0051; X:BOT), comparing sublingual buprenorphine-naloxone (BUP-NX), an established treatment for opioid dependence, to the newer extended-release injectable naltrexone (XR-NTX). Ethical issues surrounded: 1) known poor effectiveness of one possible, commonly used treatment as usual control condition-detoxification followed by counseling without medication; 2) the role of patients' preferences for treatments, given that treatments were clinically approved and available to the population; 3) differences between the optimal "usual treatment" clinical settings for different treatments making it challenging to design a fair comparison; 4) vested interest groups favoring different treatments exerting potential influence on the design process; 5) potentially vulnerable populations of substance users and prisoners; 6) potential therapeutic misconception in the implementation of safety procedures; and 7) high cost of a large trial limiting questions that could be addressed. We examine how the design features underlying these ethical issues are characteristic of effectiveness trials, which are often large trials that compare treatments with varying degrees of existing effectiveness data and familiarity to patients and clinicians, in community-based treatment settings, with minimal exclusion criteria that could involve vulnerable populations. Hence, investigators designing effectiveness trials may wish to remain alert to the possibility of similar ethical issues.