Abstract
The aim of this study was to describe rural community stakeholders’ attitudes and perceptions of providing medication for opioid use disorder (MOUD) to individuals in the criminal/legal system. Data were utilized from a technical assistance initiative aimed at strengthening community-based OUD treatment within criminal/legal systems. A mixed-methods approach was applied. Survey responses were used to compare stakeholders’ who had and had not attended an MOUD training, and semistructured interviews were conducted with a convenience sample of rural criminal/legal and treatment stakeholders. MOUD training was associated with endorsing the effectiveness of methadone, oral naltrexone, and injectable naltrexone. Three primary themes emerged from the stakeholder interviews: 1) acceptance of MOUD uptake; 2) stigma of MOUD and diversion concerns; and 3) gaps in MOUD treatment. Most interviewees noted that there is a scarcity of treatment options in their community, and among the existing services, there are considerable barriers to care.
Introduction
Rural communities across the United States have been impacted by an ongoing crisis of overdose deaths—attributed largely to opioid use. From 1999 to 2015, rural counties experienced a 325% increase in overdose-related mortality which outpaced the rates of overdose-related death in urban areas (Hedegaard, Warner, & Miniño, 2017). Reasons for these rising rates include an increased availability of prescription opioids, high rates of unemployment, rapid diffusion of drugs within kinship networks, inadequate health insurance, and co-occurring mental health concerns (Dew, Elifson, & Dozier, 2007; Roy, Arruda, Bruneau, & Jutras-Aswad, 2016; Snell-Rood, Staton-Tindall, & Victor, 2016; Wenger, Lopez, Kral, & Bluthenthal, 2016). There are also distinct characteristics of opioid-related mortality among rural residents, such as low health literacy related to opioid overdose symptomology, increased likelihood of injecting in isolation without recourse to rapid intervention in the event of overdose, and adverse effects related to injection drug use (Dunn et al., 2016; Wang, Becker, & Fiellin, 2013; Wunsch, Nakamoto, Behonick, & Massello, 2009; Young, Havens, & Leukefeld, 2010).
Many rural areas do not have access to effective evidence-based treatments; specifically, medications for opioid use disorder (MOUD): methadone, buprenorphine, and naltrexone (Brown, Goodin, & Talbert, 2018; Browne et al., 2016; Rosenblatt, Andrilla, Catlin, & Larson, 2015). A recent systematic review identified several “consumer-focused,” and “provider-focused” barriers to MOUD care in rural areas (Lister, Weaver, Ellis, Himle, & Ledgerwood, 2020). For instance, consumer-focused barriers (Ellis, Konrad, Thomas, & Morrissey, 2009; Kaufman et al., 2016) included the dearth of MOUD treatment options available to rural residents with OUD, while provider-focused studies (Andrilla, Coulthard& Larson, 2017; DeFlavio, Rolin, Nordstrom, & Louis A Kazal, 2015; Jones, 2018; McCarty, Gustafson, Capoccia, & Cotter, 2004) referenced barriers related to availability and acceptability of MOUD in rural communities (Lister et al., 2020). Anticipated stigma, whereby individuals come to expect particular forms of discriminatory treatment (Turan et al. 2017; Van Brakel et al. 2019), has also been identified as a barrier associated with MOUD—particularly agonist therapies—such that reinforcing negative attitudes may become internalized, and negatively impact on individuals’ mental health and willingness to utilize treatment (Crapanzano, Hammarlund, Ahmad, Hunsinger, & Kullar, 2018).
Publicly-enacted forms of stigma against individuals with substance use disorders (e.g., use of discriminatory/biased language, mistrust of patients; framing as unmotivated patients) has a detrimental effect on providers’ attitudes and motivation to prescribe MOUD (Andrilla et al., 2017; DeFlavio et al., 2015; Jones, 2018; McCarty et al., 2009; Quest, Merrill, Roll, Saxon, & Rosenblatt, 2012). A recent qualitative study of community stakeholders (i.e., healthcare and treatment providers, law enforcement and judicial officials) in rural Appalachia found widespread mistrust of MOUD, with stigma against MOUD accepted culturally and incorporated into local policies (Richard et al., 2020). From the perspective of individuals that live in rural areas who are in recovery from OUD, stigma-related barriers to MOUD treatment were pronounced in health care settings, with pharmacies and pharmacist technicians being the most prominent enactors of stigma, through use of stigmatizing language and discriminatory treatment in clinical settings (Burgess et al., 2021). There is also growing evidence that individuals from rural communities with OUD experience stigma across multiple domains—publicly enacted, anticipated, experienced, and internalized—see Turan et al. (2017) for a conceptual model), which, along with structural factors (Lister et al., 2020; e.g., lack of access to treatment), generate more expansive barriers to care for rural people who use drugs. There is also little knowledge whether MOUD training may help mitigate these negative attitudes (Beachler, Zeller, Heo, Lanzillotta‐Rangeley, & Litwin, 2021).
This study sought to describe community-based criminal/legal and treatment stakeholders’ attitudes and perceptions of MOUD for individuals with OUD involved in the criminal/legal system. A secondary aim of this study is to explore whether stakeholders with experience attending a prior training was correlated with scores related to MOUD familiarity, MOUD as a community issue, MOUD effectiveness, and MOUD acceptability. It is important to understand barriers and facilitators of MOUD for this vulnerable population group, among which MOUD is underutilized (Fiscella, Wakeman, & Beletsky, 2018; Wakeman & Rich, 2015) despite their heightened risk for fatal overdose (Alex et al., 2017; Binswanger, Blatchford, Mueller, & Stern, 2013; Binswanger et al., 2007; G. A. Victor, Bailey, & Ray, 2021). We used a mixed-methods approach to explore the following aims: 1) to conduct a comparative analysis on attitudes related to MOUD between survey respondents who had attended an MOUD training to those who had not; and 2) to describe community stakeholders’ attitudes via semi-structured interviews that related to the provision of MOUD in their communities.
Methods
Procedures and Sampling
This study used data from the ongoing efforts of the Opioid Treatment Ecosystem (OTE), which is a technical assistance (TA) initiative aimed at strengthening community-based OUD treatment within criminal/legal systems and was supported through a State Opioid Response grant. The TA providers were employed by a large Midwestern university. Implementation of the OTE was guided by the Network for the Improvement of Addiction Treatment (NIATx) model (Ford et al., 2018). Participation in the OTE required communities to complete full MOUD implementation in county jails, including validated screening tools, access (i.e., induction and continuation) to all three forms of MOUD, adjunctive psychosocial services, and a continuity of care plan with naloxone distribution on release. This study reports data from one rural community prior to full implementation of the OTE. Michigan’s UP is a predominately rural area of 16,377 square miles with a total population of approximately 311,000 (∼19 people per square mile). This area was identified as having major gaps in OUD treatment, for example, having no methadone providers in the entire region (Lister et al., 2020). This study was approved by the University’s Institutional Review Board.
Quantitative Survey
Feedback from the TA providers highlighted the need to capture stakeholders’ attitudes specific to buprenorphine, and pharmacotherapies more generally, outside of its clinical use to understand barriers to MOUD acceptance and utilization. Following these discussions, an online survey was developed and distributed to a sample of community stakeholders. A snowball sampling technique was used to recruit survey respondents. The snowball sampling procedure began by sending the survey to five stakeholders from the UP community and instructed them to refer the survey within their professional organization or to those within their profession. The survey included 40-items and was distributed electronically so that data could be collected on a rolling basis as new respondents were referred. The snowball sampling procedure was conducted from March 27, 2020, to June 15, 2020 (N=110). The online survey included questions on the following subjects: a) MOUD training histories; b) familiarity of MOUD; c) concerns about MOUD diversion in their communities; d) effectiveness of MOUD; and e) acceptability of MOUD as a treatment option for individuals with OUD
Questions related to MOUD training histories were operationalized categorically: “Please indicate who provided the training or workshop in which you participated: 1) Public health professional(s); 2) Public safety professional(s); 3) An advocacy organization; 4) Medical professional(s); 5) Academic researcher(s); 6) Person(s) with personal opioid use and MOUD recovery experience; 7) Other.”
Questions related to perceptions and familiarity of MOUD were operationalized dichotomously: “I am familiar with Suboxone/Sublocade/buprenorphine (Disagree = 0; Agree = 1).”
Questions related to concerns about MOUD diversion in their communities were operationalized dichotomously: “Based on your knowledge, to what extent is diversion of medications for opioid use disorder (MOUD) and issue in your community (0=No issue; 1=Serious issue).
Questions related to MOUD effectiveness were operationalized dichotomously per each type of MOUD: Injectable naltrexone (Not effective = 0; Effective = 1); Injectable buprenorphine (Not effective = 0; Effective = 1); Oral naltrexone (Not effective = 0; Effective = 1); Oral buprenorphine (Not effective = 0; Effective = 1); Methadone (Not effective = 0; Effective = 1).
Questions related to acceptability of MOUD as a treatment option were operationalized dichotomously: “Public funding should be increased to address MOUD services for those in the criminal/legal system (Disagree = 0; Agree = 1).”
Qualitative Interviews
The current study also conducted semi-structured interviews with community members in the rural UP region of Michigan. Snowball sampling methodologies were used to recruit a convenience sample (N = 7) of criminal/legal, treatment, and medical stakeholders from the UP. Interviewees were recruited by those receiving TA as part of the OTE initiative and those who were interviewed were from the same geographic location as the survey respondents, but they were not part of the survey cohort. Semi-structured interviews (N = 7) were completed prior to June 23, 2020. Each interview took between 45 and 60 minutes to complete. Two members of the research team were present for all interviews with one member responsible for extensive note taking and the other member was responsible for facilitating the interview. Each interview began by asked the interviewees to describe their professional background and their experience working with individuals with OUD. The interview guide included a total 12 questions although interviewers allowed for a fluid conversation and at times not all questions were asked, or in some cases, prompts that were asked varied between interviewees. Questions inquired about the best short- and long-term treatment options for persons with OUD, the influence of individual characteristics on treatment approaches, the extent of administrative support for MOUD and if they had ever recommended MOUD as a treatment option, and the sociopolitical conditions that impact their opinions of MOUD.
An example of questions and prompts are as follows:
Question: “What do you generally believe is the best long-term option for these individuals?
Prompts: Long-term maintenance on an opioid replacement medication (like methadone)? Maintenance with a later transition to drug free (if this option—how long on maintenance)? If endorsed, what is involved in abstinence-based care?)?”
Question: “To what extent might (health/legal/opinion) policies affect your decision to recommend or prescribe buprenorphine?”
Prompts: On or not on the formulary? Paying you to attend training about the medication? Availability of other clinicians in the clinic who could prescribe the medication? Prevalence of OUD among your community? Encouragement by the chief of your service/legal unit or other clinicians who provide addiction treatment? Availability of specialty addiction medicine department/clinicians in correctional settings? Pharmacy/dispensing or low-threshold access/policies?
Analytic approach
Qualitative semi-structured interview responses were analyzed using the principles of grounded theory (Charmaz, 2017). The research team utilized an established protocol for code construction (Saldaña, 2015; Wicks, 2017). The content coding process was refined at each reading interval, with subsequent readings conducted to refine our construct operationalization. Two research team members tested inter-rater reliability using Cohen’s Kappa to calculate the degree of agreement for each code by adhering to an 80% agreement threshold. Qualitative data analyses were conducted using NVivo (AlYahmady & Al Abri, 2013). Quantitative analyses were performed to identify differences between respondents’ who had and had not previously attended an MOUD training. We used respondents’ answerers to the survey items on the following subjects as the dependent variables: 1) familiarity of MOUD; 2) concerns about MOUD diversion in their communities; 3) effectiveness of MOUD; and 4) acceptability of MOUD as a treatment option for individuals involved in the criminal/legal system. Chi-square tests were performed to estimate significant differences between those with training histories and those without. All analyses were performed using SPSS version 26.0 (Pallant, 2003). The cut-off for statistical significance was p < 0.05.
Results
Prior MOUD Training on Attitudes
Most of the respondents were from court systems (n = 20, 18.1%). The other stakeholder groups included persons with opioid use and MOUD recovery experience (n = 19, 17.2%), public health professionals (n = 18, 16.4%), advocacy organizations (n = 16, 14.5%), academic researchers (n = 15, 13.6%), public safety professionals (n = 12, 10.9%), and medical professionals (n = 10, 9.1%). The majority of respondents (n = 66, 60.0%) reported having attended a prior MOUD training or workshop. These trainings included in-person large conference setting (n = 44, 32.6%), in-person small conference setting (n = 37, 27.4%), recorded webinar or video (n = 29, 21.5%), and live webinar (n = 25, 18.5%).
Associations between training history and attitudes related to MOUD.
Note. Training history was the independent variable and MOUD familiarity, MOUD as a community issue, MOUD effectiveness, and MOUD acceptability were the dependent variables. Questions were not mutually exclusive.
Qualitative findings
The qualitative findings were coded into three primary categories: 1) acceptance of MOUD uptake; 2) stigma toward MOUD and diversion concerns; and 3) gaps in MOUD treatment. The first category—acceptance of MOUD uptake—primarily referred to interview responses that provided rationales in support of buprenorphine as a treatment option, as well as general acceptance of other MOUD treatments. The latter two categories predominantly referred to themes that indicated barriers to MOUD. A lack of belief in the effectiveness of MOUD, viewing individuals with OUD with mistrust or with the assumption that they lacked self-control were examples of publicly enacted stigma—from open expression of unfavorable or discriminatory beliefs towards people who prescribe or seek out MOUD to descriptions of active measures to deter others in engagement with MOUD—while structural determinants further entrenched the barriers to MOUD care within rural communities.
Acceptability of Medication For Opioid Use Disorder Uptake
Several interviewees endorsed the uptake of MOUD. These endorsements ranged from believing that the provision of MOUD was a moral and ethical imperative to conditional endorsements where situational or patient characteristics influenced clinical decision-making. For instance, an opioid health home program coordinator reflected on how her personal recovery from OUD informed her opinion of MOUD: “When I was going through recovery, I was prescribed that medication. Personally, I feel like it helped me get my life back. You’re being treated for a disorder, so I don’t feel like it’s different than being treated for anything different like anxiety or any other disorder. It gave me that sense of stability to help me move forward.”
Alternatively, a local judge noted that they generally accepted the provision of MOUD, but believed that it may be best used if it was reserved for individuals with more severe OUD—such as those with injection drug use histories: “My attitude, I guess it would change, I would regard the typical person IV drug user maybe a little more entrenched in addiction and in need of some more intense intervention. I think the combination of the MAT [medication assisted treatment, often used interchangeably with MOUD] with a more intense big picture plan would be what a longer-term user would need.”
The same judge disclosed that their attitudes on MOUD generally have shifted from negative to positive with a preference for naltrexone over buprenorphine or methadone. The preference for naltrexone was nearly universal among interviewees, while exceptions to this opinion were predominantly held by clinicians, who related a positive impression of agonist or partial-agonist therapies. Buprenorphine was primarily viewed as a higher-risk alternative given concerns about diversion and the perceived potential for mood-altering affects. When asked about the long-term treatment options the judge said the following: “I do feel like an inpatient setting to start is most important and I have a more favorable opinion of MAT than I used to have. Our experience locally, was pretty much suboxone [buprenorphine/naloxone], and instances of misuse…What changed my opinion about MAT the most was the development of some of the other medications. With the suboxone we saw rampant misuse and sketchy clinics, but then when naltrexone came out we saw people do it properly. Naltrexone seems to have less abuse potential and more opportunity for success.”
Similarly, a drug court officer noted that overall, they have a positive opinion of MOUD—with a preference for naltrexone—and have witnessed the benefits of medication therapy for individuals with OUD. After being asked about patients’ medication preferences, this interviewee responded by saying that, “It’s probably pretty equal (between naltrexone and buprenorphine), maybe with a bit more requests for buprenorphine.” This response was illustrative of a theme that emerged, where most interviewees had favorable views of naltrexone, but they also acknowledged that demand was greatest for buprenorphine. For those who were in favor of MOUD generally, most remained cautious about fully endorsing buprenorphine given its perceived risk for misuse—despite acknowledging patients’ preferences. She continued by saying: “I personally am in favor of the injections – once a month, no need to remember daily, can’t be abused – we’ve had a lot of people on it (naltrexone), seems to work really well for them. We have had quite a few people who take oral buprenorphine, I was a little hesitant at first and my personal opinion from hearing word about people selling it but I have learned a lot more about how doctors monitor and how people actually really seem to be doing well, so from a program standpoint and my personal opinion I am in support of MAT…It’s great that we have the doctors with us because we know that they are properly monitoring dosing.”
Stigma of Medication For Opioid Use Disorder and diversion concerns
The concerns of diversion were most pronounced among law enforcement and prosecuting attorneys. These concerns were amplified given that the topic subject was MOUD for individuals in contact with criminal/legal systems. Stigmatizing attitudes about the ability of individuals with OUD to be trusted with a 90-day prescription (or longer) was a reoccurring theme and was primarily aimed at buprenorphine relative to methadone and naltrexone. This accords with the methods of administration for these medications. Since naltrexone is injected, there is no feasible way to divert it, and methadone is only dosed through highly regulated visits to an opioid treatment provider (OTP), significantly reducing the need to trust patients with substantial take home quantities. Nevertheless, survey findings revealed that a number of stakeholders held concerns surrounding diversion and/or misuse of naltrexone, suggesting that a lack of understandings of these treatment modalities contributed to fears and stigmas surrounding MOUD (see Table
The high prevalence of buprenorphine in rural illicit drug markets was consistently mentioned by interviewees. For instance, a drug enforcement officer described the abundance of buprenorphine in illicit markets by saying, “Buprenorphine is the number one drug that undercover officers buy on the street. Had to stop buying it because they were spending so much of it, are saving some of the drug enforcement dollars to focus on the methamphetamine problem.” A prosecuting attorney described buprenorphine as a “drug of choice” with a high probability of “abuse.” These concerns were extended to the provision of buprenorphine induction or continuation in correctional institutions, where the dispensation of non-injectable medication was viewed as a great risk. Moreover, naltrexone was primarily perceived as a low-risk and preferred medication treatment option due to the perception that its route of administration afforded greater control in prescribing. As a drug task force officer explained: “If you give addicts a medication and expect them to self-control how they take that medication, it will never work. The system is set up to be abused. If someone is prescribed MOUD, and you give it to them, they are already an addict or they wouldn’t be on that medication, then trusting them to consume an intoxicating substance consistent with treatment, which doesn’t always happen.”
There were also negative attitudes related to MOUD as a long-term treatment option that were grounded in the belief that recovery required striving for abstinence from all agonist medications. Most interviewees often opinioned that if an individual was receiving buprenorphine—via a prescription or in illicit drug markets—then that person was likely still experiencing an addiction as well as a continued risk of diversion. The statements did not show knowledge of buprenorphine’s ceiling effect, where higher doses do not produce greater intoxication, and did not account for the possibility the diversion was undertaken for therapeutic purposes in an environment where access to MOUD was scarce. As a drug task force officer stated: “If you give an alcoholic 90 beers and say drink three a day, with their addiction, they are going to drink more or divert them, and that’s what we’re facing. There’s no mechanism where there is control...But, we see people on it for years and years—not using it to get off of opioids. It just keeps them in my opinion sick, keeping them on it for years at time. I’ve also heard that it is harder to get off buprenorphine than heroin or other opiates.”
There was also a common assumption that individuals who consume drugs and individuals who supply drugs were mutually exclusive groups. The stigma that was applied to each of these perceived groups differed in that individuals who were perceived as consuming drugs were afforded more compassion, and in many instances, treatment was a preferred option rather than incarceration. However, drug suppliers were labeled as criminals and a threat to the wellbeing of the community that required a more punitive approach. The possibility that some sale or diversion was an attempt to provide safer alternatives in the midst of a highly toxic drug supply (Bardwell et al., 2021) was not considered. A local judge described his opinion of this dichotomy: “There are definitely more folks using drugs than those who sell drugs. I will say, if an individual who is using drugs possesses a drug that is not their drug of choice they will often sell that substance to gain access to money to purchase their drug of choice; however, I have no interest in sending those individuals to jail, we’d like to route them to treatment when possible. Drug traffickers on the other hand, belong in jail.”
The reputation of MOUD and individuals with OUD was conditioned by public stigmas which extended out toward harm reduction services as well. Interviewees mentioned that they believed individuals with OUD were wary of utilizing harm reduction services due to the negative community attitudes related to these services (e.g., a syringe service program) and the risk of legal consequences, such as being targeted for investigation and arrest after being seen patronizing a harm reduction site. As a result, the stigma anticipated through engagement with harm reduction services came to also impact some individual’s openness to MOUD treatment. An opioid health home care coordinator explained by saying: “We have a needle exchange that just opened up and the community had a negative taste in their mouth, but with education, the numbers show we’re not condoning this behavior but actually doing harm reduction. So, people are nervous about going in because they don’t want to be seen going in or are nervous about getting in trouble. I think this relates to MAT too, people are nervous to be viewed as an addict and may not seek out services. So really it goes back to reducing stigma.”
Here, the combination of public stigma towards harm reduction services and MOUD (referred to by this care coordinator as MAT), and the anticipated stigma of people who use opioids is understood as both a compounded problem, but also one that can be addressed through greater education and training which should, in turn reduce the role of stigma as a barrier to care. Similarly, a drug court coordinator’s description of her change in attitude towards buprenorphine pharmacotherapy after she “learned a lot more about how doctors monitor and how people actually really seem to be doing well” suggests that greater education and awareness about MOUD may decrease fear and stigma.
Gaps in Medication For Opioid Use Disorder treatment
Most interviewees, regardless of the opinions they expressed about MOUD, stated that the number of treatment facilities in their communities were inadequate; yet, differences were observed relative to the perceived implications of the lack of treatment options. For instance, some viewed the lack of treatment providers as an extension of other health care services that were not available in their community, and they believed that a reason that demand was so high for drugs such as buprenorphine was due to a lack of MOUD providers. Along this line of thinking was the suggestion that by implementing more MOUD providers would drive down the demand of illicit buprenorphine. Alternatively, those who were skeptical of, or in opposition to MOUD, believed that transient providers (those who came to the community specifically to address the shortage of MOUD) were unscrupulous, predatory, and provided too many doses per prescription, leading to an increased risk of diversion. A drug court officer explained their reasoning: “I know it sounds terrible but from my perspective, it’s a cash scam for these doctors coming up. Our rural area up here—it’s hurting us…I think it might also help to have bi-weekly appointments with the doctor where he dispenses less medication, say 10 pills, because it would put more [responsibility] on the doctor to give more interaction and more of a relationship. If they had to see the doctor more often this could make it so they weren’t using other substances more often. The downfall is there is no behavioral health and substance abuse stuff I guess.”
Many believed that with more options in the community, patients would be provided with more appropriate dosages, have better treatment outcomes (e.g., abstinence and less crime), and the risk of diversion would be reduced. Most of these sentiments were couched with the notion that treatment could be best managed with an emphasis on naltrexone or the monthly injectable formulation buprenorphine, and opinions on establishing an OTP for methadone were mixed. Drug court officers, law enforcement personnel, and a judge were skeptical of the utility of buprenorphine but acknowledged that an increase in providers that were known, and respected members of the community would maximize the benefits of this treatment modality for individuals with MOUD and the greater community. Clinicians and the pharmacist we interviewed collectively viewed buprenorphine as a vital recovery option and some also suggested that a low-threshold option would be ideal for their community. Low-threshold treatment is a term in reference to an alternative approach to treatment engagement or continuation that attempts to remove as many barriers (e.g., X waiver required to prescribe buprenorphine) to treatment as possible.
Logistical concerns (e.g., transportation challenges and too few local providers) were consistently mentioned as accessibility barriers to MOUD care. As mentioned, the paucity of providers in the area has required providers from outside the community to provide transient services, which were often met with skepticism by interviewees (e.g., predatory prescribing practices). However, proponents of MOUD care frequently mentioned in ongoing efforts to address logistical concerns of providing MOUD care along with individualized treatment plans. A local pharmacist explained their approach: “Due to transportation issues we will utilize State Opioid Response Money to get them transportation either through one of our providers or through gas cards. We will also consider writing 30-day scripts. It will depend on the person and their needs and depend on the stability in their recovery. We are also working to expand telehealth opportunists and are working with pharmacies to decrease travel costs.”
Relatedly, risk assessment and harm reduction services have been tailored services to meet the needs of individuals in remote rural areas. Going out to people with OUD and providing them with resources was seen to overcome logistical and transportation challenges.
Discussion
This mixed-methods study described knowledge of, beliefs about, and attitudes toward MOUD among community stakeholders in a rural county in the state of Michigan, with a secondary aim of examining prior MOUD trainings were associated with attitudes. Findings from survey data demonstrated that prior trainings were associated with significant differences in respondents’ familiarity with MOUD, perception of MOUD as a community issue, perception of MOUD efficacy, and perception of MOUD acceptability. Following the care coordinator quoted in the results section, this training also may work to reduce stigma, and the role of both public and anticipated stigma as a barrier to care. These findings are consistent with those found by Beachler et al. (2021), such that improving health literacy regarding OUD and MOUD can improve attitudes in rural communities. However, trainings were not associated with attitudes related to buprenorphine. It should be noted that the group differences may reflect individuals’ characteristics, such that those who attend trainings were predisposed to have a higher opinion of MOUD and its effectiveness. Future research should explore the effectiveness of trainings and health communication campaigns, such as the Healing Communities (Lefebvre et al., 2020), to improve knowledge specific to buprenorphine in rural communities.
Publicly enacted stigma toward opioid use and MOUD treatment modalities was widespread. The most common concerns regarding MOUD related to buprenorphine pharmacotherapy, diversion, and misuse. Notably, those who were generally in favor of MOUD remained cautious about fully endorsing buprenorphine given its perceived risk for misuse, despite acknowledging patients’ preferences for buprenorphine as opposed to Vivitrol, believed among the sample to be “less risky.” These findings demonstrate an implicit mistrust in the judgement of people seeking treatment, and the prevalence of these subtle forms of enacted stigma against people who use drugs.
Negative attitudes toward MOUD were particularly salient among law enforcement and people working within the justice system, and given the high propensity for overdose following incarceration, it is urgent to work to combat MOUD stigma among these stakeholders, since it is one of the principal barriers to increasing availability (Wakeman & Rich, 2018). These attitudes may be based on beliefs about what motivates diversion. Studies have shown that the primary reason why people report consuming illicit buprenorphine is to treat their addiction by achieving the same intended effects as when used under the supervision of a physician, and they do so to overcome an acute scarcity of prescribed MOUD (Carroll, Rich, & Green, 2018; Cicero, Ellis, & Chilcoat, 2018) or due to other barriers to treatment (Silverstein, Daniulaityte, Miller, Martins, & Carlson, 2020).
The prevailing attitudes witnessed in this study setting contrast with jurisdictions that have de facto decriminalized the unprescribed possession of the medication, with no observed negative effects (B. D. Pozo, Krasner, & George, 2020). Given that the pandemic has resulted in the highest number of recorded overdose deaths in US history (Centers for Disease Control & Prevention, 2020), there is a strong case for both relaxing our fears about diverted buprenorphine and exploiting the advantages of the injectable formulation, which addresses those fears in any case (B. del Pozo & Rich, 2020). Buprenorphine uptake has shown to be associated with favorable outcomes, including reduced arrest (Evans, Zhu, Yoo, Huang, & Hser, 2019) and substantial reductions in overdose deaths upon release (Green et al., 2018), and recent studies have shown that use of non-prescribed buprenorphine has been associated with decreases in accidental overdoses (Carlson, Daniulaityte, Silverstein, Nahhas, & Martins, 2020), and can even serve as a barrier to treatment (Silverstein et al. 2020).
Some of our findings are consistent with prior studies, which identified forms of public stigma toward both care providers who prescribed MOUD as well as people receiving MOUD. Prior qualitative studies of attitudes toward MOUD prescribing have demonstrated stigma and hesitancy among physicians(Andraka-Christou & Capone, 2018), MOUD-dispensing pharmacists(Cooper et al., 2020), and individuals working for the justice system (Andraka-Christou & Atkins, 2020; Ezell et al., 2021) who doubt the efficacy of MOUD and express worry about misuse, diversion, and the challenges of working with people living with OUD. In this study, generalizing language (e.g., “If you give addicts a medication…” “If you give an alcoholic 90 beers”) suggest that stakeholders working toward the support of people with SUD continue to harbor stereotypes of the “nature” of individuals living with a SUD that can produce and reproduce barriers to care. These attitudes are concerning, as the multiple forms of stigma experienced by people who use opioids, may be compounded by their criminal/legal involvement (Tomar et al., 2020), and are a crucial hindrance to addressing the ongoing crisis of overdose death in the US (Tsai et al., 2019).
Future trainings should acknowledge the historical underpinnings of these openly expressed stigmatizing attitudes, including widespread concerns about the recent crisis in over-prescription of pharmaceutical opioids against which MOUD advocates must constantly work to set themselves apart from. Trainings could also include information about the ceiling effect of buprenorphine and other pharmacotherapy characteristics that may assuage fears of repeating an cascade of pharmaceutical overprescribing—an issue that may be particularly salient in rural areas (Compton, Jones, & Baldwin, 2016; Ibragimov, Young, & Cooper, 2020; Rigg, Monnat, & Chavez, 2018; G. A. Victor, Walker, Cole, & Logan, 2017; Volkow & McLellan, 2016).
Limitations
This study has several limitations. There was no survey respondent demographic data collected and specific information on the trainings that were attended is unclear. Our qualitative interviews had no direct correspondence to the survey findings so additional breadth on the nuances of the trainings was not captured. In addition, there is no available data specific to the trainings received, thus limiting the possible interpretations of these findings, which may not be generalizable beyond the rural area from which respondents were recruited. The survey and interview data did not capture the attitudes and experiences of individuals involved in the criminal/legal system. Survey distribution was limited to those already engaged in technical assistance on criminal/legal issues and therefore may not capture the prevailing values of stakeholders not engaged with this work. Nonetheless, considering the power and influence held by these actors as judges, police officers and people who work in community supervision, their views are likely to have the ability to set and reinforce norms, so understanding their attitudes and beliefs is critical.
Conclusion
Findings from a survey in a rural community demonstrated that publicly enacted stigma of individuals with OUD was reinforced by negative attitudes related to MOUD—in particular, buprenorphine, an underutilized medicine capable of contributing to meaningful reductions in overdose death. Considering the relatively minor health risks of buprenorphine diversion and the willingness of care providers to take measures to reduce the risk of diversion (Andrilla, Moore, Patterson, & Larson, 2019), the threat of diversion should not be used as a rationale for limiting access to buprenorphine treatment. Importantly, we show that trainings may be effective methods to improve attitudes related to evidence-based treatment of OUD, although more rigorous research is needed on this topic. Interviews with a cohort of stakeholders revealed that the acceptability of MOUD may be improving in some instances (e.g., drug court officials) and were favorable among treatment providers. Anti-stigma training for stakeholders involved in the care or management of people living with OUD is also recommended. All interviewees noted that there is a scarcity of treatment options in their community, and among the existing services, there are considerable barriers to care. Further research is needed to assess how OUD and MOUD trainings may improve attitudes among criminal/legal stakeholders.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by Substance Abuse and Mental Health Services Administration(TI083298).
