1
|
Sumnall HR, Atkinson AM, Anderson M, McAuley A, Trayner K. How to save a life: Public awareness of a national mass media take home naloxone campaign, and effects of exposure to campaign components on overdose knowledge and responses. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 131:104111. [PMID: 37563039 DOI: 10.1016/j.drugpo.2023.104111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Take home naloxone (THN) programmes are effective at reducing opioid related mortality, but require high levels of distribution, including to the general public. Mass media campaigns can be effective in improving public understanding of a topic and encouraging behavior change. Whilst mass media campaigns focusing on naloxone have been developed internationally, there is a lack of research on their potential impact. We investigated the effects of components of a recent national mass media campaign (Scotland, UK) designed to improve public awareness of drug related deaths, and readiness to intervene. METHODS We undertook a cross-sectional online experimental study with a randomized design, conducted with a nationally representative sample. Participants (N = 1551; 52.6% female; age 46.1±16.5 years) were assessed on overdose knowledge and readiness to intervene after presentation of eight combinations of campaign components. RESULTS Compared to a basic campaign description, exposure to all types of campaign component were associated with higher overdose knowledge (p < .001), but not knowledge of what to do in response to an overdose (p = .374), or readiness to intervene (p= .286). The greatest effects were associated with a media rich audio-visual resource (animated video with a popular song on the soundtrack, and narrated by a well-known actor). CONCLUSION Our data suggest that harm reduction is an appropriate topic for large-scale mass media campaigns. However, effects may be limited to knowledge and awareness raising in the general public, and may be related to the types of media used. Audience segmentation is important and more general messaging about drug related deaths may be more appropriate for the majority of audiences.
Collapse
Affiliation(s)
- H R Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, UK.
| | - A M Atkinson
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - M Anderson
- Scottish Drugs Forum, Glasgow, UK; MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, UK
| | - A McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| | - Kma Trayner
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Glasgow, UK
| |
Collapse
|
2
|
Smither B, Reeves PM, Reynolds J. Effectively engaging faith-based leaders on syringe services programs: U.S. pastors' knowledge, perceptions, and questions. Subst Abuse Treat Prev Policy 2024; 19:37. [PMID: 39103935 DOI: 10.1186/s13011-024-00620-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 07/17/2024] [Indexed: 08/07/2024] Open
Abstract
OBJECTIVE To identify faith-based leaders' (FBLs') knowledge, perceptions, and questions about syringe services programs (SSPs). METHODS We conducted a one-time, national online survey of 461 Christian FBLs August-September 2022. RESULTS 56% of FBLs agreed they support having SSPs in their communities; only 7% strongly disagreed. We identified 15 main questions FBLs have about SSPs. We found statistically significant differences based on FBL Protestant affiliations. Mainline FBLs are more knowledgeable about SSPs, likely to believe a larger number of SSP services would benefit their community, supportive of SSPs, interested in data related to SSPs, and likely to look to local public health officials to shape their opinions on SSPs compared with non-mainline FBLs. CONCLUSIONS SSP advocates can address questions that FBLs have about SSPs before beginning outreach. By understanding common Protestant denominational affiliations, advocates can focus initial engagement efforts on FBLs in their communities who are more likely to support SSPs. Our findings suggest that local public health officials can influence FBLs' opinions about SSPs.
Collapse
Affiliation(s)
- Betsy Smither
- Oak Ridge Associated Universities, 100 ORAU Way, Oak Ridge, TN, 37831, United States of America.
| | - Philip M Reeves
- Oak Ridge Associated Universities, 100 ORAU Way, Oak Ridge, TN, 37831, United States of America
| | - Jennifer Reynolds
- Oak Ridge Associated Universities, 100 ORAU Way, Oak Ridge, TN, 37831, United States of America
| |
Collapse
|
3
|
Hanson BL, Finley K, Otto J, Ward NJ, Banik S. Community Support for Harm Reduction and Treatment of Opioid Use Disorder. J Community Health 2024; 49:724-731. [PMID: 38409628 DOI: 10.1007/s10900-023-01278-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 02/28/2024]
Abstract
As the opioid epidemic continues, availability of evidence-based strategies for harm reduction and treatment in communities is critical to reduce overdose and other consequences of opioid use disorder. Community members' support of harm reduction and treatment services is needed for new programs and to maintain existent programs. This study sought to understand beliefs and attitudes associated with support for three community-based strategies to address opioid misuse and addiction: naloxone, needle exchange, and medication-assisted treatment. We conducted a cross-sectional online survey with 545 adults. Results of the survey showed that participants supported all three strategies, with the strongest support for medication-assisted treatment. Multiple regression showed that stigma and perceived stigma were significant predictors for all three strategies, with inverse relationships. Stigmatizing beliefs predicted less support while perceiving stigma among others was associated with greater support for the strategies. Normative beliefs also significantly predicted support for all three strategies, such that stronger belief that others were supportive of each strategy was associated with greater support for that strategy. Other predictors varied across the three strategies. Support for harm reduction and treatment programs in communities affected by the opioid epidemic may be bolstered by reducing stigma and increasing normative beliefs. Stronger support for medication-assisted treatment may be leveraged and extended to harm reduction strategies. Results of our study contribute insights for bolstering community support for harm reduction and treatment, which is vital for adoption and maintenance of these important programs.
Collapse
Affiliation(s)
- Bridget L Hanson
- Center for Health and Safety Culture, Montana State University, P.O. Box 170548, Bozeman, MT, 59717, USA.
| | - Kari Finley
- Center for Health and Safety Culture, Montana State University, P.O. Box 170548, Bozeman, MT, 59717, USA
| | - Jay Otto
- Center for Health and Safety Culture, Montana State University, P.O. Box 170548, Bozeman, MT, 59717, USA
| | | | | |
Collapse
|
4
|
Moran L, Ondocsin J, Outram S, Ciccarone D, Werb D, Holm N, Arnold EA. How do we understand the value of drug checking as a component of harm reduction services? A qualitative exploration of client and provider perspectives. Harm Reduct J 2024; 21:92. [PMID: 38734643 PMCID: PMC11088080 DOI: 10.1186/s12954-024-01014-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered. METHODS We conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis. RESULTS We found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels. CONCLUSION This study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.
Collapse
Affiliation(s)
- Lissa Moran
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, 94143, USA.
| | - Jeff Ondocsin
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, 94143, USA
- Family & Community Medicine, Department of Medicine, University of California, San Francisco, CA, 94143, USA
| | - Simon Outram
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, 94143, USA
| | - Daniel Ciccarone
- Family & Community Medicine, Department of Medicine, University of California, San Francisco, CA, 94143, USA
| | - Daniel Werb
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, ON, M5B 1W8, Canada
- Division of Infectious Diseases & Global Public Health, UC San Diego School of Medicine, University of California, San Diego, CA, 92093, USA
| | - Nicole Holm
- Family & Community Medicine, Department of Medicine, University of California, San Francisco, CA, 94143, USA
| | - Emily A Arnold
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, 94143, USA
| |
Collapse
|
5
|
Seo B, Rider N, Rioux W, Teare A, Jones S, Taplay P, Monty Ghosh S. Understanding the barriers and facilitators to implementing and sustaining Mobile Overdose Response Services from the perspective of Canadian key interest groups: a qualitative study. Harm Reduct J 2024; 21:28. [PMID: 38308262 PMCID: PMC10837862 DOI: 10.1186/s12954-024-00946-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/25/2024] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION Unregulated supply of fentanyl and adulterants continues to drive the overdose crisis. Mobile Overdose Response Services (MORS) are novel technologies that offer virtual supervised consumption to minimize the risk of fatal overdose for those who are unable to access other forms of harm reduction. However, as newly implemented services, they are also faced with numerous limitations. The aim of this study was to examine the facilitators and barriers to the adoption of MORS in Canada. METHODS A total of 64 semi-structured interviews were conducted between November 2021 and April 2022. Participants consisted of people who use substances (PWUS), family members of PWUS, health care professionals, harm reduction workers, MORS operators, and members of the general public. Inductive thematic analysis was used to identify the major themes and subthemes. RESULTS Respondents revealed that MORS facilitated a safe, anonymous, and nonjudgmental environment for PWUS to seek harm reduction and other necessary support. It also created a new sense of purpose for operators to positively contribute to the community. Further advertising and promotional efforts were deemed important to increase its awareness. However, barriers to MORS implementation included concerns regarding privacy/confidentiality, uncertainty of funding, and compassion fatigue among the operators. CONCLUSION Although MORS were generally viewed as a useful addition to the currently existing harm reduction services, it's important to monitor and tackle these barriers by engaging the perspectives of key interest groups.
Collapse
Affiliation(s)
- Boogyung Seo
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nathan Rider
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - William Rioux
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Adrian Teare
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | - S Monty Ghosh
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
- Department of Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
6
|
Killion JA, Magana C, Cepeda JA, Vo A, Hernandez M, Cyr CL, Heskett KM, Wilson DP, Graff Zivin J, Zúñiga ML, Pines HA, Garfein RS, Vickerman P, Terris-Prestholt F, Wynn A, Martin NK. Unit costs of needle and syringe program provision: a global systematic review and cost extrapolation. AIDS 2023; 37:2389-2397. [PMID: 37773035 PMCID: PMC10653296 DOI: 10.1097/qad.0000000000003718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Needle and syringe programs (NSPs) are effective at preventing HIV and hepatitis C virus (HCV) among people who inject drugs (PWID), yet global coverage is low, partly because governments lack data on the cost and cost-effectiveness of NSP in their countries to plan and fund their responses. We conducted a global systematic review of unit costs of NSP provision to inform estimation of cost drivers and extrapolated costs to other countries. METHODS We conducted a systematic review to extract data on the cost per syringe distributed and its cost drivers. We estimated the impact of country-level and program-level variables on the cost per syringe distributed using linear mixed-effects models. These models were used to predict unit costs of NSP provision, with the best performing model used to extrapolate the cost per syringe distributed for 137 countries. The total cost for a comprehensive NSP (200 syringes per PWID/year) was also estimated for 68 countries with PWID population size estimates. RESULTS We identified 55 estimates of the unit cost per syringe distributed from 14 countries. Unit costs were extrapolated for 137 countries, ranging from $0.08 to $20.77 (2020 USD) per syringe distributed. The total estimated spend for a high-coverage, comprehensive NSP across 68 countries with PWID size estimates is $5 035 902 000 for 10 887 500 PWID, 2.1-times higher than current spend. CONCLUSION Our review identified cost estimates from high-income, upper-middle-income, and lower-middle-income countries. Regression models may be useful for estimating NSP costs in countries without data to inform HIV/HCV prevention programming and policy.
Collapse
Affiliation(s)
- Jordan A Killion
- University of California San Diego, La Jolla
- San Diego State University, San Diego, California
| | | | | | - Anh Vo
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Natasha K Martin
- University of California San Diego, La Jolla
- University of Bristol, Bristol, UK
| |
Collapse
|
7
|
Chavanne D, Ahluwalia JS, Goodyear K. The effects of race and class on community-level stigmatization of opioid use and policy preferences. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104147. [PMID: 37639913 DOI: 10.1016/j.drugpo.2023.104147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/31/2023]
Abstract
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.
Collapse
Affiliation(s)
- David Chavanne
- Department of Economics, Connecticut College, New London, CT, USA.
| | - Jasjit S Ahluwalia
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA
| | - Kimberly Goodyear
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI, USA; Center for Alcohol and Addiction Studies, Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA
| |
Collapse
|
8
|
Becker TD, Eschliman EL, Thakrar AP, Yang LH. A conceptual framework for how structural changes in emerging acute substance use service models can reduce stigma of medications for opioid use disorder. Front Psychiatry 2023; 14:1184951. [PMID: 37829763 PMCID: PMC10565357 DOI: 10.3389/fpsyt.2023.1184951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023] Open
Abstract
Stigma toward people taking medication for opioid use disorder (MOUD) is prevalent, harmful to the health and well-being of this population, and impedes MOUD treatment resource provision, help-seeking, and engagement in care. In recent years, clinicians have implemented new models of MOUD-based treatment in parts of the United States that integrate buprenorphine initiation into emergency departments and other acute general medical settings, with post-discharge linkage to office-based treatment. These service models increase access to MOUD and they have potential to mitigate stigma toward opioid use and MOUD. However, the empirical literature connecting these emerging service delivery models to stigma outcomes remains underdeveloped. This paper aims to bridge the stigma and health service literatures via a conceptual model delineating how elements of emerging MOUD service models can reduce stigma and increase behavior in pursuit of life goals. Specifically, we outline how new approaches to three key processes can counter structural, public, and self-stigma for this population: (1) community outreach with peer-to-peer influence, (2) clinical evaluation and induction of MOUD in acute care settings, and (3) transition to outpatient maintenance care and early recovery. Emerging service models that target these three processes can, in turn, foster patient empowerment and pursuit of life goals. There is great potential to increase the well-being of people who use opioids by reducing stigma against MOUD via these structural changes.
Collapse
Affiliation(s)
- Timothy D. Becker
- Department of Psychiatry, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, United States
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Evan L. Eschliman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ashish P. Thakrar
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Lawrence H. Yang
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York, NY, United States
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| |
Collapse
|
9
|
McGinty EE, White SA, Sherman SG, Lee R, Kennedy-Hendricks A. Framing harm reduction as part of an integrated approach to reduce drug overdose: A randomized message testing experiment in a nationally representative sample of U.S. adults, 2022. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 118:104101. [PMID: 37352766 DOI: 10.1016/j.drugpo.2023.104101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/05/2023] [Accepted: 06/11/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVES Low public support impedes widespread adoption of harm reduction services in the U.S. There are growing efforts to implement integrated programs offering harm reduction services alongside other services for people who use drugs. We tested how messages depicting integrated programs influence audience attitudes about harm reduction. METHODS A nine-group randomized experiment (N=3,181) embedded in a national survey of U.S. adults tested how factual and narrative messages describing programs integrating harm reduction, addiction treatment, and/or other services to reduce overdose influenced respondents' attitudes about harm reduction, relative to a comparison message defining harm reduction. The survey was fielded from September 16th to September28th, 2022 using the NORC Amerispeak probability-based online survey panel. The survey response rate was 74%. Measures included perceived effectiveness of standalone and integrated harm reduction programs, willingness to have a harm reduction program in the neighborhood or person using harm reduction services as a neighbor, and support for increasing government spending on harm reduction services. RESULTS 54.4% of respondents viewing the comparison message defining harm reduction reported that an integrated approach including harm reduction, addiction treatment, and other services is effective at reducing overdose, compared to 63.6%-69.1% of respondents viewing messages describing integrated programs (p<0.05). Messages depicting either standalone harm reduction or integrated programs lowered respondents' willingness to have a harm reduction program in their neighborhood, particularly when the messages depicted a Black person, versus a White person, benefiting from harm reduction. CONCLUSIONS Messages depicting programs offering integrated services including but not limited to harm reduction may heighten audience endorsement of the effectiveness of such an approach but lower willingness to have a harm reduction program in the neighborhood.
Collapse
Affiliation(s)
- Emma E McGinty
- Division of Health Policy and Economics, Weill Cornell Medicine, 402 E. 67th St. New York, NY, United States.
| | - Sarah A White
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Rachel Lee
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| |
Collapse
|
10
|
Morris H, Bwala H, Wesley J, Hyshka E. Public support for safer supply programs: analysis of a cross-sectional survey of Canadians in two provinces. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2023; 114:484-492. [PMID: 36689127 PMCID: PMC9869824 DOI: 10.17269/s41997-022-00736-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 12/19/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Canada's ongoing drug poisoning crisis has contributed to unprecedented rates of morbidity and mortality. Health Canada has funded safer supply pilot programs to help connect people who use drugs to pharmaceutical grade medications that reduce their reliance on a toxic drug supply. However, most provinces, including Alberta and Saskatchewan, have not endorsed these initiatives. We explored public support for safer supply programs in these two Canadian provinces and identified predictors of support for this policy option. METHODS Cross-sectional data were examined from an online panel survey that included measures assessing views on policy responses to substance use and addiction. A total of 1602 adults were recruited during March 2021. We used descriptive statistics to characterize support for safer supply programs in Alberta and Saskatchewan and multinominal logistic regression analysis to examine predictors of public support for safer supply. RESULTS The majority of respondents (AB: 63.5% and SK: 56.3%) supported safer supply programs that replace illegal street drugs with pharmaceutical alternatives for those unable to stop using. Predicted probabilities show a greater probability of support for safer supply among those with higher education and those leaning left on the political spectrum. CONCLUSION A majority of Canadians from Alberta and Saskatchewan supported provincial government efforts to expand safer supply, suggesting a lack of public support is not the main barrier to implementation. Efforts at mobilizing this public opinion are needed to scale up and facilitate evaluation of this drug poisoning response.
Collapse
Affiliation(s)
- Heather Morris
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Hauwa Bwala
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Jared Wesley
- Faculty of Arts-Political Science Department, University of Alberta, Edmonton, AB, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|
11
|
Volpe I, Brien R, Grigg J, Tzanetis S, Crawford S, Lyons T, Lee N, McKinnon G, Hughes C, Eade A, Barratt MJ. 'We don't live in a harm reduction world, we live in a prohibition world': tensions arising in the design of drug alerts. Harm Reduct J 2023; 20:3. [PMID: 36624508 PMCID: PMC9829230 DOI: 10.1186/s12954-022-00716-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/22/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Drug alerts designed for health and community workforces have potential to avert acute harms associated with unpredictable illicit drug markets, by preparing workers to respond to unusual drug-related events, and distribute information to service users. However, the design of such alerts is complicated by diverse needs of individuals, and broader socio-political contexts. Here, we discuss the tensions that arose in the process of co-designing drug alert templates with health and community workers. METHODS We conducted five in-depth digital co-design workshops with 31 workers employed in alcohol and other drug and urgent care settings. Our approach to analysis was informed by Iterative Categorisation and reflexive thematic analysis methods. RESULTS We identified five key tensions. First, there is a need to provide comprehensive information to meet the information needs of a diverse group of workers with varying knowledge levels, while also designing alerts to be clear, concise, and relevant to the work of individuals. Second, it is important that alerts do not create 'information overload'; however, it is also important that information should be available to those who want it. Third, alert design and dissemination must be perceived to be credible, to avoid 'alert scepticism'; however, credibility is challenging to develop in a broader context of criminalisation, stigmatisation, and sensationalism. Fourth, alerts must be carefully designed to achieve 'intended effects' and avoid unintended effects, while acknowledging that it is impossible to control all potential effects. Finally, while alerts may be intended for an audience of health and community workers, people who use drugs are the end-users and must be kept front of mind in the design process. CONCLUSIONS The co-design process revealed complexities in designing drug alerts, particularly in the context of stigmatised illicit drug use, workforce diversity, and dissemination strategies. This study has highlighted the value of developing these important risk communication tools with their target audiences to ensure that they are relevant, useful, and impactful. The findings have informed the development of our drug alert prototypes and provide local context to complement existing best-practice risk-communications literature.
Collapse
Affiliation(s)
- Isabelle Volpe
- grid.1017.70000 0001 2163 3550Social and Global Studies Centre, RMIT University, Melbourne, Australia ,grid.1005.40000 0004 4902 0432Drug Policy Modelling Program, Social Policy Research Centre, UNSW Sydney, Sydney, Australia
| | - Rita Brien
- grid.414366.20000 0004 0379 3501Turning Point, Eastern Health Statewide Services, Richmond, Australia ,grid.1002.30000 0004 1936 7857Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Jasmin Grigg
- grid.414366.20000 0004 0379 3501Turning Point, Eastern Health Statewide Services, Richmond, Australia ,grid.1002.30000 0004 1936 7857Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia
| | | | - Sione Crawford
- Harm Reduction Victoria (DanceWize), North Melbourne, Australia
| | - Tom Lyons
- Department of Health, Victoria State Government, Melbourne, Australia
| | - Nicole Lee
- 360Edge, Melbourne, Australia ,grid.1032.00000 0004 0375 4078National Drug Research Institute, Curtin University, Perth, Australia
| | - Ginny McKinnon
- Department of Health, Victoria State Government, Melbourne, Australia
| | - Caitlin Hughes
- grid.1014.40000 0004 0367 2697Law and Commerce, Flinders University, Adelaide, Australia ,grid.1005.40000 0004 4902 0432National Drug and Alcohol Research Centre, UNSW, Sydney, Australia
| | - Alan Eade
- Safer Care Victoria, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Department of Paramedicine, Monash University, Melbourne, Australia
| | - Monica J. Barratt
- grid.1017.70000 0001 2163 3550Social and Global Studies Centre, RMIT University, Melbourne, Australia ,grid.1005.40000 0004 4902 0432National Drug and Alcohol Research Centre, UNSW, Sydney, Australia ,grid.1017.70000 0001 2163 3550Digital Ethnography Research Centre, RMIT University, Melbourne, Australia
| |
Collapse
|
12
|
Effects of media representations of drug related deaths on public stigma and support for harm reduction. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:103909. [PMID: 36399962 DOI: 10.1016/j.drugpo.2022.103909] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/21/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022]
Abstract
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.
Collapse
|
13
|
Rudzinski K, Chan Carusone S, Ceranto A, Ibáñez-Carrasco F, McDonald L, Valentine D, Guta A, Hyshka E, O’Leary W, Cardow A, Strike C. Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting. Harm Reduct J 2022; 19:124. [PMID: 36384634 PMCID: PMC9668384 DOI: 10.1186/s12954-022-00711-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 11/02/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada. METHODS Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis. RESULTS Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services. CONCLUSIONS Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.
Collapse
Affiliation(s)
- Katherine Rudzinski
- grid.267455.70000 0004 1936 9596School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON N9A 0C5 Canada ,grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON M5T 3M7 Canada
| | - Soo Chan Carusone
- grid.498714.70000 0001 0351 7433Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada ,grid.25073.330000 0004 1936 8227McMaster Collaborative for Health and Aging, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Andre Ceranto
- grid.498714.70000 0001 0351 7433Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada
| | - Francisco Ibáñez-Carrasco
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON M5T 3M7 Canada
| | - Lisa McDonald
- grid.498714.70000 0001 0351 7433Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada
| | - Dean Valentine
- grid.498714.70000 0001 0351 7433Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada
| | - Adrian Guta
- grid.267455.70000 0004 1936 9596School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON N9A 0C5 Canada
| | - Elaine Hyshka
- grid.17089.370000 0001 2190 316XSchool of Public Health, University of Alberta, 3-256 Edmonton Clinic Health Academy, 11405 - 87 Ave NW, Edmonton, AB T6G 1C9 Canada
| | - William O’Leary
- grid.498714.70000 0001 0351 7433Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada ,grid.268252.90000 0001 1958 9263Lyle S. Hallman Faculty of Social Work, Wilfrid Laurier University, 120 Duke St W, Kitchener, ON N2H 6P6 Canada
| | - Andra Cardow
- grid.498714.70000 0001 0351 7433Casey House, 119 Isabella St, Toronto, ON M4Y 1P2 Canada
| | - Carol Strike
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON M5T 3M7 Canada
| |
Collapse
|
14
|
Filteau MR, Green B, Kim F, McBride KA. 'It's the same thing as giving them CPR training': rural first responders' perspectives on naloxone. Harm Reduct J 2022; 19:111. [PMID: 36192736 PMCID: PMC9531424 DOI: 10.1186/s12954-022-00688-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/13/2022] [Indexed: 12/03/2022] Open
Abstract
The Substance Abuse and Mental Health Services Administration's (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders' inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area's overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents' best chance for surviving an opioid overdose.
Collapse
Affiliation(s)
| | | | - Frances Kim
- JG Research and Evaluation, Bozeman, MT, USA
| | - Ki-Ai McBride
- Montana Department of Health and Human Services, Behavioral Health and Disabilities Disorders Division, Helena, MT, USA
| |
Collapse
|
15
|
Ory MG, Lee S, Smith ML, Alonzo JP, Clark HR, Burdine JN. Differences in the attitudes towards the opioid crisis between metropolitan and rural counties in Central Texas: Secondary data analysis using cross-sectional data. Prev Med Rep 2022; 26:101757. [PMID: 35310324 PMCID: PMC8931431 DOI: 10.1016/j.pmedr.2022.101757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 03/03/2022] [Accepted: 03/06/2022] [Indexed: 11/22/2022] Open
Abstract
Poorer access to opioid use disorder care reported in rural than in urban areas. Less supports for syringe exchange programs in rural than in urban areas. Important to tailor efforts to address opioid use disorder in rural and urban areas.
This study examined metropolitan and rural differences regarding concerns about opioid misuse and support for different strategies to reduce opioid use disorder risk in areas not designated as high-risk. This study used cross-sectional data from a regional community health assessment, which was collected in 2019 using a combination of stratified random sampling and clinic-based purposive sampling in Central Texas. The secondary data included 430 and 270 respondents from metropolitan and rural (not metropolitan) counties, respectively. The primary outcomes were perceived concern about the opioid crisis, perceived likelihood of getting addiction treatment, and support for strategies to reduce opioid use disorder risks. Multiple multivariable regression models were used to examine metropolitan and rural differences in the outcome variables after adjusting for age, sex, ethnicity, race, marital status, education, and household income. Respondents were about 58 years old on average. A majority were female (60%), non-Hispanic (88%), and White (83%). About 60% of rural and metropolitan respondents were concerned about opioid use and misuse in their community. After adjusting for respondents’ demographic characteristics, rural respondents were significantly less likely to perceive that individuals are getting the needed opioid use disorder treatment (aOR = 0.69, P = 0.031). Rural respondents were also significantly less supportive for legalizing syringe service programs in their communities (aOR = 0.71, P = 0.044) than metropolitan respondents. Differing attitudes by respondents from metropolitan and rural areas indicate the importance of tailoring prevention and mitigation efforts to address opioid use disorder in advance of an impending public health crisis.
Collapse
Affiliation(s)
- Marcia G Ory
- Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Shinduk Lee
- Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA.,College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Matthew Lee Smith
- Center for Population Health and Aging, School of Public Health, Texas A&M University, College Station, TX, USA.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Joy P Alonzo
- Department of Pharmacy Practice, Irma Lerma Rangel College of Pharmacy, Texas A&M Health Science Center, College Station, TX, USA
| | - Heather R Clark
- Office of Public Health Practice, School of Public Health, Texas A&M University, College Station, TX, USA.,Center for Community Health Development, School of Public Health, Texas A&M University, College Station, TX, USA
| | - James N Burdine
- Center for Community Health Development, School of Public Health, Texas A&M University, College Station, TX, USA.,Department of Health Promotion and Community Health Sciences, School of Public Health, Texas A&M University, College Station, TX, USA
| |
Collapse
|
16
|
Kaynak Ö, Whipple CR, Bonnevie E, Grossman JA, Saylor EM, Stefanko M, McKeon C, Smyser J, Kensinger WS. The Opioid Epidemic and the State of Stigma: A Pennsylvania Statewide Survey. Subst Use Misuse 2022; 57:1120-1130. [PMID: 35459425 DOI: 10.1080/10826084.2022.2064506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The opioid epidemic is a public health crisis. Among initiatives surrounding treatment and prevention, opioid use disorder (OUD) stigma has emerged as a subject for intervention. Objectives: This study examines overall results and demographic differences of three subscales of a public stigma survey instrument: general attitudes, social distance, and treatment availability and effectiveness. Methods: A statewide sample of Pennsylvanian adults (N = 1033) completed an online survey about the opioid epidemic. Weighted percentage level of agreement was reported for each item. To determine significant differences in responding across demographic groups (gender, race, and urban/rural status), multiple one-way ANOVAs were analyzed. Significant differences in the level of agreement and disagreement (p < .05) were reported. Results: The majority of respondents agreed that the opioid epidemic is a problem and that anyone can become addicted to opioids; however, many Pennsylvanians still disagree that OUD is a medical disorder and continue to endorse social distance beliefs of people with OUD. Most participants agreed that there are effective treatments available, and that recovery was possible; however, a large portion of participants were unsure whether specific treatments are effective. Subscale mean differences were significant for gender and age. Conclusions/Importance: Findings highlight that stigmatized attitudes, behaviors, and beliefs about individuals who use opioids are still prevalent and that uncertainty remains about the effectiveness of OUD treatment. OUD interventions should use targeted messaging in order to impact the ongoing opioid crisis.
Collapse
Affiliation(s)
- Övgü Kaynak
- School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA
| | - Christopher R Whipple
- School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA
| | | | - Joe A Grossman
- School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA
| | - Erica M Saylor
- School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA
| | | | | | - Joe Smyser
- School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA
| | - Weston S Kensinger
- School of Behavioral Sciences and Education, Penn State Harrisburg, Middletown, Pennsylvania, USA
| |
Collapse
|
17
|
Andraka-Christou B, Nguyen T, Harris S, Atkins DN, Totaram R, Golan O, Koval A, Madeira J. Harm Reduction Policy Support among Students at Two U.S. Universities. Subst Use Misuse 2022; 57:1185-1195. [PMID: 35491710 DOI: 10.1080/10826084.2022.2069265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The U.S. is undergoing an opioid overdose crisis. Harm reduction (HR) policies are associated with decreased overdose deaths and incidence of communicable diseases, yet legality of HR policies differs across U.S. jurisdictions. College student perceptions of HR policies are underexplored, even though their voting behavior has increased in recent years. We sought to compare their support of different HR policies and to explore relationships between demographic characteristics and support for HR policies. Methods: We collected cross-sectional, convenience sample survey data from undergraduate students at two large public universities, one in the Midwest and one in the Southeast, during Fall 2018/Spring 2019. We analyzed data using descriptive statistics and logistic regressions. Results: The final sample included 1,263 respondents. Good Samaritan laws (n = 833, 66%) and naloxone distribution (n = 476, 37.7%) were most commonly supported, while heroin maintenance treatment (n = 232, 18.4%) and heroin decriminalization (n = 208, 16.5%) were least supported. Democrat/liberal or less religious/spiritual respondents supported HR policies more than their Republican/conservative or religious/spiritual counterparts. Midwestern students were more likely to support syringe services programs. Conclusion: HR education initiatives could target religious and/or Republican/conservative students, as they have lower HR support. Among HR policies, Good Samaritan policies may be easiest to pass in college communities.
Collapse
Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, Florida, USA.,Department of Internal Medicine, University of Central Florida (Secondary Joint Appointment), Orlando, Florida, USA
| | - Thuy Nguyen
- School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Shana Harris
- Department of Internal Medicine, University of Central Florida (Secondary Joint Appointment), Orlando, Florida, USA.,Department of Anthropology, University of Central Florida, Orlando, Florida, USA
| | - Danielle N Atkins
- School of Global Health Management & Informatics, University of Central Florida, Orlando, Florida, USA
| | - Rachel Totaram
- School of Global Health Management & Informatics, University of Central Florida, Orlando, Florida, USA
| | - Olivia Golan
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Andriy Koval
- School of Global Health Management & Informatics, University of Central Florida, Orlando, Florida, USA
| | - Jody Madeira
- Maurer School of Law, Indiana University-Bloomington, Bloomington, Indiana, USA
| |
Collapse
|
18
|
Murphy J, Russell B. Police Officers' addiction frameworks and policy attitudes. Addict Behav 2021; 122:107007. [PMID: 34146796 DOI: 10.1016/j.addbeh.2021.107007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 04/08/2021] [Accepted: 06/03/2021] [Indexed: 01/01/2023]
Abstract
Police officers have frequent encounters with people who use drugs, either by making an arrest for a drug-related offense or responding to a drug overdose call. Yet, little is known about how police officers view drug addiction - as a disease, a moral failure, or something else - and how their frameworks for conceptualizing addiction impact their attitudes toward drug policies, including the use of naloxone. This research examined police officers' adherence to a moralistic addiction framework in relation to their support for treatment-oriented drug policies. Officers (N = 618) were surveyed about their beliefs on drug policy and the extent to which drug addiction was a product of one's morals or related to social or biological reasons. Results found that approximately 22% of the variance in drug policy attitudes could be explained by addiction frameworks and control variables. Officers who embraced a biological perspective of addiction were more supportive of policies that expanded treatment, including access to naloxone, and less punitive sanctions. Those with stronger moralistic views were less supportive of expanding treatment initiatives and endorsed expanding punitive sanctions. Officer age and education was positively related with expanding treatment and naloxone use while exposure to overdoses was negatively related to policy support. These results demonstrate that officers' frameworks about drug addiction play an important role in drug policy attitudes and, by extension, how they might interact with people who use drugs.
Collapse
|
19
|
Meyers SA, Earnshaw VA, D’Ambrosio B, Courchesne N, Werb D, Smith LR. The intersection of gender and drug use-related stigma: A mixed methods systematic review and synthesis of the literature. Drug Alcohol Depend 2021; 223:108706. [PMID: 33901753 PMCID: PMC8168566 DOI: 10.1016/j.drugalcdep.2021.108706] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 03/01/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma? METHODS Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma. RESULTS Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma. CONCLUSION The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.
Collapse
Affiliation(s)
- S. A. Meyers
- Department of Psychology, San Diego State University, 5500
Campanile Drive, San Diego, CA 92182, USA,Division of Infectious Diseases and Global Public Health,
Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla,
CA 92093, USA
| | - V. A. Earnshaw
- Human Development and Family Sciences, University of Delaware,
Newark, DE, 19716, USA
| | - B. D’Ambrosio
- Division of Infectious Diseases and Global Public Health,
Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla,
CA 92093, USA,School of Social Work, College of Health and Human Services,
San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, USA
| | - N. Courchesne
- Department of Psychiatry, University of California San Diego,
9500 Gilman Drive, La Jolla, CA 92093, USA
| | - D. Werb
- Division of Infectious Diseases and Global Public Health,
Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla,
CA 92093, USA,Centre for Urban Health Solutions, St. Michael’s
Hospital, 30 Bond Street, Toronto, ON, M5B 1W8 Canada
| | - L. R. Smith
- Division of Infectious Diseases and Global Public Health,
Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla,
CA 92093, USA
| |
Collapse
|
20
|
Wild TC, Koziel J, Anderson-Baron J, Asbridge M, Belle-Isle L, Dell C, Elliott R, Hathaway A, MacPherson D, McBride K, Pauly B, Strike C, Galovan A, Hyshka E. Public support for harm reduction: A population survey of Canadian adults. PLoS One 2021; 16:e0251860. [PMID: 34010338 PMCID: PMC8133460 DOI: 10.1371/journal.pone.0251860] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 05/05/2021] [Indexed: 11/19/2022] Open
Abstract
We described public views toward harm reduction among Canadian adults and tested a social exposure model predicting support for these contentious services, drawing on theories in the morality policy, intergroup relations, addiction, and media communication literatures. A quota sample of 4645 adults (18+ years), randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across Canadian provinces, was recruited in June 2018. Participants completed survey items assessing support for harm reduction for people who use drugs (PWUD) and for seven harm reduction interventions. Additional items assessed exposure to media coverage on harm reduction, and scales assessing stigma toward PWUD (α = .72), personal familiarity with PWUD (α = .84), and disease model beliefs about addiction (α = .79). Most (64%) Canadians supported harm reduction (provincial estimates = 60% - 73%). Five of seven interventions received majority support, including: outreach (79%), naloxone (72%), drug checking (70%), needle distribution (60%) and supervised drug consumption (55%). Low-threshold opioid agonist treatment and safe inhalation interventions received less support (49% and 44%). Our social exposure model, adjusted for respondent sex, household income, political views, and education, exhibited good fit and accounted for 17% of variance in public support for harm reduction. Personal familiarity with PWUD and disease model beliefs about addiction were directly associated with support (βs = .07 and -0.10, respectively), and indirectly influenced public support via stigmatized attitudes toward PWUD (βs = 0.01 and -0.01, respectively). Strategies to increase support for harm reduction could problematize certain disease model beliefs (e.g., "There are only two possibilities for an alcoholic or drug addict-permanent abstinence or death") and creating opportunities to reduce social distance between PWUD, the public, and policy makers.
Collapse
Affiliation(s)
- T. Cameron Wild
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Jakob Koziel
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | - Mark Asbridge
- Department of Community Health and Epidemiology, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lynne Belle-Isle
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - Colleen Dell
- Department of Sociology, School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Andrew Hathaway
- Department of Sociology and Anthropology, University of Guelph, Guelph, Ontario, Canada
| | | | | | - Bernie Pauly
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Adam Galovan
- Department of Human Ecology, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
21
|
Munoz Sastre MT, Kpanake L, Mullet E. French People's positions on supervised injection facilities for drug users. Subst Abuse Treat Prev Policy 2020; 15:79. [PMID: 33054832 PMCID: PMC7557075 DOI: 10.1186/s13011-020-00321-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Supervised injection facilities have been set-up in many countries to curb the health risks associated with unsafe injection practices. These facilities have, however, been met with vocal opposition, notably in France. As harm reduction policies can only succeed to the extent that people agree with them, this study mapped French people's opinions regarding the setting-up of these facilities. METHOD A sample of 318 adults--among them health professionals--were presented with 48 vignettes depicting plans to create a supervised injection facility in their town. Each vignette contained three pieces of information: (a) the type of substance that would be injected in the facility (amphetamines only, amphetamines and cocaine only, or amphetamines, cocaine and heroin), (b) the type of staff who would be working in the facility (physicians and nurses, specially trained former drug users, specially trained current drug users, or trained volunteers recruited by the municipality), and (c) the staff members' mission (to be present and observe only, technical counselling about safe injection, counselling about safe injection and hygiene, or counselling and encouragement to follow a detoxification program). RESULTS Through cluster analysis, three qualitatively different positions were found: Not very acceptable (20%), Depends on staff and mission (49%), and Always acceptable (31%). These positions were associated with demographic characteristics--namely gender, age and political orientation. CONCLUSION French people's positions regarding supervised injection facilities were extremely diverse. One type of facility would, however, be accepted by a large majority of people: supervised injection facilities run by health professionals whose mission would be, in addition to technical and hygienic counselling, to encourage patrons to enter detoxification or rehabilitation programs.
Collapse
Affiliation(s)
- Maria Teresa Munoz Sastre
- CERPPS, Maison de la recherche, Federal University of Toulouse, 5 allées Antonio Machado, 31058 Toulouse cedex 9, France
| | - Lonzozou Kpanake
- University of Québec – TELUQ, 5800, rue Saint-Denis, Bureau 1105, Montréal (Québec), Montréal, H2S 3L5 Canada
| | - Etienne Mullet
- Institute of Advanced Studies (EPHE), 17 bis, rue Quefes, Plaisance du Touch, 31830 Paris, France
| |
Collapse
|
22
|
Sumnall HR, Hamilton I, Atkinson AM, Montgomery C, Gage SH. Representation of adverse childhood experiences is associated with lower public stigma towards people who use drugs: an exploratory experimental study. DRUGS-EDUCATION PREVENTION AND POLICY 2020. [DOI: 10.1080/09687637.2020.1820450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Harry R. Sumnall
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Ian Hamilton
- Department of Health Sciences, University of York, York, UK
| | - Amanda M. Atkinson
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | | | - Suzanne H. Gage
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| |
Collapse
|
23
|
Calabrese C, Bell RA. Opposition to Nonprescription Naloxone Access: Measurement and Psychosocial Predictors. Subst Use Misuse 2019; 54:1853-1861. [PMID: 31131707 DOI: 10.1080/10826084.2019.1618331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Access of naloxone has been increased in recent years, yet opposition to unrestricted availability persists. Objectives: To validate a measure of opposition to the policy of nonprescription naloxone and foster a better understanding of the characteristics of individuals who oppose such a policy. Methods: Respondents from a crowdsource platform (N = 621) responded to an instrument developed to assess opposition to nonprescription naloxone. Construct validity was assessed by examining the relationship of the opposition scale with measures of social distance, belief in a just world, right wing authoritarianism, social dominance orientation (SDO), perceptions of the degree of threat to the nation presented by opioid users, past exposure to opioid misuse, and conservative political ideology. Results: A 9-item measure of opposition emerged (α=.96). Opposition to nonprescription naloxone was generally associated with construct validation variables as expected. In a regression analysis that adjusted for demographic characteristics, opposition was most strongly related to authoritarianism, the perception that opioid users present a threat to our nation, the belief that we live in a just world, social dominance orientation, greater perceived social distance between self and opioid users, and past experiences with users. Opposition scores differentiated those who supported versus opposed specific policies regarding naloxone access and were particularly high among Republicans. Most respondents did not oppose policies on nonprescription naloxone access. Conclusions/Importance: The instrument developed provides a reliable and valid tool that enables future investigations into understanding and overcoming the psychological, social, and political foundations of opposition to expanded naloxone access.
Collapse
Affiliation(s)
- Christopher Calabrese
- a Department of Communication , University of California, Davis , Davis , California , USA
| | - Robert A Bell
- a Department of Communication , University of California, Davis , Davis , California , USA.,b Department of Public Health Sciences , University of California, Davis , Davis , California , USA
| |
Collapse
|
24
|
Abstract
The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.
Collapse
|
25
|
Stigma and the public health agenda for the opioid crisis in America. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 59:44-49. [DOI: 10.1016/j.drugpo.2018.06.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 04/02/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022]
|
26
|
McGinty EE, Barry CL, Stone EM, Niederdeppe J, Kennedy-Hendricks A, Linden S, Sherman SG. Public support for safe consumption sites and syringe services programs to combat the opioid epidemic. Prev Med 2018; 111:73-77. [PMID: 29481827 DOI: 10.1016/j.ypmed.2018.02.026] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/22/2018] [Accepted: 02/21/2018] [Indexed: 01/25/2023]
Abstract
We examine Americans' support for two evidence-based harm reduction strategies - safe consumption sites and syringe exchange programs - and their attitudes about individuals who use opioids. We conducted a web-based survey of a nationally representative sample of U.S. adults in July-August 2017 (N = 1004). We measured respondents' support for legalizing safe consumption sites and syringe services programs in their communities and their attitudes toward people who use opioids. We used ordered logistic regression to assess how stigmatizing attitudes toward people who use opioids, political party identification, and demographic characteristics correlated with support for the two harm reduction strategies. Twenty-nine percent of Americans supported legalizing safe consumption sites and 39% supported legalizing syringe services programs. Respondents reported high levels of stigmatizing attitudes toward people who use opioids: 16% of respondents were willing to have a person using opioids marry into their family and 28% were willing to have a person using opioids start working closely with them on a job, and 27% and 10% of respondents rated persons who use opioids as deserving (versus worthless) and strong (versus weak). Stigmatizing attitudes were associated with lower support for legalizing safe consumption sites and syringe services programs. Democrats and Independents were more likely than Republicans to support both strategies. Stigmatizing attitudes toward people who use opioids are a key modifiable barrier to garnering the public support needed to fully implement evidence-based harm reduction strategies to combat the opioid epidemic. Dissemination and evaluation of stigma reduction campaigns are a public health priority.
Collapse
Affiliation(s)
- Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, United States.
| | - Colleen L Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Elizabeth M Stone
- Division of General Internal Medicine, Johns Hopkins School of Medicine, United States
| | | | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States
| | - Sarah Linden
- Division of General Internal Medicine, Johns Hopkins School of Medicine, United States
| | - Susan G Sherman
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, United States
| |
Collapse
|
27
|
Kulesza M, Watkins KE, Ober AJ, Osilla KC, Ewing B. Internalized stigma as an independent risk factor for substance use problems among primary care patients: Rationale and preliminary support. Drug Alcohol Depend 2017; 180:52-55. [PMID: 28869858 PMCID: PMC5648632 DOI: 10.1016/j.drugalcdep.2017.08.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Little is known about internalized stigma among primary care patients, and whether the presence of internalized stigma is related to the severity of substance use problems independent of substance use-related variables. We sought to examine the relationship between internalized stigma and substance use problems among primary care patients with opioid or alcohol use disorders (OAUDs). METHODS We present baseline data from 393 primary care patients who were enrolled in a study of collaborative care for OAUDs. Regression analyses examined the relationship between internalized stigma and substance use problems, controlling for demographics, psychiatric comorbidity, and quantity/frequency of use. RESULTS The majority of participants reported thinking, at least sometimes, that they "have permanently screwed up" their lives (60%), and felt "ashamed" (60%), and "out of place in the world" (51%) as a result of their opioid or alcohol use. Higher internalized stigma was significantly related to more substance use problems (β=2.68, p<0.01), even after the effects of covariates were accounted for. Stigma added 22%, out of 51% total variance explained, leading to a significant improvement in prediction of substance use problems. CONCLUSIONS Among this group of primary care patients with OAUDs, rates of internalized stigma were comparable to those reported in specialty substance use treatment settings. Consistent with extant specialty care literature, our results suggest that internalized stigma may be a unique contributor that is associated with treatment outcomes, such as substance use problems, among primary care patients with OAUDs.
Collapse
Affiliation(s)
| | | | - Allison J Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
| | - Karen C Osilla
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
| | - Brett Ewing
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
| |
Collapse
|
28
|
|
29
|
Kulesza M, Matsuda M, Ramirez JJ, Werntz AJ, Teachman BA, Lindgren KP. Towards greater understanding of addiction stigma: Intersectionality with race/ethnicity and gender. Drug Alcohol Depend 2016; 169:85-91. [PMID: 27792911 PMCID: PMC6040658 DOI: 10.1016/j.drugalcdep.2016.10.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/20/2016] [Accepted: 10/14/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND In spite of the significant burden associated with substance use disorders, especially among persons who inject drugs (PWIDs), most affected individuals do not engage with any type of formal or informal treatment. Addiction stigma, which is represented by negative social attitudes toward individuals who use alcohol and/or other drugs, is one of the barriers to care that is poorly understood. The current study: a) assessed implicit (indirect and difficult to consciously control) and explicit (consciously controlled) beliefs about PWIDs among visitors to a public web site; and b) experimentally investigated the effects of ethnicity/race and gender on those implicit and explicit beliefs. METHODS N=899 predominantly White (70%) and women (62%) were randomly assigned to one of six target PWIDs conditions: gender (man/woman) x race/ethnicity (White, Black, Latino/a). Participants completed an Implicit Association Test and explicit assessment of addiction stigma. RESULTS Participants implicitly associated PWIDs (especially Latino/a vs. White PWIDs) with deserving punishment as opposed to help (p=0.003, d=0.31), indicating presence of addiction stigma-related implicit beliefs. However, this bias was not evident on the explicit measure (p=0.89). Gender did not predict differential implicit or explicit addiction stigma (p=0.18). CONCLUSIONS Contrary to explicit egalitarian views towards PWIDs, participants' implicit beliefs were more in line with addiction stigma. If replicated and clearer ties to behavior are established, results suggest the potential importance of identifying conditions under which implicit bias might influence behavior (even despite explicit egalitarian views) and increase the likelihood of discrimination towards PWIDs.
Collapse
Affiliation(s)
| | - Mauri Matsuda
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407, USA.
| | - Jason J Ramirez
- University of Washington, Department of Psychiatry, 1100 NE 45th Street, Seattle, WA, 98105, USA.
| | - Alexandra J Werntz
- University of Virginia, Department of Psychology, 102 Gilmer Hall, Charlottesville, VA, 22904, USA.
| | - Bethany A Teachman
- University of Virginia, Department of Psychology, 102 Gilmer Hall, Charlottesville, VA, 22904, USA.
| | - Kristen P Lindgren
- University of Washington, Department of Psychiatry, 1100 NE 45th Street, Seattle, WA, 98105, USA.
| |
Collapse
|