1. October 17, 2017
Helping Practitioners with Addressing Stigma in the Context of Opioid Overdose Prevention
Southeast Regional Peer-Sharing Call
Shai Fuxman, Ed.D., CAPT Core Senior T/TA Associate
Haner Hernandez, MA, DrPH, CAPT Associate

2. This peer sharing call was developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies task order. Reference #HHSS I/HHSS T.
The views expressed on this call do not necessarily represent the views, policies, and positions of the Substance Abuse and Mental Health Services Administration or the U.S. Department of Health and Human Services.
This peer sharing call is being recorded and archived, and will be available to all call participants. Please contact the peer sharing call facilitators if you have any concerns or questions.

3. CAPT Senior T/TA Associate
Facilitators
Amanda, I’m assuming you want our bios. How’s this for me:
Shai Fuxman, a Senior Research Scientist with the Education Development Center, is an experienced researcher in the fields of public health and education. He currently serves as a Senior Training and Technical Assistance Associate for SAMHSA’s Center for the Application of Prevention Technologies (CAPT), where he supports the work of states and communities to prevent opioid misuse and overdose. Dr. Fuxman’s subject and skill expertise include positive and healthy youth development, program evaluation, and culturally responsive approaches to health promotion.
Shai Fuxman, EdD
CAPT Senior T/TA Associate
Haner Hernandez, DrPH
CAPT Associate

4. Today’s Discussion Background: Stigma and Substance Use Disorders
Addressing Stigmatizing Attitudes and Language
The Impact of Stigma on Opioid Overdose Prevention
CAPT Resources
Background: While there may be many of us who are familiar with this topic today, we’re going to go through some brief background information on stigma, especially in relation to substance misuse to get everyone grounded on the same page (hence the visualization of a book here).
Presenter Note: A lot of the language we’re going to be talking about, some folks will have said some of those things in the past. This is not an opportunity to beat people up, clarify some things, and use this conversation as a learning moment and a first step towards action in preventing stigma. We want to reiterate this point because there are folks who join the call late too.
Image Source:

5. Background: Stigma and Substance Use Disorders (SUD)

6. On a scale of 1-5, how much do you think stigma related to substance use disorders (SUD) affects your prevention work at the state or community level? What do you hope to get out of today’s conversation?
Discussion Questions
First Question is a poll and includes the following options:
1 – No visible impact 2
3- A bit of an impact, but not much 4
5-Very large impact!
Second Question box open answer

7. Defining Stigma1
Stigma is a negative view based on an attribute and stereotype about a person or group. For example, stigma may describe a negative view of substance use disorder, depression, bipolar disorder, or people who have these illnesses. These negative views create prejudice which leads to negative actions and discrimination.
Presenter Note:
Today’s discussion will solely focus on addressing unintentional stigma.
Presenters will describe what we mean by unintentional stigma

8. Report Highlights:1
Less research on stigma targeting people with SUDs compared to people with mental health disorders.
Practices that address mental health stigma are not necessarily applicable to SUD stigma.
Three interrelated types of stigma: structural, public, and self.
On the left is a picture of the cover of the SAMHSA and ASPE commissioned report entitled, Ending Discrimination Against people with Mental and Substance Use Disorders: The Evidence for Stigma Change. This is a comprehensive report of literature around stigma as well as original field work that included those affected by mental illness and substance use disorder, along with their family, friends and allies, in two public workshop settings outlines what stigma is in these contexts, and the science behind how to reduce it. I just wanted to highlight a few features from this report that are relevant to our discussion today:
First, it’s important to note that the report found there is less research on stigma against folks with SUD compared to those with mental health disorders.
Strategies to address mental health stigma are not a “one size fits all” strategies that can be applied to SUD stigma
There are three levels of stigma that exist in society to be aware of: structural, public and self stigma.

9. Levels of Stigma1 Structural Stigma Public Stigma Self Stigma
Examples:
Structural Stigma
Public Stigma
Self Stigma
State health agency workgroups make decisions with no representation of the populations they serve
Neighborhood members have negative views on local drug activity
Each level will be defined and includes an example on the left side.
I will lead into a last point from the report, the backbone of stigma.
Haner brings up a great point that this is an opportunity to take a greater look within our systems.
People using drugs believe they’re not worth treatment for SUD

10. Stigma and Intersectional Identities
Race, ethnicity, class, gender, and other factors play a role in perceived and experienced SUD stigma…
Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly. - Martin Luther King, Jr.
Presenter Notes: (Haner to add notes here)
Presenter will define what we mean by intersectional identities
Presenter will talk about the intersections of substance-use related stigma with other forms of social marginalization; and the recognition of societal power relations within mechanisms of stigma
While addressing stigma in opioid overdose prevention is a tall order in it of itself, there’s also an important consideration to the role race, class, gender and more play as well.
Those who live with a disability, especially those who live with chronic pain, may also very well depend on the use of opioids for pain management. Such dependence however comes with the stigma attached to those who also use opioids non-medically.

11. Stigma Across the Continuum of Care
When we think about opioid misuse and overdose, it is important to think about the entire continuum of care, including how stigma can impact each step of the way. For example, parents not wanting to participate in a program focused on preventing opioid misuse among youth because of the stigma associated with “bad parents” of youth who use; barriers for people accessing treatment; and the difficulty of long-term recovery associated with past addiction.

12. The Impact of Stigma on Opioid Overdose Prevention

13. Consider the following from the research literature:
The Impact of Stigma
Consider the following from the research literature:
People who use/misuse opioids may be less likely to pursue help-seeking behaviors.2,3
SUD is among the most stigmatized condition in the U.S. and around the world.2
Health care providers treat patients with an SUD differently.4,5
People with an SUD who expect or experience stigma have poorer outcomes.5,6,7

14. What other kinds of impact has stigma had on your own prevention work?
What we have heard…
Among states and territories in the Southeast, we have also heard that:
Stigma affects inclusion and engagement of potential partners (e.g., indicated populations not in treatment) in prevention efforts
What other kinds of impact has stigma had on your own prevention work?
Presenter Notes:
Presenter can connect this to Slide 12, and how participants identified examples of stigma in their prevention work, but what impacts have they’ve seen from those or other examples.

15. Addressing Stigmatizing Attitudes and Language
Presenter Notes:
Remind audience that our focus here is on unintentional stigma
NH struggled with this – had an image of a person, but that stigmatized that adult male character, and people took that. People were drawn to a particular image.
Lessons learned about that – Anyone Anytime.
Provide examples of how you can harness empirical evidence and social marketing strategies to dismantle stereotypes and discourage stigmatization of those with mental health problems.

16. Person-first language makes a difference:
Language Matters
Person-first language makes a difference:
High-risk youth  Youth living in high-risk situations or who demonstrate high-risk behaviors
Addict  Person with a substance use disorder
Getting clean  In recovery from a substance use disorder
Ask for other examples of how we can move from stigmatizing language to less stigmatizing language.

17. Changing the Perception
Consider these images. How has our visual perception of SUD and those affected by it changed over the years?
What images come to mind when you think about how people with substance misuse disorder are portrayed in media? How has it changed over time?
Need to refine or sharpen image

18. Challenging Assumptions
How many times have we heard this:
“If someone has a substance use disorder and they wanted to overcome it, they could if they just wanted it badly enough….”
But, what if…
Up until recently-substance use disorders were understood to be mostly be a matter of “bad genes” or “lack of control”
This created stigma for people with substance misuse behaviors, they were “blamed” for their problem
It isn’t a one-size fits all…. We need to check our assumptions…
Just because we don’t have the evidence that it isn’t effective, doesn’t mean something is effective, it means we just don’t have the evidence.
Some research perpetuates stigmatizing attitudes. Examples of how a diabetic is treated versus how we think about someone in recovery.
Talking about it in terms of it being a disease – versus criminal behavior, delinquent behavior – take out the moral judgement
Recognizing I have a problem – may have some behavioral problems that might worry me – and feel ok about
So important for people to get help – because it is a brain disease.
Anecdotal evidence – examples from film and television – that perpetuate stereotypes – Lobby poll?
HEALTH-SEEKING – outcomes!
Like cultural competence – it is a process, that much of this is engrained in all of us – it won’t unhappen in a day.

19. Breakout Discussion Sessions
Discussion Questions
What is the hardest part of overcoming stigma in our work at the state or community level?
How have you overcome this challenge?
Breakout Discussion Sessions
Questions include:
1. What is the hardest challenge related to overcoming the invisible barriers of stigma in our work?
Presenter note: The facilitator can prompt the conversation connecting it to the discussion about stigma discussion on stigma and intersectionality (SUD and race, ethnicity, language, rural vs urban) and on the impact on stigma
2. What has worked in addressing those challenges
Presenter note: Facilitator will try to guide participants to be concrete, and to provide solutions to a few of the examples of barriers of stigma provided)

20. Taking Action to Address Stigma
Discussion Question
What is one takeaway from today’s discussion and/or step you will take or continue taking to:
Address SUD stigma in your community?
Help practitioners address stigma in their communities?
Taking Action to Address Stigma
The question provides for a response from the two levels of participants that will join the call:
prevention practitioners at the community level ,
state staff who’s role is to assist practitioners
If you work at the community level:
What is one takeaway from today’s discussion and/or step you will take or continue taking to:
address SUD stigma in your community?
If you are an STR coordinator or staff working at the state level:
help practitioners address stigma in their communities?

21. Resources and Where to Learn More

22. Marketing Campaigns Around Reducing or Addressing Stigma
CAPT Resource
Marketing Campaigns Around Reducing or Addressing Stigma
Inventory of U.S.-based marketing and media campaigns and the efficacy of those campaigns on reducing stigma and expanding awareness and knowledge about substance use, mental health, and prevention strategies.
COMING SOON!
Presenter Note: This is not yet available from the CAPT, but should be included in the webinar follow-up materials. (Approximately a week after the webinar).

23. Words Matter: How Language Choice Can Reduce Stigma
CAPT Resource
Words Matter: How Language Choice Can Reduce Stigma
Protest any labels that turn people into things. Words are important. If you want to care for something, you call it a “flower.” If you want to kill something, you call it a “weed.”
COMING SOON!
Presenter Note: This is not yet available from the CAPT, but should be included in the webinar follow-up materials. (Approximately a week after the webinar).

24. CAPT Prevention Conversations Videos: Coming Soon!
Lessons from Massachusetts: Changing the Conversation about Addiction
Preventing Opioid Misuse and Overdose: Using Data to Correct Misperceptions
Reframing the Opioid Prevention Narrative: Addressing Misperceptions
Reframing the Opioid Prevention Narrative: Working with the Press
Presenter Note: These videos are not available on the web just yet, but will soon be. If you would like know more on these prevention conversations, please reach out to your T/TA liaison for more information. Otherwise, stay tuned!

25. Where to Learn More
Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change
Available here:
Comprehensive report of literature around stigma as well as original field work that included those affected by mental illness and substance use disorder, along with their family, friends and allies, in two public workshop settings outlines what stigma is in these contexts, and the science behind how to reduce it.

26. Any Lingering Questions?

27. Evaluation Please take the time to complete a brief feed back form:
Your feedback is appreciated!

28. Korene Stamatakos Alaimo
If you have questions or comments, please don’t hesitate to contact:
Lourdes Vázquez
Coordinator, CAPT Southeast Resource Team
Korene Stamatakos Alaimo
Associate Coordinator, CAPT Southeast Resource Team

29. References
1 National Academies of Sciences, Engineering, and Medicine. (2016). Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: /23442.
2 Barry, C. L., McGinty, E. E., Pescosolido, B. A., & Goldman, H. H. (2014). Stigma, discrimination, treatment effectiveness, and policy: public views about drug addiction and mental illness. Psychiatric Services, 65(10),
3 Van Boekel, L. C., Brouwers, E. P., Van Weeghel, J., & Garretsen, H. F. (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and alcohol dependence, 131(1),
4 Kelly, J. F., Dow, S. J., &Westerhoff, C. (2010). Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. Journal of Drug Issues, 40, 805–818.
5 Kelly, J. F., Wakeman, S. E., & Saitz, R. (2015). Stop talking 'dirty': Clinicians, language, and quality of care for the leading cause of preventable death in the United States. American Journal of Medicine, 128, 8–9.
6 Brener, L., von Hippel, W., von Hippel, C., Resnick, I., & Treloar, C. (2010). Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach. Drug and Alcohol Review, 29(5),
7 Keyes, K. M., Hatzenbuehler, M. L., McLaughlin, K. A., Link, B., Olfson, M., Grant, B. F., & Hasin, D. (2010). Stigma and treatment for alcohol disorders in the United States. American Journal of Epidemiology, 172(12),