The opioid epidemic
The United States is in the midst of a significant, decades-long opioid epidemic. Use, misuse, and abuse of prescription opioids, heroin, and synthetic opioids have risen starkly over the last two decades. Currently, it is estimated that more than 2.6 million Americans meet the criteria for opioid use disorder (OUD). Opioid-related overdoses have also been on the rise, starting with a rise in prescription opioid overdose deaths in the late 1990s, followed by a rise in heroin overdose deaths starting in 2010, and a rise in synthetic opioid overdose deaths starting in 2013. Last year, prescription opioids and heroin were responsible for more than 80,000 drug overdose fatalities – a new high point. Prescription opioids and heroin alone contribute to more annual overdose deaths in the United States than all other illicit drugs combined. In fact, for perspective, more Americans lose their lives each year from opioid overdoses than are killed in car crashes or by firearms.
The effects of the opioid epidemic have not been ubiquitous. Appalachian states, such as Pennsylvania, have been disproportionately impacted by the negative effects of the opioid crisis. Despite the many efforts to prevent, treat, and support those in recovery, Pennsylvania has routinely been near the top of the list of states with high rates of overdose deaths across the nation. Rural areas have been hit especially hard and more adversely impacted by the crisis, as exhibited by higher rates of OUD, emergency room visits, overdoses, and fatalities. Rural areas within Pennsylvania alone have witnessed more than a 600% increase in overdose deaths over the past 20 years.
The opioid epidemic has had a serious impact not just on the American public health system, but also on its criminal justice system. First responders, including police officers, are often the first ones to arrive on scene and respond to and provide treatment during opioid overdoses. In addition to providing life-saving care, law enforcement has been tasked with disrupting the illicit opioid market, making thousands of arrests annually. American courts have been backlogged with cases related to opioid use and distribution, and correctional facilities have been transformed into institutions responsible for providing care to individuals who use opioids.
Consequently, many justice-involved persons meet the criteria for OUD. Data suggest that approximately one in three individuals who use heroin become involved with the American criminal justice system each year and pass through its correctional system. It is also estimated that approximately 15% of the entire American incarcerated population meets the criteria for OUD . Unfortunately, some data show that the risk of overdose and death is higher for those currently and formerly involved with the criminal justice system than those in the general population (Binswanger et al., 2007; Merrall et al., 2010).
Historically, governmental responses to illicit drug use and treatment of those with a substance use disorder (SUD) have focused on criminalization and stigmatizing those affected. However, some of the responses to the current opioid epidemic are more progressive and less punitive than those we have seen in the past. The use of harm reduction strategies, for instance, including needle exchange programs, safe injection sites, and naloxone (i.e., “Narcan”), have become more mainstream tools used to curtail this epidemic.
The use of medications for opioid use disorder (MOUD), such as treatment with methadone, buprenorphine (i.e., suboxone), and naltrexone (i.e., vivitrol), has also become more common and accepted. As the name suggests, the goal of these ‘harm reduction’ strategies is not to stop all forms of illicit drug use, but rather to alleviate the ‘harms’ associated with illicit drug use, including communal disease spread, drug overdose, crime, and death.
Many of these strategies have been effective in achieving these goals. For instance, research indicates that increased community access to naloxone and first responder use of naloxone are associated with reductions in opioid overdose deaths. Regarding treatment, MOUD treatment using methadone or buprenorphine is considered to be the ‘ gold standard ’ for effective treatment of OUD. Data show that compared with treatment patients not enrolled in MOUD, patients enrolled in MOUD exhibit more positive treatment outcomes (i.e., increased treatment retention, reductions in positive urine drug screens, etc.). Data also show that the use of MOUD for justice-involved persons with OUD has been found to be associated with statistically significant reductions in criminal recidivism.
Yet, despite these findings, not everyone is supportive of such policies, and the use and support of harm reduction strategies varies greatly by location and jurisdiction. While most EMTs and paramedics carry naloxone, most police departments across the country do not currently have a policy that requires officers to carry and administer naloxone.
Access to MOUD also varies greatly. Many community treatment providers favor “abstinence-based” recovery methods over MOUD. In fact, “abstinence-based” treatment is the only method of treatment advocated by Narcotics Anonymous. Similarly, many drug courts do not permit participants to take medications for OUD while enrolled in their programs and few correctional facilities provide inmates with access to the full range of medications used to treat OUD.
Penn State Research Raises Awareness of Barriers to Effectively Responding to the Crisis
Researchers at Penn State have found stigma of OUD , as well as SUD in general, to be one of the biggest barriers to fully implementing evidence-based treatment responses needed to positively impact the opioid epidemic. These researchers have documented the prevalence of different types of stigma of OUD, including self (i.e., stigma internalized by individuals who use opioids), public (stigma endorsed and/or exhibited by the general public), provider-based (stigma endorsed and/or exhibited by members of the treatment community), treatment-based (stigma of certain types of treatment) and structural (institutional discrimination endorsed by polices, practices, or laws).
Further, they have shown stigma of OUD to be related to negative attitudes toward harm reduction , including beliefs about the use and efficacy of both naloxone and MOUD. The researchers also have found public stigma of OUD to be positively related to support for NIMBY (‘Not in my back yard’) syndrome for treatment center location, and potentially a barrier to increasing access to effective OUD treatment. Moreover, they have shown provider-based stigma to be negatively related to the perceived standard of care and anticipated standard of care professionals are willing to provide to individuals who experience an opioid overdose. In brief, their work shows that stigma of OUD hinders the delivery of effective treatment responses to OUD.
Penn State’s Research Efforts Support Evidence-based Responses to the Crisis
Fortunately, there are ways in which stigma of OUD can be alleviated, and Penn State researchers are leading this effort throughout the Commonwealth, as well as nationally. Researchers at the Douglas W. Pollock Center for Addiction Outreach and Research at Penn State Harrisburg have been working with the Pennsylvania Department of Drug and Alcohol Programs (DDAP),the Public Good Projects (PGP), and Shatterproof to understand and change OUD stigma on a large scale. This collaborative effort has resulted in the development of Life Unites Us (LUU), a digital media campaign utilizing evidence-based practices, including education and contact-based strategies, to reduce stigma of OUD across the Commonwealth.
Education-based strategies educate the public with a focus on correcting misinformation and dispelling stereotypes. Contact-based strategies increase stigma awareness through direct contact with people with lived experience. Repeated exposure to personal stories and testimonials can increase empathy and openness and lead to reductions in stigma . In addition to the social media campaign, LUU seeks to further reduce OUD stigma and support community-wide change by promoting engagement with stakeholders and advocates in community-based organizations (CBO) across the state, sharing statewide stigma-related data to aid in grassroots work focused on decreasing stigma at the local level, and engaging individuals with lived experience in making campaign decisions and changes. A peer reviewed article detailing the creation of the LUU Campaign can be viewed here .
A survey of a representative sample of Pennsylvanians conducted by the center found that approximately 1 in 3 Pennsylvanians viewed the LUU campaign during the first year. Campaign viewers endorsed fewer stigmatizing views when compared with those who did not view the campaign. For example, campaign-aware individuals were more likely than their counterparts to say that: prescription opioids can be a problem for anyone; MOUD is effective, they would be willing to live, work with, or be neighbors with people with an OUD; they support harm reduction strategies (e.g., safe injection sites, needle exchange programs, naloxone distribution, fentanyl test strips); and they would be willing to obtain naloxone.
The success of the LUU campaign in its first year led to the continuation and expansion of the campaign, the development and testing of a stigma reduction Extension for Community Healthcare Outcomes (ECHO) training, the development of a community grant program, and the creation of a community workbook to help CBOs build community capacity for stigma reduction work. Findings from each of the statewide stigma surveys is publicly available so that CBOs, policy makers, researchers, local and state government officials, and individuals can make data informed decisions when trying to reduce stigma in their populations. Additionally, monthly data briefs, recordings of monthly webinars, and CBO maps can be found through the data portal. Detailed analysis of the baseline statewide stigma survey was published in Substance Use and Misuse available here .
This work is one piece of the collective, system-wide effort to address substance use stigma through the Substance Use Stigma Reduction Collaborative of the Consortium on Substance Use and Addiction (CSUA) . Other researchers in the Collaborative are also taking an active role in alleviating stigma of SUD. For instance, researchers at Penn State Berks have found one’s endorsement of certain “ addiction frameworks ” – or beliefs about addiction – may further compound stigma of individuals who use opioids and perceptions of ‘effective’ responses to OUD. This work has found individuals who perceive addiction as being a ‘medical’ problem as opposed to a ‘moral’ problem, place less stigma onto individuals who use opioids and show more favorability toward certain forms of harm reduction, such as naloxone and MOUD. This research also has demonstrated that individual ‘addiction frameworks’ can be shaped by personal experiences and effective intervention, such as classroom training on substance use dependency and exposure to individuals in recovery .
Concluding Remarks
As a land grant university, Penn State has faculty and researchers who are actively engaged in research agendas aimed at developing evidence-based solutions to important societal problems, such as the opioid crisis. Collectively, the opioid-related stigma research that has been done by researchers at Penn State demonstrates promising approaches to effectively alleviating stigma of OUD. These approaches include public education and social exposure campaigns such as LUU, which may help to change the public’s views of OUD and treatment while simultaneously increasing support for individuals with OUD in their recovery. Enhanced training and understanding of the disease model of addiction may also help improve professional responses to opioid overdose, and in turn, save lives.
This research, among others, will be highlighted on September 22, 2022 at the 2022 Summit on Substance Use Disorder Stigma Reduction at Penn State , an interdisciplinary event designed to bring together practitioners and scholars to consider the importance of stigma reduction in responding to substance use. Through collaborative research and community outreach ‘We are’ helping to fight the opioid crisis.
References
Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD. Release from Prison — A High Risk of Death for Former Inmates. N Engl J Med. 2007 Jan 11;356(2):157–165. PMCID: PMC2836121
Merrall ELC, Kariminia A, Binswanger IA, Hobbs MS, Farrell M, Marsden J, Hutchinson SJ, Bird SM. Meta-analysis of drug-related deaths soon after release from prison: Drug-related deaths after release from prison. Addiction. 2010 Jun 23;105(9):1545–1554.