Opioid use and stigma: The role of gender, language and precipitating events

Adapting the Opening Minds Stigma Scale for Healthcare Providers to Measure Opioid-Related Stigma

The opioid crisis in Canada continues to cause a devastating number of deaths. Community-based naloxone programs have been identified as one of the solutions for combatting this crisis; however, there are disparities in which pharmacies stock and offer naloxone. Opioid-related stigma is a major barrier for limited naloxone distribution through pharmacies. Therefore, the development of anti-stigma interventions is crucial to improve naloxone distribution in Canada. However, there is no validated tool to specifically measure opioid-related stigma. The Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) is a validated scale used to measure mental illness-related stigma. This study will adapt the OMS-HC by using four different opioid-related terminologies to determine which is the most stigmatizing to use in an opioid-related anti-stigma intervention. Pharmacy students completed four versions of the adapted OMS-HC. The average OMS-HC scores and Cronbach's α co-efficient were calculated for each version. The term "opioid addiction" was found to be the most stigmatizing term among participants and will be used in the adapted version of the OMS-HC in a future anti-stigma interventions.

First-Year Medical Students' Perceptions of Stigma Toward People With Opioid Use Disorder Before and After an Educational Intervention

BACKGROUND

Stigma among medical trainees toward people with opioid use disorder (OUD) compounds the problems associated with opioid addiction. People with OUD who experience overt and implicit stigma from healthcare providers are less likely to seek and receive treatment, further restricting their access to already limited resources. The objective of our study was to assess an educational strategy to mitigate stigma toward people with OUD among first-year medical students.

METHODS

This study assessed perceptions of stigma toward people with OUD among first-year medical students using an adaptation of a brief, validated opioid stigma scale before and after an educational intervention. The intervention consisted primarily of a recorded panel in which people with a history of OUD shared their experiences with stigma followed by small group discussions.

RESULTS

After the educational intervention, students were more likely to respond that (1) they believed most people held negative beliefs about people with OUD and (2) they personally disagreed with negative statements about people with OUD.

CONCLUSIONS

Educational interventions addressing stigma toward people with OUD are potentially effective and should be integrated into medical curricula. Such interventions are a crucial part of the effort to improve the medical care of people with OUD.

Patient perceptions of and experiences with stigma using telehealth for opioid use disorder treatment: a qualitative analysis

BACKGROUND

Patients with opioid use disorder (OUD) experience various forms of stigma at the individual, public, and structural levels that can affect how they access and engage with healthcare, particularly with medications for OUD treatment. Telehealth is a relatively new form of care delivery for OUD treatment. As reducing stigma surrounding OUD treatment is critical to address ongoing gaps in care, the aim of this study was to explore how telehealth impacts patient experiences of stigma.

METHODS

In this qualitative study, we interviewed patients with OUD at a single urban academic medical center consisting of multiple primary care and addiction clinics in Oregon, USA. Participants were eligible if they had (1) at least one virtual visit for OUD between March 2020 and December 2021, and (2) a prescription for buprenorphine not exclusively used for chronic pain. We conducted phone interviews between October and December 2022, then recorded, transcribed, dual-coded, and analyzed using reflexive thematic analysis.

RESULTS

The mean age of participants (n = 30) was 40.5 years (range 20-63); 14 were women, 15 were men, and two were transgender, non-binary, or gender-diverse. Participants were 77% white, and 33% had experienced homelessness in the prior six months. We identified four themes regarding how telehealth for OUD treatment shaped patient perceptions of and experiences with stigma at the individual (1), public (2-3), and structural levels (4): (1) Telehealth offers wanted space and improved control over treatment setting; (2) Public stigma and privacy concerns can impact both telehealth and in-person encounters, depending on clinical and personal circumstances; (3) The social distance of telehealth could mitigate or exacerbate perceptions of clinician stigma, depending on both patient and clinician expectations; (4) The increased flexibility of telehealth translated to perceptions of increased clinician trust and respect.

CONCLUSIONS

The forms of stigma experienced by individuals with OUD are complex and multifaceted, as are the ways in which those experiences interact with telehealth-based care. The mixed results of this study support policies allowing for a more individualized, patient-centered approach to care delivery that allows patients a choice over how they receive OUD treatment services.

"In Sweden you are worthless. In Denmark you get an identity again" - on being perceived and received as a person who uses drugs in different drug policy settings

BACKGROUND

Policies to address substance use differ greatly between settings, where goals may range from zero-tolerance to harm reduction. Different approaches impact formats of care, policing, and even interpersonal interactions, and may play a role in the labelling and stigmatization of people who use drugs (PWUD). Where Sweden has a more restrictive policy, aiming to have a society free from drugs, Denmark has embraced harm reduction principles. The aim of this study was to explore PWUDs' experiences of interpersonal interactions, policing, and service formats in the two countries.

METHODS

The data consists of 17 qualitative semi-structured interviews with Swedish PWUD who have been in both Sweden and Denmark. Recruitment took place at harm reduction sites in both countries, and through snowball sampling.

RESULTS

Participants reflected on how they were perceived by those in public spaces, and received by care systems and personnel. In public settings in Sweden, participants felt they were ignored, rendered invisible, and lost their humanity. In Denmark, they were perceived and acknowledged, valued as people. This was simultaneously linked to being embodied by the availability of differing service offerings and policing practices, which solidified their "right to be out" in public. Reflecting on their reception in the treatment system, strict formatting in Sweden caused participants to feel that an identity was projected upon them, limiting their opportunities or growth of new facets of identity. Care relations in Denmark fostered more opportunity for autonomy and trust.

CONCLUSION

A zero-tolerance policy and associated public discourses could solidify and universalize stigmatizing categorizations as a central feature of PWUD identity and reception from those around them, exacerbating social exclusion. Conversely, harm reduction-centered policies fostered positive interactions between individuals with care providers, public, and police, which may promote inclusion, empowerment, and wellbeing.

Stigma Related to the Non-Medical Use and Diversion of Prescription Stimulant Drugs: Should We Care

BACKGROUND

Non-medical use (NMU) and diversion of prescription stimulants are prevalent on college campuses. Diversion represents a primary source of acquisition for NMU among young adults. This study examined relationships between stigmatizing beliefs related to NMU and diversion of stimulant medications and engagement in these behaviors, as well as how such perceptions are associated with indicators of psychological distress among those who engage in these behaviors.

METHODS

Young adults (N = 384) were recruited from a large US university to participate in this cross-sectional electronic survey-based study. Relationships between stigma variables and NMU and diversion were assessed. Among those who engage in NMU and diversion, we tested relationships between stigma variables and indicators of psychological distress, using validated instruments.

RESULTS

Perceived social and personal stigmatic beliefs did not significantly predict NMU. However, perceived social and personal stigma of diversion significantly reduced diversion likelihood. For NMU, associations were found between stigma variables and indicators of psychological distress. Markedly, we found that as stigmatic perceptions of NMU increased, so did depressive, anxiolytic, and suicidal symptomatology among those who engage in NMU.

CONCLUSIONS

Stigmatization does not deter NMU; however, stigmatization is positively associated with psychological harm among those who engage in NMU. Interventions should be developed to reduce stigmatization in order to improve psychological health among those who engage in NMU. Stigmatic perceptions of diversion were not predictive of psychological harm, though they are negatively associated with diversion behavior.

The contribution of pain catastrophizing, depression and anxiety symptoms among patients with persistent pain and opioid misuse behaviours

BACKGROUND

Anxiety, depression and pain catastrophizing are independently associated with risk of opioid misuse in patients with persistent pain but their relationship to current opioid misuse, when considered together, is poorly understood. This study will assess the relative contribution of these modifiable, and distinct psychological constructs to current opioid misuse in patients with persistent pain.

METHODS

One hundred and twenty-seven patients referred to a specialized opioid management clinic for prescription opioid misuse within a tertiary pain service were recruited for this study. The Pain Catastrophizing Scale, Depression, Anxiety and Stress Scales and the Current Opioid Misuse Measure were administered pre-treatment. Pain severity and morphine equivalent dose based on independent registry data were also recorded.

RESULTS

Higher levels of pain catastrophizing, depression, and anxiety were significantly associated with higher current opioid misuse (r = .475, 0.599, and 0.516 respectively, p < .01). Pain severity was significantly associated with pain catastrophizing (r = .301, p < .01). Catastrophizing, depression, and anxiety explained an additional 11.56% of the variance (R2 change = 0.34, p < .01) over and above age, gender, pain severity and morphine equivalent dose. Depression was the only significant variable at Step 2 (β = 0.62, p < .01).

CONCLUSION

Findings show that in a sample of people with persistent pain referred for treatment for opioid misuse, depression contributes over and above that of anxiety and pain catastrophizing. Theoretical and clinical practice implications are presented.

Stigma Communication Surrounding Nonmedical Opioid Use Among Affected Family Members

A growing body of research demonstrates the role of language in stigma toward nonmedical opioid use (NMOU). Terms like "substance abuser" perpetuate stereotypes and evoke punitive judgments. This study examines how affected family members (AFMs) communicate stigma when discussing their loved one's NMOU. Semi-structured interviews were conducted with 34 adults with a close family member with a history of NMOU. An iterative approach was used to analyze instances when stigmatizing terms or messages were used. AFMs described people engaged in NMOU as underweight, "dirty," or "nodding off," and often labeled these individuals "addicts" or opioid "abusers." Responsibility for the NMOU was attributed to both internal (e.g. choice) and external (e.g. brain disease) factors. People engaged in NMOU were linked to physical danger, resource threats, and threats to the family members' reputation and relationships. While most stigma messages related to the person engaged in NMOU, stigmatizing messages directed toward AFMs also emerged; family members labeled "enablers" were judged, blamed, and described as a threat to the person engaged in NMOU. Although AFMs expressed care and desire to support their loved ones, they often conveyed stigma in their language choices. This language among AFMs may reflect internalized stigma. Increased efforts are needed to help AFMs cope with the challenges of a loved one's NMOU and identify effective ways to support their loved one. One way AFMs can support their loved one is by using more inclusive, person-first language.

Inclusion of Sex and Gender Differences in U.S. State Action Plans for Opioid Use and Opioid Use Disorder

Background: States have developed action plans to address the "opioid crisis" over the past several years. While sex- and gender-based differences have been identified in complications of opioid use, risks of addiction to opioids, barriers to treatment of opioid use disorder, and associated stigma, it is unknown if or to what extent opioid plans consider or account for these differences. The objectives of this study were to analyze U.S. state opioid action plans and their inclusion of sex- and gender-specific concerns. Methods: A content analysis of 49 state plans was conducted in June 2020, assessing their inclusion of 14 variables covering provider education, pregnancy-related, and sex- or gender-based differences in opioid addiction and treatment. Results: Neonatal opioid withdrawal syndrome was the most common variable, noted in 57% of plans. Only 14% included pregnancy-related stigma, and 4% identified gender-specific stigma. Contraceptives and family-planning were included in 12% and 10% of plans, respectively. Two states included more than half of the variables and five plans made no mention of sex or gender differences. Conclusions: Few state plans contained sex- or gender-specific information, and those that did focused almost exclusively on childbearing, excluding other unique considerations of opioid-using-women of all ages. The results of this study could improve the care of women using opioids by informing the strategies of state agencies and impacting legislative efforts for prevention initiatives, substance use disorder treatment, and law enforcement programs.

Employing Bayesian analysis to establish a cut-off point and assess stigma prevalence in substance use disorder: a comprehensive study of the Chinese version of the Substance Use Stigma Mechanism Scale

PURPOSE

In China, individuals with substance use disorders (SUD) face severe stigma, but reliable stigma assessment tool is lacking. Therefore, this study aimed to validate the Chinese version of the Substance Use Stigma Mechanism Scale (SU-SMS-C) and set its cut-off point.

METHODS

We recruited 1005 individuals with SUDs from Chinese rehabilitation centers. These participants completed a battery of questionnaires that included the SU-SMS-C, The Multidimensional Scale of Perceived Social Support (MSPSS), Center for Epidemiologic Studies Depression Scale (CES-D), General Self-Efficacy Scale (GSES), and Perceived Devaluation and Discrimination (PDD). Confirmatory factor analysis was used to assess the construct validity of the scale. Additionally, the Naive Bayes classifier was used to establish the cut-off point for the SU-SMS-C. We additionally explored the correlation between patient demographic characteristics and stigma.

RESULTS

A confirmatory factor analysis was utilized, revealing a second-order five-factor model. Based on the Naive Bayes classifier, the area under the receiver operating characteristic (AUCROC) of 0.746, the cut-off point for the SU-SMS-C was established at 44.5. The prevalence of stigma observed in the study population was 49.05%. Significant disparities were observed in the distribution of stigma across genders, with males experiencing more pronounced stigma than females. Moreover, patients consuming different primary substances reported diverse levels of stigma. Notably, those primarily using heroin endured a higher degree of stigma than users of other substances.

CONCLUSION

The study is the first to identify a cut-off point for the SU-SMS-C by Naive Bayes classifier, bridging a major gap in stigma measurement research. SU-SMS-C may help treat and manage SUDs by reducing stigma.

America's perceptions of opioid related impairment: A national randomized study examining how different individuals may stigmatize addiction in response to different terminology

INTRODUCTION

Prior research has found that different ways of describing opioid-related impairment influences the types and degrees of stigmatizing beliefs held by the American public. In this study we examined the extent to which different characteristics of the American public (i.e., age, gender, race/ethnicity, religiosity, sexual orientation, political affiliation, personal history of addiction/mental health problem) are associated with holding different types and degrees of stigmatizing beliefs when asked to consider someone treated for opioid-related impairment. We also assessed whether any observed differences in stigmatizing beliefs related to participant characteristics are dependent on how an opioid-impaired patient is described in terms of both the nature of the impairment (e.g., as a "chronically relapsing brain disease", "brain disease", "disease", "illness", "disorder", or "problem") as well as the gender of the depicted opioid-impaired person.

METHODS

A nationally representative sample of the U.S. population (N = 3643) was randomized to one of six vignettes describing a patient being treated for opioid-related impairment that differed only in the way the impairment was described (as a "chronically relapsing brain disease", "brain disease", "disease", "illness", "disorder", or "problem"). Participants subsequently were asked to rate statements assessing five stigma dimensions (blame, prognostic pessimism, continuing care, dangerousness, and social distance).

RESULTS

Several characteristics were associated with different types and higher levels of stigmatizing beliefs: older age, male gender, White race, heterosexual orientation, being religious, Republican political affiliation, and having no prior alcohol/drug or mental health problem history (ps < 0.001). With very few exceptions, the way the opioid-impairment was described or whether the depicted patient was a man or a woman did not influence the strength of these associations.

CONCLUSIONS

Certain characteristics of members of the US population were associated with holding different types and degrees of stigmatizing attitudes when asked to consider someone receiving treatment for opioid-related impairment and these were largely unaffected by how the impairment was labeled or the opioid-impaired person's gender. Depending on the specific target of clinical and public health anti-stigma campaigns, both addiction terminology and the beliefs held by certain population sub-groups will need to be considered when creating opioid use disorder related anti-stigma campaigns.

Perceptions of medications, program settings, and drug use histories among individuals engaged in treatment for opioid use disorder

Background: Nearly two million adults in the US currently live with an Opioid Use Disorder (OUD) diagnosis. Recent efforts have encouraged and facilitated widespread adoption of empirically supported medications for opioid use disorder (MOUD), yet MOUD and OUD behavioral health interventions remain dramatically underutilized. Fear of discrimination and judgment, compounded by systemic and regulatory barriers, hinder individuals' access to specialty treatment.Objectives: The goal of the current study was to (1) reveal how perspectives toward OUD treatment may differ across medication types, program settings, and drug use history; (2) address systemic and regulatory components that potentially foster and propagate positive or negative attributions to OUD; and (3) understand how experiences reduce patients' willingness to pursue and/or maintain long term treatment.Methods: Twenty-four adults engaged in buprenorphine treatment at two outpatient addiction treatment centers participated in in-depth, qualitative interviews between 2019 and 2020 in Providence, Rhode Island.Results: Thematic analysis revealed negative attributions toward OUD across all participants. Three key themes developed from the coding and analysis: (1) differential perceptions of therapeutic medications (2) negative perceptions of treatment programs and (3) perceptions of drugs and people who use drugs.Conclusions: Stigmatizing language remains a major public health issue that needs to be addressed to facilitate treatment for individuals for OUD and other drug use disorders. Incorporating strategies targeting labeling across medication types, program settings, and drug use may improve treatment outcomes by reducing the inaccurate beliefs surrounding OUD and connecting patients to evidence-based support.

Drug transactions and the dark web: Public perceptions of the locational setting of offenders and support for drug policy outcomes

BACKGROUND

Both legal and extra-legal factors influence judicial and non-judicial opinions about persons who use drugs. Yet, how the locational setting of drug transactions influences public perceptions of drug control policies remains understudied. In particular, the public's view of drug exchanges on the dark web could directly and indirectly influence drug policy, legal decision making, and spending decisions. The study's aim is to identify whether the location of a drug exchange, specifically the dark web, influences public preferences for drug policy and police resourcing.

METHODS

A sample (n = 1359) from the United States of America was recruited and participated in a discrete choice experiment. The participants compared and repeatedly chose across five iterations between two drug offender profiles with nine set features, such as the location of drug transactions, all with randomized levels. The resulting sample included a total of 13,590 contest pairs.

RESULTS

Averaging over the non-locational attributes, respondents indicated that, compared to the dark web, several locational settings for drug exchange (such as the street corner, social media, and an unknown location) needed fewer police resources and offenders were less deserving of longer punishments. No statistically significant difference was found for opinions about harm to communities, and offenders involved in drug exchanges on university campuses were considered more deserving of a substance abuse treatment program than offenders on the dark web.

CONCLUSION

There appears to be a preference for more punitive criminal justice policies for drug transactions occurring on the dark web relative to some other common settings. Such preferences may indicate a novelty effect driven by negative sentiment surrounding the dark web or a perceived deficit in the police's ability to deal with drug crimes on the dark web. These findings suggest that the public may prefer supply-side policing efforts over demand-side policies, which emphasizes harm reduction.

The Impact of an Online Educational Intervention on Attitudes of Primary Care Clinicians Toward Managing Patients With Substance Use Disorders

BACKGROUND

Negative attitudes of primary care clinicians toward patients with substance use disorders affect the quality and delivery of care in this highly marginalized patient population.

PURPOSE

This project aimed to improve negative attitudes of primary care clinicians toward managing patients with substance use disorders.

METHODS

A pretest-and-posttest design, employing multidimensional online educational interventions, was implemented from June to August 2020. The participants (n = 18) were recruited from a pool of 70 primary care clinicians at two community primary care agencies. The Affect Scale for Substance Users and 15-item Opening Minds Scale for Health Care Providers were administered before, immediately after, and 30 days after the intervention.

RESULTS

There were statistically significant reductions in the immediate postintervention and 30-day postintervention mean scores in the Affect Scale for Substance Users and the disclosure and help-seeking subscale when compared with those of preintervention. The change in attitudes was maintained at 30-day postintervention.

CONCLUSIONS

The project findings support conducting and evaluating future educational programs for substance use disorder management among primary care clinicians. Because of the heterogeneity of the participants and the small sample size, the project results have limited generalizability. Overall, this project is among one of the few aimed at substance use disorder management among primary care clinicians.

Examining the benefit of a higher maintenance dose of extended-release buprenorphine in opioid-injecting participants treated for opioid use disorder

BACKGROUND

BUP-XR (SUBLOCADE®) is the first buprenorphine extended-release subcutaneous injection approved in the USA for monthly treatment of moderate-to-severe opioid use disorder (OUD). Among patients with OUD, those who inject or use high doses of opioids likely require higher doses of buprenorphine to maximize treatment efficacy. The objective of this analysis was to compare the efficacy and safety of 100-mg versus 300-mg maintenance doses of BUP-XR in OUD patients who inject opioids.

METHODS

This was a secondary analysis of a randomized, double-blind, placebo-controlled study in which adults with moderate or severe OUD received monthly injections of BUP-XR (2 × 300-mg doses, then 4 × 100-mg or 300-mg maintenance doses) or placebo for 24 weeks. Abstinence was defined as opioid-negative urine drug screens combined with negative self-reports collected weekly. Each participant's percentage abstinence was calculated after the first, second, and third maintenance doses in opioid-injecting and non-injecting participants. The proportion of participants achieving opioid abstinence in each group was also calculated weekly. Treatment retention rate following the first maintenance dose was estimated for opioid-injecting participants with Kaplan-Meier method. Risk-adjusted comparisons were made via inverse propensity weighting using propensity scores. Buprenorphine plasma concentration-time profiles were compared between injecting and non-injecting participants. The percentages of participants reporting treatment-emergent adverse events were compared between maintenance dose groups within injecting and non-injecting participants separately.

RESULTS

BUP-XR 100-mg and 300-mg maintenance doses were equally effective in non-injecting participants. However, in opioid-injecting participants, the 300-mg maintenance dose delivered clinically meaningful improvements over the 100-mg maintenance dose for treatment retention and opioid abstinence. Exposure-response analyses confirmed that injecting participants would require higher buprenorphine plasma concentrations compared to non-injecting opioid participants to achieve similar efficacy in terms of opioid abstinence. Importantly, both 100- and 300-mg maintenance doses had comparable safety profiles, including hepatic safety events.

CONCLUSIONS

These analyses show clear benefits of the 300-mg maintenance dose in injecting participants, while no additional benefit was observed in non-injecting participants relative to the 100-mg maintenance dose. This is an important finding as opioid-injecting participants represent a high-risk and difficult-to-treat population. Optimal buprenorphine dosing in this population might facilitate harm reduction by improving abstinence and treatment retention.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02357901.

A (In)curable Disease? Making Meaning of Addiction from the Perspective of People in Recovery from Opioid Use Disorder

People in recovery for opioid use must navigate their chronic illness and the corresponding stigma. Despite the prevalence of opioid use in the United States, contradictory determinations about the curability and responsibility of addiction remain. These contractions provide a complicated site from which to examine power in a health context where misinformation can be costly. In this study, we applied contrapuntal analysis, the corresponding method of relational dialectics theory, to examine the meaning of addiction from the perspective of people in recovery for opioid use disorder. Findings revealed two discourses: the Discourse of Addiction as a Disruptive Choice (DADC) and the Discourse of Addiction as Bad Luck (DABL) that interplayed through contractive practices and synchronic interplay. Findings also revealed a new contractive practice we term "mobbing."

Stigma Toward Substance Dependence: Causes, Consequences, and Potential Interventions

Substance dependence is a prevalent and urgent public health problem. In 2021, 60 million Americans reported abusing alcohol within the month prior to being surveyed, and nearly 20 million Americans reported using illegal drugs (e.g., heroin) or prescription drugs (e.g., opioids) for nonmedical reasons in the year before. Drug-involved overdose rates have been steadily increasing over the past 20 years. This increase has been primarily driven by opioid and stimulant use. Despite its prevalence, drug dependence is one of the most stigmatized health conditions. Stigma has myriad negative consequences for its targets, including limiting their access to employment and housing, disrupting interpersonal relationships, harming physical and mental health, and reducing help-seeking. However, because research on stigma toward people with substance use disorders (SUDs) is relatively sparse compared with research on stigma toward other mental illnesses, the field lacks a comprehensive understanding of the causes and consequences of SUD stigma. Moreover, it remains unclear how, if at all, these factors differ from other types of mental illness stigma. The goal of this review is to take stock of the literature on SUD stigma, providing a clear set of foundational principles and a blueprint for future research and translational activity.

The effects of race and class on community-level stigmatization of opioid use and policy preferences

BACKGROUND

With opioid use and overdose rates continuing to plague minority communities in the U.S., we explored whether a geographic community's racial composition and social class affect how opioid use in the community is stigmatized and what policy preferences arise in response.

METHODS

We use case vignettes in a randomized, between-subjects study (N = 1478) with a nation-wide survey. The vignettes describe a community where opioids are harmfully used, varying whether the community was (1) wealthy or poor, (2) predominantly Black or White and (3) facing prevalent use of painkillers or heroin. We tested how these variables affect public stigmatization of opioid use (measured with ratings of responsibility, dangerousness, sympathy, concern, anger, and disappointment) preferred levels of social distance from communities with opioid use (measured with responses to questions about living, working, and interacting in the community), and policy preferences for responding to opioid use (measured with levels of support for providing a safe-consumption site in the community, treating drug use in the community punitively, treating drug use in the community as an illness, and funding drug treatment in the community through income redistribution).

RESULTS

Compared to wealthy communities with opioid use, poor communities with opioid use were less stigmatized in terms of responsibility, sympathy, concern, anger, and disappointment; they were also met with less support for punitiveness, more support for treating drug use as an illness, and preferences for greater social distance. Compared to White communities with opioid use, Black communities with opioid use were less stigmatized in terms of responsibility, and they were met with stronger preferences to not live and work there and with reduced support for using income redistribution to provide drug treatment for people in the community. Poor-Black communities with opioid use were also perceived to be more dangerous than both poor-White and wealthy-Black communities with opioid use.

CONCLUSION

These results point to class- and race-based territorial stigma affecting how communities with opioid use are judged and whether policies for providing communities with treatment are supported.

Stigma and level of familiarity with opioid maintenance treatment (OMT) among specialist physicians in Israel

CONTEXT

Opioid use disorder (OUD) poses significant public health problems that have increased dramatically, resulting in high rates of morbidity and mortality.

OBJECTIVES

To minimize the risk of an opioid epidemic in Israel and be prepared, we evaluated physicians' objective knowledge, level of stigma, and approach to prescribing opioids, risk factors, and identification of patients with substance use disorder (SUD), as well as their knowledge about opioid maintenance treatment (OMT) for OUD.

METHODS

Anonymous computerized questionnaires were distributed nationally to physicians by the Israel Medical Association. Knowledge, stigma, and approach were scored.

RESULTS

Of only 249 responders, 58.6% prescribe opioids, 32.1% prescribe cannabis, and 18.5% daily encounter patients with SUD. Logistic regression found the high knowledge group had daily encounters with SUD (Odds Ratio (OR) = 3.5, 95% CI 1.7-7.1) and were familiar with OMT (OR = 10.1, 95% CI 3.5-29.0). The high stigma group was characterized by physicians who prescribe opioids (OR = 1.7, 95% CI 1.0-2.9), but who self-reported having limited knowledge regarding OMT (OR = 2, 95% CI 1.1-3.7). The high approach group was characterized by those who prescribe opioids (OR = 11.7, 95% CI 4.9-28), prescribe cannabis (OR = 2.1, 95% CI 1.0-4.3), self-report having limited knowledge regarding OMT (OR = 11.2, 95% CI 1.4-89) and self-report identifying SUD (OR = 32.5, 95% CI 4.1-260).

CONCLUSION

High stigma was most evident among physicians who prescribe opioids but, importantly, who had limited knowledge specifically regarding OMT. Gaps in knowledge and approach were observed. An educational intervention is highly recommended to reduce stigma and increase referrals of patients for OMT, the most effective treatment for opioid use disorder.

Role of Stigma for Health Care Professionals With Nonmedical Substance Use

BACKGROUND

Stigma toward those with non-medical substance use may present as anticipated, perceived, enacted, or internalized stigma.

OBJECTIVE

The purpose of the study was to describe the role of stigma on health care professionals with non-medical substance use, from the perspective of treatment providers. Soliciting information about stigma from treatment providers is a unique perspective lacking in current literature.

METHODS

A qualitative descriptive design was used with semi-structured interviews of treatment providers (N = 16) in Colorado. Inductive content analysis was used to identify concepts and themes across interviews.

RESULTS

Findings showed that stigma is a major concern and a barrier for health care professionals seeking substance use treatment. Nurses and physicians demonstrate shame and guilt (internalized stigma) around their substance use. These professionals also experience fear around their reputation (perceived stigma) and challenges around re-entry to the workforce after treatment (anticipated stigma).

CONCLUSIONS

The awareness of existing stigma as well as internalized stigma impacts how health care professionals approach treatment, recovery, and returning to work.

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

BACKGROUND

Stigma surrounding opioid use disorder (OUD) is a barrier to treatment. The use of stigmatizing language may be evidence of negative views toward patients.

OBJECTIVE

We aimed to identify associations between language and clinical outcomes in patients admitted for infectious complications of OUD.

DESIGNS

We performed a retrospective medical record review.

SETTINGS AND PARTICIPANTS

Four U.S. academic health systems. Participants were patients with OUD admitted for infectious complications of injection opioid use from January 1, 2018, to December 31, 2018, identified through international classification of diseases, 10th revision codes consistent with OUD and acute bacterial/fungal infection.

MAIN OUTCOME AND MEASURES

Discharge summaries were reviewed for language, specifically: abuse, addiction, dependence, misuse, use disorder, intravenous drug use, and others. Binary outcomes including medication for OUD, planned discharge, naloxone provision, and an OUD treatment plan were evaluated using logistic regressions and admission duration was evaluated using Gamma regression.

RESULTS

A total of 1285 records were reviewed and 328 met inclusion criteria. Of those, 191 (58%) were male, with a median age of 38 years. The most common term was "abuse" (219, 67%), whereas "use disorder" was recorded in 75 (23%) records. Having "use disorder" in the discharge summary was associated with increased odds of having a documented plan for ongoing OUD treatment (adjusted odds ratio [AOR]: 4.11, 95% confidence interval [CI]: 1.89-8.93) and having a documented plan for addiction-specific follow-up care (AOR: 2.31, 95% CI: 1.30-4.09).

CONCLUSIONS

Stigmatizing language was common in this study of patients hospitalized for infectious complications of OUD. Best-practice language was uncommon, but when used was associated with increased odds of addiction treatment and specialty care referrals.

Buprenorphine adherence and illicit opioid use among patients in treatment for opioid use disorder

Background: Buprenorphine is a partial mu opioid agonist medication that has been shown to decrease non-prescribed opioid use, cravings, and opioid related morbidity and mortality. There is an assumption that full adherence is needed to achieve ideal treatment outcomes, and that non-adherence is associated with ongoing opioid use. However, literature documenting the strength of that assertion is lacking.Objectives: Evaluate the association between daily buprenorphine adherence and illicit opioid use.Methods: Secondary analysis of a 12-week randomized controlled trial of adults with opioid use disorder who recently initiated buprenorphine. Weekly study visits included self-report of daily buprenorphine adherence over the past 7 days (Timeline Follow Back method) and urine drug tests (UDT). A log-linear regression model accounting for clustering by participant was used to assess the association between buprenorphine adherence and illicit opioid use. Buprenorphine adherence was measured as a continuous variable (0-7 days).Results: Among 78 participants (56 men, 20 women, 2 nonbinary) with 737 visits, full 7-day adherence was reported at 70% of visits. The predominant form of non-adherence was missed doses (92% of cases). Each additional day of adherence was associated with an 8% higher rate of negative UDT for illicit opioids (RR = 1.08; 95% CI:1.03-1.13, p = .0002).Conclusion: In this sample of participants starting buprenorphine, missed doses were not uncommon. Fewer missed days was significantly associated with a lower risk of illicit opioid use. These findings suggest that efforts to minimize the number of missed days of buprenorphine are beneficial for treatment outcomes.

Stigmatizing imagery for substance use disorders: a qualitative exploration

BACKGROUND

Stigma is a significant barrier to the treatment of individuals with substance use disorders. While prior efforts have been made to change stigmatizing language to refer to individuals with substance use disorders (SUD), little is known about the effects of stigmatizing imagery. There is a need for complementary qualitative research to identify both stigmatizing and non-stigmatizing imagery in the field of SUD.

METHODS

This study used qualitative methods to identify stigmatizing and non-stigmatizing imagery for SUD and explore the reactions of people with lived experience with SUD to SUD-related imagery. We conducted focus groups and brief semi-structured qualitative interviews with 14 individuals in recovery from a range of SUD.

RESULTS

Participants identified images of substance use and criminal justice contact that are negative or stigmatizing, along with alternative images that were endorsed for use. The unanticipated concept of imagery-induced triggering and cue reactivity emerged in the interviews, along with an emphasis on diversity in race/ethnicity, gender, and age for representations of both patients and clinicians in all imagery.

CONCLUSIONS

The findings can be helpful in informing imagery that can depict addiction, individuals with SUD, and individuals involved in the justice system for various fields from research to media, public health, and community-based programming. Based on qualitative feedback from patients on triggering effects and reactivity to visual cues, it is never appropriate to use drug use and drug paraphernalia imagery to depict substance use or misuse or pictures of people in cages.

Racial and ethnic disparities in emergency department-initiated buprenorphine across five health care systems

BACKGROUND

Opioid overdose deaths have disproportionately impacted Black and Hispanic populations, in part due to disparities in treatment access. Emergency departments (EDs) serve as a resource for patients with opioid use disorder (OUD), many of whom have difficulty accessing outpatient addiction programs. However, inequities in ED treatment for OUD remain poorly understood.

METHODS

This secondary analysis examined racial and ethnic differences in buprenorphine access using data from EMBED, a study of 21 EDs across five health care systems evaluating a clinical decision support system for initiating ED buprenorphine. The primary outcome was receipt of buprenorphine, ED administered or prescribed. Hospital type (academic vs. community) was evaluated as an effect modifier. Hierarchical models with cluster effects for site and clinician were used to assess buprenorphine receipt by race and ethnicity.

RESULTS

Black patients were less likely to receive buprenorphine (6.4% [51/801] vs. White patients 8.5% [268/3154], odds ratio [OR] 0.59, 95% confidence interval [CI] 0.45-0.78). This association persisted after adjusting for age, insurance, gender, clinician X-waiver, hospital type, and urbanicity (adjusted OR [aOR] 0.64, 95% CI 0.48-0.84) but not when discharge diagnosis was included (aOR 0.75, 95% CI 0.56-1.02). Hispanic patients were more likely to receive buprenorphine (14.8% [122/822] vs. non-Hispanic patients, 11.6% [475/4098]) in unadjusted (OR 1.57, 95% CI 1.09-1.83) and adjusted models (aOR 1.41, 95% CI 1.08-1.83) but not including discharge diagnosis (aOR 1.32, 95% CI 0.99-1.77). Odds of buprenorphine were similar in academic and community EDs by race (interaction p = 0.97) and ethnicity (interaction p = 0.64).

CONCLUSIONS

Black patients with OUD were less likely to receive buprenorphine whereas Hispanic patients were more likely to receive buprenorphine in academic and community EDs. Differences were attenuated with discharge diagnosis, as fewer Black and non-Hispanic patients were diagnosed with opioid withdrawal. Barriers to medication treatment are heterogenous among patients with OUD; research must continue to address the multiple drivers of health inequities at the patient, clinician, and community level.

Using Normative Rhetorical Theory to Identify Dilemmas and Responses in Internal Medicine Patient-Provider Communication

Drawing on normative rhetorical theory (NRT), we examined communication dilemmas that internal medicine residents (IMRs) experience when interacting with patients and responses they adopt to manage these dilemmas. We conducted semi-structured, intensive interviews with 15 IMRs and analyzed the data using the phronetic iterative approach. Findings suggested that IMRs experienced two interpersonal dilemmas: (a) asserting expertise while respecting patients and (b) discussing patient behaviors without indicating deviance. The two dilemmas were more salient for international IMRs who were less familiar with the local culture and embraced a different perspective of the IMR-patient relationship. The two interpersonal dilemmas were connected to a supra-level dilemma of practicing tasks required by evidence-based medicine while being patient-centered. IMRs reported engaging in an interpretive lens to view patients as "people" and communicative responses to manage the dilemmas. By applying NRT to a novel context, our findings demonstrate the impact of macro-level paradigms on IMRs' conflicting purposes in medical encounters and offer practical implications for communication interventions for IMRs.

Long-term deprescription in chronic pain and opioid use disorder patients: Pharmacogenetic and sex differences

More than half of patients with opioid use disorder for chronic non-cancer pain (CNCP) reduced their dose through a progressive opioid withdrawal supported by a rotation to buprenorphine and/or tramadol. The aim of this research is to analyse the long-term effectiveness of opioid deprescription taking into account the impact of sex and pharmacogenetics on the inter-individual variability. A cross-sectional study was carried out from October 2019 to June 2020 on CNCP patients who had previously undergone an opioid deprescription (n = 119 patients). Demographic, clinical (pain, relief and adverse events) and therapeutic (analgesic use) outcomes were collected. Effectiveness (< 50 mg per day of morphine equivalent daily dose without any aberrant opioid use behaviour) and safety (number of side-effects) were analysed in relation to sex differences and pharmacogenetic markers impact [OPRM1 genotype (rs1799971) and CYP2D6 phenotypes]. Long-term opioid deprescription was achieved in 49 % of the patients with an increase in pain relief and a reduction of adverse events. CYP2D6 poor metabolizers showed the lowest long-term opioid doses. Here, women showed a higher degree of opioid deprescription, but increased use of tramadol and neuromodulators, as well as an increased number of adverse events. Long-term deprescription was successful in half of the cases. Understanding sex and gender interaction plus a genetic impact could help to design more individualized strategies for opioid deprescription.

Impact of CYP2D6 genotype on opioid use disorder deprescription: an observational prospective study in chronic pain with sex-differences

Introduction: Opioid deprescription is the process of supervised tapering and safe withdrawal when a potentially inappropriate use is detected. This represents a challenge in chronic non-cancer pain (CNCP) patients who may respond differently to the procedure. Our aim was to analyze the potential impact of CYP2D6 phenotypes and sex on the clinical and safety outcomes during an opioid use disorder (OUD) tapering process. Methods: A prospective observational study was conducted on CNCP ambulatory OUD patients (cases, n = 138) who underwent a 6-month opioid dose reduction and discontinuation. Pain intensity, relief and quality of life (Visual analogue scale, VAS 0-100 mm), global activity (GAF, 0-100 scores), morphine equivalent daily dose (MEDD), analgesic drugs adverse events (AEs) and opioid withdrawal syndrome (OWS, 0-96 scores) were recorded at basal and final visits. Sex differences and CYP2D6 phenotypes (poor (PM), extensive (EM) and ultrarapid (UM) metabolizers based on CYP2D6*1, *2, *3, *4, *5, *6, *10, *17, *41, 2D6*5, 2D6 × N, 2D6*4 × 2 gene variants) were analyzed. Results: Although CYP2D6-UM consumed three-times less basal MEDD [40 (20-123) mg/day, p = 0.04], they showed the highest number of AEs [7 (6-11), p = 0.02] and opioid withdrawal symptoms (46 ± 10 scores, p = 0.01) after deprescription. This was inversely correlated with their quality of life (r = -0.604, p < 0.001). Sex-differences were evidenced with a tendency to a lower analgesic tolerability in females and lower quality of life in men. Discussion: These data support the potential benefits of CYP2D6-guided opioid deprescription, in patients with CNCP when OUD is detected. Further studies are required to understand a sex/gender interaction.

Stigmatization in the context of the COVID-19 pandemic: a survey experiment using attribution theory and the familiarity hypothesis

BACKGROUND

The COVID-19 pandemic has created a global health crisis, leading to stigmatization and discriminatory behaviors against people who have contracted or are suspected of having contracted the virus. Yet the causes of stigmatization in the context of COVID-19 remain only partially understood. Using attribution theory, we examine to what extent attributes of a fictitious person affect the formation of stigmatizing attitudes towards this person, and whether suspected COVID-19 infection (vs. flu) intensifies such attitudes. We also use the familiarity hypothesis to explore whether familiarity with COVID-19 reduces stigma and whether it moderates the effect of a COVID-19 infection on stigmatization.

METHODS

We conducted a multifactorial vignette survey experiment (2⁸-design, i.e., N_Vignettes = 256) in Germany (N_Respondents = 4,059) in which we experimentally varied signals and signaling events (i.e., information that may trigger stigma) concerning a fictitious person in the context of COVID-19. We assessed respondents' cognitive (e.g., blameworthiness) and affective (e.g., anger) responses as well as their discriminatory inclinations (e.g., avoidance) towards the character. Furthermore, we measured different indicators of respondents' familiarity with COVID-19.

RESULTS

Results revealed higher levels of stigma towards people who were diagnosed with COVID-19 versus a regular flu. In addition, stigma was higher towards those who were considered responsible for their infection due to irresponsible behavior. Knowing someone who died from a COVID infection increased stigma. While higher self-reported knowledge about COVID-19 was associated with more stigma, higher factual knowledge was associated with less.

CONCLUSION

Attribution theory and to a lesser extent the familiarity hypothesis can help better understand stigma in the context of COVID-19. This study provides insights about who is at risk of stigmatization and stigmatizing others in this context. It thereby allows identifying the groups that require more support in accessing healthcare services and suggests that basic, factually oriented public health interventions would be promising for reducing stigma.

A randomized controlled trial of an intervention to reduce stigma toward people with opioid use disorder among primary care clinicians

BACKGROUND

Many primary care clinicians (PCCs) hold stigma toward people with opioid use disorder (OUD), which may be a barrier to care. Few interventions exist to address PCC stigma toward people with OUD. This study examined whether an online training incorporating patient narratives reduced PCCs' stigma toward people with OUD (primary) and increased intentions to treat people with OUD compared to an attention-control training (secondary).

METHODS

PCCs from 15 primary care clinics were invited to complete a 30 min online training for an electronic health record-embedded clinical decision support (CDS) tool that alerts PCCs to screen, diagnose, and treat people with OUD. PCCs were randomized to receive a stigma-reduction version of the training with patient narrative videos or a control training without patient narratives and were blinded to group assignment. Immediately after the training, PCCs completed surveys of stigma towards people with OUD and intentions and willingness to treat OUD. CDS tool use was monitored for 6 months. Analyses included independent samples t-tests, Pearson correlations, and logistic regression.

RESULTS

A total of 162 PCCs were randomized; 88 PCCs (58% female; 68% white) completed the training (Stigma = 48; Control = 40) and were included in analyses. There was no significant difference between intervention and control groups for stigma (t = - 0.48, p = .64, Cohen's d = - 0.11), intention to get waivered (t = 1.11, p = .27, d = 0.26), or intention to prescribe buprenorphine if a waiver were no longer required (t = 0.90, p = 0.37, d = 0.21). PCCs who reported greater stigma reported lower intentions both to get waivered (r = - 0.25, p = 0.03) and to prescribe buprenorphine with no waiver (r = - 0.25, p = 0.03). Intervention group and self-reported stigma were not significantly related to CDS tool use.

CONCLUSIONS

Stigma toward people with OUD may require more robust intervention than this brief training was able to accomplish. However, stigma was related to lower intentions to treat people with OUD, suggesting stigma acts as a barrier to care. Future work should identify effective interventions to reduce stigma among PCCs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04867382. Registered 30 April 2021-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04867382.

What's in a Name? Terminology Preferences Among Patients Receiving Methadone Treatment

BACKGROUND

Despite recognition of the importance of substance use disorder (SUD) terminology, few studies examine terminology preferences among patients with SUDs.

OBJECTIVE

To examine preferences of patients with opioid use disorder (OUD) concerning the terminology used by addiction counselors.

DESIGN

From January 1, 2019, to February 28, 2020, participants were recruited consecutively from 30-day treatment review sessions at outpatient methadone treatment programs in the Northeastern United States to complete a cross-sectional survey.

PARTICIPANTS

Participants were English-speaking adult patients with OUD enrolled in methadone treatment.

MAIN MEASURES

Participants completed 7-point Likert-type scales from 1 ("Strongly Disagree") to 7 ("Strongly Agree") to rate their preferences for (a) the presenting problem, (b) collective nouns referring to those with the presenting problem, and (c) personal descriptors. We used univariate analysis of covariance (ANCOVA) to examine the associations between demographics (i.e., age, sex, and race) and terminology preferences and ordinal logit regression to explore the association between 12-step program partiality and preference for the term "addict."

KEY RESULTS

We surveyed 450 patients with mean age of 38.5 (SD = 11.1) years; 59.6% self-identified as male, 77.6% as White, and 12.7% as Hispanic. The highest-rated preferences for presenting problem were "addiction," "substance use," and "substance abuse." The highest-rated collective noun terms were "client," "patient," and "guest." "Person with an addiction," "person with substance use disorder," and "substance-dependent person" were the highest-rated personal descriptors. There were significant differences in terminological preference based on race and age. Twelve-step program partiality was associated with greater preference for the term "addict" (F = 21.22, p < .001).

CONCLUSIONS

Terminology preferences among people receiving methadone treatment aligned with existing guidelines recommending that clinicians use medically accurate and destigmatizing terminology when referring to substance use disorders and the persons who have them. Demographic differences emerged in terminological preferences, warranting further examination.

Belief that addiction is a discrete category is a stronger correlate with stigma than the belief that addiction is biologically based

BACKGROUND

Drug addiction is stigmatized, and this stigma contributes to poor outcomes for individuals with addiction. Researchers have argued that providing genetic explanations of addiction will reduce stigma, but there has been limited research testing this prediction.

METHODS

We presented participants (N = 252) with news articles that either provided genetic or anti-genetic explanations of addiction.

RESULTS

There was no effect of article condition on stigma. Participants' biological essentialism correlated with stigma in the context of both opioid and methamphetamine addiction. However, participants' non-biological essentialism was a significantly stronger correlate with stigma.

CONCLUSIONS

This suggests that other essentialist beliefs, like belief that categories are discrete, may be more useful than biological essentialism for understanding addiction stigma.

Effects of media representations of drug related deaths on public stigma and support for harm reduction

BACKGROUND

Drug related deaths (DRD) are at historically high levels in the United Kingdom (UK), but some approaches that have the potential to reduce risk of mortality remain controversial. Public support makes an important contribution to drug policy development but there are high levels of public stigma towards people who use drugs (PWUD), and this is partly shaped by media representations. We investigated whether depiction of the characteristics of decedents represented in news articles about DRD was associated with differences in stigmatising attitudes and support for harm reduction policy.

METHODS

We undertook a cross-sectional online study with a randomised design, conducted with a nationally representative sample (UK). Participants (N = 1280) were randomly presented with one of eight simulated news stories that reported on a DRD that differed with respect to drug (ecstasy or heroin), and the gender (male or female) and age (younger or older) of the decedent. Data were analysed using MANOVA.

RESULTS

Data were obtained for 1248 participants (51.0% female; mean age 45.7±15.4). Stigma was higher towards depictions of male, older, and heroin deaths (all p < .001). Harm reduction support was higher in those participants seeing older compared to younger subjects (p = .035), and the older ecstasy decedent compared to younger decedent (p = .029).

CONCLUSION

Presentation of some types of DRD are associated with higher public stigma towards the decedent than others. Those groups developing agenda-setting activities designed to reduce stigma or foster public support for harm reduction policies should consider the different ways in which audiences may respond to the depiction and framing of DRD in news media.

Causal effects of opioids on postpartum depression: a bidirectional, two-sample Mendelian randomization study

Background

Postpartum depression is the most common psychiatric disorder in pregnant women during the postpartum period and requires early detection and treatment. Previous studies have found that opioids use affects depression and anxiety disorders. Although it has long been suspected that opioids may contribute to the development of postpartum depression, observational studies are susceptible to confounding factors and reverse causality, making it difficult to determine the direction of these associations.

Methods

To examine the causal associations between opioids and non-opioid analgesics with postpartum depression, we utilized large-scale genome-wide association study (GWAS) genetic pooled data from two major databases: opioids, salicylate analgesic, non-steroidal anti-inflammatory drugs (NSAIDs), and aniline analgesics GWAS data from the United Kingdom Biobank database. GWAS data for postpartum depression were obtained from the FinnGen database. The causal analysis methods used random-effects inverse variance weighting (IVW), and complementary sensitivity analyses using weighted median, MR-Egger method, and MR-PRESSO test.

Results

In the IVW analysis, Mendelian randomization (MR) analysis showed that opioids increased the risk of postpartum depression (OR, 1.169; 95% CI, 1.050-1.303; p = 0.005). Bidirectional analysis showed a significant causal relationship between genetically predicted postpartum depression and increased risk of opioids and non-opioid analgesics use (opioids OR, 1.118; 95% CI, 1.039-1.203; p = 0.002; NSAIDs OR, 1.071; 95% CI, 1.022-1.121; p = 0.004; salicylates OR, 1.085; 95% CI, 1.026-1.146; p = 0.004; and anilides OR, 1.064; 95% CI, 1.018-1.112; p = 0.006). There was no significant heterogeneity or any significant horizontal pleiotropy bias in the sensitivity analysis.

Conclusion

Our study suggests a potential causal relationship between opioids use and the risk of postpartum depression. Additionally, postpartum depression is associated with an increased risk of opioids and non-opioid analgesics use. These findings may provide new insights into prevention and intervention strategies for opioids abuse and postpartum depression.

Experiences and Perspectives of Patients Treated with Methadone on Mental Health Aspect of Lifestyle: A Qualitative Study

Background: Drug abuse and its consequences place a considerable social and economic burden on society. Drug abuse has increased in Iran and reached three times the global average, indicating the need to develop innovative strategies to cope with this phenomenon. Objectives: Following a community-based participatory research approach, the aim was to identify the lived experience of drug users regarding the psychological aspect of their lifestyle. Methods: Narrative inquiry and phenomenological design were applied as the research framework. The use of in-depth interviewees and field notes guided the data collection and analysis. A total of 26 in-depth interviews were conducted with people who suffered from drug use (7 females and 19 males) in 2021. Interviewees ranging from 70 to 90 minutes were conducted in a quiet, private location chosen by the researcher. All interviews were audio-taped and transcribed, and analyzed using Colaizzi's method. Data analysis was administered using MAXQDA version 2020. Results: Most of the participants were educated Diploma and above. The participants' age ranged from 25 to 53 years old. During the interview, the subjects were in the following stages, methadone treatment time (n = 26). The analysis revealed four themes, and 11 sub-themes emerged. The themes were as follows: (1) negative emotions; (2) poor psychological capital; (3) poor support; and (4) psychological well-being. Conclusions: The most important problems of people with substance use, in the psychological dimension of lifestyle, include experiencing negative emotions, weak psychological capital, weak social support, unhealthy psychological well-being such as negative self-acceptance, reduced positive relations, not having a purposeful life, and inability to control environmental pressures. Hopefully, this study can help health policymakers develop more effective strategies against drug use.

The Influence of Stigmatizing Messages on Danger Appraisal: Examining the Model of Stigma Communication for Opioid-Related Stigma, Policy Support, and Related Outcomes

Drug overdose is a leading cause of injury and death in the United States, and opioids are among the most significant of causes. For people with opioid use disorders (OUDs), opioid stigma can lead to devastating consequences, including anxiety and depression. Still, mass media may stigmatize people with OUDs by ascribing stigmatizing labels (e.g., "opioid addict") and other stigma features to those individuals. However, it is unclear how these stigmatizing messages influence public perceptions of people with OUDs and public support for rehabilitation and Naloxone administration policies. The model of stigma communication (MSC) provides a framework for understanding these relationships. This study used the MSC in two online factorial experiments, the first among college undergraduates (N = 231) and the second among Amazon Mechanical Turk workers (N = 245), to examine how stigmatizing messages about people with OUDs influence stigma-related outcomes. Results reveal that opioid stigma messages influence different outcomes depending on the content of those messages. Classification messages with a stigmatizing mark (e.g., "Alex appears unkempt") and label (e.g., "opioid addict") led to greater perceptions of dangerousness and threat in both studies. High stigma classification messages also led to an increased desire for behavioral regulation and social distance in Study 2. Structural equation modeling in Study 1 also supported the applicability of the MSC in the opioid context. Implications for health communication theory development and practice are discussed.

The impact of race, gender, and heroin use on opioid addiction stigma

INTRODUCTION

Stigmatization of an opioid addiction acts as a barrier to those seeking substance use treatment. As opioid use and overdoses continue to rise and affect minority populations, understanding the impact that race and other identities have on stigma is pertinent.

METHODS

This study aimed to examine the degree to which race and other identity markers (i.e., gender and type of opioid used) interact and drive the stigmatization of an opioid addiction. To assess public perceptions of stigma, this research team conducted a randomized, between-subjects case vignette study (N = 1833) with a nation-wide survey. Participants rated a hypothetical individual who became addicted to opioids on four stigma indices (responsibility, dangerousness, positive affect, and negative affect) based on race (White or Black), gender (male or female), and end point (an individual who transitioned to using heroin or who continued using prescription painkillers).

RESULTS

Our results first showed that the White individual had higher stigma ratings compared to the Black individual (range of partial η2 = 0.002-0.004). An interaction effect demonstrated that a White female was rated with higher responsibility for opioid use than a Black female (Cohen's d = 0.21) and a Black male was rated with higher responsibility for opioid use than a Black female (Cohen's d = 0.26). Last, we showed that a male and an individual who transitioned to heroin had higher stigma than a female and an individual who continued to use prescription opioids (range of partial η2 = 0.004-0.007).

CONCLUSION

This study provides evidence that information about multiple identities can impact stigmatizing attitudes, which can provide deeper knowledge on the development of health inequities for individuals with an opioid addiction.

Podcasts as a Method to Deliver Education on Stigma Surrounding Opioid Use Disorder

The objective of this research was to evaluate the effectiveness of a podcast miniseries to reduce stigma surrounding opioid use disorder (OUD) among student pharmacists. Students in their second and third professional years from two schools of pharmacy listened to five, 10-23 min podcasts incorporated into their coursework. The podcasts highlighted: (1) interviews with OUD professionals and those with lived experiences; (2) types of stigma and how it affects health outcomes; (3) OUD disease state processes, and (4) harm reduction strategies. Surveys assessed changes in perception of OUD and its associated stigma and included free-response and Likert scale questions. Subjects (n = 121) who completed a pre- and post-podcast survey were included. Paired t-tests assessed changes in survey responses from baseline and a content analysis was performed on all free-responses. There was a statistically significant change from baseline for each survey question, demonstrating a decrease in stigma towards OUD. Free-responses were categorized into four learning domains: (1) Impact of stigma on access to care; (2) Compassion and empathy; (3) Resources and support; and (4) Call to action. Podcasts can be an effective tool to reduce student pharmacist stigma associated with OUD.

The representation of females in clinical trials for substance use disorder conducted in the United States (2010-19)

BACKGROUND AND AIMS

Women have historically been under-represented in clinical research, but the extent to which this is true for substance use disorder (SUD) trials is unknown. We aimed to determine the ratio of female:male participation in clinical trials for SUDs and describe the reporting of sex-specific outcomes from 2010 to 2019.

DESIGN

A retrospective cohort review of clinical trials involving people with SUD.

SETTING

United States.

PARTICIPANTS

Clinical trials including people with SUD registered in clinicaltrials.gov and completed between 1 January 2010 and 31 December 2019 were reviewed. Trials were excluded if they had < 30 participants, focused on SUD prevention, were conducted outside the United States and/or did not report data on participant sex or gender.

MEASUREMENTS

The following were extracted for each trial: primary outcome, number of participants enrolled, analytical sample size, percentage of participants who were female, inclusion of transgender participants, whether sex-based analyses were performed, funding source, type of SUD and type of intervention. Relative representation in trials was examined using the female:male ratio, reported using median ratios and by year of trial completion. The proportion of females participating was adjusted using the underlying disease prevalence among females using National Survey on Drug Use and Health data.

FINDINGS

A total of 316 trials met inclusion criteria: 274 were mixed-sex, 12 enrolled only males and 30 only females. In 274 mixed-sex trials, 40% of 57 544 participants were female. Only 22 trials (8%) reported any sex-specific analyses; four studies (1.5%) reported inclusion of transgender participants. Females represented 35% of participants in trials targeting illicit drug use disorder, 52% in nicotine use disorder and 29% in alcohol use disorder. Accounting for underlying disease prevalence revealed that women had the lowest relative enrollment in alcohol use disorder trials (median participation to prevalence ratio in 2017: 0.58; 95% confidence interval: 0.13, 0.91).

CONCLUSIONS

A review of 316 US clinical trials for alcohol, nicotine and illicit substance use disorders completed between 2010 and 2019 showed that females were enrolled at lower rates than males overall. Only 8% of the trials reviewed reported sex-specific analyses and 1.5% reported transgender participants.

Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy

BACKGROUND

Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.

METHODS

A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.

RESULTS

Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.

CONCLUSION

OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

Addiction onset and offset characteristics and public stigma toward people with common substance dependencies: A large national survey experiment

Drug-related overdose deaths topped 100,000 between 2020 and 2021. Opioids and stimulants are implicated as the primary drivers of this public health crisis. Stigma remains one of the primary barriers to treatment and recovery from substance use disorders. However, little is known about how stigma varies across different substance types, whether individuals are actively using or in recovery, and medical versus recreational onset. We examined these questions using data from the 2021 Shatterproof Addiction Stigma Index, the only nationally representative data available on this topic. Respondents (N = 7051) completed a vignette-based survey experiment to assess public stigma (social distance, prejudice, competence, and causal attributions) toward people with alcohol, opioid (following a prescription pain or recreational use onset), heroin, or methamphetamine dependencies. Vignette characters were described as active users or in recovery. Adjusting for covariates (e.g., race, age, gender), prejudice and desire for social distance were highest toward heroin and methamphetamine, and lowest toward alcohol dependence. The perceived onset of the dependency affected stigma. Specifically, prescription opioids with a recreational onset were more stigmatized than those with a medical onset. Moreover, individuals depicted as being in recovery were less stigmatized than those depicted as active users. Recovery status had the largest impact on prejudice and social distance toward methamphetamine, relative to other conditions. The nature and magnitude of substance dependency stigma differs across substance types and onset and offset conditions. Reducing stigma will require tailored strategies that consider the multidimensional nature of stigma toward people with addiction.

Coverage of the opioid crisis in national network television news from 2000-2020: A content analysis

Background: News coverage has both negatively and positively influenced public awareness and perceptions surrounding the opioid crisis. This study aimed to describe and analyze national network television news framing of the scope and impact of the opioid crisis in the United States. Methods: We performed a retrospective content analysis on national network television evening news segments covering the opioid crisis from 1/2000 to 8/2020, which were obtained from the Vanderbilt Television News Archive. The database was queried for: opioid epidemic, oxycontin, heroin, fentanyl, and naloxone. Two independent reviewers quantitatively coded segment characteristics, including theme, geographic location, opioids mentioned, strategies for combatting the epidemic discussed, interviews conducted, and patient demographics. Changes in segment characteristics over time were analyzed using chi-square analyses and Fisher's exact tests. Results: News segments (N = 191) most commonly provided an overview of the epidemic (55.5%) and/or conveyed personal stories (40.3%). Prescription opioids (59.7%) and heroin (62.8%) were more often referenced than fentanyl (17.8%); the focus on heroin peaked in 2011-2015 (84.8%), while references to fentanyl significantly increased over time (p = 0.021). The most frequently interviewed people included patients with opioid use disorder (OUD) (47.1%), healthcare providers (36.7%), family members/friends (31.9%), and law enforcement (30.9%). Most of the featured patients with OUD were male (63.0%), white (88.4%), and young (< 40 years) adults (77.9%). Coverage of the crisis peaked in 2016. Conclusions: Evening news segments' emphasis on personal stories, while emotionally compelling, came at the cost of thematically-framed coverage that may improve public understanding of the complexities of the epidemic. The depiction of primarily white, young adult patients with OUD revealed a need for a greater emphasis in the news on underrepresented minorities and older adults, as these populations face additional stigma and disparities in OUD treatment initiation and retention.

Discordance in Addressing Opioid Crisis in Rural Communities: Patient and Provider Perspectives

Providing patient-centered care to manage chronic pain and opioid use disorder (OUD) is associated with improved health outcomes. However, adopting a holistic approach to providing care is often challenging in rural communities. This study aims to identify and contrast challenges to providing patient-centered care from the perspective of patients and providers. A participatory design approach was adopted to elicit the perceptions of providers and patients with lived experiences of chronic pain and/or OUD in Jefferson County, Wisconsin. Two focus groups were conducted with each stakeholder group to identify problems that participants face with respect to chronic pain management and OUD and possible solutions. Four interviews were conducted with providers experienced in chronic pain management. Analysis of focus group sessions and interviews show consensus among patients and providers that lack of behavioral health and recovery resources create barriers to effectively manage OUD and chronic pain. However, there was discordance among the two groups about other barriers such as patient and provider attitudes, tapering approach, and access to medications for OUD. This tension among patients and providers can influence patients’ retention in therapy. More efforts are needed to mitigate stigma among providers in rural communities and support psychosocial needs of patients.

Substance use treatment services for older adults in five states in the Southern United States: a state-by-state comparison of available treatment services

Objectives: Substance use disorders (SUD) among older adults have become a serious public health concern. The purpose of this study was to assess which states in the Southern U.S. are more responsive to SUD treatment needs of older adults.Methods: This study is a secondary data analysis of the N-SSATS-2019 dataset.Results: There were 1,215 substance treatment facilities in the five states. Kentucky had the highest number of substance use treatment facilities (n = 449, 37%), followed by Georgia (357, 29%), Alabama (153, 13%), Louisiana (146, 12%) and then Mississippi (110, 9%). Out of the 1,215 facilities, only 20% (n = 244) indicated that they had programs specifically tailored for older adults. Kentucky had the largest number of facilities per 1 million older adults while Mississippi had the highest number of facilities per 1 million older adults offering detoxification services. Alabama had the lowest number of services per 1 million adults in all categories examined.Conclusion: Across the U.S., most adults with SUD do not have access to substance use treatment; in the southeastern region of the country, higher rates of poverty, rural geography and stigma, and lack of treatment availability may further complicate individuals' ability to access substance use-related medical care.

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.

The Use of Person-centered Language in Medical Research Articles Focusing on Hearing Loss or Deafness

BACKGROUND

Hearing loss represents one of the most common disabilities worldwide. Despite its prevalence, there is a degree of stigmatization within the public's perception of, or attitude toward, individuals diagnosed with hearing loss or deafness. This stigmatization is propagated by the way hearing loss is referenced, especially in writing. Although the medical community is familiar with hearing loss, medical research is not consistently compliant with nonstigmatizing terminology, like person-centered language (PCL). This study aims to quantify the use of PCL in medical research related to hearing loss.

METHODS

A cross-sectional analysis of articles related to hearing loss was performed using PubMed as the primary search engine. The search encompassed articles from January 1, 2016, to November 17, 2020. Journals had to have at least 20 search returns to be included in this study. The primary search resulted in 2392 articles from 31 journals. The sample was then randomized and the first 500 articles were chosen for data extraction. Article screening was performed systematically. Each article was evaluated for predetermined non-PCL terminology to determine adherence to the American Medical Association Manual of Style (AMAMS) guidelines. Articles were included if they involved research with human participants and were available in English. Commentaries and editorials were excluded.

RESULTS

Four hundred eighty-two articles were included in this study. Results from this study indicate that 326 articles were not adherent to AMAMS guidelines for PCL (326/482; 68%). Emotional language (i.e., burden, suffer, afflicted) was employed to reference hearing loss in 114 articles (114/482; 24%). Non-PCL adherent labels (i.e., impaired and handicapped) were identified in 46% (221/482) of articles related to hearing loss or deafness. Sixty-seven articles (67/482; 14%) used person-first language in reference to the word "deaf" and 15 articles (15/482; 3%) used "deaf" as a label.

CONCLUSIONS

Based on the findings from this cross-sectional analysis, the majority of medical research articles that address hearing loss contain terminology that does not conform to PCL guidelines, as established by AMAMS. Many respected organizations, like the American Medical Association, have encouraged the use of PCL in interactions between patient and medical provider. This encompasses communication in person and in writing. This recommendation stems from the understood role that language plays in how we build impressions of others, especially in a medical context. Implementing PCL to destigmatize language used in reference to deafness or hearing loss is essential to increase advocacy and protect the autonomy of these individuals.

Drivers, facilitators, and sources of stigma among Akha and Lahu hill tribe people who used methamphetamine in Thailand: a qualitative approach

Background

The stigma related to drug use has several impacts, including effects on users’ physical and mental health. Methamphetamine is a major drug that is used among hill tribes living in the border areas of Thailand and Myanmar. This study aimed to understand the drivers, facilitators, sources and outcomes of the stigma surrounding drug use, including the expectations among Akha and Lau hill tribe people who use methamphetamine in Thailand.

Methods

Qualitative data were used to elicit information from key informants and members of the hill tribes who used methamphetamine. The questionnaire was developed from a literature review and tested for validity before use. In-depth interviews were used to confidentially gather information from the participants in private rooms in villages. Each interview lasted 45 min, and a thematic analysis was conducted to examine the findings.

Results

A total of 46 participants were recruited to provide information; 95.7% were male, and 50.0% were aged 15–34 years. The majority were married (47.8%), 76.1% were Christian, and 45.7% graduated high school. Six drivers of stigma were detected: being poor, illiterate, unemployed, working aged, female, and married. Culture and tribe acted as facilitators of the stigma attached to methamphetamine use. Four sources of stigma were found: self, family members, peers, and community members. Three outcomes of stigma were determined: poor physical health, mental health, and relationships with others. There were four levels of expectations: no expectations, expectations for themselves, expectations for their family members, and expectations for their community members.

Conclusions

Many personal traits, people living nearby, and socioeconomic factors, including culture and tribes, act as drivers, facilitators, and sources of stigma among hill tribe people who use methamphetamine. A program to reduce methamphetamine use among hill tribes should be implemented, which could eventually minimize stigma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13094-z.

Social Media News Production, Emotional Facebook Reactions, and the Politicization of Drug Addiction

In times of health crisis, news media have generally contributed to public panic, though these instances are usually explored in crises involving communicable diseases. However, in 2017, the long-brewing opioid crisis was formally declared a federal emergency by the United States government, leading to a considerable uptick in media attention to drugs and drug addiction. Considering 1) the news media's tendency to contribute to public fear and panic during times of emergency or crisis, 2) the problematic representations of drug addiction in previous years, and 3) developing social media production practices among journalists on social media, this research uses content analysis to explore how highly circulated news outlets covered drug addiction in 2017-2018 and social media audiences' emotional responses. Results indicate that political intervention drove media coverage rather than the effects of opioid addiction on people. Political interference led to increased anger and laughter reactions among Facebook users.