Differences in perceptions of community stigma towards opioid use disorder between community substance use coalition members and the general public

INTRODUCTION

To examine differences in perceptions about community stigma towards individuals with opioid use disorder (OUD) between community members involved in the opioid response (i.e., coalition members) and the general public, and how community geography may moderate this relationship.

METHODS

This study administered identical cross-sectional surveys about perceived community opioid-related stigma to two distinct populations in 66 communities participating in the HEALing Communities Study prior to the intervention period (i.e., coalition members, November 2019-January 2020; residents, March-April 2020). Linear-mixed models compared survey responses of populations, including the moderating effect of community rural/urban location.

RESULTS

A total of 826 coalition members and 1131 residents completed the surveys. The study found no differences between the coalition members and residents for general perceived community opioid-related stigma. In both urban and rural communities, coalition members reported greater perceived community stigma than residents reported towards medication for opioid use disorder (MOUD), naloxone, and drug treatment as an alternative to incarceration.

CONCLUSION

Our findings suggest similar perceived community opioid-related stigma between coalition members and residents, yet differences emerge related to evidence-based practices (i.e., MOUD, naloxone, and drug treatment as an alternative to incarceration) to reduce opioid overdose deaths.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04111939.

Development and Evaluation of Messages to Facilitate Secure Storage and Disposal of Prescribed Opioid Medication

BACKGROUND

Secure storage and disposal is a critical strategy to reduce prescription opioid misuse. We sought to develop effective messages to promote secure storage and disposal of unused opioid medications that can be used in interventions designed to reduce diversion of opioid medications for nonmedical use.

METHODS

We used a mixed-method design to develop and evaluate messages. First, we pretested 34 messages in focus group discussions (FGDs; n = 12 FGDs, n = 2-5 participants per FGD; 37 total participants). Then, we tested the 12 most salient messages in an online survey with a nationally representative Qualtrics® panel (n = 1520 participants). A pretest-posttest design was conducted to assess change in beliefs about storage and disposal of opioid medication following message exposure.

RESULTS

All 12 messages favorably influenced participants' perceptions related to concerns and risks of retaining unused opioid medications and the importance of and self-efficacy in securely storing and disposing of unused opioid medications. Storage and disposal messages that included the sentence-"Your prescription can become someone else's addiction."-outperformed other messages in encouraging people to safely store or dispose of opioid medication.

CONCLUSIONS

This study informs the development of a universal text message intervention using multimodal feedback from the target population that the intervention seeks to serve. The next step is to conduct a randomized controlled trial to assess efficacy of the intervention.

The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices

BACKGROUND

Opioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths.

METHODS

The HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) a community engagement strategy with local coalitions to guide and implement the intervention; 2) a compendium of EBPs coupled with technical assistance; and 3) a series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined.

DISCUSSION

The HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Developing a health communication campaign for disposal of unused opioid medications

INTRODUCTION

Communities throughout the United States have implemented medicine disposal programs to prevent diversion of unused opioid analgesics from homes but a general lack of awareness may contribute to low rates of utilization. The objective of this study was to develop and test community-based campaign messages promoting appropriate disposal of unused opioids at disposal programs.

METHODS

In Fall 2019, 491 residents (79% female, 97% White, mean age: 40 years) of five rural, Appalachian counties (3 in Kentucky and 2 in North Carolina) completed a web-based, experimental survey. Participants were randomly exposed to two of four messages and rated each message separately. A pretest-posttest design was utilized to assess change in beliefs about retaining unused prescription opioids in the home following exposure to message sets.

RESULTS

All messages favorably influenced participants' perceptions related to concerns and risks of retaining unused prescription opioids and importance of - and self-efficacy in disposing of unused opioid medications. After controlling for social and demographic characteristics and baseline beliefs in generalized linear mixed models, Message 1 outperformed other messages in increasing participants' concern about retaining unused prescription opioids in the home and Message 3 was most effective in increasing self-efficacy to dispose of unused prescription opioids.

CONCLUSIONS

Messages including young children and pictorially demonstrate how to dispose of medications may have the greatest impact on behavioral actions related to medication disposal. The findings from this study can be used to inform community-based campaigns to facilitate disposal of unused prescription opioids.

Health communication campaigns to drive demand for evidence-based practices and reduce stigma in the HEALing communities study

BACKGROUND

The HEALing Communities Study (HCS) is testing whether the Communities that Heal (CTH) intervention can decrease opioid overdose deaths through the implementation of evidence-based practices (EBPs) in highly impacted communities. One of the CTH intervention components is a series of communications campaigns to promote the implementation of EBPs, increase demand for naloxone and medications for opioid use disorder (MOUD), and decrease stigma toward people with opioid use disorder and the use of EBPs, especially MOUD. This paper describes the approach to developing and executing these campaigns.

METHODS

The HCS communication campaigns are developed and implemented through a collaboration between communication experts, research site staff, and community coalitions using a three-stage process. The Prepare phase identifies priority groups to receive campaign messages, develops content for those messages, and identifies a "call to action" that asks people to engage in a specific behavior. In the Plan phase, campaign resources are produced, and community coalitions develop plans to distribute campaign materials. During the Implement stage, these distribution plans guide delivery of content to priority groups. Fidelity measures assess how community coalitions follow their distribution plan as well as barriers and facilitators to implementation. An evaluation of the communication campaigns is planned.

CONCLUSIONS

If successful, the Prepare-Plan-Implement process, and the campaign materials, could be adapted and used by other communities to address the opioid crisis. The campaign evaluation will extend the evidence base for how communication campaigns can be developed and implemented through a community-engaged process to effectively address public health crises.

Encouraging Disposal of Unused Opioid Analgesics in Appalachia

The Appalachian region has been disproportionately impacted by the opioid epidemic. This study, informed by the Health Belief Model (HBM), explored Appalachian community members' perspectives on prescription opioid misuse and community-based programs to dispose of unused opioid analgesics. In 2018, we conducted ten focus groups (n=94 participants) in 5 Appalachian counties. Thirteen themes across 5 of the HBM constructs emerged from our analysis. Participants perceived that their communities are susceptible to the harms associated with opioid misuse, these harms are serious, suggesting they could be motivated to change disposal behaviors. Many participants recognized the benefit to disposing of unused prescription opioids including protecting household members from misusing and protecting the home from robbery. Nevertheless, participants identified barriers to proper disposal, including keeping the medications "just in case" for future ailments and the location of drop boxes near law enforcement (due to deep-seated mistrust of law enforcement agencies). Self-efficacy was difficult to assess as many participants were completely unaware of the presence of dropboxes in the community and also expressed concerns about the inconvenience of proper disposal using dropboxes These findings have implications for developing community-based campaign messages promoting proper disposal of unused opioids.

Smokeless Tobacco and the Rural Teen: How Culture and Masculinity Contribute to Adolescent Use

Tobacco use is the leading preventable cause of disease, disability, and death in the United States. Smokeless tobacco (SLT) is primarily used by younger, rural males and often in the presence of other males. This formative study examined how hegemonic masculinity and male norms can lead to initiation and continued use of SLT by rural adolescent males and females. Survey data collected from high school sophomores in 4 rural high schools (n = 293) explores perceptions of masculinity and male norms' contribution to SLT uptake and use. About 22.5% of total sample reported lifetime use (34.4% male, 13.7% female), 10.9% reported past-month use (20.0% male, 4.2% female). Logistic regressions show a one-unit increase in adherence to traditional perceptions of masculinity more than doubled the odds of ever using SLT and significantly increased odds of 30-day use. Having male household family members who uses SLT significantly increased the odds of lifetime and 30-day SLT use for both genders, while having male family members who smoke cigarettes was not a significant correlate. Recognition of health warnings on SLT packaging was negatively associated with SLT use for both genders. Implications for inclusion of masculinity and male role models in SLT prevention intervention strategies are discussed.

Communication apprehension mediates the effects of past experience discussing substance use on child and adolescent psychiatrists' self-efficacy

Objective Child and Adolescent Psychiatrists (CAPs) treat patients who are at an increased risk of developing a substance use disorder in their lifetime. However, CAPs often experience apprehension when it comes to discussing substance use with their patients, and this apprehension may come from past experiences when these discussions have gone poorly. This study seeks to understand whether or not apprehension moderates the relationship between past experiences and self-efficacy for CAPs when discussing substance use with their patients. Methods This study used a national online survey of CAPs (n = 170) to test the extent to which apprehension mediated the relationship between past experiences discussing substance use and self-efficacy to do so. Results The results showed that past experience affects self-efficacy and apprehension serves as a mediator of this relationship. Conclusion This study helps to shed light on the determinants that influence providers' perceptions of self-efficacy. Understanding what factors affect self-efficacy is important because these factors can then be targeted through training. Practice implications Patient-provider communication skills training for CAPs should happen early in their education so that they are less likely to become apprehensive about discussing substance use with their patients.

Trauma Trainees' Multiple Competing Goals in Opioid Prescription Communication

Prescription opioids and heroin account for more than half of all drug overdose fatalities, costing an estimated 115 American lives every day. The ongoing opioid epidemic devastates communities and represents a tremendous burden to the national economy and health care system. In 2016, the Centers for Disease Control and Prevention and the White House Office of National Drug Control Policy proposed action to train prescribers on the proper dispensing of opioids, which are indispensable pharmacologic resources for treating acute pain resulting from a traumatic injury or surgery. Trauma surgeons who prescribe opioids for severe pain embark on patient consultations with multiple and conflicting goals respective to their roles as a healers of the suffering, regulators of illicit substances, members of a greater medical system working to contain an opioid epidemic, and moral beings with a distinct set of preferences, experiences, social norms, and practice philosophies. Semistructured interviews with 17 trauma and surgical residents and fellows at a southeastern academic medical center in the United States generated descriptive data regarding prescribing practices and patient communication. Guided by the multiple goals framework, the current research presents three prominent themes depicting the problematic convergence of identity, task, and relational goals during opioid-prescribing conversations between trauma trainees and their patients.

Deaf or Hearing: A Hard of Hearing Individual's Navigation Between Two Worlds

Identity construction and how an individual chooses to navigate or display his or her identity play an important role in how that person communicates and interacts with others. One group for whom identity construction and navigation is a difficult process is the hard of hearing population. In the present study, Communication Theory of Identity (Hecht, 1993) and interactive interviews were used to gain insight into four layers of identity-personal, relational, enacted, and communal-in the hard of hearing individual. The authors discuss the themes within each identity layer and the gaps that are present between layers, as well as the implications of the identified layers and gaps.

Effects of image congruency on persuasiveness and recall in direct-to-consumer prescription drug advertising

Although direct-to-consumer (DTC) prescription drug advertising is regulated by the U.S. Food and Drug Administration, content analyses suggest advertisers may not disclose drug risks in the same way they describe drug benefits. This study tests the relationship between image congruency in televised DTC advertisements, recall of risks/benefits, and perceived persuasiveness. Advertisements for Nasonex, Advair, and Lunesta were shown to college students in either their original (image incongruent) or modified (image neutral) form. Risks were easier to recall with image-neutral advertisements. Gender also had a significant interaction effect, suggesting that males and females process DTC advertisement differently.

Using the Theory of Planned Behavior to Guide Focus Group Development of Messages Aimed at Increasing Compliance With a Tobacco-Free Policy

Purpose:

This study details the persuasive message development for a theory-based campaign designed to increase compliance with a university’s tobacco-free policy.

Approach:

The theory of planned behavior (TPB) guided message design and evaluation for focus group–tested messages that were adapted to the context of complying with a tobacco-free policy.

Setting:

The study was conducted at a university located in the tobacco belt.

Participants:

Undergraduate focus group participants (n = 65) were mostly male (69%), white (82%), and freshman (62%) who smoked at least 1 cigarette in the last 30 days; on-campus smoking percentages were never/rare (60%), occasionally (23%), and often/frequently (16%).

Method:

Data analysis used a theoretical thematic approach to identify how the TPB constructs related to perceptions of message effectiveness.

Results:

Participants responded favorably to attitudinal strategies about health, respect, and university figures; they rejected approaches they considered juvenile and offensive. They also discussed the impact of noncompliance and avoiding overgeneralized statements for addressing subjective norms, suggesting shortening text, adjusting picture location, and emphasizing the importance of compliance to increase perceptions of behavioral control.

Conclusion:

Applying theory to preexisting messages is challenging. The design approach in this study is an evidence-based strategy that can be used as a universal process for message adaptation. Results offer health promotion suggestions for designing messages aimed at improving undergraduate smokers’ willingness to comply with tobacco-free campus policies.

The Development and Validation of a Coding Protocol to Measure Change in Tobacco-Control Newspaper Coverage

The national ASSIST newspaper coding protocol model was used as a template to adapt a system for measuring tobacco-related newspaper coverage in Colorado newspapers. Over a 3-month period, tobacco-related articles were clipped from 180 daily and weekly newspapers. Variables coded included adaptations of the original ASSIST categories. During development and testing, additional variables were added to make the protocol more comprehensive and sensitive to tobacco policy media coverage. Intercoder reliabilities were calculated for all nonstatic variables using Cohen’s kappa. Disagreements were resolved through group discussions. Two rounds of testing achieved ratings above .70 for all variables. The protocol improves dramatically upon the ASSIST model by providing greater breadth and depth of analysis and more sensitivity to the nuances of newspaper coverage of tobacco-related issues. Given its simplicity, the protocol could also prove valuable for antitobacco advocacy groups who wish to track the changes in public and media opinions.

The need for tobacco cessation in a free clinic population

INTRODUCTION

Free clinics are a unique safety net provider in that they exclusively serve the uninsured. Because free clinic providers are often volunteers, it is unclear whether uninsured patients seeking care in these clinics receive evidence-based tobacco cessation support. Here we report baseline data on prevalence and correlates of tobacco use and provider cessation advice among a sample of uninsured patients at six free clinics.

METHODS

Patient exit interviews were conducted after a healthcare provider visit. Logistic regression analysis was used to assess correlates of tobacco use.

RESULTS

Of the 158 patients interviewed, 83 (53%) were tobacco users. Tobacco use was less likely among Hispanics (AOR 0.13 [95% CI 0.03-0.64]) and high school graduates (AOR=0.20 [95% CI 0.08-0.55]). Among tobacco users, 62% made at least one quit attempt in the past year and the majority were in the Contemplation (33%) or Preparation (39%) stage of readiness. 70% of all patients were screened in the past 3 months, although screening was more likely among tobacco users than nonusers (AOR 3.56 [95% CI 1.47-8.61]). At the current visit, 18% of tobacco users were advised to quit and 16% were asked if they were willing to quit.

CONCLUSIONS

The prevalence of tobacco use among uninsured free clinic patients was more than twice the national average. There is substantial opportunity to increase tobacco screening among all patients and cessation advice among tobacco users. Free clinics present an untapped opportunity to reduce tobacco harm in a population at high risk for tobacco morbidity and mortality.

Predictors of Clinician Tobacco Intervention Counseling in Six North Carolina Free Clinics

While the poor and the uninsured are at increased risk for tobacco use, up to two thirds of these patients express interest in near-term quitting. Nonetheless, tobacco counseling rates remain low in clinics serving these patients. As part of a larger tobacco intervention project in North Carolina free clinics, we gathered baseline data on patient characteristics in six randomly selected facilities affiliated with the North Carolina Association of Free Clinics. An exit interview was completed by 231 patients; 126 (54%) were tobacco users. Among all patients, 71% had been asked by a clinician about tobacco use in the past 3 months. Among tobacco users, 68% had received at least one other counseling step (assessment; advice; or assistance). Patients with asthma and current tobacco users had a two-fold increase in being asked about tobacco use. Patients' diagnoses-in particular asthma-can remind clinicians of tobacco intervention.

Integrating evidence-based tobacco cessation interventions in free medical clinics: opportunities and challenges

BACKGROUND

Free medical clinics serve a critical role in health care delivery of America's uninsured population, who are less likely to receive tobacco cessation counseling and 1½ times more likely than the general population to use tobacco. The authors evaluate the opportunities for and challenges to implementing the U.S. Public Health Service Guidelines for tobacco cessation in free clinics.

METHODS

Six free clinics participated in this pilot study. Five objectives were targeted: implementation of a tobacco user identification system, education of all clinic staff and volunteers, dedication of a program champion, use of evidence-based treatment, and creation of a supportive environment that reinforces provider behavior. Key informant interviews and focus group data were used to describe the opportunities and barriers of implementing the Public Health Service Guidelines.

RESULTS

All clinics adopted a user identification system, dedicated a program champion, adopted evidence-based counseling, and created an environment conducive for cessation. Common challenges included getting volunteers to attend on-site training programs, accessing nicotine replacement therapy, and promoting Quit Line usage, all of which are part of evidence-based treatment.

CONCLUSION

With more than 1,200 free clinics nationwide, it is very important to understand the opportunities and barriers of implementing tobacco cessation services and systems in free clinics.

Tobacco use by college students: a comparison of daily and nondaily smokers

OBJECTIVES

To explore demographics, contextual factors, and health risk behaviors associated with nondaily smoking by college students.

METHODS

In fall 2005, a random sample of 4100 students completed an online survey.

RESULTS

Of those surveyed, 29% reported current smoking; of that 29%, 70% were nondaily smokers. Compared to daily smokers, nondaily smokers were younger, African American (compared to white), had mothers with higher education, belonged to Greek organizations, and attended private (vs public) schools. Nondaily smokers were less likely to have used illicit drugs.

CONCLUSIONS

Nondaily and daily smokers differed on several demographic and contextual factors, but reported mostly similar health risk behaviors.

Health, masculinity and smokeless tobacco use among college-aged men

Existing work on smokeless tobacco (SLT) often focuses on correlates and predictors of use, ignoring the social and cultural context surrounding initiation and continued use of SLT products. The current study takes a qualitative approach using guided focus groups to examine this unexplored context. The findings show that male SLT users gain social rewards from dipping with other men, and usage is initiated and continued in spite of known potential health consequences. For the men participating in this study SLT use was primarily initiated at social or athletic events with the encouragement of other men and continued for relational maintenance and bonding. Additionally, the men reported that the social rewards received from using SLT far outweighed any potential health consequences or negative social repercussions they might also experience. Implications for future research and health interventions targeting SLT use are discussed.

In-depth investigation of interpersonal discussions in response to a safer sex mass media campaign

We know from theory and limited research that people talk about campaign messages-and that these conversations may play an important role in campaign reach and possibly even efficacy. We know very little, however, about what individuals talk about and with whom they talk. The current study seeks to fill this gap by reporting qualitative and descriptive quantitative data from interviews conducted with 139 young adults about conversations that took place in the context of a large, televised safer sex mass media campaign. Results indicated that public service announcements (PSAs) were often viewed in the company of friends and significant others, and that it was not uncommon for conversations about the PSAs to take place. Three broad categories of conversations that took place involved discussions about PSA realism, the seriousness of the message, and humor. While in some cases conversations seemed to advance the goal of the campaign (e.g., participants discussed sexually transmitted disease [STD] risk and condom use), in other cases they did not (e.g., participants discussed the lack of realism in a particular PSA). Implications for campaign theory, design, and implementation are discussed.

Rural print media portrayal of secondhand smoke and smoke-free policy

The purpose of this article is to describe how the print media portrays secondhand smoke and smoke-free policy in rural communities. Baseline print media clips from an ongoing 5-year study of smoke-free policy development in 40 rural communities were analyzed. The authors hypothesized that community population size would be positively associated with media favorability toward smoke-free policy. Conversely, pounds of tobacco produced and adult smoking prevalence would be negatively associated with media favorability. There was a positive correlation between population size and percentage of articles favorable toward smoke-free policy. The authors did not find a correlation between adult smoking or tobacco produced and media favorability toward smoke-free policy, but we did find a positive relationship between tobacco produced and percentage of pro-tobacco articles and a negative relationship between adult smoking prevalence and percentage of articles about health/comfort. Implications for targeting pro-health media in rural communities as well as policy-based initiatives for tobacco control are discussed.

A classroom-administered simulation of a television campaign on adolescent smoking: testing an activation model of information exposure

In recent years, research has shown that mass media can be used effectively either alone or in conjunction with interpersonal and institutional channels, such as schools. Much has yet been be learned about the application of newer, more effective strategies for media campaigns for adolescent smoking prevention interventions. This article describes a study applying an activation model of information exposure and a sensation-seeking targeting approach to the design of a smoking prevention campaign for adolescents. The participants were 1,272 middle school students aged 12-14 from across the Colorado Front Range who were stratified by their level of sensation seeking and then exposed to both high and low sensation value anti tobacco public service announcements (PSAs) at three time points. Hypothesized effects of the intervention on the primary dependent measures--attitudes (against smoking) and behavioral intentions not to smoke--were strongly supported for high sensation seekers. Further support is offered from the secondary indicators, self-efficacy, perceived message effectiveness, and perceived risk from smoking. No differences were demonstrated, however, in message effects between those selected by focus groups to be high in sensation value and those selected to be low in sensation value.

Authoritative parenting and sensation seeking as predictors of adolescent cigarette and marijuana use

Adolescents with high sensation-seeking tendencies often seek out thrill seeking experiences to satisfy their need for stimulation and sensation. In many cases, sensation-seeking adolescents fulfill their need for stimulation and sensation by using illicit substances. However, not all high sensation seekers use drugs, although the factors that prevent or buffer sensation seeking remain unexplored. This study fills this gap in extant research by examining the role of authoritative parenting as a protective factor that prevents or buffers cigarette and marijuana use by adolescents with high sensation-seeking tendencies. Data from 1461 adolescents attending 6th through 8th grades in central Colorado were gathered during a semester-long classroom-based intervention to prevent the onset or further use of cigarettes. Results indicate that authoritative parenting moderated the effect of sensation seeking on adolescent marijuana attitudes, intentions, and peer influence but not behaviors. Further, authoritative parenting was a stronger influence than sensation seeking on cigarette-related outcomes with just the opposite effect observed for marijuana-related outcomes.

Patient accounts for noncompliance with diabetes self-care regimens and physician compliance-gaining response

The purpose of this study was to identify diabetics' accounts for medical noncompliance, physicians' compliance-gaining strategies elicited in response to those accounts, and to examine the relationship between accounts and compliance-gaining strategies. Telephone surveys of diabetics from Kentucky and Tennessee assessed patient perceptions of physician-patient communication during their last diabetes treatment-related appointment. Eighty-four patients were able to provide categorical data for analysis. Patient account strategies for noncompliance were coded as concessions, excuses, justifications, and refusals. Physician compliance-gaining strategies were coded as positive-regard, negative-regard, or neutral-regard strategies. Results showed the most common patient account was concession (33%), then excuse (23%), justification (22%), and refusal (7%). The most common physician compliance-gaining strategy was neutral regard (54%), then positive regard (31%) and negative regard (15%). Results also indicated that patient account and physician compliance-gaining strategy were related. Specifically, concession accounts from patients elicited a subsequent neutral-regard compliance-gaining strategies from the physician in 76% of concession cases. Results also show that justifications were most likely to elicit neutral- (52%) or positive-regard (43%) strategies. Implications for physician practice and future research are discussed.