Self Stigma in Opioid Use Disorder (OUD) Methadone Maintenance Treatment (MMT)

Info: 9418 words (38 pages) Dissertation
Published: 21st Feb 2022

Tagged: HealthPsychologyMental Health

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Project Summary

National data suggests that opioid use and misuse is steadily increasing in the U.S., with a reported four-fold increase in prescription opioid sales and opioid-related overdose deaths between 1990 and 2010, and 1990 and 2008, respectively¹. The most recent data on OUD indicates that nearly two million people are affected by DSM-IV prescription opioid use disorder (OUD), and that 20,101 individuals suffered from opioid-related overdose deaths in 2015, alone^2,3. While methadone maintenance treatment (MMT) has made a substantial improvement in the retention rates of relapse prevention programs, 25% will drop out within a year of entering treatment. Contributing to the urgency of this proposal, research has identified treatment adherence as a robust factor in predicting survival rates in this population^4,5.

While the empirical research on OUD-related stigma and MMT-related stigma is emerging, the field has neglected to qualitatively examine OUD- and MMT-related internalized stigma among individuals enrolled in MMT and its impact on treatment adhernece in this population. Furthermore, no interventions to date have attempted to incorporate targeted stigma-reduction strategies for specific use in MMT settings. Given the salience of internalized stigma to individuals with OUD, it is crucial to address modifiable aspects of stigma to promote improved treatment adherence and retention. As such, the goal of this proposal seeks to address these gaps in knowledge and clinical practice by (1) quantitatively assessing levels of internalized OUD-stigma among 100 individuals enrolled in a NYC MMT program, (2) qualitatively assessing pertinent themes surrounding internalized OUD- and MMT-related stigma and its effects on treatment among a subsample of 30 individuals reporting high levels of internalized stigma and (3) modifying a psychosocial intervention, the Ending Self Stigma (ESS) program, to expand its relevancy to individuals with OUD who are in MMT.

This research has major implications for moving research and clinical practice forward. While data collected from this study will fill a critical gap in knowledge about the salient aspects of OUD- and MMT-stigma that are detrimental to treatment adherence and recovery, the modified ESS intervention is positioned to shift clinical practice by offering a tailored psychosocial intervention that will promote treatment compliance in this population.

Specific Aims

Opioid use in the U.S. has reached epidemic proportions, with data indicating that the significant increase in the distribution and use of prescription opioids has resulted two million people affected by prescription opioid use disorder (OUD), and 20,101 opioid-related overdose deaths in 2015, alone^2,3. While the advent of MMT has dramatically improved treatment adherence among individuals with OUD, nearly 25% of patients will drop out of treatment within one year⁶. This is especially important as research suggests that treatment non-compliant individuals are 10 times more likely relapse within months of completing treatment⁷, and relapse is known to increase risk of fatal opioid overdose⁵. Despite this, intervention efforts to improve MMT treatment adherence have been largely ineffective⁸. Stigma may be a barrier to treatment in this group, although few studies have examined this empirically⁹. Given that stigma has been established as robust contributor to treatment non-adherence and treatment drop-out among other highly stigmatized groups, namely individuals with mental illness, stigma is a promising and pertinent factor that should be explored among individuals with OUD who are entering MMT^10-12. Despite this, no anti-stigma interventions have been implemented in MMT settings to date.

The proposed study will use the “Ending Self-Stigma” (ESS) program, a group intervention that uses psychoeducation, self-disclosure, and peer-led group support which has been effective in reducing stigma in other highly stigmatized populations^13,14. Using a mixed methods design, this proposal seeks to adapt the ESS intervention for use among individuals with OUD who are entering MMT for the first time, by identifying and incorporating the salient aspects of OUD and MMT stigma into the ESS program components.

This proposal is innovative because it applies Modified Labeling Theory to inform the adaptation of the ESS program. This will be the first study to develop a targeted anti-stigma intervention for individuals in MMT and is thus well positioned to make a major impact on the field of opioid treatment by proposing a novel intervention aimed at reducing OUD and MMT stigma to improve treatment adherence among individuals in MMT. The data collected through this R21 will inform a subsequent randomized controlled trial to establish whether the adapted ESS intervention produces positive changes in treatment adherence for individuals in MMT.

It has the following Specific Aims:

Aim 1: Identify levels of internalized stigma (stereotype awareness; stereotype agreement; self-concurrence; and self-esteem decrement) among individuals with OUD in MMT center in NYC.

1A. Administer an OUD stigma measure to a sample of individuals enrolled in an MMT center in NYC.

Hypothesis: Individuals in MMT will report high levels of OUD-related stigma

Aim 2: Develop and administer qualitative semi-structured interviews to examine OUD-related stigma and MMT-related stigma treatment adherence barriers among individuals with internalized OUD stigma.

2A. Design semi-structured interview guide that expands on the OUD stigma measure to include assessment of MMT-related stigma

2B. Conduct semi-structured interviews using the developed OUD/MMT stigma guide.

Hypothesis: Both OUD- and MMT-stigma will be salient aspects of internalized stigma related to treatment adherence

Aim 3: Modify the Ending Self Stigma Intervention to address identified stigma-related treatment adherence barriers among individuals with internalized OUD and MMT stigma.

3A. Incorporate the salient aspects of OUD and MMT stigma into the ESS program components.

Hypothesis: Psychosocial stress related to OUD- and MMT- internalized stigma may modulate opioid treatment adherence trajectories.

Research Strategy

Significance

Importance of the problem or critical barrier to progress in the field

Opioid use and misuse in the United states has steadily increased since the 1990’s when an uptick in opioid prescription rates resulted from pharmaceutical companies’ spurious assurance that opioid pain therapy would not beget addition². As a result, sales of prescription pain relievers, and subsequent overdose deaths have consistently increased. Sales of prescription pain relievers increased four-fold from 1999 to 2010, with opioid-related overdose deaths following a similar pattern, increasing four-fold from 1999 to 2008¹. Recent statistics indicate that the significant increase in the distribution and use of prescription opioids has resulted two million people affected by prescription opioid use disorder (OUD), and 20,101 opioid-related overdose deaths in 2015, alone^2,3. The widespread use of prescription opioids has additionally contributed to the increasing use of other non-prescription opioids, most notably, heroin. Opioid addiction stemming from the use and misuse of prescription painkillers is reported to contribute to 80% of all new heroin users¹⁵, with 591,000 heroin use disorder cases, and 12,990 heroine-related overdose deaths reported in 2015 in the United States^2,16. With the rise of opioid-related conditions and deaths, several avenues for treatment have become available.

Current treatments for opioid-related conditions include overdoes reversal treatments, such as Naloxone, and medication schedules targeted for the reduction of acute opioid withdrawal. These include Methadone and Buprenorphine tapers aimed at improving opioid withdrawal symptoms over a 4-week period, typically before the initiation of rehabilitation and maintenance strategies¹⁷. Inpatient and outpatient rehabilitation treatment programs for OUD often involve components of cognitive behavioral therapy and motivational interviewing which have been successfully employed for the treatment of other chronic and relapse-prone conditions¹⁷. These rehabilitation strategies can be integrated in individual care, and expanded to group settings, such as Narcotics Anonymous. Medication-assisted treatment programs may also incorporate Naltrexone, a drug that blocks opioid effects, to promote treatment adherence¹⁷. Maintenance strategies for individuals who are unable to discontinue opioid use include using orally-administered opioids to avoid the use of needles, and using long-lasting opioids (methadone or buprenorphine) to avoid daily withdrawal symptoms¹⁷. Significant efforts have been made by state and federal governments to address the growing opioid epidemic in the U.S., including a federal prevention initiative focused on improving the appropriate use of medical products for pain management¹⁸. While national initiatives are being implemented to reduce the burden of opioid dependence in the United States, and while treatments for addressing overdose, acute withdrawal, and rehabilitation, are becoming more accessible, a number of barriers to treatment remain.

Contribution to scientific knowledge

Opioid use disorder (OUD) is a complex condition that affects millions of individuals in the U.S.¹⁹. According to the Department of Health and Human Services, nearly 11.5 million people misused prescription opioids in 2016 alone, with a reported 2.1 million individuals reaching clinical diagnostic criteria for OUD, and 42,249 resulting opioid-related deaths that year¹⁹. While the impact of this public health problem is growing, the etiology of OUD remains poorly understood. Contemporary substance use research, however, has offered insight into some of the factors that may confer risk for OUD.

The major types of individual and group-based interventions for OUD include:

(1) detoxification programs, which use either abrupt termination or gradual dose reduction;

(2) abstinence-based programs which reduce relapses with the use of naltrexone, an opioid antagonist that reduces opioid cravings;

(3) maintenance and harm-reduction programs which limits the risk of relapse and overdoes via substation medication, such as methadone and buprenorphine;

(4) psychosocial interventions, such as enhanced outreach counseling and group therapy; and

(5) crisis management interventions which reduce overdose fatalities using naloxone, an overdose-reversal drug⁸.

A review of the effectiveness of each type of intervention, however, suggests that many interventions produce minimal and unstained improvements in treatment retention, duration of treatment, and opioid use⁸.

While medically assisted treatment (MAT), including Methadone Maintenance Treatment (MMT), has produced substantial improvements in the adherence rates of relapse prevention programs, reports estimate that around 25% of individuals in these programs will drop-out within a year^6,9. A Treatment Improvement Protocol published by the Substance Abuse and Mental Health Services Administration (SAMHSA) highlights the detrimental effects of MAT-stigma on treatment adherence and notes that stigma in relation to MAT may result in shorter treatment length and treatment non-compliance⁹. In line with this report, empirical findings robustly support the negative effects of stigma on treatment adherence across several conditions including schizophrenia and HIV^10-12. Theoretical models of stigma, namely Modified labeling theory²⁰, provide a structure for understanding how the stigma attached to the OUD-label and MAT-label may negatively impact quality of life, self-esteem, and self-efficacy for health behaviors (such as treatment adherence) among individuals with OUD.

The concepts, methods, technologies, treatments, services, or preventative interventions that will be changed if the proposed aims are achieved. Intervention and prevention strategies for reducing opioid use have yet to move beyond micro-level targets, thus neglecting to explore the possible mezzo-level strategies that may help address the opioid crisis. Randomized-controlled trials examining the comparative effectiveness of school-based drug prevention programs suggests that program size, type and level of interaction impact the effectiveness of such prevention efforts, with smaller interactive programs being most effective for preventing substance use, and more time-intensive programs producing greater effects (Tobler et al., 2000). Evidence-based quality criteria are echoed in a subsequent review, adding that community interventions and interventions that use peer leaders are more effective than those without these qualities²¹. Despite these guidelines, practice literature suggests that school-based substance-use prevention programs largely disregard evidence-based practices²², an issue that is exemplified by the national endorsement of Project D.A.R.E., the most widely used school-based drug prevention program in the U.S.²³ which fails to meet quality criteria and produces small effects on drug use behavior²². Furthermore, intervention efforts including abstinence-based programs, psychosocial interventions, and crisis management interventions have been shown to produce minimal and unsustained improvements in treatment retention, duration of treatment and opioid use⁸.

While contemporary research suggests that stigma related to opioid use disorder and being in methadone maintenance treatment is a powerful barrier to treatment adhernece, no intervention programs to date have focused on reducing OUD-related and MMT-related stigma to promote better treatment adherence in this population. Given the limitations of current prevention and intervention efforts and their neglect to address psychosocial factors related to treatment outcomes, this proposal seeks to modify an evidence-based intervention protocol, the Ending Self Stigma intervention (ESS), to address identified stigma-related treatment adherence barriers among individuals with internalized OUD and MMT stigma.

Innovation

Shifting current research and clinical practice paradigms to acknowledge stigma as a pertinent factor in treatment adherence.

While a dearth of U.S.-based qualitative research examining barriers to treatment seeking and treatment adherence among opioid users exists, two recent studies have reported on the role of stigma as an impediment to the treatment of opioid dependence. A qualitative study by Stumbo and Colleagues (2017)²⁴ reported that one participant with OUD originating from pain felt demoralized when participating in treatment alongside others with OUD stemming from illicit drug use. Addiction stigma was further expressed as one participant noted wanting to be treated less like an “addict” and more like someone who had been treated for pain and became dependent on medication²⁴. Woo and Colleagues (2017)²⁵ subsequently conducted a study examining beliefs and attitudes towards methadone maintenance (MMT) treatment among 18 adults in MMT. Results indicated that 78% of participants experienced MMT-related stigma²⁵. Perceived-public stigma of MMT was endorsed by 89% of participants, citing the perception that the public sees MMT as a means to “get high;” participants further expressed perceptions that the public views individuals in MMT as untrustworthy, incapable, and unreliable, especially in the context of employment²⁵. Perceived public attitudes surrounding lack of willpower, and the belief that those in MMT are heroin-users, were also endorsed²⁵. Implications of perceived public stigma included internalized stigma, detrimental impacts on self-esteem, and disinclination to seek or continue MMT²⁵. Taken together, these qualitative studies lend evidence to the detrimental impact of perceived public stigma, and resulting self-stigma, on treatment initiation and adherence among individuals with OUD. Empirical evidence for the effect of self-stigma in particular is prominent in research among those with severe mental illness, a population that experiences high substance-use comorbidity, citing that self-stigma is significantly associated with delayed treatment initiation, and reduced self-esteem and self-efficacy²⁶. Other studies have established a link between dimensions of stigma and treatment adherence among adolescents with OUD, and individuals with HIV, alcohol dependence and depression^11,27-29.

Novel theoretical concepts: Modified Labeling Theory

Modified labeling theory, put forth by Link, Cullen, Struening, Shrout, and Dohrenwend (1989)²⁰ posits that labels of mental illness produce a set of societal beliefs about how to treat individuals in this group, which perpetuate negative expectations, on behalf of group-members, surrounding how they will be treated if their stigmatizing condition is revealed. Elaborating on labeling theory, and the conceptualization of resulting social stigmas, Corrigan, Watson, and Barr (2006)³⁰ operationalized stigma with a four-factor model to delineate between perceived stigma and self-stigma. The four-factor stigma scale, thus, assessed dimensions of: (1) stereotype-awareness, or the extent to which one perceives public stigma, “I think the public believes most persons with mental illness…;” (2) stereotype-agreement, or the extent to which one endorsed these public attitudes, “I think most persons with mental illness are…;” (3) stereotype self-concurrence, or the extent to which stigma is applied to the self, “Because I have mental illness, I…;” and (4) self-esteem decrement, or the extent to which an individual’s self-esteem is impacted by self-concurrence of stigmatizing beliefs, “I currently respect myself less because I…” Notably, a newly validated scale that measures OUD-related stigma specifically, has modified and abbreviated Corrigan’s operationalization of internalized stigma to include only stereotype awareness (“Most people would not marry a person who is addicted to opioids”), stereotype agreement (“I would not marry a person who is addicted to opioids”), and self-concurrence (“I currently respect myself less because I am lazy due to my addiction to opioids”).

Modifying the Ending Self-Stigma Intervention

A promising intervention program for addressing self-stigma, which has been successfully implemented in groups of individuals with mental illness, is the “Ending Self-Stigma” (ESS) program, a 9-session group intervention that incorporates psychoeducation, self-disclosure, and group support, and that, as of 2015, has been offered at 49 agencies across the U.S.^13,31. A central aspect of ESS is the incorporation of a co-facilitator for each group, who may be an individual with lived experience with mental illness, mental health staff, or a peer counselor. Importantly, contact-based interventions, wherein individuals who have overcome stigma co-lead group discussion, have shown promise for reducing internalized stigma in Chinese caregivers of family members with severe mental illness¹⁴, and is currently being implemented among youth that are at clinical high risk for psychosis. Despite this, to date, peer co-led anti-stigma interventions have not been implemented among groups of individuals with OUD.

Approach

Specific Aim 1

To identify levels of internalized stigma (stereotype awareness; stereotype agreement; self-concurrence; and self-esteem decrement) among individuals with OUD in MMT center in NYC.

Hypothesis

Individuals in MMT will report high levels of OUD-related stigma.

Rationale

One crucial element in improving treatment adherence and recovery services for persons with opioid use disorder requires addressing internalized stigma among individuals with OUD. Research consistently reinforces the magnitude of public stigmatizing attitudes towards substance users, with one review noting that opioid misuse, specifically, is perceived as more dangerous and immoral than other substance use disorders³². These stigmatizing public attitudes are also prevalent among non-specialist professionals who might act as a first contact for individuals with OUD^33,34. Research on public attitudes indicates severe stigma towards individuals with OUD, however, studies examining internalized-stigma among opioid users and its resulting impact on treatment seeking and adherence, are just starting to emerge. Additionally, these studies are limited by the use of opioid stigma measures that had not been validated. Given the limitations in the literature, this study will administer a newly developed and validated internalized OUD-stigma measure developed by Yang, Grivel, Stein and Opler (not yet published) to empirically establish baseline levels of OUD-related internalized stigma in this population (See Appendix A, ‘Logic Model’).

Sampling Procedure

Participants will be recruited from the Bronx Lebanon Hospital Center, which provides MMT services for individuals with OUD. The Bronx Lebanon MMT program was chosen given the high rates of opioid use and opioid0realted overdose deaths in Bronx, NY, compared to other NYC boroughs³⁵. One hundred individuals entering an MMT program in will be approached at their time of admission to take part in a survey research study. Inclusion criteria includes: (1) 18 years or older; (2) English-speaking; and (3) able to provide informed consent.

Methods

The OUD-stigma measure is a 15-item self-report questionnaire which assesses three sub-scales of internalized OUD-related stigma. Items assess the following: (1) stereotype awareness (“Most people believe that a person who is addicted to opioids cannot be trusted.”); (2) stereotype agreement (“I believe that a person who is addicted to opioids cannot be trusted”); and (3) self-concurrence (“I currently respect myself less because I cannot be trusted due to my addiction to opioids”). Potential participants will be approached by clinic staff about the opportunity to participate in a short 20-minute questionnaire about the stigma surrounding OUD. Surveys will be administered using a research-use-only iPad via Qualtrics, a highly encrypted survey software which uses secure servers behind multiple firewalls to ensure that participants’ responses are kept confidential. Data will be collected in months 4 to 8 of the award (See Table 1, ‘Study Timeline’).

Table 1. Study Timeline
Timeline	Months 0-3	Months 4-8	Months 8-11	Months 11-16	Months 16-21	Months 21-24
Task	Preparatory Work/ IRB	Administer OUD-stigma measure to N=100 participants + Identify 30 participants with high levels of internalized stigma	Develop semi-structured interview	Conduct semi-structured interviews with N=30 highly stigmatized participants.	Adapt the ESS intervention using qualitative data	Manuscripts preparation + R01 grant preparation to propose efficacy testing of intervention

Analysis

Descriptive statistics will be used to gain a richer understanding of the baseline levels of internalized OUD stigma among individuals entering MMT programs. Participants who report high levels of internalized stigma will be subsequently approached to participate in in-person semi-structured interviews which will probe for more nuanced information regarding OUD-related and MMT-related internalized stigma.

Potential Problems and Alternative Approaches

Despite the increasing visibility of OUD and the national expansion of MMT programs, stigma towards OUD and MMT remain. Given this, it is likely that individuals may hesitate to participate in the 20-minute questionnaire study. To address possible hesitance and discomfort surrounding the topic of the questionnaire, provisions for providing comprehensive competency training to all research staff are set in place. Trainings will emphasize the importance of maintaining open body language and non-judgmental vocabulary. Furthermore, fear of OUD-status or MMT-status disclosure may be salient to this population. Consent forms will clearly state that all information regarding OUD and MMT-status is kept confidential and that all data collected will not be linked to personally identifying information. Research staff will also reiterate provisions for confidentiality. Lastly, monetary remuneration will be provided to all participants to compensate for their time – $30 cash will be provided to individuals who participate.

Specific Aim 2

To develop and administer qualitative semi-structured interviews to examine OUD-related stigma and MMT-related stigma treatment adherence barriers among individuals with internalized OUD stigma. 2A. Design semi-structured interview guide that expands on the OUD stigma measure to include assessment of MMT-related stigma

2B. Conduct semi-structured interviews using the developed OUD/MMT stigma guide.

Hypothesis

Both OUD- and MMT-stigma will be salient aspects of internalized stigma related to treatment adherence.

Rationale

While research on internalized OUD-stigma is expanding, there are few qualitative studies that have examined the nuances of OUD-related internalized stigma. Two recent studies have reported on the role of stigma as an impediment to the treatment of opioid dependence. A qualitative study by Stumbo and Colleagues (2017) reported that one participant with OUD originating from pain felt demoralized when participating in treatment alongside others with OUD stemming from illicit drug use. Addiction stigma was further expressed as one participant noted wanting to be treated less like an “addict” and more like someone who had been treated for pain and became dependent on medication (Stumbo et al., 2017). Notably, no studies to date have qualitatively examined OUD-related internalized stigma specifically among individuals in MMT.

While empirical evidence regarding OUD-related stigma is emerging, there is little quantitative or qualitative research available examining internalized MMT-stigma. One study examined beliefs and attitudes towards MMT among adults enrolled in an MMT program and reported high levels of experienced MMT-related stigma (78%), perceived-public MMT-stigma (89%)²⁵. Implications of perceived public stigma included internalized stigma, detrimental impacts on self-esteem, and disinclination to seek or continue MMT²⁵. As such, it remains crucial to get a deeper understanding of MMT-related stigma among individuals enrolled in MMT programs. Aim 2 of this study will address these gaps by designing and conducting a semi-structured interview that expands on the OUD stigma measure to include an assessment of MMT-related stigma among a novel and understudied group – individuals in MMT.

Sampling Procedure

Data collected through the OUD-stigma questionnaire will be used to identify 30 individuals who report high levels of OUD stigma. These 30 individuals will be approached in-person by research staff at the MMT clinic. Oversampling is used to ensure a big enough sample to reach data saturation.

Methods

The semi-structured interview guide will be developed based on the OUD-stigma measure administered to participants in months 4-8. Questions will be expanded upon and follow-up questions will be developed to probe for subjective experiences of internalized OUD- and MMT-related stigma and its impact on treatment adhernece. Additional questions targeting MMT-related internalized stigma will be developed through collaboration with experts in OUD, MMT, and Stigma. The finalized interview guide will be reviewed by a panel of experts and revised accordingly. Development of the interview guide will take place in months 8-11 of the study (See Table 1, ‘Study Timeline).

Subsequent to developing the interview guide, 30 individuals who were identified as having high internalized stigma (from the internalized OUD-stigma measure) will be contacted to participated in the interview. Interviews will take approximately 45-60minutes. The interview guide will probe for themes regarding subjective experiences of OUD-related and MMT-related internalized stigma and issues surrounding treatment compliance among individuals who are in MMT. The interviewer will be responsible for: (1) using probes to stimulate or clarify the discussion when necessary, (2) monitoring time to ensure all topics are covered, (3) recording any salient themes, ideas or comments, or observations regarding the interview and (4) taking note of other potentially useful information that cannot be captured by the digital recorder, including body language or tone of voice that may be pertinent to a participant’s comment. Data will be transcribed by trained research staff for further analysis.

Analysis

Given that OUD and MMT-related internalized stigma is a lesser-understood phenomenon, a grounded theory analysis approach³⁶ will be used to inductively analyze data and extract pertinent themes related to the stigma of OUD, stigma of MMT, and the impacts of such stigma on treatment adhernece. The identification of salient themes will be facilitated by using NVivo, a qualitative data analysis software.

Potential Problems and Alternative Approaches

Given the sensitive nature of the interview questions, there is a possibility that participant may feel uncomfortable or may want to terminate their participation. The comprehensive training provided to research staff will ensure that staff conduct the interviews in a professional and non-judgmental manner. Furthermore, staff will reiterate that participation in this study is voluntary and that withdrawal from the study will not result in loss to benefits that participants are otherwise entitled to. Consent forms will emphasize that interview questions are focused on sensitive topics and that participation in the study is completely voluntary. Compensation will also be provided to incentivize participation and compensate participants for their time. To incentivize participation and cover basic cost of time, participant will be compensated $100 for completing the interview.

Specific Aim 3

To modify the Ending Self Stigma Intervention to address identified stigma-related treatment adherence barriers among individuals with internalized OUD and MMT stigma. 3A. Incorporate the salient aspects of OUD and MMT stigma into the ESS program components.

Hypothesis

Psychosocial stress related to OUD- and MMT- internalized stigma may modulate opioid treatment adherence trajectories.

Rationale

Given the salience of stigma to individuals with OUD who are in MMT, it is crucial to address modifiable aspects of stigma to promote improved treatment adherence and retention.

While medically assisted treatment (MAT) has made a substantial improvement in the retention rates of relapse prevention programs, 25% of individuals will drop-out within a year^6,9. This is especially problematic as treatment non-compliant individuals are 10 times more likely relapse within months of completing treatment⁷ compared to individuals who comply with treatment. Even more problematic is that relapse is known to increase risk of overdose-related death^4,5. A promising intervention program for addressing self-stigma, which has been successfully implemented in groups of individuals with mental illness, is the “Ending Self-Stigma” (ESS) program, which incorporates psychoeducation, self-disclosure, and group support to effectively reduce internalized stigma among individuals with severe mental illness^13,31. A central aspect of ESS is the incorporation of a co-facilitator for each group, who may be an individual with lived experience with mental illness, mental health staff, or a peer counselor. Importantly, contact-based interventions, wherein individuals who have overcome stigma co-lead group discussion, have shown promise for reducing internalized stigma in Chinese caregivers of family members with severe mental illness (Yang et al., 2014), and is currently being implemented among youth that are at clinical high risk for psychosis. Despite this, to date, peer co-led anti-stigma interventions have not been implemented among groups of individuals with OUD. As such, this proposal will adapt the ESS program to improve the relevancy and reach of this intervention for individuals in MMT programs.

Methods

Pertinent themes related to the OUD-related and MMT-related internalized stigma will inform the modification of the ESS program to reflect unique. Program materials will be created and revised to reflect the themes captured in the semi-structured interviews. The ESS intervention program is a 9-session group intervention that incorporates psychoeducation, self-disclosure, and group support. Modification of the ESS intervention will focus on tailoring the psychoeducational content of each session to address the specific aspects of internalized OUD- and MMT-stigma identified through the semi-structured interviews.

Future Directions

Despite the development and implementation of prevention efforts, the opioid crisis has remained a major public health concern in the U.S. and has required substantial efforts in developing and implementing interventions to improve treatment seeking and adherence and reduce relapse. While this study will (1) provide insight into the role of internalized OUD- and MMT-related stigma in treatment adhernece, and (2) will produce a fully adapted intervention manual aimed at reducing internalized stigma among individuals in MMT, testing the efficacy and effectiveness of this intervention is beyond the scope of this proposal. As such, the development of an R01 grant, starting in month 21 of this project, will be focused on proposing a randomized controlled trial to establish preliminary efficacy of this manual in producing desired changes in internalized stigma, and treatment adhernece among individuals in MMT.

Notably, the majority of intervention efforts have been made at the individual- and group-levels, with little consideration for organizational-level interventions. Furthermore, while Policy-level interventions are less studied, some have been effective in reducing the number of opioids in circulation and the number of opioid-related overdoses. Such has been the case for the Governor’s Cabinet Opiate Action Team in Ohio tasked with implementing opioid overdose prevention programs and public awareness campaigns³⁷. While the proposed study seeks to fill gaps in the field’s understanding of internalized stigma and its impacts on treatment adhernece, as well as to develop a tailored intervention to reduce internalized stigma and promote treatment adherence among individuals in MMT, it does not address the dearth of higher-level interventions targeted towards improving treatment outcomes in this population. As such, future studies should focus on identifying modifiable factors at the organizational- or policy-level that would promote better treatment adhernece, treatment retention, and improve relapse rates in this group.

Endnotes

1. Control CfD, Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morbidity and mortality weekly report. 2011;60(43):1487.

2. Opioid Overdose Crisis. 2018, Frbruary 01; https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis.

3. Bose J, Hedden S, Lipari R, Park-Lee E. Key Substance use and mental health indicators in the United States: results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). 2016. 2017.

4. Esteban J, Gimeno C, Barril J, Aragonés A, Climent JMa, de la Cruz Pellı́n Ma. Survival study of opioid addicts in relation to its adherence to methadone maintenance treatment. Drug & Alcohol Dependence. 2003;70(2):193-200.

5. Strang J, McCambridge J, Best D, et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. Bmj. 2003;326(7396):959-960.

6. Kakko J, Svanborg KD, Kreek MJ, Heilig M. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. The Lancet. 2003;361(9358):662-668.

7. Tkacz J, Severt J, Cacciola J, Ruetsch C. Compliance with buprenorphine medication‐assisted treatment and relapse to opioid use. The American Journal on Addictions. 2012;21(1):55-62.

8. Veilleux JC, Colvin PJ, Anderson J, York C, Heinz AJ. A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction. Clinical psychology review. 2010;30(2):155-166.

9. Treatment CfSA. Medication-assisted treatment for opioid addiction in opioid treatment programs. 2005.

10. Fung KM, Tsang HW, Corrigan PW. Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatric Rehabilitation Journal. 2008;32(2):95.

11. Katz IT, Ryu AE, Onuegbu AG, et al. Impact of HIV‐related stigma on treatment adherence: systematic review and meta‐synthesis. Journal of the International AIDS Society. 2013;16(3S2).

12. Tsang HW-h, Fung KM-t, Chung RC-k. Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia. Psychiatry Research. 2010;180(1):10-15.

13. Lucksted A, Drapalski A, Calmes C, Forbes C, DeForge B, Boyd J. Ending self-stigma: Pilot evaluation of a new intervention to reduce internalized stigma among people with mental illnesses. Psychiatric Rehabilitation Journal. 2011;35(1):51.

14. Yang LH, Lai GY, Tu M, et al. A brief anti-stigma intervention for Chinese immigrant caregivers of individuals with psychosis: adaptation and initial findings. Transcultural psychiatry. 2014;51(2):139-157.

15. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers–United States, 2002–2004 and 2008–2010. Drug & Alcohol Dependence. 2013;132(1):95-100.

16. Rudd RA. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morbidity and mortality weekly report. 2016;65.

17. Schuckit MA. Treatment of opioid-use disorders. New England Journal of Medicine. 2016;375(4):357-368.

18. Medical Product Safety. . n.d.; https://www.healthypeople.gov/2020/topics-objectives/topic/medical-product-safety/objectives.

19. (ASPA) ASoPA. About the U.S. Opioid Epidemic. 2018, March 06; https://www.hhs.gov/opioids/about-the-epidemic/.

20. Link BG, Cullen FT, Struening E, Shrout PE, Dohrenwend BP. A modified labeling theory approach to mental disorders: An empirical assessment. American sociological review. 1989:400-423.

21. Cuijpers P. Effective ingredients of school-based drug prevention programs: A systematic review. Addictive behaviors. 2002;27(6):1009-1023.

22. Ennett ST, Ringwalt CL, Thorne J, et al. A comparison of current practice in school-based substance use prevention programs with meta-analysis findings. Prevention Science. 2003;4(1):1-14.

23. Kumar R, O’Malley PM, Johnston LD, Laetz VB. Alcohol, tobacco, and other drug use prevention programs in US schools: a descriptive summary. Prevention science. 2013;14(6):581-592.

24. Stumbo SP, Yarborough BJH, McCarty D, Weisner C, Green CA. Patient-reported pathways to opioid use disorders and pain-related barriers to treatment engagement. Journal of substance abuse treatment. 2017;73:47-54.

25. Woo J, Bhalerao A, Bawor M, et al. “Don’t Judge a Book by Its Cover”: A Qualitative Study of Methadone Patients’ Experiences of Stigma. Substance abuse: research and treatment. 2017;11:1178221816685087.

26. Luoma JB, Kohlenberg BS, Hayes SC, Bunting K, Rye AK. Reducing self-stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addiction Research & Theory. 2008;16(2):149-165.

27. Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Friedman SJ, Meyers BS. Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric services. 2001;52(12):1615-1620.

28. Wu L-T, Blazer DG, Li T-K, Woody GE. Treatment use and barriers among adolescents with prescription opioid use disorders. Addictive Behaviors. 2011;36(12):1233-1239.

29. Keyes K, Hatzenbuehler M, McLaughlin K, et al. Stigma and treatment for alcohol disorders in the United States. American journal of epidemiology. 2010;172(12):1364-1372.

30. Corrigan PW, Watson AC, Barr L. The self–stigma of mental illness: Implications for self–esteem and self–efficacy. Journal of social and clinical psychology. 2006;25(8):875-884.

31. Yanos PT, Lucksted A, Drapalski AL, Roe D, Lysaker P. Interventions targeting mental health self-stigma: A review and comparison. Psychiatric rehabilitation journal. 2015;38(2):171.

32. Yang LH, Wong LY, Grivel MM, Hasin DS. Stigma and substance use disorders: an international phenomenon. Current opinion in psychiatry. 2017;30(5):378-388.

33. Lloyd C. The stigmatization of problem drug users: A narrative literature review. Drugs: education, prevention and policy. 2013;20(2):85-95.

34. Olsen Y, Sharfstein JM. Confronting the stigma of opioid use disorder—and its treatment. Jama. 2014;311(14):1393-1394.

35. Health Department Releases 2016 Drug Overdose Death Data in New York City — 1,374

Deaths Confirmed, A 46 Percent Increase From 2015. 2017; https://www1.nyc.gov/site/doh/about/press/pr2017/pr048-17.page.

36. Corbin JM, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative sociology. 1990;13(1):3-21.

37. Penm J, MacKinnon NJ, Boone JM, Ciaccia A, McNamee C, Winstanley EL. Strategies and policies to address the opioid epidemic: a case study of Ohio. Journal of the American Pharmacists Association. 2017;57(2):S148-S153.

Bibliography

Assistant Secretary of Public Affairs (ASPA). (2018, March 06). About the U.S. Opioid Epidemic. Retrieved March 08, 2018, from https://www.hhs.gov/opioids/about-the-epidemic/

Bose, J., Hedden, S. L., Lipari, R. N., & Park-Lee, E. (2017). Key Substance use and mental health indicators in the United States: results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). 2016.

Centers for Disease Control and Prevention (CDC). (2011). Vital signs: Overdoses of prescription opioid pain relievers – United States, 1999–2008. MMWR. Morbidity and Mortality Weekly Report, 60(43), 1487.

Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid addiction in opioid treatment programs.

Corbin, J. M., & Strauss, A. (1990). Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative sociology, 13(1), 3-21.

Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The self–stigma of mental illness: Implications for self esteem and self–efficacy. Journal of social and clinical psychology, 25(8), 875-884.

Cuijpers, P. (2002). Effective ingredients of school-based drug prevention programs: A systematic review. Addictive behaviors, 27(6), 1009-1023.

Ennett, S. T., Ringwalt, C. L., Thorne, J., Rohrbach, L. A., Vincus, A., Simons-Rudolph, A., & Jones, S. (2003). A comparison of current practice in school-based substance use prevention programs with meta-analysis findings. Prevention Science, 4(1), 1-14.

Esteban, J., Gimeno, C., Barril, J., Aragonés, A., Climent, J. M., & de la Cruz Pellı́n, M. (2003). Survival study of opioid addicts in relation to its adherence to methadone maintenance treatment. Drug & Alcohol Dependence, 70(2), 193-200.

Fung, K. M., Tsang, H. W., & Corrigan, P. W. (2008). Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatric Rehabilitation Journal, 32(2), 95.

Health Department Releases 2016 Drug Overdose Death Data in New York City — 1,374 Deaths Confirmed, A 46 Percent Increase From 2015. (2017, June 13). Retrieved from https://www1.nyc.gov/site/doh/about/press/pr2017/pr048-17.page

Jones, C. M. (2013). Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers–United States, 2002–2004 and 2008–2010. Drug & Alcohol Dependence, 132(1), 95-100.

Kakko, J., Svanborg, K. D., Kreek, M. J., & Heilig, M. (2003). 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. The Lancet, 361(9358), 662-668.

Katz, I. T., Ryu, A. E., Onuegbu, A. G., Psaros, C., Weiser, S. D., Bangsberg, D. R., & Tsai, A. C. (2013). Impact of HIV‐related stigma on treatment adherence: systematic review and meta‐synthesis. Journal of the International AIDS Society, 16(3S2).

Keyes, K. M., Hatzenbuehler, M. L., McLaughlin, K. A., Link, B., Olfson, M., Grant, B. F., & Hasin, D. (2010). Stigma and treatment for alcohol disorders in the United States. American Journal of Epidemiology, 172(12), 1364-1372.

Kumar, R., O’Malley, P. M., Johnston, L. D., & Laetz, V. B. (2013). Alcohol, tobacco, and other drug use prevention programs in US schools: a descriptive summary. Prevention science, 14(6), 581-592.

Link, B. G., Cullen, F. T., Struening, E., Shrout, P. E., & Dohrenwend, B. P. (1989). A modified labeling theory approach to mental disorders: An empirical assessment. American sociological review, 400-423.

Lloyd, C. (2013). The stigmatization of problem drug users: A narrative literature review. Drugs: education, prevention and policy, 20(2), 85-95.

Lucksted, A., Drapalski, A., Calmes, C., Forbes, C., DeForge, B., & Boyd, J. (2011). Ending self-stigma: Pilot evaluation of a new intervention to reduce internalized stigma among people with mental illnesses. Psychiatric Rehabilitation Journal, 35(1), 51.

Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., Bunting, K., & Rye, A. K. (2008). Reducing self stigma in substance abuse through acceptance and commitment therapy: Model, manual development, and pilot outcomes. Addiction Research & Theory, 16(2), 149-165.

Medical Product Safety. (n.d.). Retrieved February 16, 2018, from https://www.healthypeople.gov/2020/topics-objectives/topic/medical-product-safety/objectives

Olsen, Y., & Sharfstein, J. M. (2014). Confronting the stigma of opioid use disorder—and its treatment. Jama, 311(14), 1393-1394.

Opioid Overdose Crisis. (2018, February 01). Retrieved February 15, 2018, from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

Penm, J., MacKinnon, N. J., Boone, J. M., Ciaccia, A., McNamee, C., & Winstanley, E. L. (2017). Strategies and policies to address the opioid epidemic: a case study of Ohio. Journal of the American Pharmacists Association, 57(2), S148-S153.

Rudd, R. A. (2016). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR. Morbidity and Mortality Weekly Report, 65.

Schuckit, M. A. (2016). Treatment of opioid-use disorders. New England Journal of Medicine, 375(4), 357-368.

Sirey, J. A., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Friedman, S. J., & Meyers, B. S. (2001). Stigma as a barrier to recovery: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services, 52(12), 1615- 1620.

Strang, J., McCambridge, J., Best, D., Beswick, T., Bearn, J., Rees, S., & Gossop, M. (2003). Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. Bmj, 326(7396), 959-960.

Stumbo, S. P., Yarborough, B. J. H., McCarty, D., Weisner, C., & Green, C. A. (2017). Patient reported pathways to opioid use disorders and pain-related barriers to treatment engagement. Journal of Substance Abuse Treatment, 73, 47-54.

Tsang, H. W. H., Fung, K. M. T., & Chung, R. C. K. (2010). Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia. Psychiatry Research, 180(1), 10-15.

Tkacz, J., Severt, J., Cacciola, J., & Ruetsch, C. (2012). Compliance with buprenorphine medication assisted treatment and relapse to opioid use. The American Journal on Addictions, 21(1), 55-62.

Veilleux, J. C., Colvin, P. J., Anderson, J., York, C., & Heinz, A. J. (2010). A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction. Clinical psychology review, 30(2), 155-166.

Woo, J., Bhalerao, A., Bawor, M., Bhatt, M., Dennis, B., Mouravska, N., … & Samaan, Z. (2017). “Don’t Judge a Book by Its Cover”: A qualitative study of methadone patients’ experiences of stigma. Substance Abuse: Research and Treatment, 11, 1178221816685087.

Wu, L. T., Blazer, D. G., Li, T. K., & Woody, G. E. (2011). Treatment use and barriers among adolescents with prescription opioid use disorders. Addictive Behaviors, 36(12), 1233- 1239.

Yang, L. H., Lai, G. Y., Tu, M., Luo, M., Wonpat-Borja, A., Jackson, V. W., … & Dixon, L. (2014). A brief anti-stigma intervention for Chinese immigrant caregivers of individuals with psychosis: adaptation and initial findings. Transcultural Psychiatry, 51(2), 139-157.

Yang, L. H., Wong, L. Y., Grivel, M. M., & Hasin, D. S. (2017). Stigma and substance use disorders: an international phenomenon. Current opinion in psychiatry, 30(5), 378-388.

Yanos, P. T., Lucksted, A., Drapalski, A. L., Roe, D., & Lysaker, P. (2015). Interventions targeting mental health self-stigma: A review and comparison. Psychiatric Rehabilitation Journal, 38(2), 171.