Many patients seeking help for a health-related crisis are relieved to learn that their new caregiver has had a similar experience—especially when it’s treatment for a substance use disorder (SUD). As patients face stigma and other barriers, empathy from a caregiver with shared experiences can help keep them in treatment while they receive medication for opioid use disorder (MOUD).
A recent study in the Journal of Substance Abuse Treatment notes: “Peer recovery specialists (PRSs), individuals with shared experience in substance use and recovery, may be particularly well suited to support patients in MOUD treatment, and may have capacity to play a key role in decreasing stigma-related barriers to MOUD retention.” The study’s authors are from the University of Maryland, College Park, and the Henry Ford Health System in Detroit, Michigan. The study was funded by a grant from the National Institutes of Health.
It’s well known that methadone and buprenorphine can provide effective treatment for OUD, yet fewer than half of patients remain in treatment after six months, with low-income and Black populations at greatest risk of dropping out.
The study’s authors looked for feedback on how patients receiving methadone encountered stigma toward substance use and methadone treatment, then investigated ways PRSs could help.
Stigma—the devaluation and discrediting associated with a personal attribute, mark, or characteristic, such as race, ethnicity, or sexual minority orientation Goffman, 2009
The study comprised 32 participants and was part of a larger investigation involving PRS delivery at the University of Maryland Drug Treatment Center (UMDTC). Taking part were:
- 20 patients enrolled in methadone programs
- 8 staff members—drug treatment counselors, case managers, nurses, and physicians
- 4 PRSs
Study participants could choose either semi-structured individual interviews (10 did) or focus groups (22 did), but not both. Those choosing focus groups could join only groups with other patients. Staff and PRSs had separate groups.
Each of the four focus groups had no more than six participants. All patients received methadone treatment at the UMDTC.
The investigators wanted to know:
- How stigma shows itself among predominantly low-income, ethnoracial minority individuals in methadone treatment; perspectives included were those of the patient, the staff, and the PRS
- How SUD and methadone treatment stigma shows itself at multiple levels (ie, patient, organizational, and societal) and mechanisms, including enacted, anticipated, and internalized
- How the role of a PRS may reduce stigma and improve retention in OUD care—including the barriers and facilitators the PRS encounters in shifting stigma
Data were gathered between September 2019 and March 2020 and were analyzed between December 2020 and January 2021. Tools included thematic analysis and rapid qualitative analysis methods.
Study results supported several themes in alignment with the study aims.
How Patients Encounter Stigma
Patients and providers said internalized stigma related to patients’ methadone treatment and SUD created negative self-views, and were barriers to successful treatment outcomes. Some comments:
It “sucks that a guy like me needs that [methadone].”
Staff participants spoke of the many layers of stigmas that confront “a poor person of color in Baltimore City with a heroin addiction; they “compound one another, creating an overwhelming experience for patients to handle . . .”
Some patients “worry that they won’t be accepted and wonder if they’re, especially when it comes to the self-help groups, whether they’re still really clean.”
“It’s the stigma of society . . . I’ve had some client[s] that was bouncing back into society. You look at this person, you would never know they got high. But in their mind, they always felt less than . . . people would plant the seed that if you’re on prescribed medication, you still getting high. . . it’s the stigma that has to be broken.”
Patients also talked about internalized stigma from their SUD and their methadone treatment:
“So, I just went from one drug to the other . . . and then the methadone itself is a drug.”
Some patients shared stigmatizing views from family members:
“ . . . my daughter, she wanted me to get off methadone, and she said [methadone] wasn’t a good idea . . . ”
—and the stigmatizing views of counselors, such as the counselor who continuously referred to patients as “junkies.”
A staff participant spoke of the stigmatizing views of government officials, including a previous mayor who said on television that “everybody who’s noddin’ down the market is on methadone.”
Role of the PRS In Reducing Stigma And Improving Retention
- Support patients and treatment-team members
- Create healthy relationships with patients
- Create open spaces where patients can safely disclose information
- Dispel myths and stigma about methadone treatment—thus reducing miseducation, stigma, and confusion
- Shift organizational stigma: Have peers work within the context of methadone treatment programs
- Serve as a role model for recovery for patients
Seeing someone in recovery who contributes to the organization may help shift stigma that exists within the organization itself.
Patients said that although the unique role of a PRS may reduce stigma and improve retention in care, a PRS who considers MOUD a less-appropriate path to recovery may instead perpetuate stigma.
PRS qualities that could impact stigma
The authors note the advantages of the shared experience between PRS and patient.
A comment from staff:
“Having a peer, there’s just a certain level of credibility that’s already there… being somebody with whom he could speak without necessarily being judged. And I think that that’s another key thing about peers; is that I think there’s this inherent understanding that there really isn’t room for that it’s a judgment free zone.”
A different recovery history
But, as has been mentioned, stigma may be intensified if patient and PRS have different recovery pathways. Stigma may then become “a barrier to the supportive, nonjudgmental services the PRS might otherwise provide.”
Peer actions and behaviors
Study participants described approaches to other stigmas. For example, seeing peers directly support staff “may help to alleviate stigma toward people in recovery, and in turn, [help] the staff aid the peers by giving them responsibilities that benefit the organization.”
A staff participant commented on the advantages of having peers working in treatment programs:
“It reduces stigma within the organization because now clinicians, regardless of their own internal bias, are seeing that people with lived experience are benefiting to the organization, which creates opportunity for the clients to have a beneficial contribution.”
Barriers to shifting stigma
Barriers exist when a PRS tries to shift stigma. If there are “differences in recovery paths” between peers and patients, these barriers could make the patient feel that the peer is looking down on them. The patient could become more guarded during sessions, and even “close right up like a book.”
Two tasks are critically important, the study found:
- To improve engagement in care and the care experiences of ethnoracial minority communities, such as those described in the study
- To identify effective ways of intervention, using peer supports
To improve MOUD outcomes, the authors emphasized, it’s essential to better understand—and to reduce—SUD and MOUD stigma.
Possible barriers to taking part and staying in methadone treatment include the stigmas around SUD, OUD, and methadone treatment itself. The authors note that future work is needed “to rigorously evaluate how a PRS intervention can shift stigma at multiple levels.”
The authors concluded: “Improving our understanding of the experiences of SUD and MOUD stigma within ethnoracial minority communities and identifying accessible intervention strategies using peer supports is critically important for improving engagement in care and care experiences for this population. Stigmas around SUD, OUD, and methadone treatment exist at multiple levels, which may act as barriers to engaging in and remaining adherent to methadone treatment.
“Moreover, results suggest that working with a PRS may offer a unique opportunity to shift stigma through normalization of SUD, modeling long-term recovery, as well as educating and supporting clients.” Here again the authors emphasize the risks of peers’ stigmatizing clients whose recovery pathways are different.
As for future research, it should investigate the importance of having PRSs and clients share recovery pathways and the impacts on treatment outcomes, and evaluating “how a PRS intervention can shift stigma at multiple levels.”
In an email correspondence with Addiction Treatment Forum, Morgan Anvari, lead author of the study, offered an additional comment: “It is also crucial to disseminate research on how other forms of discrimination, such as racism and classism, intersect with and compound experiences of SUD and methadone stigmas. While we had some data that described experiences of SUD and methadone stigma alongside racism and classism, it was not one of the main aims of the study and warrants much more attention.”
Anvari MS, Kleinman MB, Massey EC, et al. “In their mind, they always felt less than”: The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention. J Subst Abuse Treat. 2022;138:108721. doi:10.1016/j.jsat.2022.108721
For Further Reading
Goffman, E. (2009). Stigma: Notes on the management of spoiled identity. Simon and Schuster.