Internalized Stigma Among People Who Inject Drugs

Background: Perceived experiences of stigma have been found to be associated with poorer psychosocial outcomes and engagement in risk practices among people who inject drugs. Yet the extent to which people internalize or accept the stigma surrounding their injecting drug use, and whether this is associated with risky injecting practices, is not well known. Objectives: The aim of this study was to assess the extent of internalized stigma among a sample of people who inject drugs in Australia and identify socio-demographic, injecting risk, and mental health correlates. Methods: People who inject drugs were recruited from a needle and syringe program located in Sydney, Australia to complete a brief survey. The survey included measures of internalized stigma, severity of drug dependence, self-esteem, depression, and shared use of injecting equipment. Results: The sample comprised 102 people who inject drugs. Internalized stigma was higher among participants who reported being depressed in the past month, and was also associated with greater severity of drug dependence and diminished self-esteem. There was no relationship between internalized stigma and shared use of needles or other injecting equipment in the past month. Conclusions/Importance: Findings underscore the need for further investigation of internalized stigma among people who inject drugs. In particular, future research should assess the impact of implicit (i.e., subconscious) internalized stigma on mental health.     

Cigarette Smoking in Youths With Mental Health and Substance Use Problems: Prevalence,Patterns, and Potential for Intervention

Mental health symptoms and substance use disorders are clear risk factors for cigarette smoking and nicotine dependence among young people, yet research on cigarette smoking among youths with concurrent mental health and substance use disorders (“dual diagnosis”) is considerably lacking. We examined smoking history and perspectives regarding smoking, cessation, and mental health and substance use in 97 adolescents and emerging adults (ages 14 to 24) referred to a program for youths with concurrent mental health and substance use disorders in Canada. Results show high rates of cigarette smoking, and modest interest in quitting but little interest in attending formalized programs to assist with cessation. Many participants reported smoking more when mental health was worse; most reported that they frequently smoke cigarettes and use drugs or alcohol concurrently. Current smokers perceived more benefits from cigarette smoking in regulating emotions and ameliorating their mental health symptoms than former smokers. In contrast, perceived detrimental effects of smoking were unrelated to current smoking status. Results suggest a need for integrated treatment that incorporates emotion regulation as part of cessation approaches. Integrating smoking cessation approaches into existing mental health and substance use treatments may be more palatable to adolescents and emerging adults than stand-alone smoking cessation programs.     

Biased labels: An experimental study of language and stigma among individuals in recovery and health professionals

Background: Labels such as “addict” and “substance abuser” have been found to elicit implicit and explicit stigma among the general public previously. The difference in the levels of this bias among individuals in recovery and those employed in the health profession has not yet been identified, however. The current study seeks to answer this question using measures of implicit bias. Methods: A subset sample (n?=?299) from a previously completed study (n?=?1288) was selected for analysis. Mixed-model ANOVA tests were completed to identify variance between d-prime automatic association scores with the terms “addict” and “substance abuser” among individuals in recovery and those identified as working in the health professions. Results: Individuals in recovery did not have lower negative associations with either term, whereas individuals employed as health professionals had greater negative associations with the term “substance abuser” but did not have greater negative associations with the term “addict.” Conclusions: Results provide further evidence that previously identified stigmatizing labels have the potential to influence medical care and medical practitioner perceptions of individuals with substance use disorders and should be avoided. Further exploration into the role negative associations derived from commonly used labels have in the individual recovery process is needed to draw appropriate recommendations.     

The Rapid Recovery Progression Measure: A Brief Assessment of Biopsychosocial Functioning During Substance Use Disorder Recovery

Background: There is debate in the literature around how to measure outcomes in treatment and recovery from substance use disorder (SUD). Various constructs have been suggested as appropriate including “recovery capital” and “treatment progression.” To contribute to this debate, the construct of “recovery progression” has been suggested by the authors, and a psychometric assessment, the Recovery Progression Measure (RPM). Although published psychometrics data have demonstrated the RPM to be reliable, at 36-item long, it may be too lengthy to complete in clinic environments. Therefore, a shorter version has been developed, the Rapid RPM. Objectives: To examine reliability, validity, sensitivity and specificity of the Rapid RPM via data from 9208 service users. Methods: Data were collected from service users accessing the Breaking Free Online (BFO) treatment and recovery program, which has within its baseline assessment the six-item, 11-point Likert scale Rapid RPM. Psychometric properties were examined. Results: Internal reliability of the Rapid RPM was excellent, α =.92. The Rapid RPM also had good concurrent and predictive validity, with baseline scores, and changes in scores to follow-up, being significantly associated with scores on standardized measures of common mental health sequela, severity of substance dependence and quality of life, and changes in self-reported substance use. The Rapid RPM was also able to differentiate between participants scoring above thresholds on these measures for clinically relevant substance dependence and mental health difficulties. Conclusions: This study provides data to support reliability, validity, sensitivity and specificity of the Rapid RPM, indicating potential as a clinical tool.     

Attitudes and Perceived Social Norms toward Drug Use among Gay and Bisexual Men in Australia

Background: Gay and bisexual men (GBM) report distinctive patterns and contexts of drug use, yet little has been published about their attitudes toward drug use. Objectives: We developed measures of attitudes and perceived social norms toward drug use, and examined covariates of more accepting attitudes and norms among GBM in Australia. Methods: We analyzed baseline data from the Following Lives Undergoing Change (Flux) study. Flux is an online prospective observational study of drug use among Australian GBM. We used principal components factor analysis to generate two attitudinal scales assessing “drug use for social and sexual enhancement” and “perceptions of drug risk.” A third perceived social norms scale examined “acceptability of drug use among gay friends.” Results: Among 2,112 participants, 61% reported illicit drug use in the preceding six months. Stronger endorsement of drug use for social and sexual engagement and lower perceptions of drug risk were found among men who were more socially engaged with other gay men and reported regular drug use and drug use for sex. In multivariate analyses, all three scales were associated with recent drug use (any use in the previous six months), but only the drug use for social and sexual enhancement scale was associated with regular (at least monthly) use. Conclusions: Drug use and sex are difficult to disentangle for some GBM, and health services and policies could benefit from a better understanding of attitudinal and normative factors associated with drug use in gay social networks, while recognizing the role of pleasure in substance use.     

Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms

ObjectiveStigma is a frequently cited barrier to help-seeking for many with substance-related conditions. Common ways of describing individuals with such problems may perpetuate or diminish stigmatizing attitudes yet little research exists to inform this debate. We sought to determine whether referring to an individual as “a substance abuser” vs. “having a substance use disorder” evokes different judgments about behavioral self-regulation, social threat, and treatment vs. punishment.MethodA randomized, between-subjects, cross-sectional design was utilized. Participants were asked to read a vignette containing one of the two terms and to rate their agreement with a number of related statements. Clinicians (N = 516) attending two mental health conferences (63% female, 81% white, M age 51; 65% doctoral-level) completed the study (71% response rate). A Likert-scaled questionnaire with three subscales [“perpetrator-punishment” (α = .80); “social threat” (α = .86); “victim-treatment” (α = .64)] assessed the perceived causes of the problem, whether the character was a social threat, able to regulate substance use, and should receive therapeutic vs. punitive action.ResultsNo differences were detected between groups on the social threat or victim-treatment subscales. However, a difference was detected on the perpetrator-punishment scale. Compared to those in the “substance use disorder” condition, those in the “substance abuser” condition agreed more with the notion that the character was personally culpable and that punitive measures should be taken.ConclusionsEven among highly trained mental health professionals, exposure to these two commonly used terms evokes systematically different judgments. The commonly used “substance abuser” term may perpetuate stigmatizing attitudes.     

A latent class analysis of the co-occurrence of sexual violence,substance use,and mental health in youth

Purpose: The purpose of this study was to understand co-occurrence of sexual violence, substance use, and mental health in youth and see if there are differences in experiences among sexual identities, races, and genders. Methods: The 2017 Youth Risk Behavior Survey sampled 14,638 high school students. Latent class analysis was used to understand the relationship between incidence of sexual violence, substance use, and depression and suicidality in a nationally representative sample. The model controlled for demographic and bullying covariates. Results: A four-class solution provided optimal fit. Classes were low risk (51.8%); low violence, frequent substance use, and high depression and suicidal ideation (29.7%); experienced violence and moderate mental health issues(5.1%); and some violence, high substance use, and high depression and suicidal ideation (13.4%). Youth who identified as sexual minority youth were almost 2.5–5 times more likely to be in the three higher risk classes than their heterosexual peers. Those who identified as “I don’t know” were almost 3 times more likely to be in the three higher risk classes than heterosexual youth. Multiracial youth had higher likelihood of being in the three riskier classes compared to Caucasian youth. Females were 2.5 and 3 times more likely to be in the low violence and some violence classes compared to males. Conclusion: The study’s finding distinct classes of co-occurring behavioral and mental health outcomes fill gaps in the current literature and informs practitioners that LGB youth and bi/multiracial youth were at an elevated risk of co-occurring victimization, substance use, and mental health problems.     

INTEREST IN AND OBSTACLES TO PURSUING WORK AMONG UNEMPLOYED DUALLY DIAGNOSED INDIVIDUALS

Employment status is commonly used as a sign of stability in recovery and an outcome variable for substance abuse treatment and research. However, there has been little attention in the literature on the topic of work for the dually diagnosed (i.e., persons diagnosed with both substance use and mental health disorders). Data collected in 1999 are presented on expressed interest in and perceived barriers to pursuing work and on the utilization of vocational rehabilitation (voc-rehab) services among unemployed members of a dual recovery self-help fellowship (N = 130). While members generally expressed high interest in working, they also cited multiple obstacles to attaining and maintaining employment. A path model was specified and tested. Significant contributors to interest in working were substance use status and physical health rating. Consistent with our hypotheses, mental health symptoms and greater perceived obstacles (e.g., stigma, fear of failure, and insufficient skills) were significant contributors to perceived difficulty in pursuing work, whereas substance use, physical health, and recency of employment were not. Finally, those who perceived less difficulty in pursuing work were more likely to utilize voc-rehab services, and men were more likely than women to use these facilities; interest in work was not significantly associated with utilizing voc-rehab services. The roles of mental health disorders and substance use in relation to pursuit of employment are discussed, as well as that of perceived obstacles such as stigma. The paper addresses the setting of realistic vocational goals and possible strategies to mitigate barriers to increased employment of dually diagnosed individuals.     

“I'm Going to Shut Down All of Your Tricks”: Depictions of Treatment Professionals in Addiction Entertainment

Background: Previous research on addiction themed reality television shows has focused on the depiction of addiction and treatment and has concluded that these shows reinforce stigma. Existing research has not investigated the depiction of treatment professionals in these series. Objectives: This study fills the gap in existing research by analyzing the representations of treatment professionals in reality television shows, including the ways that the shows are edited, the statements made by treatment professionals, and interactions between treatment professionals and laypersons. Methods: The data for this study was drawn from two popular reality shows Intervention and Celebrity Rehab with Dr. Drew. Using a total of 117 episodes, a qualitative content analysis of the representations of treatment professionals in the two series was conducted. Results: The data reveal the ways that depictions of treatment professionals are carefully controlled compared to those of people with substance use issues. In addition, treatment professionals are granted opportunities to interpret, explain, and diagnose the behaviors and experiences of people with substance use problem. Finally, when confronted with resistance treatment professionals assert their authority and demand compliance with their orders. Conclusions/Importance: In strategically presenting treatment professionals in sharp contrast to people with substance use problems, these portrayals of treatment professionals actually reinforce rather than contradict the stigma of addiction.     

Socio-demographic characteristics and stereotyping of people who frequently attend accident and emergency departments for alcohol-related reasons: Qualitative study

Abstract

Aims: To provide new insights into the socio-demographic characteristics of people who frequently attend Accident and Emergency (A&E) departments for alcohol-related reasons and to explore the findings with reference to stereotyping and prejudice. Methods: Semi-structured qualitative interviews with 30 individuals (18 males; 12 females; aged 20–68 years) recruited from six A&E departments across London, United Kingdom. Participants had all attended A&E ≥10 times within the last year or ≥5 times in the last three months for an alcohol-related condition. Detailed data relating to participants’ socio-demographic characteristics were systematically coded and analysed. Findings: Participants reported many years of heavy drinking, and high levels of mental and physical ill health, unemployment, dependence on state benefits, housing problems and social isolation. Frequency of A&E attendances varied greatly by participant, patterns of drinking and other substance use were diverse, and the nature and extent of self-reported health and social problems were wide-ranging. Conclusions: Findings suggest that people who regularly attend A&E for alcohol-related reasons collectively experience multiple and complex needs, but individually have diverse patterns of drinking and other problems. Flexible person-centred systems could help to support this patient population, whilst avoidance of terminology that overstates group traits should help to minimise stigma.     

The relationship between social desirability bias and self-reports of health,substance use,and social network factors among urban substance users in Baltimore,Maryland

BackgroundSocial desirability response bias may lead to inaccurate self-reports and erroneous study conclusions. The present study examined the relationship between social desirability response bias and self-reports of mental health, substance use, and social network factors among a community sample of inner-city substance users.MethodsThe study was conducted in a sample of 591 opiate and cocaine users in Baltimore, Maryland from 2009 to 2013. Modified items from the Marlowe-Crowne Social Desirability Scale were included in the survey, which was conducted face-to-face and using Audio Computer Self Administering Interview (ACASI) methods.ResultsThere were highly statistically significant differences in levels of social desirability response bias by levels of depressive symptoms, drug use stigma, physical health status, recent opiate and cocaine use, Alcohol Use Disorders Identification Test (AUDIT) scores, and size of social networks. There were no associations between health service utilization measures and social desirability bias. In multiple logistic regression models, even after including the Center for Epidemiologic Studies Depression Scale (CES-D) as a measure of depressive symptomology, social desirability bias was associated with recent drug use and drug user stigma. Social desirability bias was not associated with enrollment in prior research studies.ConclusionsThese findings suggest that social desirability bias is associated with key health measures and that the associations are not primarily due to depressive symptoms. Methods are needed to reduce social desirability bias. Such methods may include the wording and prefacing of questions, clearly defining the role of “study participant,” and assessing and addressing motivations for socially desirable responses.     

Substance Use and Mental Illness Among Nurses: Workplace Warning Signs and Barriers to Seeking Assistance

Background: Although some studies have examined the prevalence of substance use among nurses, few have assessed substance use in the workplace or early cues for identifying these health conditions. Primary data collected as part of a larger program evaluation were examined with the purpose of better understanding (a) the context and perceived consequences of substance use and mental illness among nurses and (b) barriers and opportunities for earlier identification and treatment of these issues among nurses, their colleagues, and employers. Methods: Anonymous surveys were mailed to 441 active and recent participants of a peer health assistance program in the summer of 2010. The survey examined drug-related behaviors in the workplace; behavioral cues that may permit earlier identification of substance use and mental illness; perceptions of barriers to seeking assistance; and strategies for preventing problems and overcoming barriers to seeking assistance. Results: Responses were received from 302 nurses (69%). Nearly half (48%) reported drug or alcohol use at work, and two fifths (40%) felt that their competency level was affected by their use. More than two thirds of respondents thought their problem could have been recognized earlier. The most highly rated barriers to seeking assistance for substance use and mental illness included fear and embarrassment and concerns about losing one's nursing license. Respondents recommended greater attention be paid to early identification of risk factors during nurses’ professional training as a prevention strategy. Conclusions: Findings from this study provide preliminary data that can be used by schools of nursing and health care employers to improve early identification of nurses’ substance use and mental illness treatment needs. These data also suggest a need for more research to explore the prevention and early identification of co-occurring disorders in health care settings where nurses practice.     

Friends matter but so does their substance use: The impact of social networks on substance use,offending and wellbeing among young people attending specialist alcohol and drug treatment services

Abstract

Aims: The current study assesses the impact of youth drug treatment on substance use, offending and wellbeing in a sample of young people recruited from specialist youth alcohol and drug treatment. The paper examines the impact of treatment engagement on the size and substance use profile of the young person's social network and hypothesises that the best treatment outcomes are associated with maintaining the size of the young person's social network but changing its composition to reduce the representation of substance use in social networks. Methods: A cohort study of 112 young people (aged 16–21) engaged in specialist youth alcohol and drug treatment services in Victoria, Australia, were recruited at the beginning of treatment and re-interviewed six months later using a structured questionnaire. Findings: There were improvements in substance use, social functioning, mental health and life satisfaction from baseline to follow-up. While network size was associated with mental health and quality of life markers, only having a lower proportion of substance users in the social network was associated with lower substance use and offending at follow-up. Conclusions: Social networks are a key component of wellbeing in adolescence. This study suggests that through independent analysis of network size and network composition, both the size and the composition of social networks have an important role to play in developing interventions for adolescent substance users that will sustain behaviour changes achieved in specialist treatment.     

“Stigma is where the harm comes from”: Exploring expectations and lived experiences of hepatitis C virus post-treatment trajectories among people who inject drugs

BackgroundThe advent of direct-acting antiviral (DAA) medications has facilitated opportunities to treat hepatitis C virus (HCV) among people who inject drugs (PWID). However, there remains a need for data about how to optimally support PWID throughout DAA post-treatment trajectories, including with regard to re-infection prevention. The objective of this study is therefore to identify how PWID with lived experience of HCV describe their expectations and experiences related to health and social outcomes, contexts, and substance use practices following completion of DAA treatment.MethodsWe thematically analyzed data from in-depth, semi-structured interviews, conducted between January and June 2018, in Vancouver, Canada, with a purposive sample (n = 50) of PWID at various stages of DAA treatment (e.g., pre, peri, post).ResultsOur analysis yielded three themes. First, while participants had hoped to experience holistic enhancements in wellbeing following HCV cure, discussions of actual post-treatment experiences tended to be located in physical health (e.g., increased energy). Second, participants often pointed to the ways in which HCV-related and other stigmas had restricted opportunities for health and healthcare access. Participants therefore identified stigma-reduction as a key motivator of HCV cure, and while reductions in internalized stigma were sometimes achieved, participants underscored that other forms of enacted stigma (e.g., related to: substance use, HIV, poverty) had continued to feature prominently in their post-treatment lives. Third, participants described considerable knowledge about how to prevent HCV re-infection following cure, but they also expressed apprehensiveness about how socio-structural barriers, including stigma and criminalization, could interfere with harm reduction and re-infection prevention efforts.ConclusionsDAAs are transforming the health and wellbeing of some PWID. Yet, HCV-related policy must extend beyond the scale-up of DAAs to include concerted public health investments, including anti-stigma efforts and improvements to the social welfare system, to meaningfully advance equity in PWID's post-treatment trajectories and outcomes.     

Gender Differences in Substance Use,Consequences, Motivation to Change,and Treatment Seeking in People With Serious Mental Illness

Gender differences in patterns and consequences of substance use, treatment-seeking, and motivation to change were examined in two samples of people with serious mental illness (SMI) and comorbid substance use disorders (SUDs): a community sample not currently seeking substance abuse treatment (N = 175) and a treatment-seeking sample (N = 137). In both groups, women and men demonstrated more similarities in the pattern and severity of their substance use than differences. However, treatment-seeking women showed greater readiness to change their substance use. Mental health problems and traumatic experiences may prompt people with SMI and SUD to enter substance abuse treatment, regardless of gender.     

Perceived risk associated with tobacco,alcohol and cannabis use among people with and without psychotic disorders

Background

Perceived harmfulness of substances is a key concept of behavioural theories that have been used to explain substance use behaviours. However, perceptions of risk associated with substance use have rarely been examined among people with psychotic disorders. This study examined the relationship between perceived harm and patterns of substance use among people with and without psychotic disorders. It also aimed to identify the factors that may be associated with perceived harmfulness of tobacco, alcohol and cannabis use among these populations.

Methods

Participants were recruited via first year psychology courses, research databases and the social networking service ‘Facebook’. Participants completed a self-report questionnaire either online or on paper which assessed substance use, perceived harmfulness of substance use, history of mental illness, current psychological distress, and exposure to and acceptance of anti-substance use campaigns. A series of linear regressions were conducted to examine key predictors of the perceived harmfulness of tobacco, alcohol and cannabis use.

Results

1046 participants were recruited. Participants were aged 18 to 86 years and 53.2% were female. For tobacco and cannabis, substance use was found to be inversely and significantly related to perceived harm of these substances. In addition, higher risk perceptions for tobacco and cannabis were associated with: being female, perceived effectiveness of anti-substance use campaigns, and less hazardous substance use. Increased age and negative psychosis status were also associated with higher risk perceptions for tobacco, while positive psychosis status was associated with higher risk perceptions for cannabis. Only perceived effectiveness of anti-drinking campaigns was found to be significantly related to perceived harmfulness of alcohol.

Conclusions

These results suggest that demographic, substance use, mental health and public health campaign variables are associated with perceptions of the harmfulness of tobacco, cannabis, and to a lesser extent alcohol, among people with and without mental disorders. While messages regarding the negative consequences associated with cannabis use among people with psychotic disorders may be accepted, there is a continued need to highlight the negative consequences of smoking among people with psychotic disorders.