Funded Projects

Stigma is a key barrier to retention in medication-based treatment for opioid use disorder, particularly among low-income, minority individuals. Stigma that exists at multiple levels contributes to poor retention in care, including internalized and anticipated stigma at the individual level, as well as enacted stigma at the health care provider- and community levels. There is an urgent need to develop and evaluate innovative strategies to reduce stigma at these multiple levels among low-income, racial/ethnic minority individuals to improve engagement in care. One of the most promising strategies to reduce multiple intersecting stigmas simultaneously and improve engagement in care for low-income, minority individuals is through the use of peer recovery coaches (PRCs). PRCs, individuals who have gone through the recovery process themselves and are typically state-certified, have been shown to be more acceptable for engaging and retaining low-income, racial/ethnic minority patients in treatment compared to other health workers. However, scarce research has formally evaluated the effects of PRCs on stigma. This study will test how a PRC model can reduce multiple intersecting stigmas among low-income, racial/ethnic minority individuals to improve retention in methadone treatment.

Patients with chronic low back pain, often have depressive and anxiety symptoms and use opioids all of which are associated with stigma. In turn stigma leads to decreased treatment seeking and adherence, increased depression and pain, and poor treatment outcomes. Intersection of these health-related stigmas may have synergistic effects. This study aims to enhance the findings of a clinical trial to test antidepressant medication and Enhanced Fear Avoidance Rehabilitation in patients with chronic low back pain and high levels of depression and anxiety. The effects of these intersecting types of stigma on the efficacy of the interventions will be evaluated to better understand the needs of the patient population and to inform development of a stigma reducing intervention that can be implemented care providers.

Increasing primary care clinician intention and behavior to obtain waivers to prescribe buprenorphine for treatment of opioid use disorder and increase use of the Opioid Wizard, a clinical decision support tool, has potential for patient benefit. This supplement will provide support to evaluate a training tool as an intervention to reduce stigma in primary care clinics by integrating a stigma reduction training component into the Opioid Wizard training at multiple sites of the NIDA Clinical Trial Network. Primary care providers will be randomized to novel stigma reduction training, grounded in stigma science, or an attention-control training to determine whether stigma reduction training reduces provider stigma, increases intention to apply for a waiver to prescribe buprenorphine, and ultimately increase the likelihood that providers use Opioid Wizard. The proposed supplement will utilize the randomized controlled trial design embedded in the larger multisite trial to evaluate the Opioid Wizard tool to help primary care clinicians identify, diagnose, and treat patients with opioid use disorder while evaluating the effect of the stigma reduction training.

Among the more than half-million adults entering addiction treatment for prescription opioid abuse every year, 50%-60% report co-morbid chronic pain, and 80% report that pain triggers relapse. Individualized/self-stigma among adults with substance abuse has been shown to lead to delayed recovery, increased relapse and reduced treatment-related attendance. Stigma may induce significant burden on patients with OUD and chronic pain and there may be unique characteristics of stigma for this population due to the overlap between medical treatment and substance abuse. Multiple sources of stigma may be imposed including internalized/self-stigma as well as intragroup/peer-to-peer (?horizontal?) stigma whereby peers impose stigma upon each other based on the type and severity of past drug use. Furthermore, stigma could be ?vertical? in that stigma may be enacted by health care providers or by treatment center staff. However, there is notably a lack of research and related assessment tools to measure these multidimensional facets of stigma, particularly in patients with OUD and chronic pain. The investigators will utilize a mixed-methods approach to evaluate internalized/self-stigma, anticipated/expected stigma and enacted stigma using existing standardized surveys, and to describe horizontal and vertical stigma in individuals with OUD and pain at multiple sites. In addition, the investigators will integrate the quantitative and qualitative information to help inform modifications to the psychotherapy component (I-STOP) of the parent award intervention, which would then also target multidimensional stigma in patients with OUD and chronic pain.