‘Heroin is the devil’: addiction, religion, and needle exchange in the rural United States

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

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.

Racial resentment and support for decriminalization of drug possession in the United States

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States.

Religious and spiritual beliefs and attitudes towards addiction and addiction treatment: A scoping review

INTRODUCTION

Throughout history, ideas about addiction have been informed and influenced by religious belief and practice. Even continuing into the present, religion and spirituality are often thought to impact attitudes towards addiction and its treatment, particularly given the use of religion and spirituality in various well-known treatments such as Alcoholics Anonymous. Although research has flourished with regards to the role that addiction and spirituality might play in vulnerability to addiction or the treatment of addiction, there has been comparatively less research examining how religion might impact attitudes toward addiction more broadly.

METHOD

The present work sought to examine the current state of empirical literature evaluating the relationships between religion and attitudes toward addiction and addiction treatment. In service of the above aim, a scoping review was conducted.

RESULTS

This summary of peer-reviewed, quantitative studies (n = 36) found that higher religiosity is related to more belief in the disease model of addiction in providers, negative attitudes towards addiction, and a stronger support for spiritually-based treatments. However, results varied based on the measures used and many relationships tested were not significant. There also appeared to be differences in the interaction between religion and spirituality and other variables, such as the respondent's sex or whether the individual was a student or provider, in terms of attitudes.

CONCLUSIONS

Further research is needed to fully understand the nuances in the relationship between these variables, including more clear operationalization and standardized measurement. Until such research is conducted, no cohesive conclusions can be drawn, and clinical implications remain unclear.

Faith leaders' perceptions of needle exchange programs in the rural Illinois Delta Region: Religion as a social determinant of health

BACKGROUND AND OBJECTIVES

Despite increasing drug use in rural communities, potentially life-saving harm reduction interventions, such as needle exchange programs (NEPs), remain underutilized. Religion is an integral component of the rural culture that has been shown to influence health, yet no studies to date have explored rural faith leaders' perceptions of harm reduction strategies.

METHODS

An online cross-sectional survey was conducted among rural faith leaders (n = 133) in the rural Illinois Delta Region.

RESULTS

While most of the respondents felt that drug abuse was an issue in their communities, support was mixed regarding whether they were in favor of NEPs with the majority of respondents having never heard of an NEP before this survey. While the majority believed that NEPs would help decrease bloodborne disease transmission, it was also perceived that NEPs would increase drug use. Significant differences in perceptions based on race, marital status, and political party also exist.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

Congruent with previous harm reduction literature, many rural faith leaders have varied perceptions of NEPs. Rural faith leaders could benefit from education about NEPs, including the possible positive and negative impacts they can have on the community. Future studies should explore contextual differences among rural faith leaders. To date, no studies have examined faith-based organizations' perceptions of NEPs. The findings have the potential to increase the current body of knowledge and provide data to support recommendations for engaging faith-based organizations in behavioral health service delivery.

Predictors of US states' adoption of naloxone access laws, 2001-2017

BACKGROUND

The opioid crisis has put an increasing strain on US states over the last two decades. In response, all states have passed legislation to implement a portfolio of policies to address the crisis. Although effects of some of these policies have been studied, research into factors associated with state policy adoption decisions has largely been lacking. We address this gap by focusing on factors associated with adoption of naloxone access laws (NAL), which aim to increase the accessibility and availability of naloxone in the community as a harm reduction strategy to reduce opioid-related morbidity and mortality.

METHODS

We used event history analysis (EHA) to identify predictors of the diffusion of naloxone access laws (NAL) from 2001, when the first NAL was passed, to 2017, when all states had adopted NAL. A variety of state characteristics were included in the model as potential predictors of adoption.

RESULTS

We found that state adoption of NAL increased gradually, then more rapidly starting in 2013. Consistent with this S-shaped diffusion process, the strongest predictor of adoption was prior adoption by neighboring states. Having a more conservative political ideology and having a higher percentage of residents who identified as evangelical Protestants were associated with later adoption of NAL.

CONCLUSION

States appear to be influenced by their neighbors in deciding whether and when to adopt NAL. Advocacy for harm reduction policies like NAL should take into account the political and religious culture of a state.

The Bell Tolls for Thee & Thine: Compassion Fatigue & the Overdose Epidemic

Non-fatal and fatal overdoses are traumatic events that have been increasing over the past 20 years and disproportionately impacting rural communities in the United States. The human suffering caused by the opioid epidemic is rarely described in the empirical literature. The purpose of this article is to 1) define individual- and community-level overdose-related compassion fatigue (OCF), 2) review measurement of compassion fatigue (CF) and interventions to reduce CF, 3) discuss strategies that may reduce OCF and 4) briefly discuss policy implications. OCF is distress resulting from knowledge of or exposure to overdose-related harms, which at the community-level may prohibit collaboration and adaptive agency to effectively respond. When OCF occurs at a community-level, it could have negative consequences by eroding support for evidence-based services and fueling stigma-driven policies that blame people who use drugs. Empathy underlies both OCF and vicarious resilience by allowing one to understand the suffering caused by overdose deaths and to witness the joy of addiction recovery. Using the risk environment framework, OCF at the micro- and macro-levels of the social environment, may increase rural communities' vulnerability to harm by emphasizing individual responsibility for reducing overdoses rather than community-level infrastructure and resource management. Additional research is needed to develop a measure of OCF and to confirm whether OCF is associated with increased stigma and decreased support for harm reduction in rural areas.