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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions to reduce self-stigma in people who use drugs: A systematic review

BACKGROUND

Substance use stigma is a key barrier to treatment and harm reduction engagement among people who use drugs (PWUD). Previous systematic reviews have focused on interventions to reduce stigma in healthcare providers and the public; less is known about interventions to address self-stigma among PWUD. The purpose of this review is to evaluate the evidence for substance use self-stigma reduction interventions.

METHODS

We reviewed English-language studies published between 2011 and 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO #CRD42022321305). We searched seven bibliographic databases (PubMed; SCOPUS; APA PsycInfo; CINAHL; Social Work Abstracts; Sociological Abstracts; ProQuest Dissertations & Theses). This review included studies if 1) they evaluated the effectiveness of a psychosocial intervention, 2) participants were PWUD, 3) authors reported self-stigma as a primary outcome, 4) the study design was experimental or quasi-experimental. We reviewed, interpreted and reported intervention characteristics and effectiveness using narrative synthesis. We assessed study quality with the Downs & Black checklist.

RESULTS

Among 1195 screened studies, 15 met the inclusion criteria (N = 2280 PWUD). We categorized the interventions according to three approaches: psychotherapeutic (n = 8), psychoeducational (n = 5), and multimodal (n = 2). Most interventions were delivered in clinical settings (n = 11) and in a group format (n = 13). Study quality was fair-to-good and included nine randomized controlled trials (RCTs) and six quasi-experiments. Measurement heterogeneity was high, with 11 different stigma-related scales used across the 15 studies. Eleven studies showed significant favorable effects in at least one stigma measure. Six of these demonstrated positive effects in all stigma measures. Evidence was mixed for all three intervention categories; however, Acceptance and Commitment Therapy, a form of group psychotherapy, demonstrated effectiveness in four of five RCTs incorporating this approach.

CONCLUSIONS

Overall, there is promising evidence for the effectiveness of substance use self-stigma interventions, although more studies are needed to determine which approaches are most effective. Consistent conceptualization and measurement of self-stigma across studies will improve comparability in future intervention trials. Current offerings are largely limited to clinical settings and group-based formats; self-help interventions, available for other stigmatized conditions, could be developed to serve the majority of PWUD not engaged in treatment.

"I would do anything but that": Attitudes towards sex work among rural people who use drugs

BACKGROUND

Stigma towards people who use drugs and those who engage in sex work is well-documented, leading to consequences such as reduced access to health services and support, especially in rural milieus. Stigma reduction has been recognized as a priority in the opioid overdose crisis, but little attention has been paid to within-group attitudes and beliefs. This study aimed to explore how people who use drugs in rural counties across the United States appraise sex work by themselves or other community members.

METHODS

Qualitative interview data came from the Rural Opioid Initiative (ROI), a project coordinated by research teams across 65 rural counties in 10 states. Interviews were individual and conducted from 2018 to 2020. All participants reported past 30-day opioid use and/or any injection drug use. A working group coded the data, then used an iterative inductive-deductive approach to organize data into themes of stigma among people who use drugs, focusing on stigma towards sex work.

RESULTS

Across sites, 355 interviews were conducted. Mean participant age was 36, 55 % of participants were male, and 93 % were white. Participants expressed negative attitudes towards sex work as a function of its criminal-legal repercussions or framed sex work as morally transgressive. Many appraisals were gendered, with the behavior conveyed as being "easier" for women who were often described as "whores," with more neutral terms used to describe men. Some viewed sex work as an implicit "exchange" for drugs. Several participants noted a lack of agency as a feature leading to involvement in sex work, with partner power dynamics influencing an individual's behavior. Finally, a few participants acknowledged the circumstances under which they would newly engage in sex work.

CONCLUSION

We identified several patterns by which people who use drugs evaluate community members who sell sex. These included gendered and morally-charged forms of stigma, which may represent barriers to community acceptance and support among this subgroup.

"I am not a junkie": Social categorization and differentiation among people who use drugs

BACKGROUND

Substance use stigma is a form of group-based exclusion, and delineating pathways from stigma to poor health requires a deeper understanding of the social dynamics of people who use drugs (PWUD). Outside of recovery, scant research has examined the role of social identity in addiction. Framed by Social Identity Theory/Self-Categorization Theory, this qualitative study investigated strategies of within-group categorization and differentiation among PWUD and the roles these social categories may play in shaping intragroup attitudes, perceptions, and behaviors.

METHODS

Data come from the Rural Opioid Initiative, a multi-site study of the overdose epidemic in rural United States. We conducted in-depth interviews with people who reported using opioids or injecting any drug (n=355) living in 65 counties across 10 states. Interviews focused on participants' biographical histories, past and current drug use, risk behaviors, and experiences with healthcare providers and law enforcement. Social categories and dimensions along which categories were evaluated were inductively identified using reflexive thematic analysis.

RESULTS

We identified seven social categories that were commonly appraised by participants along eight evaluative dimensions. Categories included drug of choice, route of administration, method of attainment, gender, age, genesis of use, and recovery approach. Categories were evaluated by participants based on ascribed characteristics of morality, destructiveness, aversiveness, control, functionality, victimhood, recklessness, and determination. Participants performed nuanced identity work during interviews, including reifying social categories, defining 'addict' prototypicality, reflexively comparing self to other, and disidentifying from the PWUD supra-category.

CONCLUSION

We identify several facets of identity, both behavioral and demographic, along which people who use drugs perceive salient social boundaries. Beyond an addiction-recovery binary, identity is shaped by multiple aspects of the social self in substance use. Patterns of categorization and differentiation revealed negative intragroup attitudes, including stigma, that may hinder solidary-building and collective action in this marginalized group.

Acceptability and feasibility of long-acting injectable antiretroviral therapy for HIV-infected persons who inject drugs in Vietnam: A qualitative study

BACKGROUND

In Vietnam, HIV prevalence among people who inject drugs (PWID) is several times higher than in the general population (15% versus 0.3%). PWID also experience higher rates of HIV-related mortality, driven by poor antiretroviral therapy (ART) adherence. Long-acting injectable ART (LAI) is a compelling opportunity to improve treatment outcomes, but acceptability and feasibility among HIV-infected PWID remains unexplored.

METHODS

We conducted key informant in-depth interviews in Hanoi, Vietnam (February-November 2021). Participants were purposively sampled and included policymakers, ART clinic staff, and HIV-infected PWID. We applied the Consolidated Framework for Implementation Research to guide study design and analysis, using thematic coding to develop and iteratively refine a codebook and characterize barriers and facilitators to LAI implementation.

FINDINGS

We interviewed 38 key stakeholders: 19 PWID, 14 ART clinic staff, and five policymakers. Participants were enthusiastic about LAI convenience, highlighting less frequent and more discreet dosing. However, contrasting providers, several policymakers suggested LAI was not needed given perceived exceptional oral ART outcomes and rare viral failure among PWID. Policymakers also criticized strategies prioritizing PWID for LAI, emphasizing equity, whereas providers identified PWID as an ideal population for LAI given adherence challenges. LAI complexity, including storage and administration logistics, were deemed surmountable with training and resources. Finally, providers and policymakers acknowledged that adding LAI to drug formularies was key, but an onerous process.

INTERPRETATION

Although anticipated to be resource-intensive, LAI was a welcome addition for interviewed stakeholders and likely an acceptable alternative to oral ART among PWID living with HIV in Vietnam. Despite enthusiasm among PWID and providers that LAI could improve viral outcomes, some policymakers-whose buy-in is critical to LAI implementation-opposed strategies that preferentially distributed LAI to PWID, highlighting values of equity and revealing differences in perceived HIV outcomes among PWID. Results provide a vital foundation for developing LAI implementation strategies.

FUNDING

Supported by National Institutes of Health.

1253. Acceptability and feasibility of long-acting injectable antiretroviral therapy for persons who inject drugs in Vietnam: using the Consolidated Framework on Implementation Research to identify determinants and inform implementation strategies

Background

Long-acting injectable antiretroviral therapy (LAI) is an exciting alternative to daily oral ART. Less frequent dosing afforded by LAI may be especially pertinent for persons who inject drugs (PWID), who experience more HIV-related mortality largely driven by inadequate ART adherence. We used the Consolidated Framework on Implementation Research (CFIR) to characterize determinants of LAI implementation, focusing on use among PWID, in Hanoi, Vietnam.

Methods

We conducted in-depth interviews with HIV-infected PWID, ART providers, and policymakers using purposive sampling, recruiting respondents with diverse ART experience from public HIV/ART clinics and national regulatory agencies. Participants were briefed regarding LAI ART, including administration, effectiveness, side effects, and dosing frequency. Data were coded and analyzed using thematic analysis.

Results

We interviewed 19 PWID, 14 providers, and five policymakers (February-November, 2021). We identified recurrent themes in CFIR domains. Intervention: All informants were excited about LAI, citing convenience and discrete dosing as major facilitators. Surprisingly, provider concerns, including more frequent clinic visits and injection reactions, were rarely voiced by PWID who described monthly injections as similar to current visit frequency and cited “high pain tolerance.” Outer: Providers and policymakers were eager to offer patients ART choice but were divided as to if LAI distribution should proceed with sub-population prioritization. Inner: Providers described personnel and clinic logistic concerns but were confident these could be addressed. Individual: Providers were motivated and confident in their ability to deliver LAI. Process: Transitions to new ART and provision of COVID-19 vaccines were frequently invoked by providers and policymakers as interventions informing LAI implementation. FigureDeterminants of LAI ART implementation in Vietnam using the domains of the Consolidated Framework on Implementation Research

Conclusion

Using CFIR, we identified multiple determinants of LAI implementation in Vietnam. Stakeholders agreed that LAI was feasible and acceptable. Medication tolerance and efficacy concerns highlight the importance of patient and provider education. Areas where stakeholders diverge should be considered in designing LAI implementation strategies.

Disclosures

Joseph J. Eron, MD, Adagio Therapeutics: data safety monitoring committee|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|Glaxo Smith Kline: Advisor/Consultant|Merck: Advisor/Consultant|ViiV Healthcare: Advisor/Consultant|ViiV Healthcare: Grant/Research Support.

914. The Relationship Between Buprenorphine Maintenance Therapy and Hepatitis C Virus Infection, Testing, and Treatment in Southern Appalachian Ohio

Background

The hepatitis C virus (HCV) epidemic in the United States is primarily among young people who use drugs (PWUD), especially in rural and Appalachian regions. Buprenorphine maintenance therapy (BMT) may indirectly prevent HCV infection by reducing injection drug use. We aim to assess the relationship between BMT and HCV infection, testing, and treatment among rural PWUD.

Methods

We conducted a cross-sectional respondent driven sampling survey of 243 PWUD adults in southern Appalachian Ohio from May to November 2019. Participants completed audio computer-assisted self-interview and were tested for HCV antibodies. We defined recent BMT use as self-reported BMT in the past 30 days and prior BMT use as self-reported BMT any time prior to the past 30 days. HCV antibody positive participants were incentivized to receive confirmatory HCV RNA testing. We fit log-binomial regression models to assess the relationship between BMT and HCV infection, testing, and treatment.

Results

72% of participants were HCV antibody positive (n=175). 31% (n=54) of antibody positive participants received an RNA test; of those, 96% (n=52) were HCV RNA positive. Compared to participants with no history of BMT, those with prior BMT were more likely to be HCV antibody positive (PR=1.3, 95% CI: 1.1-1.6) and to have been tested for HCV (PR=1.3 95% CI: 1.1-1.5); they were somewhat more likely to have been treated for HCV (PR=1.3 95% CI: 0.5-3.4). Compared to participants with no history of BMT, those reporting recent BMT had similar HCV antibody positivity (PR=1.1 95% CI: 0.9-1.5) but were more likely to have been tested (PR=1.3 95% CI: 1.1-1.6) and possibly more likely to have been treated for HCV (PR=2.0 95% CI: 0.6-5.9). Compared to those with a prior BMT, people with recent BMT use had slightly lower HCV antibody positivity (PR=0.8 95% CI: 0.7-1.1) and possibly higher prevalence of HCV treatment (PR=1.5 95% CI: 0.6-3.8) but had similar prevalence of HCV testing (PR=1.0 95% CI: 0.9-1.2).

Conclusion

Participants with a recent history of BMT were more likely to have been tested for HCV and possibly to have received prior treatment. Participants with prior BMT were more likely to be antibody positive and to have tested for HCV. Improved coordination between BMT and HCV care may increase HCV treatment among rural PWUD.

Disclosures

All Authors: No reported disclosures

Topics Analysis of Reddit and Twitter Posts Discussing Inflammatory Bowel Disease and Distress From 2017 to 2019

Background

Social media platforms are popular tools for people with inflammatory bowel disease (IBD) to seek support. In the current study, we sought to examine and characterize IBD and distress discourse on public social media platforms. Our goal was to identify topics associated with these online discussions.

Methods

We collected public social media posts about IBD and distress from Reddit (N = 40 625) and Twitter (N = 40 306) published between September 2017 and August 2019. We created a term-based dictionary to characterize posts based on 8 different, nonmutually exclusive topics: (1) symptoms, (2) medication, (3) nutrition, (4) procedures, (5) marijuana, (6) stigma, (7) ostomy, and (8) intimacy. We used descriptive statistics to characterize the frequency and order the prevalence of the topics on the 2 platforms, and to assess topic co-occurrences among posts.

Results

Most Reddit (79%) and Twitter (56%) posts mentioned at least 1 IBD topic. The order of topic prevalence was the same for the 2 platforms. Symptoms was the most mentioned topic (Reddit: 57%, Twitter 36%), followed by medication (Reddit: 30%, Twitter 11%), and nutrition (Reddit: 27%, Twitter 9%). Intimacy was the least mentioned topic (Reddit: 2%, Twitter: <1%). Topic co-occurrences varied by platform. Most Reddit posts (57%) mentioned at least 2 IBD topics, whereas only 27% of tweets mentioned multiple IBD topics.

Conclusions

This study contributes to a growing literature examining how IBD is discussed on social media-specifically, in distress-related contexts on Reddit and Twitter. These cross-platform findings highlight important areas potentially associated with IBD-related distress, which could help facilitate future support.

The Relationship Between Hepatitis C Virus Rates and Office-Based Buprenorphine Access in Ohio

Background

The United States is experiencing an epidemic of hepatitis C virus (HCV) infections due to injection drug use, primarily of opioids and predominantly in rural areas. Buprenorphine, a medication for opioid use disorder, may indirectly prevent HCV transmission. We assessed the relationship of HCV rates and office-based buprenorphine prescribing in Ohio.

Methods

We conducted an ecological study of the county-level (n = 88) relationship between HCV case rates and office-based buprenorphine prescribing in Ohio. We fit adjusted negative binomial models between the county-level acute and total HCV incidence rates during 2013–2017 and 1) the number of patients in each county that could be served by office-based buprenorphine (prescribing capacity) and 2) the number served by office-based buprenorphine (prescribing frequency) from January–March, 2018.

Results

For each 10% increase in acute HCV rate, office-based buprenorphine prescribing capacity differed by 1% (95% CI: –1%, 3%). For each 10% increase in total HCV rate, office-based buprenorphine prescribing capacity was 12% (95% CI: 7%, 17%) higher. For each 10% increase in acute HCV rate, office-based buprenorphine prescribing frequency was 1% (95% CI: –1%, 3%) higher. For each 10% increase in total HCV rate, office-based buprenorphine prescribing frequency was 14% (95% CI: 7%, 20%) higher.

Conclusions

Rural counties in Ohio have less office-based buprenorphine and higher acute HCV rates versus urban counties, but a similar relationship between office-based buprenorphine prescribing and HCV case rates. To adequately prevent and control HCV rates, certain rural counties may need more office-based buprenorphine prescribing in areas with high HCV case rates.

"Now We Are Seeing the Tides Wash In": Trauma and the Opioid Epidemic in Rural Appalachian Ohio

Background: Ohio's opioid epidemic continues to progress, severely affecting its rural Appalachian counties-areas marked by high mortality rates, widespread economic challenges, and a history of extreme opioid overprescribing. Substance use may be particularly prevalent in the region due to interactions between community and interpersonal trauma. Purpose/Objectives: We conducted qualitative interviews to explore the local context of the epidemic and the contributing role of trauma. Methods: Two interviewers conducted in-depth interviews (n = 34) with stakeholders in three rural Appalachian counties, including healthcare and substance use treatment professionals, law enforcement officials, and judicial officials. Semi-structured interview guides focused on the social, economic, and historical context of the opioid epidemic, perceived causes and effects of the epidemic, and ideas for addressing the challenge. Results: Stakeholders revealed three pervasive forms of trauma related to the epidemic in their communities: environmental/community trauma (including economic and historical distress), physical/sexual trauma, and emotional trauma. Traumas interact with one another and with substance use in a self-perpetuating cycle. Although stakeholders in all groups discussed trauma from all three categories, their interpretation and proposed solutions differed, leading to a fragmented epidemic response. Participants also discussed the potential of finding hope and community through efforts to address trauma and substance use. Conclusions: Findings lend support to the cyclical relationship between trauma and substance use, as well as the importance of environmental and community trauma as drivers of the opioid epidemic. Community-level and trauma-informed interventions are needed to increase stakeholder consensus around treatment and prevention strategies, as well as to strengthen community organization networks and support community resilience. Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1887248.

1053. The Ecological Relationship Between County-Level HCV Case Rates and Office-Based Buprenorphine in Ohio

Background

The United States is experiencing an epidemic of hepatitis C virus (HCV) infections due to injection drug use, especially in rural areas. Counties may be expanding access to buprenorphine, an evidence-based treatment that has been shown to reduce injection drug use, to control the HCV epidemic. We assessed the county-level relationship between HCV rates in 2013-2015 and office-based buprenorphine prescribing in 2018 in Ohio. We also assessed if this relationship varied between rural and urban counties.

Methods

We fit crude and adjusted negative binomial models to assess the relationship between HCV incidence rates in 2013-2015 and office-based buprenorphine prescribing capacity and frequency in Ohio in 2018. We examined effect measure modification of this relationship by rural-urban status using an interaction term.

Results

We found that a 1% higher acute HCV rate was associated with an 18% (95% Confidence Interval [CI]: -3%, 44%) higher office-based buprenorphine prescribing capacity and an 22% (95% CI: -4%, 55%) higher office-based buprenorphine prescribing frequency. We found that a 1% higher total HCV rate was associated with a 239% (95% CI: 179%, 317%) higher office-based buprenorphine prescribing capacity and a 273% (95% CI: 183%, 405%) higher office-based buprenorphine prescribing frequency. We found no evidence of effect measure modification by rural-urban status.

Conclusion

Counties across Ohio may have expanded access to office-based buprenorphine in response to high rates of total HCV. Expansion of office-based buprenorphine may be less associated with acute HCV rates due to the low frequency with which these cases are seen in outpatient settings.

Disclosures

All Authors: No reported disclosures

"I Was Raised in Addiction": Constructions of the Self and the Other in Discourses of Addiction and Recovery

The aim of this article is to address how conceptualizations of addiction shape the lived experiences of people who use drugs (PWUDs) during the current opioid epidemic. Using a discourse analytic approach, we examine interview transcripts from 27 PWUDs in rural Appalachian Ohio. We investigate the ways in which participants talk about their substance use, what these linguistic choices reveal about their conceptions of self and other PWUDs, and how participants' discursive caches might be constrained by or defined within broader social discourses. We highlight three subject positions enacted by participants during the interviews: addict as victim of circumstance, addict as good Samaritan, and addict as motivated for change. We argue participants leverage these positions to contrast themselves with a reified addict-other whose identity carries socially ascribed characteristics of being blameworthy, immoral, callous, and complicit. We implicate these processes in the perpetuation of intragroup stigma and discuss implications for intervention.

"You are not clean until you're not on anything": Perceptions of medication-assisted treatment in rural Appalachia

BACKGROUND

Medication-assisted treatment (MAT) is an evidence-based strategy to treat opioid use disorder (OUD). However, MAT-related stigma reduces MAT uptake, which is particularly low in rural areas. To date, perceptions and attitudes towards MAT in rural settings have not been described.

OBJECTIVE

This qualitative study aims to characterize perceptions and attitudes towards MAT and the environmental factors contributing to these views in Appalachian Ohio.

METHODS

From February to July 2018, semi-structured interviews were conducted with 34 stakeholders (12 healthcare professionals, 12 substance use treatment providers, 7 law enforcement agents and judicial officials, and 3 members of relevant organizations) in three rural counties in Appalachian Ohio. Interviews were transcribed, coded, and analyzed to characterize the risk environment and participants' perceptions and attitudes towards MAT.

RESULTS

Participants expressed or described pervasive MAT-related stigma in the region. Participants consistently described three elements of the environment affecting stigma: (1) a "conservative" culture in which abstinence is necessary to be in recovery successfully, (2) fear of medication diversion and abuse, and (3) drug court policies that keep MAT out of the criminal justice system.

CONCLUSION

MAT-related stigma will need to be addressed to tackle the opioid epidemic through evidence-based treatment effectively.