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The EXPLORE toolkit is a resource designed to support researchers and frontline workers addressing substance use in the Borderlands. It addresses equity, stigma, and participation barriers, promoting culturally sensitive and community-centered research practices.

This toolkit is an ideal tool for clinical trials researchers and community health workers who are interested in learning more about how to engage underrepresented populations in clinical trials research in Southern New Mexico and beyond.

Related protocols: CTN-0133

In this session, John Kelly, PhD, ABPP of Harvard University discussed the fundamental causes of stigma in relation to substance use disorder, reviewed some of the paradoxical findings from the latest stigma research, and suggested how stigma might be more systematically addressed to enhance the clinical care and outcomes of individuals suffering from substance use disorder.

Background: Stigma toward people with substance use disorders (SUD) remains a major barrier to care. There have been multiple calls to action to address SUD stigma in healthcare settings and other reviews have clarified the need for more rigorous effectiveness research. In addition to attention to effectiveness research, there is a need to attend to the implementation strategies used to deliver SUD stigma reduction interventions. Delineating discrete implementation strategies that have been used to address stigma will support future research efforts to arrive at the most optimal interventions to address SUD stigma.

Methods: We searched three databases and extracted data to identify interventions tested to reduce SUD stigma. We used the adapted Expert Recommendations for Implementing Change (ERIC) taxonomy to characterize the discrete implementation strategies used to support the adoption, implementation, sustainment, and scale-up (or spread) of each intervention.

Results: This scoping review synthesized 108 peer-reviewed studies reporting on interventions which to address SUD stigma among healthcare professionals. Most interventions were implemented in training environments, including higher education and continuing education settings, and focused on providing basic education on SUD broadly or opioid use disorder. Within interventions, educational and training implementation strategies were most prominent with 74% of studies using educational meetings and 39% distributing training materials. Far fewer studies used implementation strategies that used experiential approaches such interactive assistance, simulation, case-based learning, or contact with people with lived experience. Most studies (73%) reported reductions in stigmatizing attitudes, most often immediately post-intervention, though the need for higher study quality was notable.

Conclusions: Existing stigma-reduction interventions are overwhelmingly education-focused and primarily implemented in academic settings, with limited use of strategies that promote reflective learning, contact-based engagement, or organizational change. Future work should employ more rigorous designs that systematically test implementation strategies to create packaged SUD stigma reduction interventions optimized for effectiveness and implementation.

Stigma toward people with substance use disorders (SUD) remains a major barrier to care. This presentation described the methods, results, and implications of a scoping review completed by the CTN T&I SIG’s Implementation Strategies Workgroup to identify and describe implementation strategies used to reduce stigmatizing attitudes toward people with SUD in healthcare settings.

This narrative review, which is not directly part of a CTN study but whose primary authors are funded by the CTN and are working on protocols related to this topic, addresses post-2020, specific, complex challenges for use of and adherence to pre-exposure prophylaxis (PrEP) for HIV prevention among out-of-treatment people who use drugs (PWUD) at syringe services programs (SSPs).

The COVID-19 pandemic and its associated changes to the provision of healthcare have significantly impacted HIV prevention, especially for PWUD. Through a synthesis of literature and clinical experience, we (1) characterize the operational changes imposed by the pandemic on SSPs that shaped the current HIV prevention landscape; (2) describe three levels of current challenges for PWUD, including consumer attitudes, non-medical and medical provider attitudes, and structural and scalability barriers; (3) characterize current models for PrEP in SSPs; and (4) offer practical recommendations for HIV prevention in harm reduction programs.

Conclusions: PrEP is a highly effective prevention tool if taken as prescribed. It has been enthusiastically promoted by members of the research, public health and provider communities. Despite its efficacy, PWUD struggle to engage with the PrEP care continuum. We highlight opportunities to advance HIV prevention for PWUD by enhancing tailored, whole-person approaches that may set aside PrEP in favor of other risk reduction routes. For most PWUD who receive services at SSPs, PrEP is a single tool and not realistic until other social and structural determinants of health are addressed.

Substance use is a public crisis in the U.S. Substance use can be understood as a series of events in the life course, from initiation to mortality. Social Determinants of Health (SDoH) have increasingly been recognized as essential contributors to individuals’ health. This scoping review aims to examine available evidence of SDoH impact on the life course of substance use disorder (SUD).

Substance use is a public crisis in the U.S. Substance use can be understood as a series of events in the life course, from initiation to mortality. Social Determinants of Health (SDoH) have increasingly been recognized as essential contributors to individuals’ health. This scoping review, supported by the NIDA CTN Greater Southern California Node, aims to examine available evidence of SDoH impact on the life course of substance use disorder (SUD).

Among the 50 studies identified, ten revealed parental monitoring/support and early childhood education as protective factors, while negative peer influences and neighborhood instability were risk factors of substance use initiation. Nineteen articles reported factors associated with escalation in substance use, including unemployment, neighborhood vulnerability, negative peer influence, violence/trauma, and criminal justice system (CJS) involvement. Ten articles suggested that employment, social support, urban living, and low-barrier medication treatment facilitated treatment participation, while stigma and CJS involvement had negative impact on treatment trajectory. Social support and employment could foster progress in recovery and CJS involvement and unstable housing deterred recovery. Four studies suggested that unemployment, unstable housing, CJS involvement, and lack of social support were associated with overdose and mortality.

Conclusions: This review underscores the influence of social networks and early life experiences on the life course of SUD. Future SDoH research should investigate overdose and mortality and the impact of broader upstream SDoH on SUD. Interventions addressing these social factors are needed to mitigate their detrimental effects on the trajectories of SUD over the life course.

The US overdose epidemic is an escalating public health emergency, accounting for over 100,000 deaths annually. Despite the availability of medications for opioid use disorders, provider-level barriers, such as negative attitudes, exacerbate the treatment gap in clinical care settings. Assessing the prevalence and intensity of provider stigma, defined as the negative perceptions and behaviors that providers embody and enact toward patients with substance use disorders, across providers with different specialties, is critical to expanding the delivery of substance use treatment.

Objective: To thoroughly understand provider stigma toward patients with substance use disorders, we conducted a nationwide survey of emergency medicine and primary care physicians and dentists using a questionnaire designed to reveal how widely and intensely provider attitudes and stigma can impact these providers’ clinical practices in caring for their patients. The survey also queried providers’ stigma and clinical practices toward other chronic conditions, which can then be compared with their stigma and practices related to substance use disorders.

Methods: Our cross-sectional survey was mailed to a nationally representative sample of primary care physicians, emergency medicine physicians, and dentists (N=3011), obtained by American Medical Association and American Dental Association licensees based on specified selection criteria. We oversampled nonmetropolitan practice areas, given the potential differences in provider stigma and available resources in these regions compared with metropolitan areas. Data collection followed a recommended series of contacts with participants per the Dillman Total Design Method, with mixed-modality options offered (email, mail, fax, and phone). A gradually increasing compensation scale (maximum US$250) was implemented to recruit chronic nonresponders and assess the association between requiring higher incentives to participate and providers stigma. The primary outcome, provider stigma, was measured using the Medical Condition Regard Scale, which inquired about participants’ views on substance use and other chronic conditions. Additional survey measures included familiarity and social engagement with people with substance use disorders; clinical practices (screening, treating, and referring for a range of chronic conditions); subjective norms and social desirability; knowledge and prior education; and descriptions of their patient populations.

Results: Data collection was facilitated through collaboration with the National Opinion Research Center between October 2020 and October 2022. The overall Council of American Survey Research Organizations completion rate was 53.62% (1240/2312.7; physicians overall: 855/1681.9, 50.83% [primary care physicians: 506/1081.3, 46.79%; emergency medicine physicians: 349/599.8, 58.2%]; dentists: 385/627.1, 61.4%). The ineligibility rate among those screened is applied to those not screened, causing denominators to include fractional numbers.

Conclusions: Using systematically quantified data on the prevalence and intensity of provider stigma toward substance use disorders in health care, we can provide evidence-based improvement strategies and policies to inform the development and implementation of stigma-reduction interventions for providers to address their perceptions and treatment of substance use.

Related protocols: CTN-0104

Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs.

A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) study evaluating PSS effectiveness (CTN-0107). Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis.

A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided “general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding.

Conclusions: The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.

Related protocols: CTN-0107

This is the Results Article for CTN-0095-A-2.

Many primary care clinicians (PCCs) hold stigma toward people with opioid use disorder (OUD), which may be a barrier to care. Few interventions exist to address PCC stigma toward people with OUD. This study examined whether an online training incorporating patient narratives reduced PCCs’ stigma toward people with OUD (primary) and increased intentions to treat people with OUD compared to an attention-control training (secondary).

PCCs from 15 primary care clinics were invited to complete a 30 minute online training for an electronic health record-embedded clinical decision support (CDS) tool that alerts PCCs to screen, diagnose, and treat people with OUD. PCCs were randomized to receive a stigma-reduction version of the training with patient narrative videos or a control training without patient narratives and were blinded to group assignment. Immediately after the training, PCCs completed surveys of stigma towards people with OUD and intentions and willingness to treat OUD. CDS tool use was monitored for 6 months. Analyses included independent samples t-tests, Pearson correlations, and logistic regression.

A total of 162 PCCs were randomized; 88 PCCs (58% female; 68% white) completed the training (Stigma=48; Control=40) and were included in analyses. There was no significant difference between intervention and control groups for stigma (t=-0.48, p=.64, Cohen’s d=-0.11), intention to get waivered (t=1.11, p=.27, d=0.26), or intention to prescribe buprenorphine if a waiver were no longer required (t=0.90, p=0.37, d=0.21). PCCs who reported greater stigma reported lower intentions both to get waivered (r=-0.25, p=0.03) and to prescribe buprenorphine with no waiver (r=- 0.25, p=0.03). Intervention group and self-reported stigma were not significantly related to CDS tool use.

Conclusions: Stigma toward people with OUD may require more robust intervention than this brief training was able to accomplish. However, stigma was related to lower intentions to treat people with OUD, suggesting stigma acts as a barrier to care. Future work should identify effective interventions to reduce stigma among PCCs.

Related protocols: CTN-0095-A-2

Opioid use disorder (OUD) is a deadly illness that remains undertreated, despite effective pharmacological treatments. Barriers, such as stigma, treatment affordability, and a lack of training and prescribing within medical practices result in low access to treatment. Software-delivered measurement-based care (MBC) is one way to increase treatment access. MBC uses systematic patient symptom assessments to inform an algorithm to support clinicians at critical decision points.

Focus groups of faculty clinicians (N=33) from 3 clinics were conducted to understand perceptions of OUD diagnosis and treatment and whether a computerized MBC model might assist with diagnosis and treatment. Themes from the transcribed focus groups were identified in two phases: (1) content analysis focused on uncovering general themes; and (2) systematic coding and interpretation of the data.

Analysis revealed six major themes utilized to develop the coding terms: “distinguishing between chronic pain and OUD,” “current practices with patients using prescribed or illicit opioids or other drugs,” “attitudes and mindsets about providing screening or treatment for OUD in your practice,” “perceived resources needed for treating OUD,” “primary care physician role in patient care not specific to OUD,” and “reactions to implementation of proposed clinical decision support tool.”

Conclusions: Results revealed that systemic and attitudinal barriers to screening, diagnosing, and treating OUD continue to persist. Providers tended to view the software-based MBC program favorably, indicating that it may be a solution to increasing accessibility to OUD treatment; however, further interventions to combat stigma would likely be needed prior to implementation of these programs.

Related protocols: CTN-0090