Literature Collection

PURPOSE: Community Health Centres (CHCs) are an essential component of primary health care (PHC) in Canada. This article examines health providers' understandings and experiences regarding stigma towards mental health and substance use (MHSU) issues, as well as their ideas for an effective intervention to address stigma and discrimination, in three CHCs in Toronto, Ontario. METHODS: Using a phenomenological approach, we conducted twenty-three interviews with senior staff members and peer workers, and three focus groups with front-line health providers. Ahybrid approach to thematic analysis was employed, entailing a combination of emergent and a priori coding. RESULTS: The findings indicate that PHC settings are sites where multiple forms of stigma create health service barriers. Stigma and discrimination associated with MHSU also cohere around intersecting experiences of gender, race, class, age and other issues including the degree and visibility of distress. Clients may find social norms to be alienating, including behavioural expectations in Canadian PHC settings. CONCLUSIONS: Given the turmoil in clients' lives, systematic efforts to mitigate stigma were inhibited by myriad proximate factors that demanded urgent response. Health providers were enthusiastic about implementing anti-stigma/recovery-based approaches that could be integrated into current CHC services. Their recommendations for interventions centred around communication and education, such as training, CHC-wide meetings, and anti-stigma campaigns in surrounding communities.

BACKGROUND: Opioid-related overdose deaths have risen sharply among young adults. Despite this increase, access to evidence-based medication for opioid agonist treatment (OAT) for youth remains low. Among older adults, barriers to OAT include the paucity of buprenorphine-waivered prescribers and low rates of prescribing among waivered physicians. We have increasingly found in our clinical practice significant stigma related to using OAT to treat addiction for young adults. In this series, we describe three cases of young adults who faced significant stigma related to their treatment. CASE PRESENTATIONS: The first case is a young male with a history of significant trauma and a severe opioid use disorder. He started buprenorphine and has found a job, stayed abstinent, and began a healthy relationship. At each step in his recovery, he has faced resistance to taking medication from other treatment providers, directors of sober houses, and his parents. The second case is a young woman who presented to a substance use treatment program after a relapse. She was unable to restart buprenorphine despite our calling to ask that it be restarted. Ultimately, she left against medical advice and was stabilized as an outpatient on buprenorphine. The final case is a young woman who stopped buprenorphine after being told she was "not sober" while attending 12-step group but restarted after conversations with her clinical team. In each case, the patient has continued their medication treatment and are stable. CONCLUSIONS: Opioid-related deaths continue to rise among all age groups, including young adults. Stigma related to medication treatment can be a substantial barrier for many young adult patients but there are concrete steps that providers and communities can take to address this stigma.

Background: 12-step groups are the most common approach to managing opioid use disorder (OUD) in the U.S. Medications for OUD (MOUD) are the most effective tool for preventing opioid misuse and relapse. Previous research has identified stigma of MOUD in 12-step groups. Objectives: We sought to identify how MOUD stigma is operationalized in 12-step groups and to identify responses to stigma. Methods: We recruited individuals with both MOUD experience and 12-step group experience from three syringe exchange programs in the U.S. using snowball sampling. We conducted individual telephone semi-structured interviews during 2018 and 2019. We coded data in Dedoose software and conducted thematic analysis using iterative categorization. Results: We recruited 30 individuals meeting our inclusion criteria. The following stigma operationalization methods were identified: prohibiting people using MOUD from speaking at meetings; encouraging shortened duration of MOUD treatment; refusing to sponsor people using MOUD; and refusing to let people using MOUD claim recovery time. Responses to stigma included the following: feeling shame; feeling anger; shopping around for different groups, leaving the group, or forming a new group; not revealing MOUD utilization or only telling a sponsor; speaking out on behalf of MOUD; and using cognitive approaches to avoid stigma internalization. Cognitive approaches included believing that anti-MOUD stigma is contrary to 12-step principles; disregarding statements as inaccurate based on one's experience of MOUD benefits; and accepting that all groups of humans have some ignorant people. Conclusion: Healthcare systems should help address MOUD stigma experienced by patients in 12-step groups, such as by offering non-12-step alternative groups and encouraging MOUD healthcare providers to prepare patients for potential stigma they may face. Some stigma response options, like shopping around for different groups, may not be feasible in rural areas or for participants newer to recovery.

BACKGROUND: Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). METHODS: Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. RESULTS: The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. CONCLUSIONS: Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.