This case study was developed with funding and support from the Implementation Research Institute at Washington University in St. Louis.
Fifty-seven million people in the U.S. report nonmedical drug use in the past year, and eight million people over the age of 12 have a drug use disorder.1 Drug use is highly stigmatized.2,3 Stigma occurs when a group of people, such as those experiencing addiction, are labelled and stereotyped with negative attributes, resulting in loss of status and discrimination.4 For example, 90% of U.S. adults are unwilling to have someone with drug addiction marry into their family and 78% are unwilling to have a person with drug addiction work with them on a job. Stigmatizing attitudes are not limited to the public. Three-quarters of doctors are unwilling to have a person with opioid use disorder marry into their family and two-thirds view people with opioid use disorder as dangerous.5
While evidence-based interventions to support recovery and prevent overdose exist, they are severely under-implemented, in large part due to the stigma around addiction and lack of support among the public, some treatment providers, and policymakers.3,6 Medication for opioid use disorder and overdose prevention sites are two examples of effective interventions to address addiction and overdose that are not widely implemented due to lack of public and key actor support.3,6,7
To address addiction stigma and increase support for expanding evidence-based interventions, government agencies and advocacy groups have implemented messaging campaigns through television, radio, social media, billboards, and other channels. However, the evidence base for which communication strategies successfully reduce addiction stigma is extremely limited.2 The Johns Hopkins Center for Mental Health and Addiction Policy launched the Stigma Lab research portfolio to address this gap.11 The Stigma Lab conducts randomized experiments testing the effects of different communication strategies on addiction stigma, perceived effectiveness of evidence-based interventions, and support for policies to scale-up those interventions.
Broader support among the public, policymakers, and people with substance use disorders is critical to scale up addiction prevention and treatment interventions. Support from these groups also increases the likelihood that policies and practices will be adopted and implemented as intended.8,9 Reducing stigma can also enhance engagement in services by people with addiction and ultimately increase recovery.10 Stigma Lab research produces actionable findings that can inform the development of public health campaigns to reduce addiction stigma and increase support for evidence-based interventions led by government agencies, advocacy groups, healthcare systems, and others. The portfolio of Stigma Lab research has already been used by a wide range of actors, including state health departments, the Joe Biden Presidential Campaign, and the United Nations.
Beth McGinty, PhD, Professor (primary contact); Alene Kennedy-Hendricks, PhD, Assistant Professor
Johns Hopkins Bloomberg School of Public Health
Colleen Barry, PhD, Inaugural Dean
Jeb E. Brooks School of Public Policy at Cornell University
Johns Hopkins Hospital; National Association of Attorneys General; National Business Group on Health
Funded by the National Institute of Mental Health, National Institutes of Health grant K01MH106631
Check out the Impact Profile, a one-page summary of project impact.
Learn more about the project
- JHSPH Stigma Lab website
- Is Your Anti-Stigma Campaign Designed for Impact? Increase Efficacy Using Evidence (Blog post, Business Group on Health)
- Stigma of Addiction Summit (National Academy of Medicine)
Learn more about addiction stigma
- Reducing Stigma: Understanding Addiction and Supporting Recovery (CDC)
- Guiding Principles for Addressing the Stigma on Opioid Addiction (Bloomberg American Health Initiative)
- Words Matter – Terms to Use and Avoid When Talking About Addiction (National Institute on Drug Abuse)
Stigma Lab is also working to address the compounding effects of stigma related to race, class, and other social factors when coupled with addiction stigma.11–16 For example, one Stigma Lab experiment demonstrated that members of the public were more likely to stigmatize a low-socioeconomic status pregnant woman experiencing addiction than a high-socioeconomic status pregnant woman. The researchers also found that messages about systemic barriers to treatment faced by low-socioeconomic status pregnant women increased support for expanding insurance coverage for drug addiction treatment, a policy change that could significantly increase access to effective addiction care by this group.17 Addiction stigma reduction could also reduce support for ineffective punitive approaches to reduce substance use, such as arrest and incarceration, which are disproportionally experienced by Black people, despite similar rates of drug use among whites and Blacks.18
Demonstrated benefits are those that have been observed and are verifiable. Potential benefits are those logically expected with moderate to high confidence.
The National Institute on Drug Abuse used Stigma Lab research to develop guidelines for doctors on how reduce stigma when talking about addiction with pregnant women and mothers.19
Stigma Lab developed effective addiction-stigma reduction messages with the Johns Hopkins Health System that will be disseminated through multiple communication channels and made available to other health systems for broader dissemination.20 Demonstrated.
Stigma Lab identified effective addiction-stigma reduction messages and collaborated on campaign design with the state of West Virginia. Demonstrated.
Campaigns informed by Stigma Lab research could reduce stigma and discriminatory practices among healthcare providers towards people with addiction. Potential.
Reductions in addiction stigma among healthcare providers could increase engagement in services and increase recovery by people with addiction. Potential.
Stigma Lab helped West Virginia develop the state’s strategic plan around addiction stigma reduction. Demonstrated.
Dr. McGinty, one of the Stigma Lab core faculty, serves on the United Nations Technical Consultation Panel on Stigma Reduction and Drug Use.21 Demonstrated.
The U.N. Technical Consultation Panel on Stigma Reduction and Drug Use is developing a final report, informed by Stigma Lab research, to serve as a blueprint for stigma reduction policies and practices in U.N. member states.21 Potential.
Stigma Lab research directly informed the terminology used in city legislation to legalize facilities in which people can safely use pre-obtained drugs under medical supervision. This intervention has been shown to prevent infectious disease transmission and fatal overdose.22 Demonstrated.
As a member of the Joe Biden campaign/transition team behavioral health committee, Dr. McGinty led the development of a draft executive order detailing actions the federal government could take to reduce addiction stigma. Potential.
This research has clinical, community, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.
Clinical: The National Institute on Drug Abuse used Stigma Lab research to develop health education for doctors on how to reduce stigma when discussing addiction with pregnant women and mothers.19 Stigma Lab’s research has the potential to improve the quality of care, including addiction treatment, received by people with addiction.
Community: Stigma Lab researchers developed and tested addiction stigma reduction campaigns for health systems and community settings. Using a large national sample of health professionals, Stigma Lab showed that several strategies reduced addiction stigma among health professionals: combining images and text, including messages about the importance of non-stigmatizing language and the value of medications to treat opioid use disorder, and delivering messages from the perspective of a patient with addiction or a health system administrator (unpublished data, 2021). The campaign will be disseminated in 2021-2022 in the Johns Hopkins Health System through electronic bulletin boards, screensavers, and the Johns Hopkins website. The campaign will also be made available to other health systems for broader dissemination.
Stigma Lab also worked with the West Virginia Governor’s Council Public Education & Stigma Awareness Action Group to develop the state’s strategic plan on reducing addiction stigma. Researchers also helped West Virginia develop and disseminate stigma reduction campaigns, including a campaign to decrease the stigma surrounding medication for opioid use disorder.24 Disseminating Stigma Lab research through statewide media campaigns can reduce addiction stigma in communities, which can increase support for and use of evidence-based addiction interventions in community settings.
Policy: Stigma Lab research has informed local, federal, and international stigma reduction policy. For example, Stigma Lab researchers found that using the term “overdose prevention site” instead of “safe consumption site” increased public support for this politically controversial but evidence-based intervention by more than 15 percent.23 As a result, Baltimore updated legislation to legalize facilities where people can safely use pre-obtained drugs under medical supervision. At the time of the experiment, “safe consumption site” (or sometimes the similar “safe injection site”) was commonly used by the harm reduction community, including in previous versions of the Baltimore proposal.22,24
Stigma Lab Core researcher Dr. Beth McGinty also served on the Joe Biden campaign/transition team to develop an executive order detailing actions the federal government could take to reduce addiction stigma, including requiring that all federal agencies use non-stigmatizing, person-centered language in all internal and external-facing documents, websites, policies, and other materials, and replacing the term “addict,” which has been shown to be stigmatizing, with the clinically correct “person with substance use disorder.” The executive order has been fully drafted and could be implemented during the Biden Administration. Dr. McGinty also serves on the United Nations Technical Consultation Panel on Stigma Reduction and Drug Use, which is developing a final report for U.N. member states on policies and practices to reduce addiction stigma, including messages emphasizing treatment effectiveness.21
Committing to partnership opportunities was critical to achieve impact. This included devoting significant time and effort to planned partnerships, in which community and policy partners were involved in the project from the outset, but it also involved seizing new partnership opportunities as they arose. The unexpected partnerships, which often came to be through organic interactions with decisionmakers – sometimes designed to be about a totally different topic – proved to be really critical in facilitating the reach and impact of the research.
- Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration Accessed October 21, 2020. https://store.samhsa.gov/product/key-substance-use-and-mental-health-indicators-in-the-united-states-results-from-the-2019-national-survey-on-Drug-Use-and-Health/PEP20-07-01-001
- McGinty EE, Barry CL. Stigma reduction to combat the addiction crisis — developing an evidence base. N Engl J Med. 2020;382(14):1291-1292. doi:10.1056/NEJMp2000227
- Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLOS Med. 2019;16(11):e1002969. doi:10.1371/journal.pmed.1002969
- Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27(1):363-385. doi:10.1146/annurev.soc.27.1.363
- Kennedy-Hendricks A, Busch SH, McGinty EE, et al. Primary care physicians’ perspectives on the prescription opioid epidemic. Drug Alcohol Depend. 2016;165:61-70. doi:10.1016/j.drugalcdep.2016.05.010
- National Academies of Sciences, Engineering, and Medicine. Medications for Opioid Use Disorder Save Lives. The National Academies Press; 2019. Accessed November 4, 2021. https://doi.org/10.17226/25310
- Barry CL, Sherman SG, Stone E, et al. Arguments supporting and opposing legalization of safe consumption sites in the U.S. Int J Drug Policy. 2019;63:18-22. doi:10.1016/j.drugpo.2018.10.008
- Stimson J. Tides of Consent: How Public Opinion Shapes American Politics. Cambridge University Press; 2004.
- Van Meter DS, Van Horn CE. The policy implementation process: a conceptual framework. Adm Soc. 1975;6(4):445-488. doi:10.1177/009539977500600404
- McGinty EE, White S. Substance use stigma and policy. In: The Stigma of Substance Use Disorders. Cambridge University Press; 2021.
- Pescosolido BA, Martin JK. The stigma complex. Annu Rev Sociol. 2015;41:87-116. doi:10.1146/annurev-soc-071312-145702
- Santoro TN, Santoro JD. Racial bias in the US opioid epidemic: a review of the history of systemic bias and implications for care. Cureus. 10(12):e3733. doi:10.7759/cureus.3733
- Hansen H, Roberts SK. Two tiers of biomedicalization: methadone, buprenorphine, and the racial politics of addiction treatment. In: Netherland J, ed. Critical Perspectives on Addiction. Vol 14. Advances in Medical Sociology. Emerald Group Publishing Limited; 2012:79-102. doi:10.1108/S1057-6290(2012)0000014008
- Netherland J, Hansen H. White opioids: pharmaceutical race and the war on drugs that wasn’t. BioSocieties. 2017;12(2):217-238. doi:10.1057/biosoc.2015.46
- Wood E, Elliott M. Opioid addiction stigma: the intersection of race, social class, and gender. Subst Use Misuse. 2020;55(5):818-827. doi:10.1080/10826084.2019.1703750
- Turan JM, Elafros MA, Logie CH, et al. Challenges and opportunities in examining and addressing intersectional stigma and health. BMC Med. 2019;17(1):7. doi:10.1186/s12916-018-1246-9
- Kennedy-Hendricks A, McGinty EE, Barry CL. Effects of competing narratives on public perceptions of opioid pain reliever addiction during pregnancy. J Health Polit Policy Law. 2016;41(5):873-916. doi:10.1215/03616878-3632230
- Rates of drug use and sales, by race; rates of drug related criminal justice measures, by race. The Hamilton Project website. Accessed September 28, 2021. https://www.hamiltonproject.org/charts/rates_of_drug_use_and_sales_by_race_rates_of_drug_related_criminal_justice
- Abuse NI on D. Your Words Matter – Language Showing Compassion and Care for Women, Infants, Families, and Communities Impacted by Substance Use Disorder. National Institute on Drug Abuse. Published July 21, 2021. Accessed September 23, 2021. https://www.drugabuse.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-language-showing-compassion-care-women-infants-families-communities-impacted-substance-use-disorder
- Stigma Free WV. West Virginia Department of Health and Human Services website. Accessed September 23, 2021. https://stigmafreewv.org/
- Promoting Non-Stigmatizing Attitudes to Ensure the Availability of, Access to and Delivery of Health, Care and Social Services for Drug Users. Accessed September 23, 2021. https://www.unodc.org/documents/commissions/CND/CND_Sessions/CND_61/CND_res2018/CND_Resolution_61_11.pdf
- Pena-Melnyk J. Public Health – Overdose and Infectious Disease Prevention Services Program. Accessed September 23, 2021. http://mgaleg.maryland.gov/mgawebsite/Legislation/Details/HB0396?ys=2021RS
- Barry CL, Sherman SG, McGinty EE. Language matters in combatting the opioid epidemic: safe consumption sites versus overdose prevention sites. Am J Public Health. 2018;108(9):1157-1159. doi:10.2105/AJPH.2018.304588
- Baltimore Sun Editorial Board. Maryland can stop overdoses by allowing safe consumption sites. Baltimore Sun. https://www.baltimoresun.com/opinion/editorial/bs-ed-0221-heroin-safe-consumption-site-20190219-story.html. Published February 20, 2019. Accessed September 23, 2021.