Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

Heather Klusaritz; Andrea Bilger; Emily Paterson; Courtney Summers; Frances K. Barg; Peter F. Cronholm; M. Elle Saine; Julie Sochalski; Chyke A. Doubeni

doi:10.1370/afm.2920

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Table 1.

Characteristics of Training Programs in the Collaborative

Characteristic	All Programs, % (N = 59)	Participating Programs, % (N = 23)
Home department of training program
Family medicine residency	29	26
Internal medicine residency	3	4
Pediatrics residency	3	…
Physician assistant program	7	17
Consortium/collaboration	24	26
Institution awardee (eg, hospital)	20	13
Not specified^{^a}	14	13
Geographic region
Midwest	22	26
Northeast	34	30
South	27	22
West	17	22
Rural location	32	35
Medically underserved area	58	48
Primary care provider shortage area	46	30

↵a Not enough information to determine specialty from abstract provided.

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Table 2.

Types of Trainees in Training Programs in the Collaborative

Trainee Type	All Programs, % (N = 59)	Participating Programs, % (N = 23)
Students
Allied health (eg, PT, OT)	14	3
Medical (MD or DO)	32	13
Nursing (BSN or RN)	11	6
Physician assistant	21	10
Graduate medical education trainees^{^a}
Family medicine	32	13
Internal medicine	13	5
Pediatric	6	2
Others or unspecified	8	0
Clinicians^{^b}
Allied health	6	2
Family medicine	19	7
Internal medicine	9	3
Pediatric	5	1
Physician assistant	6	1
Others/unspecified	17	6
Community stakeholder trainees	4	0
Not reported	8	3

APRN = advanced practice registered nurse; BSN = bachelor of science in nursing; DO = doctor of osteopathic medicine; MD = doctor of medicine; OT = occupational therapist; PT = physical therapist; RN = registered nurse.
↵a Includes residents and fellows.
↵b Includes fully licensed and practicing physicians, physician assistants, APRNs, and faculty members.

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Table 3.

Stigma Subdomains: Definitions, Sample Quotes, and Related CFIR Constructs

Subdomain	Definition and Sample Quotes for the Subdomain	CFIR Construct
Origin stigma	Definition: Stigma based on perceptions about the controllability of the stigmatizing condition (ie, OUD) “So number one, they really don’t believe that substance use disorders are diseases. They think that they ascribe to the moral model. And so if you don’t believe it’s a disease, then why would you even believe that it’s treatable?” (Participant 2281) “I sat with him during one of the addiction lectures, and it was clear that he just had no idea what to do. He’s sort of thinking in the old way. This is medicine. The patient doesn’t want to change, and so I can’t make them change.” (Participant 3071) “Fortunately, or unfortunately, to me that still revolves a lot around sigma and how they personally feel about it, if they’re people who feel well, all they do—they just have to stop. It takes willpower…” (Participant 3291)	Characteristics of individuals
Origin stigma	“And in some of the rural areas, there are community standards and even ordinances that are, I would say, decidedly anti-MAT…and they are still trying to kind of apply Deuteronomic justice to the addiction problem. This is a character failing, and these people need punishment, not treatment … they’re coming on board with ideas, like universalizing Narcan, and using Vivitrol, since that’s pure antagonist therapy. But replacement therapy—there are still barriers in outlying areas …” (Participant 6081) “… I think that that happens not just at that program but our patients who are going to various NA or AA groups around the city. I think that the 12-step program still, depending upon which program it is, can have a culture that’s against MAT, and sometimes our patients share that with us, and sometimes they don’t, but I think that’s been one of the big sort of cultural issues we’ve been working with.” (Participant 3072)	Outer setting
Enacted stigma	Definition: Behaviors or policies that are enacted in such a way as to discriminate against people with the stigmatized traits “It’s almost like back maybe when HIV came out and it was bad… I have my first patient who’s HIV positive and I don’t know what to do … they just didn’t have that knowledge, and so people didn’t want to learn how to even manage or treat these people … I see the same parallel with opioids.” (Participant 3291) “They have this impression that, if they get a waiver, then their entire practice will become nothing but Suboxone prescribing. They think they’re going to be flooded with these addicted patients, and they’re terrified to lose the variety in their practice … that’s their fear.” (Participant 3071) “I think we would be pretty naïve to believe that there aren’t clinicians out there who have some type of a substance abuse disorder… But for others, if they have it and overcome it, basically they just need to stay away from dealing with it to protect their own sobriety.” (Participant 3291)	Characteristics of individuals
	“So it’s basically, it’s really shut down any kind of controlled substance prescribing in many case, kind of regionwide. There’s been a series of highly publicized drug busts all over the evening news and all over the newspapers. And it has really changed I think the local perception of what’s safe to do in your medical practice and what isn’t.” (Participant 2281)	Outer setting
	“However, after, quite frankly 2 very brutal conversations … before we even got started doing that program, we knew right away that we were going to need to develop a module to accompany the training that was going to alleviate physical fears of bringing an addictive patient population into the practice … we tried to develop a supplement to the waiver training that would help providers address all of their fears and all of their concerns, and package it into 4 hours. We did that, and when folks found out that we were going to address those things, they were very willing to sign up for the training.” (Participant 6121) “I think some of it too is just you have to go out and get educated and trained. Many of them are already busy with the practices that they have, or the responsibilities in the residency, or the medical school education. They just don’t have the time to take this on … I think some of it is beliefs, but some of it is just the practicality of going and learning one more skill set.” (Participant 3053) “… but for folks who are thinking about getting X-Waivers, it’s primarily primary care … those folks are already busy. They’re already inundated, and so the weight of something like this is perceived as just a step too far. It’s getting through all of those mental barriers and then getting through the procedural barriers with things like insurance.” (Participant 7031)	Inner setting
Intersectional stigma	Definition: The consequences of stigma on multiple attributes possessed by an individual as part of their social identity or clinical phenotype “He’s talking about how this has challenged his own assumptions on things. I think just going through the training … and talking about who’s involved and who are these people, and really removing that idea that these are dirty creatures that live on the street that nobody would ever want in their community, this is everybody …” (Participant 2282)	Characteristics of individuals
	“In many ways we’re lucky because we really explicitly—if you’re going to come work here, you already have bought in that marginalized people matter. And that people can do ugly things and still deserve kindness. That’s such hard work if that’s not a core value for everyone in the institution. I think that’s a huge barrier.” (Participant 3011)	Inner setting
	“I think if you don’t see it, you’re not around it, and it’s not impacting you, or your community, or your clinic, or your patients, you’re going to be like it’s really not—we don’t have that issue around here, so it’s not that big of a deal for us that we need to consider it.” (Participant 3291)	Outer setting

AA = Alcoholics Anonymous; CFIR = Consolidated Framework for Implementation Research; MAT = medication-assisted treatment; NA = Narcotics Anonymous; OUD = opioid use disorder.