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

Public stigma against fentanyl overdose decedents in the United States: A conjoint vignette experiment

The United States is facing a drug overdose crisis, and stigma against people who use drugs is a major roadblock to implementing solutions. Despite the public health importance of understanding and mitigating substance use stigma, prior research has focused mainly on perceptions of individuals with substance use disorders and a limited set of demographic traits. This leaves critical gaps in our understanding of stigma against fentanyl overdose decedents, who represent a much broader group, including people who use substances recreationally. This study develops a more robust understanding of these attitudes through an experimental vignette survey fielded to a national sample of American adults (n = 1432). Respondents were shown two fictional fentanyl overdose obituaries where a complex suite of decedent characteristics-including demographic traits and contexts of substance use-were randomly varied in a conjoint design. Respondents then endorsed one of the two decedents for each of several attitudinal outcomes, including blameworthiness and support for various interventions, and justified their choices in an open-ended format. Results indicate that the public assesses victims of fentanyl overdose meritocratically, making judgments based on personal history and life experience rather than traditional race, class, and gender status beliefs. While certainly a signal of progress on some fronts, this meritocratic lens conflicts with the public health model of addressing the overdose crisis and exposes the alarming persistence of explicit stigma against people who use drugs.

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.

Using a life course health development framework to combat stigma-related health disparities for individuals with intellectual and/or developmental disability (I/DD)

In the U.S., 1 in 6 children has an intellectual and/or developmental disability (I/DD). This population experiences a multitude of negative health outcomes across the life course, relative to the general population. Stigma-the social devaluation of individuals with certain characteristics, identities, or statuses within interpersonal, educational, healthcare, and policy contexts-is a potentially preventable contributor to health disparities. To date, existing approaches for addressing and preventing stigma are limited to discrete and siloed interventions that often fail to address the lifelong, cumulative impacts of the specific types of stigma experienced by the I/DD population. In the current paper, we describe three elements of Life Course Health Development (LCHD)-a novel translational framework that draws on evidence from biology, sociology, epidemiology, and psychology-that healthcare providers can use to prevent stigma-related health disparities and improve outcomes for individuals with I//DDs. We discuss the utility of targeting prevention to sensitive periods; prioritizing interventions for the most damaging types of stigmas; and leveraging supports from multiple service systems and sectors. By incorporating evidence from life course science into efforts to address stigma-related health disparities, providers can more effectively and strategically prevent and combat stigma-related health disparities for the I/DD population in childhood and across the life course.

Racial Disparities in Severe Maternal Morbidity in an Integrated Health Care System, Southern California, 2008-2017

OBJECTIVE

The study's objectives were to examine rates of severe maternal morbidity (SMM) over a 10-year period and assess racial/ethnic disparities in SMM among insured women in a large, integrated health care system in Southern California.

METHODS

We included Kaiser Permanente Southern California (KPSC) health plan members who gave birth at ≥20 weeks' gestation in a KPSC-owned hospital during 2008-2017. An SMM case was defined as presence of one or more indicators of an SMM event during a birth hospitalization, identified using maternal electronic health records. Crude SMM rates/10,000 births were calculated by year and maternal race/ethnicity. Modified Poisson regression models were used to assess the association between race/ethnicity and SMM adjusted for other maternal demographics, pregnancy characteristics, and preexisting conditions.

RESULTS

We identified 5,915 SMM cases among 335,310 births. Crude SMM rates increased from 94.7 per 10,000 in 2008 to 192.6 in 2015 and 249.5 in 2017. Non-Hispanic Black (adjusted risk ratio [aRR] 1.52; 95% confidence interval [CI] 1.37-1.69), Asian/Pacific Islander (aRR 1.29, 95% CI 1.18-1.41), and Hispanic (aRR 1.18, 95% CI 1.10-1.27) women had greater likelihood of SMM than non-Hispanic White women. After further adjusting for preexisting health conditions, differences in SMM by race/ethnicity remained.

CONCLUSIONS

SMM rates increased during 2008-2017 and women of racial and ethnic minority groups, particularly non-Hispanic Black women, were more likely to experience an SMM event than non-Hispanic White women. Multilevel approaches to understanding structural and social factors that may be associated with racial and ethnic disparities in SMM are needed to develop and test effective interventions to reduce SMM.

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.

Perceived stigma, barriers, and facilitators experienced by members of the opioid use disorder community when seeking healthcare

INTRODUCTION

Healthcare professionals, particularly nurses, have negative attitudes towards individuals with opioid use disorder (OUD) and these attitudes can contribute to suboptimal care. The aim of this study was to identify stigma, barriers and facilitators experienced by members of the OUD community when interacting with the healthcare system.

DESIGN

A qualitative exploratory design used semi-structured focus group interviews to address the study aim.

METHODS

Following IRB approval, purposive sampling was used to recruit participants with a history of OUD, family caregivers of individuals with OUD, and support group leaders from regional recovery groups to provide a broad perspective of stigmatizing issues and barriers to care. Focus group discussions were conducted, and video recorded using web-based conferencing software. Transcripts from the focus groups and field notes were analyzed and coded into themes.

RESULTS

Both structural and social determinants of health were identified by participants as stigmatizing and/or barriers to care. Thematic content analysis resulted in eight themes: stigmatizing language, being labeled, inequitable care, OUD as a chronic illness, insurance barriers, stigma associated with medications for OUD (MOUD), community resources, and nursing knowledge and care.

CONCLUSION

Members of the OUD community are challenged by both internal and external stigma when seeking healthcare. Stigma negatively affects public support for allocation of resources to treat OUD. Interventions aimed at reducing stigma are critical to support effective OUD treatment and prevent barriers to OUD care.

CLINICAL RELEVANCE

Understanding the complex relationships between stigma and structural determinants of health will allow nursing science to develop educational interventions that provide the next generation of nurses with the knowledge, skills, and attitudes needed to advance health equity for individuals with OUD.