‘Do No Harm’ Meets Harm Reduction: A Theory-Driven Investigation of Provider-Based Stigma Among Medical Students

There were an estimated 100,000 drug overdose deaths in 2021, three-quarters of which were caused by opioids. For people with opioid use disorder (OUD), there are medications for opioid use disorder (MOUD)—methadone, buprenorphine, and naltrexone—that can reduce cravings and/or risk of overdose, and naloxone is another medication that can rapidly reverse an overdose before it becomes fatal. However, many people with OUD do not have access to these medications. Among the many contributing factors, the attitudes of providers have been identified as a barrier to care, such as provider-based stigma and risk compensation beliefs. The purpose of this dissertation is to investigate the underlying mechanisms that drive these attitudes and the relationship among these attitudes in the context of OUD treatment. Data were drawn from a quantitative survey of U.S. medical students (N=484) from a diverse sample of medical schools (N=15). Informed by the Framework for Integrating Normative Influences on Stigma (FINIS), Paper 1 explored which theoretically-grounded perceptions medical students endorsed in relation to OUD and MOUD and the associations between those perceptions and provider-based stigma. Results indicated that perceptions of OUD and MOUD were largely overlapping. Though relatively uncommon, perceptions related to embarrassment, moral weakness, and criminality were associated with greater provider-based stigma whereas perceptions of blamelessness were associated with less stigma. Paper 2 applied Affect Control Theory (ACT) to characterize the affective meanings associated with the language and terminology used in an OUD care context. These findings underscore the importance of using clinical, person-centered terms instead of stigmatizing labels and revealed that the medications associated with OUD and overdose have unique affective profiles. Finally, Paper 3 investigated the empirical and theoretical connections between provider-based stigma and risk compensation beliefs as well as associations between those attitudes and perceptions of the acceptability and effectiveness of naloxone. The results showed that risk compensation beliefs were significantly associated with provider-based stigma. Further, beliefs were associated with perceptions of naloxone acceptability. Stigma was negatively associated with perceptions of naloxone effectiveness, but only among students who had received training in harm reduction. Overall, the findings of this dissertation underscore provider-based stigma as a complex and nuanced concept. Further, while the most stigmatizing attitudes were not common, they were nevertheless important when it came to perceptions of medications used to treat OUD and prevent overdose. Finally, results from all three studies highlighted the importance of training in mitigating stigma and improving perceptions of OUD interventions. In sum, this work contributes towards theory-building and measurement around the concept of stigma and efforts to improve medical education efforts around OUD