Full length articleOpioid use and stigma: The role of gender, language and precipitating events
Introduction
The opioid epidemic in the United States is a growing public health concern. Since 1999, the sales of prescription opioids have nearly quadrupled (Frenk et al., 2015), as has the number of overdose deaths from prescription opioids (CDC, 2016). In 2015, 91 individuals a day died from an opioid overdose (including prescription opioids and heroin), totaling to more than 33,000 deaths (Rudd et al., 2016).
The increase in prescriptions for opioids has been attributed to a number of factors such as new standards for appropriate pain control management, liberalizing laws for opioid prescriptions to treat non-cancer chronic pain from state medical boards in the 1990’s (Kenan et al., 2012; Kuehn, 2007; Manchikanti et al., 2010) and the marketing and promotion of opioids from pharmaceutical companies to doctors, which minimized the risk of addiction to opioids (Van Zee, 2009). In addition, pain management clinics inappropriately prescribing/distributing drugs, labeled as, “pill mills”, may in part have contributed to the proliferation of overprescribed opioids (Rigg et al., 2010). Despite the minimization of the addictive properties of opioids, both research and clinical practice have shown that repeated use of opioids can affect brain connectivity and function that lead to severe consequences such as physical dependence and chronic addiction (Volkow and McLellan, 2016).
In spite of the prevalence of nonmedical opioid use, however, there remain barriers to receiving treatment (e.g., lack of health coverage, costs of treatment) after developing an opioid addiction. In 2016, more than 2 million Americans had an opioid use disorder, but a little more than 20% of individuals had received treatment for opioid addiction (SAMHSA, 2017b). The lack of individuals receiving treatment for opioid use points to the importance of understanding such barriers, one of which is the stigmatization of individuals with an opioid use disorder. Stigma is a multidimensional construct that can be in the form of an attitude, an attribute or characteristic, or a shared belief about a behavior (Crocker et al., 1998; Goffman, 1963; Stafford and Scott, 1986) and can manifest in different ways. Self-stigma is an internalized negative belief that individuals hold about themselves, while public stigma refers to the negative beliefs of the public toward a person or group (Corrigan and Watson, 2002). Perceived stigma is an internalized negative belief that others have a commonly held stereotype about a stigmatized group. Perceived stigma is associated with higher internalized shame and can be a barrier for individuals to enter treatment (Luoma et al., 2010). Stigma can lead to fear and social isolation and may deter individuals from seeking treatment and/or help and can impact the way treatment providers interact with someone with a substance use disorder (Botticelli and Koh, 2016). For example, it has been demonstrated that healthcare professionals commonly have negative attitudes towards individuals with a substance use disorder, which can contribute to lower quality of care that these individuals receive (Van Boekel et al., 2013). Furthermore, the effect of language on stigmatizing attitudes in two studies showed that when an individual is referred to as a “substance abuser” compared to having a “substance use disorder”, healthcare providers judged the substance abuser as less deserving of treatment (Kelly, 2004) and more culpable and deserving of punitive action (Kelly and Westerhoff, 2010).
Stigmatizing individuals with an opioid use disorder or other substance use disorders can lead to stereotyping, labeling, prejudice, and discrimination. For instance, previous research has shown that public attitudes towards drug addictions are more stigmatized than mental illnesses (Barry et al., 2014) and individuals with a substance use disorder may be perceived as having control over their illness and, therefore, being more responsible for their behaviors (Corrigan et al., 2009). Moreover, prescription opioids can be obtained legally from a medical doctor, and in some cases, addiction can develop from repeated use of opioids (Kolodny et al., 2015). Individuals who obtain an opioid prescription from a doctor may have “less control” over the development of an addiction and may be held less responsible for their behaviors. Therefore, individuals who use opioids compared to other substances may be stigmatized differently, and improving public policies through the use of communication strategies (e.g., highlighting individual stories with contextual information) should be considered (McGinty et al., 2017). It has recently been shown that higher stigma towards individuals with an opioid use disorder was associated with greater public support for punitive policies and lower support for health-oriented policies such as increasing government spending (Kennedy-Hendricks et al., 2017). While these results provide evidence for policy implications, whether they can be attributed to individual factors (e.g., taking opioids from someone) or system factors (e.g., prescribing practices) is unknown. Therefore, we aimed to understand public stigma towards an opioid addiction by comparing individual and system factors.
Although it has been previously reported that rates of nonmedical prescription opioid use are greater among men, there are no differences in the occurrences of opioid use disorder among men and women (Saha et al., 2016). In the past year, it has been estimated that 11% of men and 6% of women received treatment for illicit drug use (SAMHSA, 2017a). The role that gender plays in stigmatizing attitudes towards opioid use has not been thoroughly explored, and only a few studies have investigated gender and drug addiction in the context of stigma. Studies have shown that respondents rated a male with a drug addiction higher for variables such as blame, fear, and anger compared to a female (Sattler et al., 2017) and women were rated with higher negative attributions who used cannabis and methamphetamine compared to men (Sorsdahl et al., 2012). Another recent study investigating implicit and explicit beliefs about persons who inject drugs found that there were no differences between genders, but a higher implicit belief about warranting punishment was found for a person framed as a Latino(a) versus a person framed as White (Kulesza et al., 2016).
The stigmatization of individuals with an addiction can be influenced by many complex factors (Sattler et al., 2017); therefore, we aimed to encompass different characteristics and dimensions involved with stigma (e.g., responsibility, positive and negative effect and dangerousness). Previously, there has been a focus on stigma research investigating attitudes towards alcohol use (Keyes et al., 2010; Schomerus et al., 2010) and substance use (Corrigan et al., 2009; Luoma et al., 2007; Sattler et al., 2017). A recent study investigated social stigma and social distance (e.g., experience with prescription opioid use disorders) towards individuals with an opioid use disorder (Kennedy-Hendricks et al., 2017). They found that there were higher levels of stigma towards individuals framed as “having an addiction to prescription painkillers” and there was no difference in regards to social distance. These findings provide evidence that there is stigma towards individuals with an opioid use disorder, but how information contributes to public stigma and opioid use needs further exploration. We, therefore, focused on the effect that language, target gender and precipitating events (i.e., how the drug was initially obtained) have on the stigmatization of opioid use. In light of previous research on the role of language in stigmatization, we first looked at stigmatizing attitudes when an individual is labeled as a “drug addict” versus an individual with an “opioid use disorder”. Given the role that gender may play in stigmatizing attitudes and the prevalence of opioid use disorder, we investigated how the gender of an individual with an opioid use disorder affects stigma. Lastly, we wanted to discern whether stigma is affected by information provided about the precipitating events that may contribute or lead to excessive opioid use. We examined an individual who was prescribed opioids from a doctor and an individual who took opioids from a friend. To our knowledge, the role of precipitance has never been studied in the context of opioid use, and in light of the role that overprescribing may have played in exacerbating the opioid epidemic, we sought to uncover the pertinence of precipitance. We used case vignettes to investigate the influence of language, precipitance of obtaining the opioids and gender on stigmatizing attitudes. We hypothesized that there would be greater stigmatizing attitudes (higher responsibility, dangerousness and negative affect and lower positive affect) towards 1) a male versus a female, 2) an individual labeled as a “drug addict” versus having an “opioid use disorder” and 3) an individual who took prescription opioids from a friend versus receiving a prescription from a doctor.
Section snippets
Participants
Participants were recruited and paid through Amazon’s Mechanical Turk (MTurk; http://www.mTurk.com), a crowdsourcing website. MTurk, which has become a popular tool to conduct survey-based research, connects suppliers of basic labor tasks (known as “requesters”) with people who are willing to complete them (known as “workers”) in an online labor market. MTurk workers provide samples that are more representative (Berinsky et al., 2012; Buhrmester et al., 2011; Mason and Suri, 2012) and more
Responsibility
There were significant main effects of Language (F(1, 2594) = 5.11, p = .024) and Precipitance (F(1, 2594) = 49.59, p < .0001), but no significant main effect of Target Gender (F(1, 2594) = 0.31, p = .577). For Language, the addict was rated with higher responsibility compared to disorder (Fig. 1A), and for precipitance, the individual was rated with higher responsibility than the doctor (Fig. 1B). No interaction or covariate effects were found for responsibility (all p’s > .05).
Planned
Discussion
In this study, we aimed to discern the variables involved with stigmatization of an individual with an opioid addiction. When assessing the role of precipitance, our results illustrate that there were higher stigmatizing attitudes (i.e., responsibility, dangerousness, positive affect and negative affect) towards an individual who took opioids from a friend (individual factor), compared to an individual who received an opioid prescription from a doctor (system factor), despite the fact that each
Role of funding source
Nothing Declared.
Contributors
KG, DC and CLHK contributed to the conception of the design and protocol. KG and DC acquired data for analysis and analyzed data. KG, DC and CLHK contributed to the drafting of the work, revision and approved the final version of the work. All authors have reviewed and approved the final manuscript.
Conflict of interest
No conflict declared.
Acknowledgements
This study was funded by Connecticut College, faculty support account 152-10000-202380 (PI: Dr. Chavanne). Dr. Goodyear is supported by the 5T32AA007459 training grant. Dr. Haass-Koffler’s work is currently supported by the NIAAA K01AA023867 and previously by the 5T32AA007459 training grant.
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