Utilization of Drug Treatment Programs by Methamphetamine Users: The Role of Social Stigma

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1 The American Journal on Addictions, 14: , 2005 Copyright # American Academy of Addiction Psychiatry ISSN: print / online DOI: / Utilization of Drug Treatment Programs by Methamphetamine Users: The Role of Social Stigma Shirley J. Semple, Ph.D., Igor Grant, M.D., Thomas L. Patterson, Ph.D. We examined the link between drug use stigma and use of drug treatment services in a sample of 292 heterosexually identified, methamphetamine (meth) users. Participants who had ever been in treatment for their meth use (N ¼ 82) were compared with those who had never been in treatment (N ¼ 210). Three dimensions of stigma proposed by Link et al. 1 were examined. In univariate analyses, participants who had never been in treatment for meth use reported significantly more expectations of rejection and endorsed more stigma coping strategies as compared to those who had ever been in treatment. Regression analysis revealed that all three dimensions of stigma distinguished between participants who did and did not receive treatment for their meth use. Stigma is discussed as a potential barrier to drug use treatment. (Am J Addict 2005;14: ) I n the past fifteen years, there has been a steady rise in the use of methamphetamine (meth) in California and other western states. 2 Meth use has been associated with a variety of negative social and health outcomes, including high levels of unprotected sex; problems with work, family, personal relationships, and the legal system; emergency room admissions; and death from heart attack and stroke. 2 7 In recent years, meth use admissions to publicly funded drug treatment programs in California have also increased dramatically. 2 Despite the availability of public treatment programs, meth use continues to be a major medical and social issue for individuals, families, and communities. 6 To effectively address meth use, a better understanding is needed of the factors that influence an individual s decision to enter treatment for his=her meth use. Social stigma is one factor that has been shown to have an impact on the long-term benefits of treatment among drug users. In a longitudinal study, Link et al. 1 found that social stigma had an enduring negative Received December 4, 2003; revised February 27, 2004; accepted April 23, From the University of California, San Diego, Calif. (Drs. Semple, Grant and Patterson) and the Department of Veterans Affairs Medical Center, San Diego, Calif. (Drs. Grant and Patterson). Address correspondence to Dr. Patterson, Department of Psychiatry (0680), University of California, San Diego, 9500 Gilman Drive, La Jolla, CA

2 Stigma and Drug Treatment among Meth Users effect on the well-being of patients even after treatment had improved their symptoms and functioning. Clinical experience also suggests that the stigmatizing attitudes of the public and health care professionals act as barriers to seeking treatment and affect treatment outcomes among users of illicit drugs. 8,9 To date, there is a paucity of studies that have examined the relationship between social stigma and the use of drug treatment services among meth users. The present study is exploratory in nature. It provides a preliminary examination of the relationship between drug use stigma and the use of drug treatment programs in a sample of meth users. A key feature of this analysis involved an examination of the dimensionality of drug use stigma. This approach enabled us to make a more detailed determination of which aspect(s) of stigma are most likely to have an impact on the use of drug treatment programs by meth users. A better understanding of the relationship between drug use stigma and use of treatment services should help to inform intervention content and ultimately improve the effectiveness of treatment programs. DRUG USE STIGMA According to Jones et al., 10 stigma marks an individual as being different, and those differences are linked to undesirable characteristics of the person. A number of illnesses, including epilepsy, cancer, tuberculosis, obesity, HIV=AIDS, and mental illness, have been studied in relation to their stigmatizing nature Based on this research, it has been concluded that stigma results in discrimination, rejection, ostracism, ridicule, prejudice, discounting, and discrediting of stigmatized individuals. 8,12 The fear, uncertainty, oppression, and emotional pain associated with stigma can also be exacerbated by the interaction of sexism, racism, and social disadvantage. 16 Studies of drug use stigma are few in number. In one study of the stigma associated with drug addiction, the term drug addict evoked images of disoriented, unhealthy, thin, and low-class individuals with behavioral problems. 17 In another study of public attitudes toward individuals who use illicit drugs, drug users were viewed as dangerous, unpredictable, and difficult to communicate with. 18 Health care professionals have also been shown to have stigmatizing attitudes toward patients who use illicit drugs. Drug users are viewed as one of the most difficult, unpleasant, and unrewarding of patient types. 19 According to Link et al., the labeling of a person as a drug addict triggers powerful expectations of rejection that in turn erode confidence, disrupt social interaction, and impair social and occupational functioning. 1(p179) The personal impact of stigma has been associated with a variety of negative outcomes, including depression; low self-esteem; delays in seeking medical treatment; loss of family ties, friendships, employment, and housing; problems with sexual intimacy; and communication difficulties within relationships. (20 24) Sources of drug use stigma are varied and can include family members, friends, neighbors, co-workers, and health professionals. 9 Link et al. 25 proposed three components of a stigmatization process, which include both cognitive and behavioral dimensions. Culturally induced expectations of rejection is the first dimension of stigma. This dimension is similar to internalized stigma proposed by Goffman. 21 Culturally induced expectations of rejection are beliefs that people develop regarding whether or not they will be rejected, devalued, and perceived as less worthy because they are identifiable by a particular characteristic (eg, drug use or mental illness). This type of stigma is anticipated and expected discrimination and ostracism; it can occur without ever having experienced direct mistreatment by others. Experiences of rejection represent the second dimension of stigma. Studies of the mentally ill have documented 368 VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

3 Semple et al. rejection in the form of housing discrimination and a dismissal of legitimate requests for services in psychiatric hospitals. 26,27 Studies of drug users have also reported rejection and discrimination in the workplace and in personal relationships with family and friends. 1 The third dimension of stigma is directly related to the first two. As a consequence of expectations and experiences of rejection, individuals typically seek ways of managing the threat of stigmatization. Stigma coping strategies are actions that individuals take in order to minimize the real or perceived effects of stigma. 21 Researchers have identified a number of strategies for managing or coping with stigma. The majority of drug users manage stigma by being secretive or by practicing selective disclosure. 25 Another coping strategy for managing stigma involves seeking social support from individuals who are sympathetic and=or share the stigma (fellow drug users). Sources of support can include fellow drug users and health professionals (eg, psychologists, drug counselors, or social workers). In the present study, each dimension of stigma was examined in relation to the use of drug treatment services. METHOD Sample Selection The present sample consisted of 292 HIV-negative, heterosexually identified, meth-using men and women (>18 years) who were enrolled in the FASTLANE research project at the University of California, San Diego. FASTLANE is an eight-session, one-on-one counseling program designed to reduce the sexual risk practices of heterosexual meth users. Eligible participants self-identified as heterosexual reported having unprotected vaginal, anal, or oral sex with at least one opposite sex partner during the past two months and using meth at least twice in thesametimeperiod.hiv-negativeserostatus was assessed using the OraSure HIV-1 Oral Collection Specimen Device. This test has a reported reliability of 99.9%. 28 Oral specimens were gathered at baseline and analyzed at the Long Beach Health Laboratory in Long Beach, California. Recruitment Community outreach strategies were used to recruit FASTLANE participants. A primary recruitment strategy involved a large-scale poster campaign. With the consent of business owners, posters were placed in a variety of locations (eg, bars, after-hours clubs, and adult bookstores). Posters were developed to appeal to different ethnic groups and communities. A smaller scale media campaign involved placing weekly advertisements in local magazines and newspapers. Another recruitment strategy involved direct contact between potential participants and outreach workers. Several geographic areas in San Diego County with high concentrations of meth users and young adults were targeted for recruitment. Outreach workers distributed cards containing eligibility criteria and condom packets; interested persons were instructed to contact our project offices for a screening interview. A fourth recruitment strategy involved obtaining referrals from case managers and program staff at local agencies such as Family Health Centers of San Diego. Participants were also referred through family, friends, and enrolled participants. In the present sample, 47% of participants were recruited through the poster and media campaign, and 53% were referrals from local agencies, enrolled participants, family members, and friends. Procedures Eligible participants completed a baseline assessment, four ninety-minute weekly counseling sessions, four ninety-minute THE AMERICAN JOURNAL ON ADDICTIONS 369

4 Stigma and Drug Treatment among Meth Users booster sessions, and followup assessments at six, twelve, and eighteen-months postbaseline counseling. The counseling and booster sessions involved motivational interviewing 29 and skill-building exercises. 30 The intervention counseling sessions covered five domains, including the context of meth use and unsafe sex, condom use, negotiation of safer sex practices, and enhancement of social supports. The intervention was not designed to reduce or abate drug use behaviors. Baseline and followup data were gathered through computer-assisted interview technology (audio-casi). 31 The audio-casi interview covered a range of topics, including sociodemographic characteristics, patterns of meth use, sexual risk behavior, social cognitive factors, social support, and social network factors. Participants were paid $30 for their baseline assessment and the first ninety-minute counseling session. Data for the present analyses were gathered between June 2001 and November MEASURES Use of Drug Treatment Programs Participants were asked a series of questions regarding their participation in meth use treatment programs. Those who had ever been in treatment for their meth use provided information regarding the location of the facility, type of treatment program (eg, inpatient versus outpatient), duration of program, date(s) of program enrollment, and record of program completion. Participants who had never been in treatment for their meth use were asked questions regarding their reasons for not seeking treatment. For the present analyses, participants who had ever been in treatment for their meth use (ie, treatment) were compared with their counterparts who had never been in treatment (ie, no treatment). Substance Use Classification System. The Semi- Structured Assessment for the Genetics of Alcoholism (SSAGA) was used to classify the severity of participants use of meth and other substances. SSAGA diagnoses are based on DSM-III-R and at least one other classification system. Many of the interview questions derive from other psychiatric research instruments, including the CIDI 32 and the SCID. 33 The SSAGA covers a range of psychiatric diagnoses, including psychoactive substance dependence and abuse. Reliability of the SSAGA has been found to be good for substance dependence diagnoses. 34,35 In the present study, the SSAGA-II Section G (DSM=ICD Drug Diagnosis) was used to determine dependence and abuse in relation to the participant s use of meth. Pattern of Meth Use. Multiple items were used to assess participants patterns of meth use. Duration of meth use was measured by the following question: During the past thirty days, on how many days did you do meth? Frequency of meth use was measured by the following question: On a typical day, how many times did you do meth? Amount of meth used was recorded as number of grams consumed during the past thirty days. Stigma Scales. The drug use stigma scales were developed specifically for use in this research. Each scale corresponds to one of three underlying theoretical dimensions of stigma delineated by Link et al. 1 : culturally-induced expectations of rejection, experiences of rejection, and stigma coping strategies. Expectations of rejection captures anticipated and expected discrimination that can occur without having been mistreatment by others. This dimension was measured by eight items that asked participants about their beliefs regarding the way others think about meth users and their expectations for how others treat meth users. Sample items include: most 370 VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

5 Semple et al. people hold negative stereotypes about people who use meth, people will treat me differently if they find out that I use meth, and meth users are rejected by society. The second dimension of stigma experiences of stigma was measured by six items. Participants were asked to report on their actual experiences of rejection, ranging from minor slights to major life events, such as the loss of friends and family members. Sample items include: family members act differently toward me because I use meth and I have lost friends because they found out about my meth use. Stigma coping strategies are actions that individuals take in order to minimize the real or perceived effects of stigma. 21 This dimension of stigma was measured by nine items. Sample items include: I try to hide all signs of my meth use to avoid negative reactions from others, to avoid a negative reaction, I only reveal my meth use to certain people, and I seek understanding and support from other meth users. The items that make up each stigma scale were measured on a four-point scale with the following response categories: 1 ¼ strongly disagree, 2 ¼ somewhat disagree, 3 ¼ somewhat agree, and 4 ¼ strongly agree. Cronbach alpha coefficients of reliability were as follows: global stigma scale (alpha ¼.86); culturally induced expectations of rejection (alpha ¼.82); experiences of rejection (alpha ¼.83); and stigma coping strategies (alpha ¼.82). RESULTS Sample Description Sample characteristics are presented in Table 1. Overall, participants were predominately male (72.3%), Caucasian (54.8%), 37.8 years old, never married (52.6%), holding a high school diploma or less (56.4%), unemployed (72.1%), living with adults who were not sexual partners (35.1%), and reporting a median income of $10,000 to $19,999 per year. Using the SSAGA, 91.8% of the sample met criteria for meth dependence, and 8.2% met criteria for meth abuse. Chisquare analysis revealed that the two groups (treatment and no treatment) did not differ significantly on gender, ethnicity, marital status, education, employment status, living arrangement, income, or meth use diagnosis. A t-test for the difference between means indicated that the groups did not differ significantly on age. Patterns of Meth Use. The majority of participants either snorted or smoked meth (68.5% and 77.4%, respectively). Approximately 32% of the sample reported injecting meth at least once in the past two months; among injectors, the average number of injections in the past two months was 34.6 (SD ¼ 28.7). For the entire sample, participants reported using meth an average of 14.0 days over a thirty-day period (SD ¼ 9.1). On a typical day, participants used an average of five times per day (SD ¼ 6.2). On average, participants consumed 2.2 grams of meth in a thirtyday period (SD ¼ 4.5). Chi-square analysis revealed that the two groups (treatment and no treatment) differed on two variables. Participants who had ever been in treatment currently used meth on more days in the past thirty days as compared to those who had never been in treatment (15.9 versus 13.3, t ¼ 2.2, p <.05). Moreover, participants who had ever been in treatment were significantly more likely to have injected meth in the past two months (46.3% versus 25.6%, v 2 ¼ 11:7, p <.001). Stigmatization of Meth Users With respect to culturally induced expectations of rejection, the majority of participants either agreed or strongly agreed that most people hold negative stereotypes of meth users (95.5%), don t want their THE AMERICAN JOURNAL ON ADDICTIONS 371

6 Stigma and Drug Treatment among Meth Users TABLE 1. (N ¼ 292) Sample Characteristics of Heterosexually Identified, Meth-Using Men and Women Variable Have Been in Treatment (N ¼ 82) Never Been in Treatment (N ¼ 210) Gender Male 70.7% 72.9% Female Marital status Never married 49.4% 53.8% Married Divorced=separated Widowed Living arrangement Living with spouse=steady 11.1% 17.2% Living with other adult(s) Living alone Other Ethnicity Caucasian 62.2% 51.9% African American Latino=a Other Education Some high school or less 23.5% 17.8% High school or equivalent Two-year degree or some college College degree Advanced degree Income $19, % 66.7% >$19, SSAGA classification Meth dependence 96.8% 89.7% Meth abuse Percent employed 29.3% 27.4% Mean age in years (SD) (Range) 37.6 (8.5) (21 52) 37 (10.5) (18 63) children around meth users (94.8%), are prejudiced against people who use meth (92.0%), and will treat someone differently if they are found out to be a meth user (92.0%). In terms of experiences, participants reported moderate degrees of rejection associated with their meth use. Sixty-nine percent of the sample reported that family members act differently toward them because they use meth; 56% indicated that they had lost friends because they found out about their meth use; and 372 VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

7 Semple et al. 58% reported that they had been mistreated by others because they are meth users. Participants also endorsed three major stigma coping strategies. The majority of participants (91.8%) either agreed or strongly agreed that they avoided the negative reactions of others by only revealing their meth use to certain people (ie, selective disclosure). Eighty-five percent endorsed stigma coping strategies involving secrecy ( I have kept my meth use a secret ) and coverup ( I try to hide all signs of my meth use from others ). Description of Treatment History Twenty-eight percent of the sample indicated that they had ever been in treatment for their meth use. Among those who had been in treatment for meth use, 70 percent participated in an inpatient program. Approximately half of those who had been in treatment (47.5%) did not complete their program. The main reasons for not completing treatment were that the participant wanted to start using meth again (25.6%) and the participant did not get along with program staff (17.9%). Other reasons for treatment dropout included the program was too long, the program was not helpful, the participant became incarcerated, the program was too strict, the program was unaffordable, the participant was accepted into a diversion program, and the participant switched to a support group. The average duration of treatment was 9.7 months (SD ¼ 13.1). The average length of time since completion of drug treatment was 4.4 years (SD ¼ 4.5). Among participants who have never been in treatment for their meth use (N ¼ 210), approximately half (54.4%) indicated that they did not need treatment. Other reasons for not seeking drug treatment were that the participants can take care of themselves=can handle it on their own (19.8%); don t know how to get treatment (8.9%); can t afford drug treatment (7.4%); don t think treatment is available (5.4%); and prefer a support group (4.0%). The Relationship between Drug Treatment and Stigma Participant scores on each dimension of stigma were examined separately for those who had been in drug treatment for their meth use and their counterparts who had never been in drug treatment. A t-test for the difference between means (treatment and no treatment) revealed no group differences in relation to degree of stigma associated with expectations of rejection (3.4 versus 3.4, respectively, t ¼.85, df ¼ 290, p >.05). In contrast, participants who had ever been in treatment for their meth use scored significantly higher than those who had never been in treatment in terms of their experiences of rejection (2.8 versus 2.4, respectively, t ¼ 3.7, df ¼ 289, p <.001). The two groups were also significantly different with respect to their use of stigma coping or management strategies. Participants who had never been in treatment endorsed significantly more stigma coping strategies (eg, secrecy, selective disclosure) as compared to their treatment counterparts (3.0 versus 2.8, respectively, t ¼ 2.7, df ¼ 290, p <.01). Logistic Regression Logistic regression analysis was used to examine whether the three dimensions of stigma distinguished between participants who had ever been in treatment for their meth use and those who had never been in treatment. The logistic equation defined group membership as a dichotomous outcome variable. Participants who had been in treatment were coded 1, and those who had never been in treatment were coded 0. The logistic regression evaluated the probability that a participant did or did THE AMERICAN JOURNAL ON ADDICTIONS 373

8 Stigma and Drug Treatment among Meth Users TABLE 2. (N ¼ 292) Means, Standard Deviations and Correlations among Logistic Regression Variables Expectations of Rejection Experiences of Rejection Stigma Coping Strategies Gender Ethnicity Years of Meth Use Expectations of rejection 1.00 Experiences of rejection.34 y 1.00 Stigma coping strategies.26 y Gender Ethnicity Years of meth use y 1.00 Mean N=A N=A 14.4 S.D N=A N=A 9.3 p <.01. y p <.001. not ever receive treatment for meth use, given his=her pattern of responses on measures of stigma and controlling for background variables. A multivariate logistic regression analysis was performed. Three stigma variables (culturally induced expectations of rejection, experiences of stigma, stigma coping strategies) and background variables (gender, ethnicity, number of years as a meth use) were entered using the direct method. 36 Table 2 displays zero-order correlations among the predictor variables in the logistic model. The three dimensions of stigma were moderately correlated, ranging from.16 to.34 (p <.01 to p <.001). A standard diagnostic check for multicollinearity was performed. The absence of any high negative correlations among the estimates (ie, >.8) reduced concerns regarding multicollinearity in the logistic regression analysis. A test of the full model with all predictors against a constant-only model was statistically significant, indicating that our set of variables reliably distinguished between participants who had ever been in treatment for their meth use and those who had never been in treatment for their meth use. Adequacy of classification is an important criteria for evaluating the usefulness of a logistic regression. Using our set of predictor variables, we correctly classified 74% of the sample. This classification rate suggests that the ability of our model to distinguish between the two groups is reasonably good. Table 3 shows the regression coefficients, standard error, Wald statistics, odds ratio, and 95% confidence intervals for each predictor variable. According to the Wald criterion, all three dimensions of drug use stigma were statistically significant. The OR of 2.4 for experiences of rejection suggests that as scores on this dimension of stigma increase by one unit, the likelihood of being in the treatment group is more than double. The OR of.56 for expectations of rejection indicates that the probability of being in the treatment group decreases by about 50% as the respondent s score on expectations of rejection increases by one unit. Similarly, the probability of being in the treatment group decreases by about 50% as scores on coping strategies increases by one unit (OR ¼.52). The significance levels suggest that experiences of rejection and stigma coping strategies are the two variables that best discriminate between participants who have at some point been in treatment 374 VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

9 Semple et al. TABLE 3. Logistic Regression to Examine the Relationship Between Stigma and Treatment Among Meth Users (N ¼ 292 ) Model 1: full model with all predictors (6-factor model) 2 log likelihood Model Chi square df p < % C.I. Variable B SE Wald p value OR Lower Upper Gender Ethnicity Number of years of meth use Expectations of rejection y Rejection experiences x Stigma coping strategies z Constant Two cases with incomplete data. y p <.05. z p <.01. x p <.001. for their meth use and those who have never been in treatment for their meth use. DISCUSSION This research contributes to a growing body of literature that suggests a relationship between drug use stigma and participation in drug treatment programs. In univariate analyses, the treatment and non-treatment groups were significantly different in terms of their experiences of rejection and use of stigma coping strategies. While the differences were small, they appear to be clinically meaningful because they provide insight into possible mechanisms or social processes through which utilization of drug treatment programs may have an effect on meth user stigma. We contend that negatively labeling may be the social process through which participation in treatment leads to experiences of rejection. Previous research in the field of mental health provides support for the negative labeling theory. For example, Page 26 documented discrimination by landlords when prospective renters identified themselves as former mental hospital patients. In another study, Rosenhan 27 documented discrimination and stigma directed at normal individuals who identified themselves as patients who were seeking help at psychiatric hospitals. A similar process may be operating among meth users who have participated in drug treatment. Entering a drug treatment program creates the perception that the individual has a severe problem; in turn, this may increase the likelihood of being negatively labeled as a drug addict. In contrast, individuals who never enter drug treatment may be known as a drug user but are better able to avoid the more serious label of drug addict. Similar to the experience of psychiatric patients, we contend that once an individual becomes negatively labeled as being addicted to drugs, experiences of rejection are more likely to occur. The process of negative labeling may also help to explain the finding that individuals in the THE AMERICAN JOURNAL ON ADDICTIONS 375

10 Stigma and Drug Treatment among Meth Users treatment group endorsed significantly fewer stigma coping strategies as compared to their counterparts in the non-treatment group. Specifically, individuals who are labeled as a drug addict probably find it difficult to conceal their treatment history and problem behavior upon completion of their program. Thus, many of the coping strategies that were measured in this research (eg, secrecy, selective disclosure) may be inappropriate and ineffective for individuals who have been in treatment. It is also possible that those who have been in treatment had learned more constructive ways of coping with their addiction. In contrast, individuals who have never been in treatment are probably more likely to find avoidant-type stigma coping strategies quite effective. Future studies should seek to determine if the mechanism of negative labeling helps us to understand how participation in drug treatment may increase experiences of rejection and=or affect the type of coping strategies that meth users adopt post-treatment. Empirical support for the negative labeling hypothesis could impact treatment planning and recruitment of meth users into treatment programs. For example, some client-centered treatment programs, such as motivational interviewing, de-emphasize labeling. 29 Counselors are trained to explore a client s drug or alcohol behavior without attaching labels because the labeling trap can lead to client resistance, and impede treatment progress. 29 In terms of multivariate analyses, a logistic regression revealed a significant association between all three dimensions of stigma and participants utilization of drug treatment programs. Specifically, having been in treatment was associated with more experiences of rejection, endorsement of fewer stigma coping strategies, and lower expectations of rejection. These data provide support for considering the dimensionality of stigma and the differential impact that dimensions of stigma may have upon meth users utilization of treatment programs. Because our data were preliminary, we were unable to explore the underlying processes that might help to account for the relationship between the stigma and use of drug treatment programs by the participants in our sample. Previously, we suggested that the process of negative labeling may help to explain group differences in experiences of rejection and use of stigma coping strategies. Similar social processes may be at work in terms of explaining the association between non-treatment and higher scores on expectations for rejection. It is not unreasonable to suggest that individuals who have higher expectations for rejection would avoid seeking treatment since participation in treatment may result in more people knowing about one s drug use, which in turn might increase the potential for experiencing stigma and rejection. By not participating in drug treatment programs, participants may be effectively avoiding the perceived threat of stigma. Participants who had never been in treatment also endorsed more stigma coping strategies as compared to those who had ever been in treatment. The avoidant-type coping strategies measured in this research may be viewed as consistent with the cognitive framework of a person who wants to avoid drug treatment. Moreover, participants who had been in treatment were more than twice as likely as those who had never been in treatment to report experiences of rejection. It is plausible that participation in treatment sensitizes meth users to the extent of stigma and rejection experienced by fellow clients in drug treatment programs. Also, since all the participants in our sample were active meth users, experiences of stigma and rejection may be higher for those who have been in treatment and failed to achieve abstinence. These findings may help to inform the content of drug treatment programs for 376 VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

11 Semple et al. meth users. Our data suggest that addressing stigma coping strategies may be an important component of drug treatment programs for meth users. Attention should be paid to the type of coping strategies reported by meth users. Our data indicate that avoidant-type coping strategies are associated with the avoidance of treatment. Accordingly, approach-style coping may be key to reducing participants perceptions of stigma and rejection. Although one might hypothesize that seeking social support from a health care professional would be a more effective coping strategy than denial and concealment of one s drug use, this is an assumption that can only be addressed through examination of empirical data. These analyses also provide directions for future research. There is a growing body of literature that shows a relationship between depressed mood and use of treatment services among drug users. 37 Specifically, individuals who are depressed are more likely to seek treatment for drug use. Thus, it is possible that depression mediates the relationship between stigma and use of treatment services. Preliminary support for this interpretation can be found by examining the correlations among dimensions of stigma and depressive symptoms in our sample. All three dimensions of stigma were significantly correlated in a positive direction with Beck depression scores. 38 Moreover, individuals who had been in treatment were significantly more likely to have a psychiatric diagnosis as compared to those who had never been in treatment. Future research might also examine the extent to which meth users are stigmatized by other characteristics such as gender, ethnicity, age, mental illness, or social disadvantage. It is possible that the effects of drug use stigma are amplified in the context of one s exposure to other forms of stigma. For example, studies of alcoholics have reported lower levels of stigma among men who are in socially successful professions as compared to women who are older or socially disadvantaged. 9 Additional research is also needed to enhance our understanding of the various sources of stigma. At a fundamental level, it may be important to distinguish between the impact of public versus professional sources of stigma, particularly in relation to drug treatment. The impact of public stigma on drug treatment has received the least attention from researchers. One study of methadone patients in California indicated that rejection from social network members may be the most potent form of stigma in terms of its impact on the individual behavior. 39 The impact of stigma associated with health care professionals also warrants further investigation. If health care professionals hold stigmatizing beliefs about meth users, it is possible that stigma may be a barrier to obtaining help and completing treatment programs. Indeed, the inability to get along with staff was a primary reason for participant dropout among those in our study. This finding may suggest that stigmatization and discrimination of meth users within treatment settings may be factors that influence the course of treatment. Health care professionals who harbor negative views toward meth users may unwittingly be affecting the course of treatment. Stigmatization of drug users by professionals within the medical and health services community has previously been documented. 19,40 41 Illicit drug use is commonly viewed as a self-inflicted problem, drug users are perceived to have serious character flaws, and the treatment outcome for these individuals is thought to be poor. 40,41 Several medical researchers have called for the removal of stigma within the health care delivery system in order to obtain proper assessment and treatment for drug users. 8,42 Bolton 8 delineated a number of strategies for reducing illness-related THE AMERICAN JOURNAL ON ADDICTIONS 377

12 Stigma and Drug Treatment among Meth Users stigma within the health care profession. These strategies can be adopted by professionals who work with drug users and include the following: examining personal attitudes toward drug use and drug users, enhancing knowledge about the underlying motivations for drug use, listening to what patients have to say about their illness and its consequences, avoiding stigmatizing language, and being an advocate for the effective treatment of drug users, particularly during a time when competition for financial resources within the health care delivery system is a major issue. Study Limitations There are a number of limitations associated with the present work. To begin, data for this study were gathered from a convenience sample of community-residing meth users. Participants were also volunteers in a sexual risk reduction intervention. Thus, the sample may be biased in important ways, including their perceptions and experiences of drug use stigma. For example, one might hypothesize that drug users who volunteer for an intervention are more motivated to change their behavior and thus may have heightened awareness and sensitivity in relation to stigma issues. Also, our eligibility criteria may have resulted in the screening out of certain types of meth users (eg, homeless or seriously mentally ill) who may have much higher levels of drug use stigma as compared to those in the current sample. Overall, the reader is cautioned against overgeneralization of these research findings to the global population of community-residing meth users. This research also relied upon participant self-report as the primary method of data collection. The accuracy and reliability of data gathered from active drug users has been a topic of controversy; however, there is sufficient evidence to suggest that self-report data from drug users is reasonably reliable and valid. 43,44 The FASTLANE Project also sought to minimize self-report bias by utilizing computer-assisted (audio-casi) technology, which has been demonstrated to reduce the underreporting of sensitive behaviors in drug-using populations. 45 Another limitation of this research stems from the use of cross-sectional data. We were unable to disentangle the causal direction in the relationship between the three dimensions of stigma and participants use of treatment programs. For example, it is possible that experiences of rejection lead some individuals to participate in drug treatment programs. On the other hand, participation in treatment may alter the individual s definition of what defines a rejection experience. Longitudinal data are needed to assess the reciprocal links between dimensions of stigma and use of treatment programs. Lastly, this research is limited by the measurement of our outcome variable. Our measure of drug treatment utilization was brief, focused on past use of services, and failed to ascertain whether participation was voluntary or mandated. More detailed questions regarding participants reasons for entering treatment may help to shed light on the role of stigma in the treatment-seeking process. For example, our finding that those who had ever been in treatment used meth on significantly more days in the past thirty days as compared to those who had never been in treatment may suggest that the treatment group get into treatment because they have a history of heavier meth use. Stigma may be less important in terms of treatment-seeking, particularly given our finding that expectations for rejection did not differ between the two groups in univariate analysis. Overall, a stronger research design for this study would have involved a comparison of participants who were currently in treatment with those who were not in treatment. Such a design would have permitted an examination of patterns of 378 VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

13 Semple et al. meth use, drug use stigma, and the use of drug treatment programs by meth users, taking into account concurrent measures of social, psychological, behavioral, and contextual factors. SUMMARY This research provides preliminary evidence that drug use stigma is associated with the use of drug treatment programs by individuals who use meth. The implications of this finding are twofold: drug use stigma may be a barrier to seeking treatment among meth users, and drug use stigma may play a role in the noncompletion of treatment programs. The exploratory nature of this study suggests that further research be conducted to elaborate upon these findings. REFERENCES 1. Link BG, Struening EL, Rahav M, et al. On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav. 1997;38: Molitor F, Truax S, Ruiz J, et al. Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among noninjection drug users. West J Med. 1998;168: Morgan P. Researching Hidden Communities: A Quantitative Comparative Study of Methamphetamine Use in Three Sites. Epidemiologic Trends in Drug Abuse. Bethesda, MD, U.S. Department of Health and Human Services, National Institute of Drug Abuse; National Institute of Justice. Meth Matters: Report on Methamphetamine Users in Five Western Cities. Washington, DC: US Department of Justice; San Diego Association of Governments. Methamphetamine. Unpublished report. 6. San Diego Association of Governments. Arrestee Drug Abuse Monitoring (ADAM): Drug Use among the San Diego County Offender Population. San Diego, CA: Criminal Justice Research Division; September Semple SJ, Patterson TL, Grant I. Motivations associated with methamphetamine use among HIVþ men who have sex with men. J Subst Abuse Treat. 2002;22: Bolton J. How can we reduce the stigma of mental illness? Br Med J. 2003;S57: Ritson EB. Alcohol, drugs and stigma. Int J Clin Pract. 1999;53: Jones E, Amerigo F, Hastorf A, et al. Social Stigma: The Psychology of Marked Relationships. New York: Freeman and Company; DeJong W. The stigma of obesity: the consequences of naïve assumptions concerning the causes of physical deviance. J Health Soc Behav. 1980;21: Herek GM. AIDS and stigma. The American Behaviorial Scientist. 1999;42: Link BG, Francis TC, Frank J, et al. The social rejection of former mental patients: understanding why labels matter. American Journal of Sociology. 1987;92: Stahly GB. Psychosocial aspects of the stigma of cancer: an overview. Journal of Psychosocial Oncology. 1988;6: Weitz R. Uncertainty and the lives of persons with AIDS. J Health Soc Behav. 1989;30: Poindexter C, Linsk NL. HIV-related stigma in a sample of HIV-affected older female African American caregivers. Soc Work. 1999;44: Dean JC, Rud F. The drug addict and the stigma of addiction. Int J Addict. 1984;19: Crisp A. Changing minds: every family in the land. Psychiatr Bull. 1998;22: McLaughlin D, Long A. An extended literature review of health professionals perceptions of illicit drugs and their clients who use them. Journal of Psychiatric and Mental Health Nursing. 1996;3: Chesney MA, Smith AW. Critical delays in HIV testing and care: the potential role of stigma. Am Behav Sci. 1999;42: Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice Hall; Link B. Mental patient status, work and income: an examination of the effects of a psychiatric label. American Sociological Review. 1982;47: Link B. Understanding labeling effects in the area of mental disorders: an assessment of the effects of expectations.of rejection. Am Sociol Rev. 1987;52: THE AMERICAN JOURNAL ON ADDICTIONS 379

14 Stigma and Drug Treatment among Meth Users 24. Van Der Straten A, Vernon K, Knight K, et al. Managing HIV among serodiscordant heterosexual couples: serostatus, stigma, and sex. AIDS Care. 1998;10: Link B, Francis TC, Struening E, et al. A modified labeling theory approach in the area of the mental disorders: an empirical assessment. American Sociological Review. 1989;54: Page S. Effects of the mental illness label in attempts to obtain accommodation. Canadian Journal of Behavioral Science. 1977;9: Rosenhan D. On being sane in insane places. Science. 1973;179: George JR, Fitchen JH, Goldstein AS, et al. Evaluation of a system using oral mucosal transudate for HIV-1 antibody screening and confirmatory testing. JAMA. 1997;277: Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: The Guilford Press; Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; Turner CF, Forsyth BH, O Reilly J, et al. Automated self-interviewing and the survey measurement of sensitive behaviors. In: Couper MP, ed. Computer-Assisted Survey Information Collection. New York: Wiley and Sons;1998: Robins LN, Wing J, Wittchen HU, et al. The composite international diagnostic interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry. 1988;45: Spitzer RL, Williams JB, Gibbon M, et al. The structured clinical interview for DSM-III-R (SCID), I: history, rationale, and description. Arch Gen Psychiatry. 1992;49: Bucholz KK, Cadoret R, Cloninger RD, et al. A new semi-structured psychiatric interview for use in genetic linkage studies: a report on the reliability of the SSAGA. J Stud Alcohol. 1994;55: Bucholz KK, Hesselbrock VM, Shayka JJ, et al. Reliability of individual diagnostic criterion items for psychoactive substance dependence and the impact on diagnosis. J Stud Alcohol. 1995;56: Tabachnick BJ, Fidell LS. Using Multivariate Statistics. Third edition. New York: HarperCollins College Publishers; Schade CP, Jones ER, Wittlin, BJ. A ten-year review of the validity and clinical utility of depression screening. Psychiatr Serv. 1998;49: Beck A. Depression: Clinical, Experimental, and Theoretical Aspects. New York: Harper & Row; Murphy S, Irwin J. Living with the dirty secret: problems of disclosure for methadone maintenance clients. J Psychoactive Drugs. 1992;24: Bienev L. Perceptions by emergency room staff: substance abusers versus non-substance abusers. J Health Soc Behav. 1983;24: George M, Martin E. GP s attitudes toward drug users. Br J Gen Prac. 1992;42(360): Haleja R. The stigma facing drug abusers impedes treatment. Canadian Medical Association Journal. 1998;158: Adair EBG, Craddock G, Miller HG, et al. Assessing consistency of responses to questions on cocaine use. Addiction. 1995;90: Needle R, Weatherby N, Chitwood D, et al. Reliability of self-reported HIV risk behaviors of drug users. Psychol Addict Behav. 1995;9: DesJarlais DC, Paone D, Milliken J, et al. Audiocomputer interviewing to measure risk behavior for HIV among injecting drug users: a quasirandomized trial. Lancet. 1999;353: VOLUME 14 NUMBER 4 JULY SEPTEMBER 2005

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