The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review

A phase I pilot study of a mobile education tool for supporting pregnant women with opioid use disorder

Background

Perinatal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) require targeted interventions to address gaps in maternal education and support. Maternal involvement in non-pharmacological NAS care is essential for improving neonatal outcomes, yet many mothers lack accessible resources to manage NAS symptoms and to navigate social and healthcare challenges. Mobile health applications offer a promising solution, but few cater specifically to the needs of perinatal women with OUD.

Objective

We assessed the usability, acceptability, and feasibility of a new mobile educational tool for pregnant women with OUD, focusing on the perinatal period and NAS care.

Results

Six perinatal women with OUD (n = 1 pregnant, n = 5 postpartum; mean age 31) found the tool highly acceptable (modified CSQ-8 mean=28.8 out of 32) and usable (modified SUS mean=45.0 out of 50). Most were likely to use the tool during pregnancy and postpartum, citing improved preparedness for advocating for themselves, managing NAS, and navigating CPS. Feedback suggested expanding content on infant withdrawal medications.

Conclusions

This mobile tool shows promise in empowering perinatal women with OUD. Further research is needed to evaluate its impact on clinical and neonatal outcomes.

Systemic barriers and stigma: Healthcare provider perspectives on perinatal and neonatal care in the fentanyl crisis

INTRODUCTION

The rise in fentanyl use during pregnancy has created new challenges in caring for women with opioid use disorders (OUD) and their infants with neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NAS/NOWS). Despite complexities in treating opioid-affected dyads, little research exists on healthcare workers' perspectives regarding fentanyl's impact on perinatal and neonatal care.

OBJECTIVES

Explore dynamic challenges fentanyl has brought to the care of perinatal women with OUD and their infants experiencing NAS/NOWS from healthcare providers' perspectives.

METHODS

Fifteen healthcare providers (neonatologists, OBGYNs, nurse practitioners, registered nurses, and pediatricians) from the Pacific Northwest completed an online qualitative survey with a mixture of Likert-type and open-ended questions. Reflexive thematic analysis was used to analyze open-ended responses.

RESULTS

Three themes emerged from provider data that reflect systemic failures in addressing the complex needs of perinatal women and their families and highlight challenges in implementation of evidence-based care: 1) Systemic Barriers to Perinatal and Infant Care, 2) Impact of Increasing Polysubstance Use on Neonates and Mothers, and 3) Stigma and Judgment from Healthcare Providers toward Perinatal Women with Substance Use Disorders.

CONCLUSIONS

Themes reflected how broad and interconnected systemic issues contribute to inadequate care and support for mothers and newborns in the context of rising fentanyl and polysubstance use. Themes echoed the root of the problems lies in systemic failures-issues within the healthcare system, societal attitudes, and policy frameworks that collectively fail to meet the complex and evolving needs of families affected by the ever-changing landscape of substance use.

Promoting substance use stigma resistance through an automated text message intervention (project RESTART): Outcomes of a pilot feasibility trial

BACKGROUND

Stigma in people who use drugs predicts treatment engagement, psychosocial health, and overdose, yet there are few evidence-based interventions to support people who use drugs in managing and coping with substance-related stigma and even fewer for people in active use. mHealth is one option to engage this hard-to-reach population.

METHODS

Premised on the theory of stigma resistance, this mixed-methods study explored the feasibility, acceptability, and preliminary effectiveness of Project RESTART, a four-week, automated text message intervention for rural-dwelling people who use drugs (n = 30) using a one-group pre-post design. The study recruited participants from syringe service programs and by word-of-mouth.

RESULTS

Key outcomes included high retention (90 %), message engagement (median responses: 4, interquartile range: 1-17), acceptability (mean item score: 3.55, standard deviation: 0.34, range: 1-4), and preliminary effectiveness in the main outcomes (Cohen's d: stigma resistance (0.56), self-stigma (0.50)). Results were corroborated in sub-sample follow-up interviews (n = 13).

CONCLUSION

These promising findings suggest text messaging is a feasible and acceptable modality for delivering stigma education and coping resources. Effectiveness should be established in a full-scale randomized controlled trial. This trial was registered at ClinicalTrials.gov on February 20, 2024 (NCT06281548).

Exploring barriers and potential solutions before implementing a scale-up strategy to expand methadone coverage among people who inject drugs in Tajikistan

INTRODUCTION

The Eastern European and Central Asian region has the most rapidly growing HIV epidemic worldwide, concentrated among people who inject drugs (PWID). Scaling up opioid agonist therapies (OAT) is a highly effective primary and secondary HIV prevention strategy, yet coverage remains low (2.7 %) among the 18,000 PWID injecting opioids in Tajikistan.

METHODS

As part of a pre-implementation activity before using the blended NIATx implementation strategy, we focused on the first NIATx principle, to understand and involve the customer by exploring the barriers and facilitators to OAT scale-up (i.e. greater methadone program entry and retention resulting in more people on methadone). From October to December 2023, recipients (i.e., PWID) were assessed across all 14 OAT sites in 12 cities in 28 focus groups, stratified by those on (N = 120) and not on (N = 108) methadone. Nominal group technique (NGT) was selected as a rapid, inclusive and mixed methods strategy to identify and prioritize the most important barriers and facilitators. Barriers and solutions were categorized to guide implementation targeting individual (i.e., patients/providers), organizational (i.e., clinic) and policy (e.g., laws/regulations) factors.

RESULTS

The three highest-ranking barriers nationally to scaling up methadone were similar for both groups: 1) organizational factors like logistical inconvenience and demands on patients (transport, schedule, daily dosing); 2) policy factors like requirements to be listed in the national OAT registry which can restrict access to a driver's license and employment; and 3) individual and societal factors like widespread disinformation about methadone. The three highest-ranking solutions included: 1) changing policies to allow take-home dosing (both groups); 2) expanding the number of sites where methadone could be dispensed (e.g., primary healthcare clinics and pharmacies); and 3) widely disseminating reliable information about methadone to PWID and other stakeholders like governmental organizations and police. For those not on methadone, site expansion was the second highest solution, while for those not on methadone, disseminating accurate information was second highest.

CONCLUSION

This pre-implementation study provides important insights into implementation strategies that might be considered to scale-up methadone that targets recipients (patients, providers, and family), organizations and policies.

Experiences of stigmatization among people who use drugs in the initial year of British Columbia's drug decriminalization policy: A qualitative study

BACKGROUND

On January 31, 2023, Health Canada approved a three-year pilot decriminalization initiative allowing adults in British Columbia (BC), Canada, to legally possess a cumulative 2.5 g of opioids, cocaine, methamphetamine, or MDMA. The policy aims to reduce the harms associated with drug use, including stigma, which contributes to barriers for people who use drugs in accessing harm reduction and treatment services. Addressing stigma is considered a crucial step in mitigating BC's overdose crisis, by encouraging people who use drugs to feel more comfortable to access and utilize services without fear of judgment. This study examined the impacts of the decriminalization policy on stigma among people who use drugs within the first year of implementation.

METHODS

From October 2023 to February 2024, 100 semi-structured telephone interviews and brief socio-demographic surveys with people who use drugs from across BC were conducted to explore their experiences of stigmatization post-decriminalization. A qualitative thematic analysis was used to synthesize the data.

RESULTS

Findings revealed that societal, structural and self-stigma remain pervasive among people who use drugs post-decriminalization. While most participants reported little change in their experiences of stigma since the policy's implementation, some reported an increase, while others observed a decrease across all forms of stigma. Increased stigma was attributed to perceived heightened visibility of public drug use, which amplified societal stigma. Conversely, decreased stigma was linked to shifting public perceptions of drug use as a public health issue and more humanized interactions with the police. Despite mixed experiences, participants remained optimistic that the policy could contribute to long-term stigma reduction and offered recommendations to support this goal.

CONCLUSION

While decriminalization has the potential to reduce stigma and increase comfort in accessing critical harm reduction and substance use treatment services among people who use drugs, achieving these outcomes requires additional efforts. Public awareness campaigns, targeted anti-stigma education, and broader systemic changes were suggested by participants as essential to address stigmatization in BC. Strengthening these areas could enhance access to and utilization of services, ultimately supporting the broader goals of decriminalization.

Labor and Delivery Nurses' Perceptions of Their Colleagues' Attitudes and Behaviors Toward Pregnant Patients with Substance Use

OBJECTIVE

To understand labor and delivery nurses' attitudes and behaviors toward pregnant patients with substance use disorders or mental health concerns. Suicide and overdose are among the leading causes of preventable maternal deaths nationwide, underscoring the urgency of addressing issues related to supporting pregnant patients with behavioral health concerns.

DESIGN

We surveyed a subpopulation of nurses in Colorado to understand attitudes and behaviors toward patients with substance use disorders and mental health concerns.

RESULTS

Survey respondents were 154 nurses from 14 Colorado hospitals that represented 45% of the state's 2022 births: Half of the nurses reported their colleagues have negative attitudes and nearly one-third reported negative behaviors toward patients who disclose substance use. Qualitative data revealed instances of positive behaviors, with examples of supportive clinical care and resource provision for patients disclosing substance use. Negative examples described mistrust, negative attitudes, and lack of compassion toward patients, as well as instances of substandard clinical care.

CONCLUSIONS

In this study, negative attitudes and behaviors were noted by some labor and delivery nurses by their colleagues toward pregnant patients with substance use disorders. Positive behaviors were also reported. Comprehensive processes to decrease negative behaviors are necessary to improve care for pregnant patients and to decrease maternal mortality from suicide and accidental overdose.

Experiences of healthcare discrimination and treatment outcomes among pregnant and postpartum people with opioid use disorder

INTRODUCTION

Experiences of discrimination among pregnant and postpartum people with opioid use disorder likely affect utilization of medications for opioid use disorder (MOUD), which reduce the risk of overdose and death. We evaluated experiences of discrimination in this population by healthcare setting and estimated their effects on MOUD treatment outcomes.

METHODS

Participants who had received MOUD at least once during pregnancy were enrolled into this retrospective cohort study. A modified Healthcare Discrimination Scale assessed discrimination within prenatal care (PNC) and substance use disorder treatment (SUD) settings. Patient-members from the Empower project co-designed survey items to measure treatment outcomes: MOUD misuse, discontinuation, return to use, and overdose. We examined the proportion of participants who endorsed each item on the Healthcare Discrimination Scale and summed the total scores by healthcare setting. Relative risk (RR) and 95 % confidence intervals (CI) were estimated using log-binomial models.

RESULTS

Among 100 participants, 57 reported experiencing discrimination, 56 within PNC and 33 within SUD clinics. Discrimination in the SUD setting was associated with an over two-fold increased risk of MOUD discontinuation (RR 2.56, CI 1.19-5.54) and return to use (RR 2.36, CI 1.18-4.73). Increased risk of misusing MOUD was associated with discrimination in both PNC (RR 2.6, 95 % CI 1.06-6.40) and SUD (RR 3.26, CI 1.59-6.70) settings.

CONCLUSIONS

Experiences of discrimination were common, especially in prenatal care settings, and were associated with postpartum MOUD misuse. Addressing discrimination within healthcare settings may improve treatment outcomes for pregnant and postpartum people with OUD.

Bereavement and support in the conduct of everyday life: Insights from dual experiences of loss and drug use

Aims: Individuals with a history of heavy drug use are especially vulnerable to losing loved ones to drug-related deaths, and drug use and complicated grief reactions are closely linked. However, limited knowledge exists on supporting them through bereavement. The present study, which was conducted in Norway, aims to provide a comprehensive understanding of how individuals dealing with heavy drug use and bereavement can be supported through professional support services. The bereaved person's reflections on help experiences are seen as grounded in their conduct of everyday life. Methods: We conducted qualitative interviews with individuals who have experienced bereavement in the context of heavy drug use. Using reflexive thematic analysis, we examined their stories and reflections on what was helpful and unhelpful, aiming to identify key themes, providing an understanding of how individuals dealing with heavy drug use and bereavement can be supported. Results: Five themes were identified. The first theme, 'Support Complexity', addresses the uncertainty about strengthening the help provided for processing losses. The other themes - "The Ripple Effect of Trust and Distrust", "Offering Supportive Communication", "Fostering Tailored Support" and "Promoting Support Through Companionship" - point to the key dimensions of the support that can help strengthen responses to drug-related bereavement. Conclusions: The study underlies how diverse expectations, norms and positions in the help provision setting influence the nature of support, as well as the access to, acceptance of and adaption to support initiatives. Furthermore, we discuss how the support context can provide multifaceted and contextualised bereavement support tailored to the various needs of the bereaved. The study also underscores the need for provider training focused on the intersections of bereavement and drug use.

Implementation of an Emergency Department Opioid Use Disorder Initiative: Clinical Processes and Institution Specific Education Improve Care

BACKGROUND

Emergency department (ED) visits associated with opioid use and fatal overdoses increase annually. Emergency clinician-initiated medication for opioid use disorder (MOUD) reduces mortality and improves treatment retention.

OBJECTIVE

We describe and evaluate a program to implement MOUD at an academic ED using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.

METHODS

This was a retrospective cohort study of patients presenting to the ED who were eligible for MOUD. A multipronged MOUD program consisting of electronic health record (EHR) order set, email communications, and resident education was delivered over 1 year. Clinical processes were measured before and after program implementation, including buprenorphine and naloxone utilization and outpatient referrals for treatment.

RESULTS

We identified 319 eligible encounters over the 2-year study period. Patients were predominantly non-Hispanic white men with a mean age of 40 ± 12.8 years. After program initiation, 109/189 patients (57.7%) were offered or initiated on buprenorphine, compared to 46/130 patients (35.4%) before (95% confidence interval). Protocol dosing was used in 92% of initiations. Outpatient treatment provider referrals increased from 46.1% (60/130) to 63% (119/189; 95% confidence interval). More patients in the postintervention group period requested buprenorphine during their visit compared to before the intervention (24.6% vs. 10%).

CONCLUSIONS

We observed improvements in the rate of buprenorphine prescription and outpatient treatment referrals at an academic ED following a quality improvement program implemented using the RE-AIM framework.

Strategies to Improve Access to Care for Patients With Opioid Use Disorder

Treatment of opioid use disorder (OUD) faces several challenges, including restricted access to medications, geographical and logistical barriers, and variability in treatment availability across different communities. This article outlines several strategies aimed at improving access to medications. Pharmacy-based care could potentially extend access to medications but would require regulatory changes to empower pharmacists. In addition, telemedicine has shown promise in improving access by mitigating geographic and transportation barriers. Mobile health clinics also offer a direct approach to delivering medication-based treatments to underserved communities. Furthermore, integrating OUD treatment into primary care settings could facilitate early detection and treatment. Policy changes have increased access to take-home medications and buprenorphine initiation at home. Community engagement would be crucial for tackling the social determinants of health to offer equitable care for patients. The implementation of these strategies has the potential to significantly enhance the accessibility and delivery of effective, timely and equitable treatment to patients with OUD.

Siyakhana: A hybrid type 2 effectiveness-implementation stepped-wedge trial to reduce stigma towards substance use and depression among community health workers in HIV/TB care in South Africa

INTRODUCTION

Substance use (SU) and other mental health conditions, such as depression, contribute to poor engagement in HIV and TB care in South Africa, a country with the highest global prevalence of HIV and a significant TB burden. Yet, community health workers (CHWs)-frontline lay health workers who play a central role in re-engaging patients in HIV/TB care-receive little-to-no training on supporting patients with SU or other mental health concerns. CHWs also display stigma towards patients with SU and depression, which may contribute to HIV/TB care disengagement. We developed and tested a CHW training ("Siyakhana") to reduce CHW stigma towards SU and depression in HIV/TB care.

METHODS

A cluster randomized, stepped-wedge hybrid type 2 effectiveness-implementation trial (N = 82 CHWs) evaluated Siyakhana across six clinics in a low-resource area of Cape Town, SA. The three-day Siyakhana training included psychoeducation, self-care strategies, non-judgmental communication, problem solving, and contact-based stigma reduction using lived experience narratives. Pre-training and three- and six-month post-training assessments were conducted. Primary effectiveness outcomes were CHW stigma towards SU and depression, assessed using the Social Distance Scale. Primary implementation outcomes were guided by Proctor's model, including fidelity, acceptability, appropriateness, and feasibility, assessed using structured coding of role plays and a validated quantitative measure for assessing implementation outcomes in low- and middle-income countries.

RESULTS

Participants were on average 46.8 years old (SD = 8.9), 99% female, and 100% Black African. Ninety-five percent of CHWs completed the Siyakhana training, with approximately 90% retention over six months. A linear mixed effects model showed a significant effect of the Siyakhana training on reducing SU stigma over six months after adjusting for time (β = -1.46, SE = 0.67, p < 0.05), but no effect on depression stigma (β = -0.20, SE = 0.57, p > 0.05). CHW fidelity was 89.4% (SD = 11.3%) at six-months. Quantitative implementation outcomes indicated high acceptability (M = 2.85, SD = 0.27), appropriateness (M = 2.77, SD = 0.31), and feasibility (M = 2.41, SD = 0.38).

CONCLUSIONS

Siyakhana was associated with reductions in CHW SU stigma in the context of HIV/TB care, with promising implementation outcomes. Findings will inform a larger randomized trial evaluating the effectiveness and implementation of Siyakhana and examine whether shifting CHW stigma improves patient-level health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05282173. Registered on 7 March 2022.

Importance of Fetal Alcohol Spectrum Disorders Prevention and Intervention

The consumption of alcohol and other substances during pregnancy can impair prenatal development. While scientifically informed public health measures have raised awareness of the risks of harmful prenatal substance exposures, the use of alcohol and other substances during pregnancy continues to rise. The successful dissemination of consistent messaging, health care professional education and training, and universal implementation of clinical interventions may help reduce drinking in pregnancy and prevent fetal alcohol spectrum disorders (FASDs), a constellation of developmental disabilities and birth defects caused by alcohol use during pregnancy. Alcohol screening and brief intervention (alcohol SBI) is an evidence-based preventive practice that enables early identification of excessive drinking and intervention prior to serious consequences. Routine clinical implementation of alcohol SBI has been shown to effectively reduce excessive alcohol consumption among adults, including pregnant people. Many barriers prevent widespread implementation of the practice: a lack of health care professional knowledge of the prevalence and implications of prenatal alcohol exposure, stigma surrounding individuals who use substances potentially harmful to their pregnancy, resistance to public health messages encouraging alcohol avoidance during pregnancy, and discomfort and hesitancy with alcohol SBI procedures among practitioners. The Centers for Disease Control and Prevention (CDC) leads the public health effort to prevent alcohol use during pregnancy and improve identification of and care for children living with FASDs. CDC partners with health systems, health care professional associations, universities, and community-based networks to promote alcohol SBI as an effective but underused preventive health service. This special section consisting of 6 articles including this introductory commentary represents the efforts of 11 CDC projects and their partners to demonstrate the rationale for FASD prevention and intervention, engage health care disciplines to expand prevention messaging and education for providers, develop practical approaches for implementing alcohol SBI in diverse clinical settings, and prevent alcohol use in pregnancy and FASDs.

Stigma and Behavior Change Techniques in Substance Use Recovery: Qualitative Study of Social Media Narratives

BACKGROUND

Existing literature shows that persons with substance use disorder (SUD) experience different stages of readiness to reduce or abstain from substance use, and tailoring intervention change strategies to these stages may facilitate recovery. Moreover, stigma may serve as a barrier to recovery by preventing persons with SUDs from seeking treatment. In recent years, the behavior change technique (BCT) taxonomy has increasingly become useful for identifying potential efficacious intervention components; however, prior literature has not addressed the extent to which these techniques may naturally be used to recover from substance use, and knowledge of this may be useful in the design of future interventions.

OBJECTIVE

We take a three-step approach to identifying strategies to facilitate substance use recovery: (1) characterizing the extent to which stages of change are expressed in social media data, (2) identifying BCTs used by persons at different stages of change, and (3) exploring the role that stigma plays in recovery journeys.

METHODS

We collected discussion posts from Reddit, a popular social networking site, and identified subreddits or discussion forums about 3 substances (alcohol, cannabis, and opioids). We then performed qualitative data analysis using a hybrid inductive-deductive method to identify the stages of change in social media authors' recovery journeys, the techniques that social media content authors used as they sought to quit substance use, and the role that stigma played in social media authors' recovery journeys.

RESULTS

We examined 748 posts pertaining to 3 substances: alcohol (n=316, 42.2%), cannabis (n=335, 44.8%), and opioids (n=135, 18%). Social media content representing the different stages of change was observed, with the majority (472/748, 63.1%) of narratives representing the action stage. In total, 11 categories of BCTs were identified. There were similarities in BCT use across precontemplation, contemplation, and preparation stages, with social support seeking and awareness of natural consequences being the most common. As people sought to quit or reduce their use of substances (action stage), we observed a variety of BCTs, such as the repetition and substitution of healthful behaviors and monitoring and receiving feedback on their own behavior. In the maintenance stage, reports of diverse BCTs continue to be frequent, but offers of social support also become more common than in previous stages. Stigma was present throughout all stages. We present 5 major themes pertaining to the manifestation of stigma.

CONCLUSIONS

Patterns of BCT use and stigmatizing experiences are frequently discussed in social media, which can be leveraged to better understand the natural course of recovery from SUD and how interventions might facilitate recovery from substance use. It may be important to incorporate stigma reduction across all stages of the recovery journey.

A stakeholder-driven approach to designing a peer recovery coach role for implementation in community-oriented primary care teams in South Africa

INTRODUCTION

In South Africa, community-oriented primary care teams work to re-engage out-of-care people with HIV (PWH) in treatment, many of whom have substance use (SU) concerns. SU stigma is high among these teams, limiting care engagement efforts. Integrating peer recovery coaches into community-oriented primary care teams could shift SU stigma and improve patients' engagement in care. The peer role does not exist in SA and represents a workforce innovation. To enhance acceptability, feasibility, and appropriateness for the local context, we engaged multiple stakeholder groups to co-design a peer role for community-oriented primary care team integration.

METHODS

We used a five-step human-centered design process: (i) semi-structured interviews with healthcare worker (n = 25) and patient (n = 15) stakeholders to identify priorities for the role; (ii) development of an initial role overview; (iii) six ideation workshops with healthcare worker (n = 12) and patient (n = 12) stakeholders to adapt this overview; (iv) refinement of the role prototype via four co-design workshops with healthcare worker (n = 7) and patient (n = 9) stakeholders; and (v) consultation with HIV and SU service leaders to assess the acceptability and feasibility of integrating this prototype into community-oriented primary care teams.

RESULTS

Although all stakeholders viewed the peer role as acceptable, patients and healthcare worker identified different priorities. Patients prioritized the care experience through sharing of lived experience and confidential SU support. Healthcare worker prioritized clarification of the peer role, working conditions, and processes to limit any impact on the community-oriented primary care team. A personal history of SU, minimum 1 year in SU recovery, and strong community knowledge were considered role prerequisites by all stakeholders. Through the iterative process, stakeholders clarified their preferences for peer session structure, location, and content and expanded proposed components of peer training to include therapeutic and professional work practice competencies. Service leaders endorsed the prototype after the addition of peer integration training for community-oriented primary care teams and peer mentoring to address community and team dynamics.

CONCLUSION

Stakeholder engagement in an iterative design process has been integral to co-designing a peer role that multiple stakeholder groups consider acceptable and that community-oriented primary care teams are willing to implement. This offers a methodological framework for other teams designing SU workforce innovations.

Care for patients with cancer and substance use disorders: a qualitative study of oncology team experiences

PURPOSE

Clinical decisions surrounding cancer care can be complicated by co-occurring substance use disorders (SUDs), particularly with respect to pain management and cancer treatment safety. Yet, few studies have examined oncology teams' experiences treating patients with co-occurring cancer and SUDs. We therefore sought to understand the perspectives of oncology team providers regarding the challenges they face when caring for patients with cancer and SUDs.

METHODS

We conducted a qualitative study to understand the experiences of clinicians who have provided cancer care to patients with concurrent SUD. Questions about substances used focused mainly on non-prescribed opioids and stimulants. Individual interviews were conducted in March-July 2023 by telephone or videoconference, recorded, transcribed verbatim, and analyzed rigorously using thematic analysis.

RESULTS

Twenty-seven individuals were interviewed (15 physicians, 8 advanced practice providers, 2 registered nurses, and 2 social workers). Specialties included medical oncology, hematology, radiation oncology, and gynecology oncology. We identified four themes representing the challenges oncology teams face when caring for patients with cancer and SUD: (1) patients' unmet social needs; (2) uncertainty about pain management options; (3) implicit biases about patients with SUDs; and( 4) patients' active substance use.

CONCLUSION

Oncology teams face many challenges when caring for patients with cancer and SUDs. Understanding these challenges is critical and can both inform the design of interventions for patients with cancer and SUD and guide future research.

Decrease in provider stigma is associated with improved quality health indicators among individuals receiving methadone in primary care centers in Ukraine

INTRODUCTION

People who inject drugs experience poor health and social outcomes which improve with opioid agonist therapies like methadone, yet provider stigma may influence healthcare utilization. In Ukraine, integrating methadone into primary care centers (PCCs) provides an opportunity to examine provider stigma and its impact on patient outcomes.

METHODS

This sub-analysis included patients randomized to receive methadone in PCCs as part of an implementation trial in which the control group received methadone in specialty addiction clinics in Ukraine. Methadone integration in PCCs was supported through continuous tele-education for providers. Provider stigma towards people who inject drugs, methadone, and attitudes towards evidence-based practices were assessed at baseline, 12, and 24 months using standardized scales (range 1-10). Patient-level outcomes were measured bi-annually over 24 months using a quality health indicator (QHI) score, a percentage of guideline-concordant primary and specialty health services accessed. Linear mixed-effects models examined the changes in provider stigma and attitudes, and the association of these measures with patient outcomes.

RESULTS

The sample included 583 patients and the 112 providers in 24 clinics. Provider fear and stereotypes toward people who inject drugs improved significantly, by 0.6 (95 % CI 0.2-1.1) and 0.4 points (95 % CI 0.1-0.8), respectively, as did preference for methadone over abstinence-based treatment (0.7 points, 95 % CI 0.2-1.1). A 1-point improvement in provider prejudice correlated with a 7.0-point increase (95 % CI: 1.1-13.0) in patient primary care QHI scores at 12 months, while improved attitudes towards evidence-based practices were associated with an 8.3-point increase (95 % CI: 1.1-13.0). Preference for methadone maintenance over abstinence was associated with a 3.7-point increase (95 % CI: 0.6-6.7) in specialty care QHI scores at 12 months, and reduced stereotypes were associated with a 10.9-point increase (95 % CI: 1.2-20.7) at 24 months.

CONCLUSIONS

Integrating methadone into PCCs with the support of provider tele-education may reduce provider stigma, particularly fear and stereotypes, toward people who inject drugs and methadone maintenance. Reducing provider stigma has the potential to improve patient outcomes through increased access to preventive care and screenings.

'Zombie drugs': Dehumanising news frames and public stigma towards people who use drugs

BACKGROUND

News media is an important determinant of public understanding of drug policy topics. Recent media reporting around the use of synthetic drugs such as xylazine makes frequent use of non-human metaphors, including reference to the effects of 'zombie drugs'. We investigated whether presentation of news stories which included such dehumanising frames were associated with i) increased stigmatising attitudes towards people who use drugs; and ii) lower support for relevant harm reduction programmes.

METHODS

We undertook a cross-sectional online experimental study with a randomised factorial design, using a nationally representative sample (UK). Participants (N = 1417) were randomly presented with one of six simulated news stories based on recent reports of the identification of xylazine in the drug market. Stories differed with respect to text (neutral or referred to either a 'zombie drug', or a drug that 'turns people into zombies'); and accompanying imagery (neutral or depicting immobile people under the influence of drugs). Stigmatising attitudes and support for harm reduction were assessed using instruments including an adapted version of the Attribution Questionnaire-Substance Use Disorders (AQ-SUD) and analysed using MANOVA.

RESULTS

Data were obtained for 1235 participants (52 % female; mean age 47 ± 16). Attitudes towards people who use drugs were more stigmatising amongst participants presented with either of the dehumanising text conditions (both p < 0.001). There was no main effect of imagery and no interaction between text and imagery on stigma scores. Support for harm reduction programmes did not differ between conditions.

CONCLUSION

Our study is the first to show that dehumanising 'zombie' framing frequently used in news reporting is associated with higher public stigma towards people who use drugs. News media is an important source of public education on drugs, so to avoid reinforcing stigma the use of dehumanising language and framing, such as 'zombie' metaphors, should be avoided. Organisations working to reduce stigma towards people who use drugs should encourage news outputs and journalists to avoid this type of representation.

What happens after the funding ends?: A qualitative sustainability investigation of emergency department-based peer support programs implemented as part of Indiana's opioid state targeted response initiative

INTRODUCTION

In 2017, funding disseminated through the US Substance Abuse and Mental Health Services Administration's Opioid State Targeted Response (STR) program accelerated the expansion of peer recovery support services across several states to engage emergency department patients presenting with opioid use disorder. While there is some literature on the initial implementation of these programs, little is known about their sustainability after the STR funding's end. Identifying what happened to these programs is a key component of understanding their ultimate impact and can inform future activities to develop, fund, or sustain similar efforts.

METHODS

We collected qualitative data from six organizations that participated in Indiana's STR-funded Recovery Coaching and Peer Support Initiative (RCPSI). The semi-structured interview guide was designed to gather data related to eight domains of sustainability (i.e., environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, program evaluation, communications, and strategic planning). The analysts followed a deductive-inductive analysis approach, using the eight domains as an a priori coding structure and developing higher-level inductive themes.

RESULTS

A total of ten individuals (roles included 4 Program Supervisors, 2 Nurse Administrators, a Psychiatric Social Worker, a Mobile Treatment Manager, a Grant Coordinator, and a Vice President of Planning) participated in six interviews. Two programs did not sustain services, primarily because they lacked a sufficient volume of eligible patients to justify services. Factors identified as supporting sustainability in the other four programs included (1) identification of alternate funding sources, (2) evolving internal support for ED-based opioid use disorder treatment, and (3) investment in internal and external relationships. Furthermore, these themes operated across multiple sustainability domains.

CONCLUSIONS

The findings illustrate a dynamic interplay between program context and multiple theorized sustainability domains that impacted the viability of RCPSI programs after the end of STR funding. Results indicate a need for a better understanding of the factors influencing the sustainability of programs supported by federal funding to mitigate the opioid crisis, and such findings will likely apply to a broader range of grant-supported programs.

Physician Interactions Associated With Increased Reception of Substance Use Disorder Treatment

Objectives According to the 2020 National Survey on Drug Use and Health (NSDUH), only 10% of the estimated 40 million individuals with substance use disorder (SUD) sought treatment. In this analysis, we aimed to examine the factors and characteristics of individuals who had received SUD treatment to gain a better understanding of why some patients attend treatment while the majority do not. Methods We performed a retrospective analysis of publicly available data from the 2020 NSDUH, accessed through the Substance Abuse and Mental Health Service Administration (SAMHSA) using IBM SPSS Statistics for Windows, Version 27.0 (Released 2020; IBM Corp., Armonk, New York, United States). We limited our analysis to individuals who self-reported having an alcohol or illicit drug use disorder in the preceding year. We examined the relationship between physician interactions and reception of SUD treatment at any facility in the preceding year (2019-2020) or in their lifetime using the chi-squared analysis and odds ratios (OR) with a 95% confidence interval (CI) and 0.05 alpha level. Results Traditional physician inquiries regarding the amount and frequency of substance use were not significantly associated with treatment receipt (p>0.05). However, more personalized interactions were significantly associated with treatment receipt (p<0.05). For example, individuals who reported an interaction where a physician asked if they had any drinking problems had a 2.52-fold increase in the odds of treatment receipt in 2020 (OR: 2.52; 95% CI: 3.7-1.7; p<0.001), and individuals who reported an interaction where a doctor advised them to cut down on drinking were 3.86 times more likely to receive treatment in 2020 (OR: 3.86; 95% CI: 5.85-2.55; p<0.001). Moreover, individuals who reported an interaction with a doctor where they were offered information on alcohol treatment had a fourfold increase in treatment receipt in 2020 (OR: 4.84; 95% CI: 7.54-3.1; p<0.001) and a threefold increase over a lifetime (OR: 3.20; 95% CI: 4.62-2.22; p<0.001); however, only 9.6% of individuals reported such an interaction. Conclusions Personalized and informative discussions offering information on SUD treatment options and cessation strategies were associated with higher rates of treatment reception compared to traditional inquiries about the amount and frequency of substance use.

Older adults who use drugs: an examination of policy and preparedness in nursing facilities

Currently, over 5.7 million adults 65+ are projected to have a SUD, and the number of fatal overdose deaths among older adults is rising in both community and facility settings. This exploratory study involved surveys of 37 nursing facilities (NF) in Kentucky in order to identify current admission practices to screen, prevent, and/or address resident substance use. Respondents indicated that they were ill-equipped to address such problems and fail to offer specialized programs for residents or training for staff. Training and best practices for residents, their families, and staff should be established to address residents with substance use and SUD.

enCompass: evaluation of a community-based substance use disorder stigma intervention

INTRODUCTION

Stigma within communities is pervasive and a barrier to substance use disorder (SUD) treatment. The current proof-of-concept study evaluated enCompass, a community-based SUD knowledge and stigma intervention.

METHODS

In 2021, 22 enCompass trainings were offered to community members in partnership with the Ohio Governor's RecoveryOhio initiative to 22 Ohio counties with high numbers of overdose deaths. Participants of the current study included 492 individuals who completed surveys measuring knowledge of SUD treatment and medication, and SUD stigma (i.e., stereotypes, prejudice, discrimination), before and after the intervention. Implementation-related outcomes (i.e., acceptability, appropriateness, feasibility) were also measured after the intervention.

RESULTS

Participants' knowledge increased, and their SUD stigma decreased, from before to after the intervention. Participants strongly agreed that the intervention was acceptable, appropriate, and feasible.

DISCUSSION

Although more testing with longitudinal, randomized designs is needed, preliminary results suggest that enCompass is a promising community-based SUD knowledge and stigma intervention.

Perceptions of substance use disorder in rural areas: how the brain disease model impacts public stigma

BACKGROUND

Rural communities are disproportionately affected by substance use disorder (SUD) and public stigma impedes access to and utilization of treatment and support services.

METHODS

This study compares data from a 2020 study conducted in rural Ohio (N = 173) with results from a recent study conducted in South Dakota (N = 41) on publicly-held stigmatizing views of SUD. South Dakota participants were recruited at several public events across the state via convenience sampling between August 2022-February 2023 to complete a survey. Data from responses to 19 stigma-related questions were merged with the associated data from the 2020 Ohio study and a comparative analysis was performed using Fisher's exact and Chi square tests.

RESULTS

The data shows that respondents in South Dakota, when compared to respondents in Ohio, are more likely to believe addiction is an illness (SD = 86.5%, OH = 48.5%, p < 0.001). The belief in SUD as an illness aligns with reduced stigmatizing beliefs, as indicated by respondents in SD showing lower stigmatizing ideologies and higher support for naloxone and harm reduction services, when compared to Ohio respondents. In both studies, the belief that SUD is an illness was associated with a reduction in other stigmatizing beliefs.

CONCLUSIONS

These results can be used to inform more focused anti-stigma efforts. As more people adopt fewer stigmatizing views on SUD in rural areas, more people with SUD may be supported to seek treatment and recovery services.

Unveiling the landscape of antistigma interventions for individuals with substance use disorders: A scoping review

Background

Stigma against persons living with substance use disorders (PLSUD) fosters social and health inequities.

Aim

We aimed to map different populations targeted by antistigma interventions, analyze specific characteristics of these interventions, and identify and categorize the theoretical frameworks used in these interventions.

Methods

We examined randomized controlled trials and quasi or pre-experimental studies targeting stigma against PLSUD. Using two English databases, our analysis involved mapping study populations, antistigma interventions, and trial characteristics through a narrative synthesis. We adhered to the Workgroup for Intervention Development and Evaluation Research (WIDER) checklist for assessing reporting quality. The Theoretical Domain Framework (TDF) identified intervention domains and constructs of the interventions.

Results

Of 698 studies, 29 met eligibility, with three from low-middle-income countries: 12 studies addressed the public, 11 self, and 5 structural stigmas. Reduction in stigma or improvements in knowledge of and attitude toward PLSUD was observed in 23 studies. Eight used social contact-based interventions, and one used direct social contact. Other interventions were psychoeducation, collaborative community care and linkage to social services, acceptance and commitment therapy, and gatekeepers' training. Five focused on injection drug use stigma; others were not substance-specific. Most studies reported the characteristics of the recipients (n = 28), mode of delivery (n = 28), and delivery settings (n = 24). Adherence to delivery protocol was the least reported (n = 5). The number of theoretical domains varied: 18 studies had 1-5 domains, 3 studies had 10, and 8 studies had 6-9 domains.

Conclusion

Social contact-based interventions show promise for PLSUD; future research must improve the quality of reporting and design theory-informed interventions.

Knowledge of medications for opioid use disorder and associated stigma among primary care professionals

BACKGROUND

Medications for opioid use disorder (MOUD) are the gold standard. However, significant barriers limit their use in the primary care setting, including limited knowledge of the medications and stigmatizing attitudes. In this study, we assess knowledge levels among primary care-aligned professionals (PCPs) currently in practice, and whether knowledge of MOUD is associated with stigma and treatment attitudes.

PARTICIPANTS AND METHODS

Using rosters from the state of Ohio licensing boards, we surveyed 403 physicians, nurse practitioners, and physician associates in 2022, on the mechanism of different MOUD, as well as stigma and treatment attitudes. To assess MOUD knowledge, we employed descriptive and bivariate statistics. We fit four linear regression models, which controlled for empathy towards patients with OUD and provider demographics to assess the relationship between MOUD knowledge and four endpoints: stigma, perceived controllability of opioid use, perceived vulnerability to opioid use disorder, and support for abstinence-only treatment.

RESULTS

43% of participants correctly identified the mechanism of all 3 medications whereas 13% of participants did not identify the mechanism of any MOUD correctly. MOUD knowledge was higher among physicians as compared to nurse practitioners and physician associates. Lower MOUD knowledge was associated with more negative attitudes towards patients with OUD and MOUD treatment.

CONCLUSION

Expanding access to MOUD treatment requires a trained and willing health-care professional (HCP) workforce. Our findings highlight considerable variation in clinician knowledge of MOUD and suggest that knowledge levels are also related to negative attitudes towards patients with OUD and MOUD. Training interventions that increase knowledge, as well as focus on stigma reduction, are critical for reducing the longstanding treatment gap for opioid use disorder.

"Bupe by the Book": A study protocol for a pilot randomized controlled trial of library-facilitated telehealth to increase buprenorphine treatment among unstably housed individuals

Background

Accessing opioid use disorder (OUD) treatment is difficult for individuals in unstable housing. This population often uses public libraries for computer and internet access, which could provide telehealth access to OUD treatment. Therefore, we developed a novel 12-week library-facilitated telehealth intervention study called "Bupe by the Book" (BBB), which uses library resources to facilitate the initiation and retention of OUD treatment with buprenorphine.

Methods

This study involved a partnership between the San Diego Public Library and a federally qualified healthcare center attached to a homeless shelter (Father Joe's Villages (FJV) Village Health Center). We codesigned a pilot randomized controlled trial to evaluate a library-facilitated telehealth intervention in San Diego, California. We evaluated the intervention for its feasibility and acceptability and to obtain an estimate of the effect of the intervention on buprenorphine treatment outcomes. Individuals reporting homelessness and OUD (with or without other substance use) were eligible. Forty library patrons were recruited via flyers, screened for eligibility, and referred to the FJV Health Center for initial buprenorphine treatment intake visits. Participants who completed intake were enrolled and randomized to the library-facilitated telehealth condition, which involved the use of library internet and computer resources for follow-up visits to the clinic for buprenorphine treatment. The participants completed treatment follow-up in person or by phone in the control condition. Planned analyses (not powered to assess efficacy) will provide effect size estimates of the library-facilitated telehealth intervention on 1) buprenorphine use (measured in weekly urine drug screenings), 2) use of illicitly manufactured fentanyl (IMF) and other opioids (measured in weekly urine drug screens), 3) number of buprenorphine prescription pick-ups, 4) number and frequency of clinic visits, and 5) self-reported substance use, mental health, and quality of life measures at 1, 2, 4, 8, and 12 weeks.

Discussion

The findings from this pilot study may support the adoption of library-facilitated telehealth treatment as a feasible and acceptable strategy to engage and retain unstably housed people with OUD in buprenorphine treatment. The lessons from this pilot study include the importance of community-academic partnerships in sustainably adapting interventions in community-based settings.

Trial registration

This trial was registered prospectively at ClinicalTrials.gov (registration number NCT05872386) on May 24, 2023.

Breaking barriers: a qualitative exploration of healthcare access for crack cocaine users in Limerick

BACKGROUND OF STUDY

Crack cocaine use in Ireland began to emerge as a significant problem in the early 2000s, with prevalence increasing from 2016 onwards. Services such as harm reduction, treatment/rehabilitation, primary healthcare and social services are available to crack cocaine users in Ireland. However, research addressing specific barriers to accessing these services remains limited. Internationally, while research on healthcare access barriers for crack cocaine users exists, it predominantly focuses on user perspectives. This paper uses a dual-perspective approach to investigate access challenges from both service user and service provider viewpoints, promoting a more patient-centred, holistic approach to service provision.

METHODOLOGY

The study is qualitative and used semi-structured interviews and a focus group to obtain study data. Levesque's conceptual framework for healthcare access underpins this study. Data were analysed using thematic analysis.

RESULTS

The study highlighted barriers to healthcare access such as the inadequacy of services to support those with dual diagnosis. However, an advancement has been made through the establishment of specialised dual diagnosis teams and community dual diagnosis services in Ireland. Stigma from health care providers further hindered people from seeking help, highlighting the significance of ongoing efforts in Ireland to address stigma. Systemic factors such as distrust in services, stringent requirements and insufficient knowledge of user needs hamper timely access to care, underlining the need for more adaptive responses.

CONCLUSION

The study underlines the need for a tailored approach to enhancing access to health care for crack cocaine users in Ireland. Facilitating collaboration among health care providers, fostering partnerships with educational institutions/communities, and implementing policy changes are essential in creating a supportive environment that promotes help-seeking in Ireland.

Examining the Relationship between Culture and Perceived Societal Substance Use Stigma in a Michigan-Based Mental Health & Addiction Focused Community

Introduction: Substance use disorder (SUD) stigma undermines the implementation of effective harm reduction and treatment strategies in the U.S. and can impede individuals from seeking treatment. One research question guided this study: How do personal beliefs regarding SUD, familiarity with SUDs, and culture (religion, political ideology, and urbanicity), shape perceived societal SUD stigma? Methods: An online survey was sent to affiliates of a Michigan-based organization, Families Against Narcotics and administrators of Michigan Prepaid Inpatient Health Plan regional entities (N = 1,559). Results: On average respondents viewed society as moderately stigmatizing. The beliefs that drug users can stop whenever they want and that drug users have weak character were significantly associated with greater perceived levels of societal SUD stigma. The effects of religion on perceived stigma may be affected by beliefs of the immorality of drug use, while the effects of political ideology on perceived stigma may differ based on beliefs of the controllability of drug use. The effect of urbanicity may rely on perceived accessibility of treatment. Conclusion: Our findings reflect the intersection of personal beliefs and cultural contexts as they shape perceived societal SUD stigmatization.

Feasibility of a cinematic-virtual reality training program about opioid use disorder for osteopathic medical students: a single-arm pre-post study

CONTEXT

Opioid use disorder (OUD) has a considerable morbidity and mortality in the United States. Healthcare providers are key points of contact for those with OUD; however, some providers may hold stigma toward OUD. Stigma toward OUD can lead to lower quality of care and more negative health outcomes. Thus, new trainings designed to reduce stigma toward OUD while increasing empathy are critical. We created a web-based cinematic virtual reality (cine-VR) training program on OUD for osteopathic medical students.

OBJECTIVES

The aim of this pilot study was to assess changes in stigma toward OUD and empathy before and after the online cine-VR training program on OUD.

METHODS

We employed a single-arm, pre- and posttest pilot study to assess changes in stigma toward OUD and empathy. Osteopathic medical students from one large medical school in the Midwest with three campuses were invited to participate in the online cine-VR training. Participants completed two surveys before and after the cine-VR training. We performed paired t tests to examine changes in stigma toward OUD and empathy scores before and after the cine-VR OUD training program.

RESULTS

A total of 48 participants completed the training. We observed a decrease in stigma toward OUD posttraining (t=4.402, p<0.001); this change had a Cohen's d of 0.64, indicating a medium effect. We also observed an increase in participants' empathy scores posttraining (t=-2.376, p=0.023), with a Cohen's d of 0.40 signifying a small effect.

CONCLUSIONS

Findings from this pilot study suggest that the online cine-VR training may reduce stigma toward OUD while increasing empathy. Future research employing a randomized controlled trial design with a larger, more diverse sample and a proper attention control condition is needed to confirm the effectiveness of the online cine-VR training. If confirmed, this cine-VR training may be an accessible approach to educating osteopathic medical students about OUD.

Access and care for people with opioid use disorder in U.S. skilled nursing facilities: A policy commentary

Referrals for people with opioid use disorder (OUD) to skilled nursing facilities (SNFs) are increasing in the United States (U.S.). Further, legal guidance from the U.S. Department of Justice states that people with OUD cannot be discriminated against by health care institutions because of OUD or treatment with medications for OUD (MOUD). As such, SNFs are an important touchpoint for initiating or continuing MOUD, particularly amid rising drug-related overdose deaths among older adults and because people with OUD experience frailty and other geriatric syndromes at younger chronological ages. Informed by research, clinical expertise, and lived experience, this commentary describes policy and practice opportunities to help address challenges faced by people with OUD in gaining access to care and MOUD in SNFs. We propose opportunities to intervene against barriers that impede SNF placement and access to MOUD for people with OUD, including further revisions to 42 CFR Part 8 regulations to extend waivers for certification as opioid treatment programs (OTPs) to SNFs, allowing them to administer and dispense methadone in the same way as hospitals. If passed, proposed federal changes under the Modernizing Opioid Treatment Act would eliminate the requirement for methadone to be dispensed through OTPs, offering another opportunity to improve access to methadone for SNF residents. Also, we propose national and state-level investment in mobile substance use disorder services and partnerships with OTPs and hospital-based addiction consult services. We also recognize the need for more compassionate attitudes toward people with OUD in healthcare settings and discuss opportunities to address stigma. Although people with OUD are referred to SNFs for skilled care needs and not specifically for OUD care, it is essential for SNFs to be prepared to continue MOUD. It is both legally mandated and imperative that people with OUD have access to high quality and equitable SNF care.

Design and implementation of a Type-2 hybrid, prospective randomized trial of opioid agonist therapies integration into primary care clinics in Ukraine

INTRODUCTION

Ukraine has high HIV prevalence, concentrated among people who inject drugs (PWID), mostly of opioids. Maintenance on opioid agonist therapies (OAT) is the most effective evidence-based treatment for opioid use disorder. As PWID experience high morbidity and mortality from preventable and treatable non-communicable diseases, international agencies recommend integrating OAT into primary care centers (PCC).

METHODS

A randomized, type-2 hybrid implementation trial was carried out to compare outcomes of OAT integration in PCC to OAT delivery at specialty treatment centers (STC) - standard-of-care. Tele-education supporting PCC providers in managing OAT, HIV, tuberculosis and non-communicable diseases along with pay-for-performance incentives were used to facilitate implementation. Consenting patients underwent 1:2 randomization to either STC or PCC. Quality health indicators (QHIs), a composite percentage of recommended primary and specialty services accessed by patients (blood/urine tests, cancer screenings, etc.), were defined as efficacy outcomes and were assessed by participant self-report at baseline and every 6 months over 24 months and electronic chart reviews after the completion of the follow-up. The primary outcome is defined as the difference in composite QHI scores at 24 months, in which a repeated measures likelihood-based mixed model with missing at random assumptions will be used. Providers at PCC completed surveys at baseline, 12 and 24 months to assess implementation outcomes including changes in stigma and attitudes towards OAT and PWID.

PRELIMINARY RESULTS

Among the 1459 participants allocated to STC (N = 509) or PCC (N = 950), there were no differences in clinical and demographic characteristics. Self-reported prevalences were available for HIV (42 %), HCV (57 %), and prior tuberculosis (17 %). Study retention at 6, 12, 18, and 24 months was as 91 %, 85 %, 80 %, and 74 %, respectively.

CONCLUSION

PWID have a high prevalence of medical comorbidities and integrating OAT into primary care settings has the potential to improve the health of PWID. Findings from this study can help guide implementation of integrated care in Ukraine and throughout similar low-resource, high-burden countries in the Eastern European and Central Asian region.

The mindful resiliency in recovery model: empowering the transcendence of stigma

Introduction

Mindfulness-based interventions show unique promise in treating substance use disorders among marginalized populations who face heightened stigma. The Mindful Resiliency in Recovery Model is introduced as a novel theoretical framework articulating how mindfulness training can mitigate the adverse effects of stigma, enhance psychological resilience, and facilitate sustained recovery from addiction.

Methods

The current manuscript synthesizes various models of mindfulness processes, stigma, and substance use disorder recovery to propose an integrated theoretical framework on the promise of mindfulness-based interventions in supporting recovery. Further, the current manuscript draws upon empirical literature to establish preliminary support for the premises and hypotheses of the Mindful Resiliency in Recovery Model concerning the mechanisms influencing the efficacy of mindfulness-based interventions among marginalized individuals.

Results

Preliminary evidence supports the premises of the proposed model. There is evidence to suggest that specific processes like increased present-moment awareness, acceptance, decentering, reappraisal, and savoring may be especially salient in mitigating internalized stigma and fostering resiliency in recovery. There is a need for additional research on these processes, and contextual factors that may moderate their efficacy.

Discussion

The Mindful Resiliency in Recovery Model has significant implications for optimizing mindfulness-based interventions to empower marginalized individuals to transcend stigma and actualize their capacity for wellbeing in substance use disorder recovery. It provides a roadmap for future research on the mechanisms and contextual factors affecting the efficacy of mindfulness-based interventions for marginalized and stigmatized communities. It further offers guidance to clinicians utilizing mindfulness-based interventions to support individuals experiencing stigma.

"We're Not Gonna Aid You in Shooting Up": Stigma's Relationship to Harm Reduction in People Who Inject Drugs

BACKGROUND

Harm reduction, when applied to drug use, prioritizes improving patient-centered health outcomes and reducing drug-related harm. In order for harm reduction strategies to be adopted by people who inject drugs (PWID), they need to be promoted, accessible, and accepted in that population and the community-at-large. While PWID face stigma at multiple levels, less is known about how stigma influences uptake and acceptance of harm reduction services and strategies among PWID.

OBJECTIVE

We aim to characterize the stigmatizing experiences PWID have had related to harm reduction and the role of stigma in influencing their acceptance and adoption of harm reduction services and strategies.

DESIGN

A qualitative study using in-person, semi-structured interviews.

PARTICIPANTS

We recruited hospitalized participants, age 18 and over, with a history of injection drug use.

APPROACH

We developed an interview guide asking about various aspects of stigma and participants' experiences with naloxone, syringe service programs, fentanyl test strips, HIV and hepatitis C testing, and any other harm reduction strategies. Key themes were generated using a thematic analysis. We reached thematic saturation at 16 participants.

KEY RESULTS

PWID reported multi-level stigma related to harm reduction from themselves, the public, the healthcare system, and the legal and carceral systems. Themes were grouped into four main categories: internalized, interpersonal, intervention, and structural stigma. Stigma across all of these domains negatively impacted the ability of PWID to access harm reduction resources. Positive, non-stigmatizing experiences from others, such as syringe service programs and peer navigators, countered historically negative experiences and promoted greater education and comfort about using harm reduction resources among PWID.

CONCLUSIONS

To expand the reach of harm reduction services, it is critical to develop interventions that can reduce the stigma against PWID and harm reduction.

Making sense of drug use and dependence-A scoping review of mass media interventions intended to reduce stigma towards people who use drugs

BACKGROUND

People who use drugs face entrenched stigma, which fosters shame, restricts service access, and exacerbates inequalities. The use of mass media in anti-stigma interventions offers an opportunity to challenge stigmatising attitudes at scale. There are, however, inconsistencies in messaging approaches used in mass media anti-stigma interventions, and how authors conceptualise and measure 'stigma'.

METHODS

This scoping review maps literature on the development and/or evaluation of mass media interventions intended to reduce stigma towards people who use drugs. We systematically searched seven databases for reports about: (i) people who use drugs, (ii) stigma, (iii) mass media. We charted data about intervention (i) subjects and recipients, (ii) format, (iii) authors, (iv) content; and (v) conceptualisation and measurement of stigma. We narratively synthesised findings with qualitative content analyses.

RESULTS

From 14,256 records, we included 49 reports about 35 interventions. 25/35 were from the last five years and 19/35 were from the United States. Intended recipients included the public and/or specified sub-populations, often including healthcare workers. Most interventions were intended to reduce stigma towards people with patterns of drug use perceived to be problematic, as opposed to people who use drugs in general. Interventions ranged from single pieces of media to complex multi-format campaigns. People who use(d) drugs contributed to 22/35 interventions. Professionals working in medical disciplines co-authored 29/35 interventions. Intervention content often had a medical focus, describing dependence as a 'disease' or medical issue, and emphasised the benefits of recovery. Other interventions, however, criticised medical framings. In some interventions drug use and people who use drugs were described in markedly negative terms. 'Stigma' was often under-theorised, and measurement approaches were inconsistent, with 42 instruments used to measure phenomena associated with stigma across 19 quantitative evaluations.

CONCLUSION

We found inconsistencies in approaches to reduce and measure stigma, potentially reflecting different motivations for intervention development. The primary motivation of many interventions was seemingly to promote drug service engagement and recovery.

Implementation Science's Role in Community Engagement for Substance Use Prevention

Until recently, the field of implementation science has provided limited insight and guidance on the use of community engagement and partnership to support implementation of evidence-based practices. Listing community engagement as a barrier to optimal implementation is often the extent of the discussion. An article recently published by Perry et al. (PS 24:61-76, 2023) details what community engagement can entail and documents how this engagement can shape opioid use prevention research. The article also describes benefits of engaging community partners in prevention interventions, particularly for opioid use disorder, and the feasibility of employing multiple levels of engagement to do so. The article concludes by emphasizing areas for future research including examining the role community engagement has on the success of prevention interventions and the impact on long-term intervention outcomes. To respond to the Perry et al. (PS 24:61-76, 2023) article, our team conducted a literature scan of recently published implementation science and community engagement manuscripts, which demonstrated a growing body of research on the subject. We summarize these findings by offering suggested approaches for integrating implementation science and community engagement for substance use prevention programs and suggestions for advancing this intersection.

Comprehensive analysis of social stigma of ındividuals with substance use disorder in Turkey in the context of Erving Goffman's stigma theory

Goffman defines stigma as a disgrace and social outcast/disqualification. Individuals with substance disorder are exposed to stigma at certain periods of their lives. Stigma particularly affects their thoughts, behaviors, and treatment processes, as well as their social life and identity perception. This paper examines the effects of social stigma experienced by individuals with substance disorder in Turkey and its reflections on social life in terms of Goffman's stigmatization theory. In this regard, studies examining the social stigmatization of individuals with addictions and social perceptions and attributes toward these individuals in Turkey were analyzed. This analysis suggests that socio-demographic and cultural factors play a significant role in stigmatization, that society has negative perception and representations toward addicts, that stigmatized addicts are likely to avoid interactions with "normals" and are often stigmatized by the media, colleagues, and health professionals, and that stigma develops/creates "an addicted identity.". This paper suggests the need for robust social policies that would aim to minimize stigmatizing attitudes and misconceptions toward individuals with addiction, ensure access to effective treatment, fulfill their social functioning, and integrate them into society should be implemented.

"Politics Versus Policy": Qualitative Insights on Stigma and Overdose Prevention Center Policymaking in the United States

BACKGROUND

Federal, state, and municipal governments in the United States have been reluctant to authorize overdose prevention centers (OPCs), which are evidence-based approaches for preventing overdose deaths and blood-borne pathogen transmission.

METHODS

From July 2022 to February 2023, we explored how stigma manifests in OPC policymaking by conducting in-depth interviews with 17 advocates, legislators, service providers, and researchers involved with OPC advocacy and policymaking in Rhode Island, California, Pennsylvania, and New York.

RESULTS

We found that although jurisdictions differed in their OPC policymaking experiences, stigma manifested throughout the process, from planning to authorization. Participants described OPCs as a tool for destigmatizing overdose and substance use, yet confronted institutionalized stigma and discriminatory attitudes toward people who use drugs (PWUD) and harm reduction from multiple sources (eg, politicians, media, and members of the public). Opposition toward OPCs and harm reduction approaches more broadly intersected with public discourse on crime, homelessness, and public disorder. Employed stigma-mitigation strategies included humanizing PWUD, publicizing the benefits of OPCs to the wider community, and strategically engaging media.

CONCLUSION

These findings illustrate the importance of understanding stigma at different stages of the policymaking process to better facilitate authorization and eventual implementation of OPCs in the United States.

Perceptions of lifestyle-related risk communication in patients with breast and colorectal cancer: a qualitative interview study in Sweden

BACKGROUND

Informing individuals about their risk of cancer can sometimes have negative consequences, such as inflicting unnecessary worry and fostering stigma. This study aims to explore how patients diagnosed with breast or colorectal cancer perceive and experience risk communication, particularly concerning the increased focus on lifestyle behaviors as the cause of cancer.

METHODS

Semi-structured interviews were conducted during autumn 2023, with 23 Swedish individuals, aged 34 to 79 years, diagnosed with breast or colorectal cancer. The collected data were analyzed using inductive thematic analysis described by Braun & Clark. The study adopted an experiential orientation grounded in critical realism.

RESULTS

Five themes with ten sub-themes were identified: Thoughts and feelings about the causes of cancer, Moralizing messages and negative encounters, The need to take action, Balancing uncertain risks and a fulfilling life, and Societal benefits of risk communication. The participants expressed that knowledge of the the cause of cancer is closely related to the possibility of taking preventive action against relapses. Ability to take action was also perceived important for their well-being. Therefore, risk information entails both feelings of self-blame and hope for the future. Participants asked for both information and lifestyle support from healthcare professionals. Lifestyle interventions and patient support groups were solicited and perceived as an important aspect of cancer survivals' well-being, and may help to reduce the cancer-related stigma.

CONCLUSION

Individuals that have or have had breast or colorectal cancer, including those leading healthy lifestyles, found moralistic risk information offensive, leading to feelings of shame when thinking about other peoples thoughts. Balancing information involves providing transparent, evidence-based information while considering individual and social contexts, avoiding stigmatization and blame, and supplementing information with support.

Exploring barriers and facilitators to addressing hazardous alcohol use and AUD in mental health services: a qualitative study among Dutch professionals

BACKGROUND

Hazardous alcohol use and alcohol use disorder (AUD) are highly prevalent among clients in mental health services, yet significant gaps remain in the adequate assessment of alcohol use and provision of appropriate alcohol interventions. The aim of this study was to conduct an exploration of (i) alcohol intervention elements used in mental health services and (ii) professionals' reported barriers and facilitators in identifying and intervening with hazardous alcohol use and AUD.

METHODS

Qualitative data were obtained by conducting semi-structured interviews among a purposive sample of 18 professionals from 13 different Dutch mental health services organizations (i.e., five integrated mental health organizations with addiction services, five mental health organizations without addiction services, and three addiction services organizations without mental health services). Transcripts were qualitatively analyzed using inductive thematic analysis.

RESULTS

Identified alcohol intervention elements included conducting assessments, brief interventions, treatment, referrals of clients, collaborations with other parties, and providing information to professionals. Professionals mentioned nine barriers and facilitators in the identification and intervention with hazardous alcohol use and AUD, including three aspects of professionals' behavior (i.e., professionals' agenda setting, knowledge and skills, and attitudes), actions related to identification and intervening, client contact, collaboration with other parties, and three factors in a wider context (i.e., organizational characteristics, organizational resources, and governmental aspects).

CONCLUSIONS

Although diverse alcohol intervention elements are available in Dutch mental health services, it remains unclear to what extent these are routinely implemented. To better address hazardous alcohol use and AUD in mental health services, efforts should focus on enhancing alcohol training, improving collaboration with addiction services, providing appropriate tools, and facilitating support through organizational and governmental measures.

An Automated Text Messaging Intervention to Reduce Substance Use Self-Stigma (Project RESTART): Protocol for a Feasibility and Acceptability Pilot Study

BACKGROUND

Stigma is a barrier to treatment and harm reduction seeking in people who use drugs. Most stigma reduction interventions offer psychotherapy or psychoeducation in group-based clinical settings, failing to reach people who are not in treatment. SMS text messaging is an effective and acceptable modality for delivering health information to people who use drugs and may be a suitable conduit for providing information and advice to understand and cope with stigma.

OBJECTIVE

This paper presents the protocol for a study that aims to determine the feasibility, acceptability, and preliminary effectiveness of a 4-week automated SMS text message intervention to increase stigma resistance and reduce self-stigma in people who use drugs.

METHODS

We designed a novel automated SMS text message intervention to address the four personal-level constructs of stigma resistance: (1) not believing stigma and catching and challenging stigmatizing thoughts, (2) empowering oneself through learning about substance use and one's recovery, (3) maintaining one's recovery and proving stigma wrong, and (4) developing a meaningful identity and purpose apart from one's substance use. Theory-based messages were developed and pilot-tested in qualitative elicitation interviews with 22 people who use drugs, resulting in a library of 56 messages. In a single-group, within-subjects, community-based pilot trial, we will enroll 30 participants in the Resisting Stigma and Revaluating Your Thoughts (RESTART) intervention. Participants will receive 2 daily SMS text messages for 4 weeks. Implementation feasibility will be assessed through recruitment, enrollment, retention, and message delivery statistics. User feasibility and acceptability will be assessed at follow-up using 23 survey items informed by the Theoretical Framework of Acceptability. Primary effectiveness outcomes are changes in self-stigma (Substance Abuse Self-Stigma Scale) and stigma resistance (Stigma Resistance Scale) from baseline to follow-up measured via a self-administered survey. Secondary outcomes are changes in hope (Adult Dispositional Hope Scale) and self-esteem (Rosenberg Self-Esteem Scale). Feasibility and acceptability will be assessed with descriptive statistics; effectiveness outcomes will be assessed with paired 2-tailed t tests, and group differences will be explored using ANOVA. Overall, 12 participants will also be selected to complete acceptability interviews.

RESULTS

This pilot study was funded by the National Institute on Drug Abuse in April 2023 and received regulatory approval in January 2024 by the University of North Carolina-Chapel Hill Institutional Review Board. Recruitment and enrollment began in March 2024. Follow-up visits are expected to conclude by May 2024. Results will be disseminated in relevant peer-reviewed journals.

CONCLUSIONS

To the best of our knowledge, this is the first study to address substance use stigma via a self-help SMS text messaging program. Results will add to the nascent literature on stigma reduction in people who use drugs. This protocol may interest researchers who are considering text messaging to address psychosocial needs in hard-to-reach populations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06281548; https://clinicaltrials.gov/ct2/show/NCT06281548.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59224.

Perspectives and Recommendations from Hospitalized Patients with Substance Use Disorders: A Qualitative Study

BACKGROUND

Individuals with substance use disorders (SUDs) are hospitalized in growing numbers. Stigma is pervasive among their hospital providers, and SUD management during medical admissions is often inadequate. However, little is known about how these patients perceive their care quality. In particular, few studies have explored their positive care perceptions or recommendations for improvement.

OBJECTIVE

To explore perspectives on positive aspects, negative aspects, and consequences of care, as well as recommendations for improvement among hospitalized patients with SUDs.

DESIGN AND PARTICIPANTS

We conducted semi-structured, in-depth bedside interviews (n = 15) with patients who have been diagnosed with a SUD and were admitted to medical or surgical floors of an urban academic medical center.

APPROACH

Interviews explored patients' hospital experiences and recommendations for improvement. The interviews were audio-recorded, transcribed verbatim, and imported into NVivo software. Two reviewers independently coded the transcripts using interpretative phenomenological analysis and inductive thematic analysis according to grounded theory, and recurring themes were identified from the data. Patients' demographic and clinical data were analyzed with descriptive statistics.

KEY RESULTS

Perceived clinical and emotional proficiency were the most important components of positive experiences, whereas perceived bias and stigmatized attitudes, clinical improficiency, and inhumane treatment were characteristic of negative experiences. Such care components were most consequential for patients' emotional well-being, trust, and care quality. Recommendations for improving care included specific suggestions for initiating and promoting continued recovery, educating, and partnering in compassionate care.

CONCLUSIONS

Hospitalized patients with SUDs often experience lower quality and less compassionate care linked to pervasive stigma and poor outcomes. Our study highlights under-recognized perspectives from this patient population, including socioemotional consequences of care and recommendations grounded in lived experiences. By striving to advance our care in accordance with patients' viewpoints, we can turn hospitalizations into opportunities for engagement and promoting recovery.

Characterizing people who inject drugs with no history of opioid agonist therapy uptake in Iran: Results from a national bio-behavioural surveillance survey in 2020

Injection drug use is the primary driver of the human immunodeficiency virus HIV epidemic in Iran. We characterized people who inject drugs (PWID) living in Iran who had never received opioid agonist therapy (OAT) and examined barriers to OAT uptake. We recruited 2,684 PWID with a history of drug injection in the previous 12 months using a respondent-driven sampling approach from 11 geographically dispersed cities in Iran. The primary outcome was no lifetime uptake history of OAT medications. The lifetime prevalence of no history of OAT uptake among PWID was 31.3%, with significant heterogeneities across different cities. In the multivariable analysis, younger age, high school education or above, no prior incarceration history, and shorter length of injecting career was significantly and positively associated with no history of OAT uptake. Individual-level barriers, financial barriers, and system-level barriers were the main barriers to receiving OAT. PWID continue to face preventable barriers to accessing OAT, which calls for revisiting the OAT provision in Iran.

A stakeholder-driven approach to designing a peer recovery coach role for implementation in community-oriented primary care teams in South Africa

Introduction

In South Africa (SA), community-oriented primary care (COPC) teams work to re-engage out-of-care people with HIV (PWH) in treatment, many of whom have substance use (SU) concerns. SU stigma is high among these teams, limiting care engagement efforts. Integrating peer recovery coaches (PRCs) into COPC teams could shift SU stigma and improve patients' engagement in care. The PRC role does not exist in SA and represents a workforce innovation. To enhance acceptability, feasibility, and appropriateness for the local context, we engaged multiple stakeholder groups to co-design a PRC role for COPC team integration.

Methods

We used a five-step human-centered design process: (i) semi-structured interviews with healthcare worker (HCW, n = 25) and patient (n = 15) stakeholders to identify priorities for the role; (ii) development of an initial role overview; (iii) six ideation workshops with HCW (n = 12) and patient (n = 12) stakeholders to adapt this overview; (iv) refinement of the role prototype via four co-design workshops with HCW (n = 7) and patient (n = 9) stakeholders; and (v) consultation with HIV and SU service leaders to assess the acceptability and feasibility of integrating this prototype into COPC teams.

Results

Although all stakeholders viewed the PRC role as acceptable, patients and HCWs identified different priorities. Patients prioritized the care experience through sharing of lived experience and confidential SU support. HCWs prioritized clarification of the PRC role, working conditions, and processes to limit any impact on the COPC team. A personal history of SU, minimum 1 year in SU recovery, and strong community knowledge were considered role prerequisites by all stakeholders. Through the iterative process, stakeholders clarified their preferences for PRC session structure, location, and content and expanded proposed components of PRC training to include therapeutic and professional work practice competencies. Service leaders endorsed the prototype after the addition of PRC integration training for COPCs and PRC mentoring to address community and COPC dynamics.

Conclusion

Stakeholder engagement in an iterative HCD process has been integral to co-designing a PRC role that multiple stakeholder groups consider acceptable and that COPC teams are willing to implement. This offers a methodological framework for other teams designing SU workforce innovations.

Perceived social support and symptoms of prolonged grief after a drug-related death

Social network support can be important when adjusting to life after the death of a close family member or friend. However, research has yielded inconclusive results regarding the relationship between social support and complicated grief reactions. Persons bereaved after a drug-related death (DRD) are a group of people who are at high risk of developing bereavement complications. Based on a Norwegian study on DRD bereaved close family members and friends (n = 250), this study examines the association between perceived social support, societal stigma, own social withdrawal, and prolonged grief symptoms (PGS). Own social withdrawal predicts the most variance in PGS symptoms: 8%, perceived social support: 3%, and societal stigma: 1%. Together the three focal variables explain 17.5% of variations in PGS. Results from the study point to the importance of social network support, which could reduce bereavement complications after a DRD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using qualitative system dynamics modeling to understand overdose bystander behavior in the context of Connecticut's Good Samaritan Laws and identify effective policy options

BACKGROUND

Good Samaritan Laws are a harm reduction policy intended to facilitate a reduction in fatal opioid overdoses by enabling bystanders, first responders, and health care providers to assist individuals experiencing an overdose without facing civil or criminal liability. However, Good Samaritan Laws may not be reaching their full impact in many communities due to a lack of knowledge of protections under these laws, distrust in law enforcement, and fear of legal consequences among potential bystanders. The purpose of this study was to develop a systems-level understanding of the factors influencing bystander responses to opioid overdose in the context of Connecticut's Good Samaritan Laws and identify high-leverage policies for improving opioid-related outcomes and implementation of these laws in Connecticut (CT).

METHODS

We conducted six group model building (GMB) workshops that engaged a diverse set of participants with medical and community expertise and lived bystander experience. Through an iterative, stakeholder-engaged process, we developed, refined, and validated a qualitative system dynamics (SD) model in the form of a causal loop diagram (CLD).

RESULTS

Our resulting qualitative SD model captures our GMB participants' collective understanding of the dynamics driving bystander behavior and other factors influencing the effectiveness of Good Samaritan Laws in the state of CT. In this model, we identified seven balancing (B) and eight reinforcing (R) feedback loops within four narrative domains: Narrative 1 - Overdose, Calling 911, and First Responder Burnout; Narrative 2 - Naloxone Use, Acceptability, and Linking Patients to Services; Narrative 3 - Drug Arrests, Belief in Good Samaritan Laws, and Community Trust in Police; and Narrative 4 - Bystander Naloxone Use, Community Participation in Harm Reduction, and Cultural Change Towards Carrying Naloxone.

CONCLUSIONS

Our qualitative SD model brings a nuanced systems perspective to the literature on bystander behavior in the context of Good Samaritan Laws. Our model, grounded in local knowledge and experience, shows how the hypothesized non-linear interdependencies of the social, structural, and policy determinants of bystander behavior collectively form endogenous feedback loops that can be leveraged to design policies to advance and sustain systems change.

Fentanyl and xylazine crisis: Crafting coherent strategies for opioid overdose prevention

The United States is in the throes of a severe opioid overdose epidemic, primarily fueled by the pervasive use of fentanyl and the emerging threat of xylazine, a veterinary sedative often mixed with fentanyl. The high potency and long duration of fentanyl is compounded by the added risks from xylazine, heightening the lethal danger faced by opioid users. Measures such as enhanced surveillance, public awareness campaigns, and the distribution of fentanyl-xylazine test kits, and naloxone have been undertaken to mitigate this crisis. Fentanyl-related overdose deaths persist despite these efforts, partly due to inconsistent policies across states and resistance towards adopting harm reduction strategies. A multifaceted approach is imperative in effectively combating the opioid overdose epidemic. This approach should include expansion of treatment access, broadening the availability of medications for opioid use disorder, implementation of harm reduction strategies, and enaction of legislative reforms and diminishing stigma associated with opioid use disorder.

Substance use stigma: A systematic review of measures and their psychometric properties

Background

Instruments to measure substance use stigma are emerging, however little is known regarding their psychometric properties. While research has evolved to view substance use stigma as a context sensitive international phenomenon that is embedded within cultures, validated self-report measures are lacking and comprehensive reviews of the existing measures are extremely limited. In this systematic review of substance use stigma and shame measures, we aim to contextualize results from existing research, lay the groundwork for future measurement development research, and provide a thorough resource for research scientists currently designing studies to measure substance use stigma.

Methods

We searched three databases using Boolean search terms for psychometric evaluations of measures of substance use stigma and shame and evaluated the quality/psychometric properties using an adaptation of the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) systematic review guidelines.

Results

We identified 18 measures of substance use stigma. Overall, most measures had minimal psychometric assessments and none of the measures met all domains of the COSMIN measure quality criteria. However, most studies reported satisfactory factor analyses and internal consistency scores.

Conclusions

Most measures of substance use stigma and shame had psychometric assessment across a limited range of criteria and no measures of structural substance use stigma were found. The most reported psychometric properties were structural validity and convergent validity. We suggest future researchers investigate test-retest reliability and cross-cultural validity for existing substance use stigma measures, as well as develop and evaluate novel measures assessing structural stigma of substance use.

Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.