Exploring the public stigma of substance use disorder through community-based participatory research

Background: In their 2016 report, the National Academy of Sciences identified that the existing literature on the stigma of substance use disorder (SUD) is sparse compared to the stigma of mental illness.

Methods: This study utilizes a community-based participatory research (CBPR) approach to identify stereotypes, prejudice, and discrimination of SUD from the perspectives of important stakeholders such as current users, former users, family members, and service providers.

Results: Findings from twelve focus groups (n?=?99) revealed a total of 66 stigma themes. Stereotype themes for people with SUD included dangerous, self-destructive, and no job potential. Themes for prejudice included fear, pity, confusion, and indifference. Themes for discrimination included avoidance, being suspicious, and drug testing.

Conclusion: Thematic analyzes revealed that the stigma of SUD shares similarities with the stigma of mental illness, but important differences exist. Among these differences are criminal stereotypes, subtle prejudice such as curiosity, and discrimination through drug testing. Implications for future research are discussed.     

“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.     

Alcohol Use,High Risk Behaviors,and Experiences of Discrimination Among Transgender Women in the Dominican Republic

Objectives: This study examines associations between alcohol use, high risk sexual behaviors, and experiences of stigma among transgender women across the Dominican Republic. Data from the 2015 Transgender Health Needs Study were analyzed using bivariate analyses (N?=?291). Results: High rates of stigma, verbal abuse, alcohol use, and sex work are found and are associated with each other. Almost 45% of regular alcohol users are engaging in sex work (43.6%), compared with 31.1% of the non-regular alcohol users (χ²=4.82, p?<?.05). Having sex under the influence of alcohol is statistically associated with high risk behaviors, such as engaging in sex work, sometimes or never using a condom when receiving anal sex, and higher numbers of sexual partners. Furthermore, transgender women who have had sex under the influence of alcohol report statistically significantly higher levels of verbal abuse, discrimination, and levels of perceived transgender stigma. Conclusions/Importance: Findings suggest that although anti-discrimination laws exist, policies may not protect transgender women from experiencing stigma and discrimination at work, potentially forcing them to seek alternative careers and engage in behaviors that expose them to greater personal risk and harm. This intersection of factors may indicate a notable public health gap in transgender health in the Dominican Republic.     

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.     

Treating Trauma in Addiction with EMDR: A Pilot Study

Objective: This study investigated the effects of standard eye movement desensitization and reprocessing (EMDR) protocol in chronically dependent patients. We propose that reprocessing traumatic memories with EMDR would lead to measurable changes of addiction symptoms. Method: Twelve patients with alcohol and/or drug dependency were randomly assigned to one of two treatment conditions: treatment as usual (TAU) or TAU plus eight sessions of EMDR (TAU+EMDR). Measures of PTSD symptoms, addiction symptoms, depression, anxiety, self-esteem, and alexithymia were included in this study. Results: The TAU+EMDR group showed a significant reduction in PTSD symptoms but not in addiction symptoms. EMDR treatment was also associated with a significant decrease in depressive symptoms, while patients receiving TAU showed no improvement in this area. The TAU+EMDR group also showed significant changes in self-esteem and alexithymia post-treatment. Conclusions: This study suggests that PTSD symptoms can be successfully treated with standard EMDR protocol in substance abuse patients.     

Novel approaches for the treatment of psychostimulant and opioid abuse – focus on opioid receptor-based therapies

Introduction: Psychostimulant and opioid addiction are poorly treated. The majority of abstinent users relapse back to drug-taking within a year of abstinence, making ‘anti-relapse’ therapies the focus of much current research. There are two fundamental challenges to developing novel treatments for drug addiction. First, there are three key stimuli that precipitate relapse back to drug-taking: stress, presentation of drug-conditioned cue, taking a small dose of drug. The most successful novel treatment would be effective against all three stimuli. Second, a large number of drug users are poly-drug users: taking more than one drug of abuse at a time. The ideal anti-addiction treatment would, therefore, be effective against all classes of drugs of abuse.

Areas covered: In this review, the authors discuss the clinical need and animal models used to uncover potential novel treatments. There is a very broad range of potential treatment approaches and targets currently being examined as potential anti-relapse therapies. These broadly fit into two categories: ‘memory-based’ and ‘receptor-based’ and the authors discuss the key targets here within.

Expert opinion: Opioid receptors and ligands have been widely studied, and research into how different opioid subtypes affect behaviours related to addiction (reward, dysphoria, motivation) suggests that they are tractable targets as anti-relapse treatments. Regarding opioid ligands as novel ‘anti-relapse’ medication targets, research suggests that a ‘non-selective’ approach to targeting opioid receptors will be the most effective.     

Illicit drug use among Bangladeshi women living in the United Kingdom: An exploratory qualitative study of a hidden population in East London

This explorative study focused on Bangladeshi women using illicit drugs in the London Borough of Tower Hamlets, which has a large Bangladeshi population. The study was designed to: examine Bengali women's perceptions of their drug use and perception of treatment services; identify the cultural determinants of service utilization; examine the concept of izzat (honour) and its role in contributing to the secrecy surrounding Bengali women's drug use; examine the pressures that have contributed to Bengali women accessing drug treatment services in Tower Hamlets; and examine barriers to the utilization of drug treatment services.

?Eight Bengali female drug users were recruited via two treatment settings and one by snowballing methods and data gathering was through qualitative discourse.

?The findings revealed that Bengali female drug users constitute a hidden population that is engaging in high-risk behaviours, especially unsafe sex. Cultural constructs, such as shame about drug use, antipathy towards injecting and stigmatization of drug use in the community are all present in this group. Gender role expectations are particularly pronounced for this group and they face greater gender discrimination from within their community in respect of substance use and misuse than their male counterparts. They experience profound barriers to treatment, which prevent them from accessing services at an earlier stage in their drug use. Their presentation to drug services frequently involves a coercive element whether from family members or social services.

?Service provision should include targeted hepatitis- and HIV-prevention programmes.     

Adolescent stigma towards drug addiction: Effects of age and drug use behaviour

The objective of this study was to examine adolescent age and experience with drug use on stigmatizing attitudes toward drug addiction. Data were derived from the  2005 cycle of the Ontario Student Drug Use Survey. In total, 4078, 7- to 12-graders completed self-administered questionnaires that included a measure of drug abuse stigma. Results indicated that stigma scores were higher among younger than older adolescents, and the decline across age was robust, occurring among both males and females and those from rural and non-rural areas. The decline, however, was stronger among non-drug users and among those who had no close friends that use drugs. Despite the age-related decline, the level of stigma in general suggested that drug abuse stigma may continue into adulthood. Findings highlight that individual attitudes toward drug use and drug abusers are salient factors for personal drug use. Given that stigma is a barrier to treatment, but reduced stigma may encourage greater adolescent use, this study highlights the need for more in-depth studies of drug stigma.     

An investigation of stigma in individuals receiving treatment for substance abuse

This study examined the impact of stigma on patients in substance abuse treatment. Patients (N=197) from fifteen residential and outpatient substance abuse treatment facilities completed a survey focused on their experiences with stigma as well as other measures of drug use and functioning. Participants reported experiencing fairly high levels of enacted, perceived, and self-stigma. Data supported the idea that the current treatment system may actually stigmatize people in recovery in that people with more prior episodes of treatment reported a greater frequency of stigma-related rejection, even after controlling for current functioning and demographic variables. Intravenous drug users, compared to non-IV users, reported more perceived stigma as well as more often using secrecy as a method of coping. Those who were involved with the legal system reported less stigma than those without legal troubles. Higher levels of secrecy coping were associated with a number of indicators of poor functioning as well as recent employment problems. Finally, the patterns of findings supported the idea that perceived stigma, enacted stigma, and self-stigma are conceptually distinct dimensions.     

Common Neural Adaptations and Bidirectional Influences of Stress and Addiction

Abstract

Objective: Clinical evidence suggests a complex-per-haps correlative-relationship between stressful experiences and addiction. The goal of this review is to provide an overview of recent basic research linking stress and addiction, to indicate novel areas of study, and to suggest how data from basic research may influence clinical assessment and treatment of patients with stress-related disorders, substance abuse, or a history of both disorders.

Methods: Reviewed here are recent basic research (preclinical) articles available via PubMed (www.ncbi.nlm.nih.gov) with particular relevance to novel neural mechanisms underlying the putative stress/addiction relationship.

Findings: Three types of relationships between stress and addiction are identified and discussed: (1) Neural adaptations common to both chronic stress and chronic exposure to drugs of abuse; (2) The influence of stress on the rewarding or sensitizing aspects of drugs of abuse; and (3) The influence of stress on the relapse to drug taking after a drug-free period. Each relationship appears to involve alterations in dopaminergic and glutamatergic systems and their related second messenger pathways. However, brain regions that influence the brain's reward pathway, such as the hippocampus, and other novel aspects of neuroplasticity, such as adult neurogenesis, are also receiving attention.

Conclusions: A wealth of evidence shows that stress and addiction can produce similar adaptations in discrete brain regions, and that there is bidirectional influence of the experience of stress and drug exposure. These preclinical findings encourage further exploration of the neural mechanisms underlying stress and addiction with the hope that additional discoveries will aid treatment of patients with stress-related disorders and addiction, or comorbid diagnoses.     

Early childhood experiences, parenting and the process of drug dependency among young people in Tehran, Iran

Introduction and Aims. Substance abuse has become a major public health problem in Iran. The process of developing an addiction is complex and multifaceted. Early childhood experiences are thought to be one of the important determinants of addictive behaviour. The aim of this qualitative study is to explore the early childhood experiences, especially the experiences within the immediate family, of current substance‐using young adults in Iran. Design and Methods. The study is qualitative in nature. In‐depth interviews were conducted with 15 young men and women who were either in treatment for their addiction or were active drug users at the time of the interviews. Moreover, four interviews have been conducted with family members of participants. Results. The majority of the participants experienced traumatic events during childhood and came from dysfunctional families. There appears to be a significant disconnect between these individuals and their families. An obedience‐instilling parenting style and parents' knowledge and attitude toward drug using and prevention were also identified as important determinants of substance use. Discussion and Conclusions. The results of this research point out the need for early interventions for at‐risk families as well as at‐risk individuals.[Mirlashari J, Demirkol A, Salsali M, Rafiey H, Jahanbani J. Early childhood experiences, parenting and the process of drug dependency among young people in Tehran, Iran. Drug Alcohol Rev 2012;31:461–468]     

Stigma, social inequality and alcohol and drug use

A heavy load of symbolism surrounds psychoactive substance use, for reasons which are discussed. Psychoactive substances can be prestige commodities, but one or another aspect of their use seems to attract near--universal stigma and marginalization. Processes of stigmatization include intimate process of social control among family and friends; decisions by social and health agencies; and governmental policy decisions. What is negatively moralized commonly includes incurring health, casualty or social problems, derogated even by other heavy users; intoxication itself; addiction or dependence, and the loss of control such terms describe; and in some circumstances use per se. Two independent literatures on stigma operate on different premises: studies oriented to mental illness and disability consider the negative effects of stigma on the stigmatized, and how stigma may be neutralized, while studies of crime generally view stigma more benignly, as a form of social control. The alcohol and drug literature overlap both topical areas, and includes examples of both orientations. Whole poverty and heavy substance use are not necessary related, poverty often increases the harm for a given level of use. Marginalization and stigma commonly add to this effect. Those in treatment for alcohol or drug problems are frequently and disproportionately marginalized. Studies of social inequality and substance use problems need to pay attention also to processes of stigmatization and marginalization and their effect on adverse outcomes.     

Depressive Symptoms and Associated Clinical Characteristics in Outpatients Seeking Community-Based Treatment for Alcohol and Drug Problems

Background: Comorbid psychiatric and substance use disorders are common and associated with poorer treatment engagement, retention, and outcomes. This study examines the presence of depressive symptoms and the demographic and clinical correlates in a diverse sample of substance abuse treatment seekers to better characterize patients with co-occurring depressive symptoms and substance use disorders and understand potential treatment needs. Methods: Baseline data from a randomized clinical effectiveness trial of a computer-assisted, Web-delivered psychosocial intervention were analyzed. Participants (N = 507) were recruited from 10 geographically diverse outpatient drug treatment programs. Assessments included the self-report Patient Health Questionnaire, and measures of coping strategies, social functioning, physical health status, and substance use. Results: One fifth (21%; n = 106) of the sample screened positive for depression; those screening positive for depression were significantly more likely to screen positive for anxiety (66.9%) and posttraumatic stress disorder (PTSD; 42.9%). After controlling for anxiety and PTSD symptoms, presence of depressive symptoms remained significantly associated with fewer coping strategies (P = .001), greater impairment in social adjustment (P < .001), and poorer health status (P < .001), but not to days of drug use in the last 90 days (P = .14). Conclusions: Depression is a clinically significant problem among substance abusers, and, in this study, patients who screened positive for depression were more likely to have co-occurring symptoms of anxiety and PTSD. Additionally, the presence of depressive symptoms was associated with fewer coping strategies and poorer social adjustment. Coping skills are a significant predictor of addiction outcomes, and it may be especially important to screen for and enhance coping among depressed patients. Evidence-based interventions that target coping skills and global functioning among substance abusers with depressive symptoms may be important adjuncts to usual treatment.     

Comparative profiles of addicted adult populations in rehabilitation and correctional services

For many years, clinicians, especially those working in rehabilitation centers for alcohol and drug users, have been preoccupied with clients presenting with dual diagnosis: substance abuse and legal problems. Comparative analyses of three groups of addicted men, 553 offenders and 499 nonoffenders in treatment for addiction problems and 103 addicted inmates were made to ascertain the biopsychosocial profile of these persons. Results showed that dual-diagnosis clients experienced more severe biopsychosocial problems than the nonoffending group of subjects. Offenders in prison experienced more social maladjustment than offenders in drug addiction treatment, they were less preoccupied by their drug consumption, and less motivated to change. Implications for treatment are discussed.     

An Exploratory Attempt to Distinguish Subgroups Among Crack-Abusing African-American Women

Abstract

Despite the significant emergence of research on female addiction over the last two decades, specific research on African-American women substance abusers, particularly crack cocaine users, is limited. The identification of meaningful subgroups of substance abusing populations, particularly minority women is important both clinically, and because of their over-representation in the epidemiological data on crack cocaine use in many urban centers across this country. An extensive battery of instruments was administered to 110 women entering treatment in an intensive outpatient substance abuse treatment program in Philadelphia, serving women who are primarily indigent, African-American, and whose primary substance of abuse is crack cocaine. Factor analysis and cluster analysis procedures were utilized to classify women into subgroups across relevant clinical, behavioral, and background concerns relevant to studying substance abusing populations. Five conceptually meaningful subgroups emerged which classified women across various indicators such as HIV sex risk factors, personality traits/Axis II dimensions, clinical syndromes, psychological symptomatology, lifetime and recent drug and alcohol use, prior physical and sexual abuse, and social context variables such as parental addiction, and whether they live with a substance abuser. Attempts to classify women into identifiable clinical subtypes is essential in order to better inform treatment initiatives designed to serve this group, as well as prevention and community outreach intervention strategies which attempt to bring them into treatment.     

Psychiatric Symptoms,Parental Attachment,and Reasons for Use as Correlates of Heavy Substance Use Among Treatment-Seeking Hispanic Adolescents

In early adolescence, Hispanics self-report higher drug use rates compared to White and African American peers. Among adolescent users, heavy users have more negative behavioral and health consequences. The purpose of this cross-sectional study is to examine whether psychiatric symptoms, parental attachment, and reasons for use predict heavy alcohol and illicit drug use (more than 10 times in the past three months) among Hispanic adolescents. Methods: This study examines baseline data from a study evaluating a family based substance abuse treatment program for Hispanic adolescents. Participants were 14–17 years old (N = 156, 44% female). Adolescent reports on the Diagnostic Interview Schedule for Children Predictive Scales measured psychiatric symptoms of major depressive disorder, attention deficit hyperactivity disorder, conduct disorder, and anxiety. The Personal Experiences Inventory measured type and amount of drug use, as well as perceived social and psychological benefits of drug use. The Inventory of Parent and Peer Attachment measured trust, communication, and alienation between adolescents and their mothers. Logistic regression identified correlates of heavy alcohol use and heavy illicit drug use among Hispanic adolescents. Results: Higher social benefits were associated with increased likelihood of heavy alcohol use. Conduct disorder, higher levels of maternal attachment, lower levels of acculturation, and higher levels of psychological benefits of use were associated with an increased likelihood of heavy illicit drug use. Conclusion: These findings support the assumption that substance use treatment among Hispanic adolescents must be capable of addressing co-occurring psychiatric disorders, familial relationships, and the individual reasons/motivators to use.     

Attitudes Toward Drug Abuse Among Residents* in a Therapeutic Community

In recent years there has been a considerable amount of literature reported about drug abuse and the drug abuser. Generally, the reported evidence pertaining to attitudes toward drug abuse has been concerned with nonusers. Among those, Baker and Isaacs (1970) in a study of visiting nurses, law students, and policemen suggest that these individuals see drug abuse as a physical and mental illness. Pattison (1968) in a study of public attitudes toward narcotic addiction suggests the public sees the addict as less responsible for his behavior. Ferneau and Gertler (in press) studied the first-year psychiatric residents' attitudes toward drug abuse and the drug user and concluded that “this is how we rate these beginners in psychiatry—as more negative than not in the area of drug abuse.” Levitt and his colleagues (1963), in a study of hospital employee attitudes toward the treatment of drug addiction, noted that addicts were perceived as less undesirable among those employees whom they had direct contact with than those with whom they did not have direct contact.

Several investigators have reported on the attitudes of drug users. Recently, Soverow and his coworkers (in press) compared the attitudes of methadone patients ward drug abuse with those of the clinic staff. The report concluded that there was considerable agreement in attitude among the two groups. Grupp (1970) investigated the drug users' attitudes toward the Nalline test and noted that drug users with positive attitudes and expectations are likely to benefit by the test. However, it appears that other than these reports little attention has been given concerning the drug users' attitudes. Grupp (1970) further notes that in the literature there is little consideration given to the attitudes of addicts. Additionally, the New York Academy of Medicine's Committee on Public Health (1963) has eloquently noted the importance of attitudes of drug users:

Among addicts, attitudes toward addiction differ, and individual attitudes may change in time. … It is necessary to recognize these different andvarying attitudes of addicts toward their addiction in order to understand their attitude toward treatment: to seek it or resist it. In short, attitude affects the utilization of treatment and its outcome.

The study reported here was undertaken because of the importance of drug users' attitudes and because of the lack of available literature in this area. This report is an attempt to remedy this deficiency.     

Skeptical Attunement: Modifying Psychodynamic Technique for Substance Abuse Treatment

ABSTRACT

Despite enormous advances in the field brought on by psychology's reintegration, modern substance abuse treatment fails to adequately treat substance abusers' emotional lives.

Objectives: Psychodynamic technique can fill this gap by addressing the emotional discomfort and disconnection that underlies much of substance abuse.

Methods: A new model of substance abuse treatment integrating psychodynamic technique with recent developments in addiction treatment (harm reduction, relapse prevention and cognitive-behavioral therapy, motivational interviewing/motivational enhancement) is described with examples from a clinic in the Bronx currently using this method with positive clinical results. A modified version of psychodynamic technique is described in which the clinician is more active and symptom focused, addressing both emotional issues and symptoms of ongoing drug use. Skeptical attunement is the use of healthy skepticism as a means of confronting the patient in a way that is experienced as empathic attunement, leading to more meaningful therapeutic work.

Results: This model has proven efficacious in a low-income community. Patients showed an increased awareness of their feelings, ability to identify how feelings can lead to action, and awareness of how physical and emotional reactions can trigger cravings and relapse.

Conclusions: This model has implications for full substance abuse programs as well as private practice settings.     

“A scarlet letter”: Stigma and other factors affecting trust in the health care system for women seeking substance abuse treatment in a community setting

Background: Trust in health care has been shown to influence health care utilization, perceptions of fair treatment, and health outcomes in the general population. The literature on trust in health care in individuals with a history of substance use disorder (SUD) is more limited, primarily examining the patient-provider relationship. Women seeking substance abuse treatment in community-based programs have higher rates of prior trauma and health disparities compared with male counterparts and the general population. With higher rates of prior trauma, this population is theoretically at high risk of decreased interpersonal trust and altered interpersonal relationships. Objective: This study sought to identify factors influencing trust in the health care system for women seeking substance abuse treatment in a community-based residential treatment program. Methods: Six client focus groups (n?=?30), 1 provider focus group (n?=?7), and 2 individual clinical administrator interviews (n?=?2) were conducted between November 2016 and August 2017. Focus groups and interviews were audio recorded and transcribed. Coding and coding reconciliation were conducted by 2 independent coders. Themes were extracted and analyzed from sorted and coded quotes. Results: Six themes emerged. Factors that influence trust in the health care system in this population include (1) prior experiences with diagnosis, treatment, and outcomes; (2) stigma of addiction; (3) payment and reimbursement structure; (4) patient rights and protections; (5) efficiency-driven care; and (6) the health care system's role in causing and/or enabling addiction. Conclusions: These themes demonstrate a general distrust of the health care system by women in this population. Distrust is influenced by a perception of a health care system providing care that is variable in quality, often stigmatizing, unaffordable, efficiency driven, and often influencing individuals’ SUD. This aligns with and extends prior literature around trust of health care in individuals with SUD. Future directions in research include formally assessing the impact of trust on health outcomes such as treatment entry and retention.