Understanding How Peers Can Shift Stigma to Retain Low-Income, Minority Individuals in Opioid Treatment

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PROJECT SUMMARY There is an urgent need to develop and evaluate innovative strategies to reduce substance use stigma and improve opioid use disorder (OUD) treatment outcomes. Particularly in the context of the devastating health disparities of COVID-19, we must also consider how other health- and race-related stigmas further contribute to poor retention in care among low-income, minority individuals with OUD. One of the most promising strategies to reduce multiple intersecting stigmas and improve engagement in care for low-income, minority individuals is through the use of peer recovery coaches (PRCs). PRCs, individuals who have gone through the recovery process themselves, have been shown to be more acceptable for engaging and retaining low-income, racial/ethnic minority patients compared to other health workers. A predominant theory is that a PRC’s shared lived experience and background may decrease stigma, which can then translate into improved patient care. However, surprisingly little research has formally evaluated the effects of PRCs on substance use stigma, nor how PRC interventions reducing stigma may result in improved treatment outcomes. Our parent award (R61AT010799) is evaluating a PRC-delivered behavioral intervention to improve retention in methadone treatment among low-income, racial/ethnic minority individuals in Baltimore City. The overall aim of the proposed supplement is to test whether and how a PRC model can reduce multiple intersecting stigmas, and whether changes in stigma translate into improvements in methadone treatment retention. First, using in-depth, individual interviews with key stakeholders (patients, PRCs, and staff; n=24), we will explore how PRCs can shift intersecting stigmas among racial/ethnic minority individuals with OUD to improve retention in care, and how to tailor a PRC intervention to reduce these intersecting stigmas and their impact on OUD outcomes. Next, we will evaluate the effects of a PRC intervention being evaluated in the parent award on internalized and anticipated substance use stigma over 3 months (primary), methadone stigma (secondary), and other intersecting stigmas (guided by Aim 1), among low-income, minority individuals initiating methadone or demonstrating challenges with retention (n=30). As a final exploratory aim, we will examine changes in substance use and methadone stigma as predictors of methadone retention over six months. This supplement is responsive to high priority areas of NOT-OD-20-101 in that: (1) we will analyze strategies to reduce internalized and anticipated substance use and methadone stigma to improve treatment access, effectiveness, and recovery for low-income, minority patients; and (2) we will utilize existing psychometrically validated tools and theories to assess stigma that leverages our team’s work with other health-related stigma (i.e., in HIV care globally). This is the first stage development of a multicomponent approach that could be expanded and implemented for large-scale projects (i.e., in the R33 phase) and potentially scaled nationally to reduce stigma and support low-income, minority patients with OUD.