Interventions to Reduce Stigma Related to People who Use Drugs: Systematic Review

Tostes, Joanna Gonçalves de Andrade; Dias, Rafaela Toledo; Reis, Andressa Aparecida da Silva; Silveira, Pollyanna Santos da; Ronzani, Telmo Mota

doi:10.1590/1982-4327e3022

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Systematic Literature Review • Paidéia (Ribeirão Preto) 30 • 2020 • https://doi.org/10.1590/1982-4327e3022 copy

Interventions to Reduce Stigma Related to People who Use Drugs: Systematic Review

Intervenções para Redução do Estigma Relacionado às Pessoas que Usam Drogas: Revisão Sistemática

Intervenciones para la Reducción del Estigma Relacionado a las Personas que Usan Drogas: Revisión Sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Interventions to reduce stigma related to people who use drugs can improve their quality of life and adherence to treatment. This review aimed to identify and analyze studies on interventions to reduce the stigma related to people who use drugs. Searches were performed in the following databases, without period delimitation: PubmMed, APA PsycNET, ScienceDirect, Web of Science, and VHL. Considering secondary referencing, we identified a total of 5,488 records. This review covered 28 articles and was based on PRISMA. Although target audiences comprising students and health professionals were predominant, as well as the use of quantitative methods, sample size and interventions varied among studies. The selected studies present considerable methodological limitations. We concluded that no evidence confirms the effectiveness of the proposed interventions and which of them should continue to be applied for this specific aim. It is essential to invest in approaches other than those traditionally adopted.

Keywords:
stigma; substance use disorders; psychosocial intervention; systematic review

Categ.	Description	n
A	Evaluation and description of stigma and related constructs related to people who use drugs	385
B	Evaluation and description of stigma and related constructs related to other groups (e.g. attitudes towards people with HIV) OR other constructs and people who use drugs (e.g. social support of people who use drugs) OR other constructs and other groups (e.g. muscle dysmorphia in male bodybuilders)	2,878
C	Theoretical studies or literature review on stigma and related constructs (e.g. stigma and pejorative language in dependence) OR other constructs (e.g. AIDS and law)	1,321
D	Interventions to reduce stigma and related constructs related to other groups (Ex. intervention for internalized stigma among hospitalized veterans) OR interventions on other constructs and related to people who use drugs (e.g. assertiveness training for adolescents with parents who use drugs) OR interventions on other constructs and related to other groups (e.g. intervention to improve patient adherence to antidepressants after psychiatric hospitalization)	569
E	Materials other than articles (e.g. indexes, panels, lists)	228

Authors and year	Sample	Intervention	Main results
Albright, Skipper, Riley, Wilhelm e Rayburn (2012)Albright, B., Skipper, B., Riley, S., Wilhelm, P., & Rayburn, W. F. (2012). Medical students’ comfort with pregnant women with substance-use disorders: A randomized educational study. Academic Psychiatry, 36(6), 457-460. doi:10.1176/appi.ap.11070134 https://doi.org/10.1176/appi.ap.11070134...	96 medical students	Education and contact with pregnant women who use drugs	Increased comfort in talking about drug use and its negative effects
Ballon and Skinner (2008)Ballon, B. C., & Skinner, W. (2008). Attitude is a little thing that makes a big difference”: Reflection techniques for addiction psychiatry training. Academic Psychiatry , 32(8), 218-224. doi:10.1176/appi.ap.32.3.218 https://doi.org/10.1176/appi.ap.32.3.218...	28 psychiatric residents	Education, contact with dependents, training, group visits	Improved attitudes
Barron et al. (2012)Barron, R., Frank, E., & Gitlow, S. (2012). Evaluation of an experiential curriculum for addiction education among medical students. Journal of Addiction Medicine, 6(2), 131-136. doi:10.1097/ADM.0b013e3182548abd https://doi.org/10.1097/ADM.0b013e318254...	140 doctors and 105 medical students	Experiential learning at the Summer Institute for Medical Students	Increased confidence in acknowledging available resources for dependents and talking about drug use
Bigby and Barnes (1993)Bigby, J., & Barnes, H. N. (1993). Evaluation of a faculty development program in substance abuse education. Journal of General Internal Medicine, 8(6), 301-305. doi:10.1007/bf02600141 https://doi.org/10.1007/bf02600141...	87 professor and doctors	Course; role-play, case discussions, and group meeting	Improved attitudes; increased confidence in clinical skills
Bland et al. (2001)Bland, E., Oppenheimer, L., Brisson-Carroll, G., Morel, C., Holmes, P., & Gruslin, A. (2001). Influence of an educational program on medical students’ attitudes to substance use disorders in pregnancy. American Journal of Drug and Alcohol Abuse, 27(3), 483-490. doi:10.1081/ada-100104513 https://doi.org/10.1081/ada-100104513...	84 medical students	Educational modules, simulated contact with the patient, and lectures	Increased comfort in dealing with patients; improved attitudes
Chappel and Veach (1987)Chappel, J. N., & Veach, T. L. (1987). Effect of a course on students’ attitudes toward substance abuse and its treatment. Journal of Medical Education, 62(5), 394-400. doi:10.1097/00001888-198705000-00004 https://doi.org/10.1097/00001888-1987050...	45 medical students	Course; discussion groups, clinical cases, and technical visits	Improved attitudes, unrelated to good clinical practices
Cleary et al. (2009)Cleary, M., Hunt, G. E., Malins, G., Matheson, S., & Escott, P. (2009). Drug and alcohol education for consumer workers and caregivers: A pilot project assessing attitudes toward persons with mental illness and problematic substance use. Archives of Psychiatric Nursing, 23(2), 104-110. doi:10.1016/j.apnu.2008.05.004 https://doi.org/10.1016/j.apnu.2008.05.0...	32 caregivers	Workshops	Improved attitudes; greater sympathy; equal rights to health
Crapanzano et al. (2014)Crapanzano, K., Vath, R. J., & Fisher, D. (2014). Reducing stigma towards substance users through an educational intervention: Harder than it looks. Academic Psychiatry , 38(4), 420-425. doi:10.1007/s40596-014-0067-1 https://doi.org/10.1007/s40596-014-0067-...	28 doctors	Teaching and discussions, contact, and reflective writing	Contact had positive effects, but stigmatizing attitudes were maintained
Gabel and Pearsol (1993)Gabel, L. L., & Pearsol, J. A. (1993). The twin epidemics of substance use and HIV: A state-level response using a train-the-trainer model. Family Practice, 10(4), 400-405. doi:10.1093/fampra/10.4.400 https://doi.org/10.1093/fampra/10.4.400...	120 doctors and nurses	Training for professionals	Improved knowledge and attitudes towards people who use drugs and with HIV/AIDS
Gerace et al. (1995)Gerace, L. M., Hughes, T. L., & Spunt, J. (1995). Improving nurses’ responses toward substance-misusing patients: A clinical evaluation project. Archives of Psychiatric Nursing , 9(5), 286-294. doi:10.1016/s0883-9417(95)80048-4 https://doi.org/10.1016/s0883-9417(95)80...	32 nurses	Classes, contact, self-awareness exercises, role-play, case studies, and brief intervention	Positive results in the experimental group, compared to the control group, mainly in the optimism in treatment
Gopalan et al. (1992)Gopalan, R., Santora, P., Stokes, E. J., Moore, R. D., & Levine, D. M. (1992). Evaluation of a model curriculum on substance abuse at The Johns Hopkins University School of Medicine. Academic Medicine, 67(4), 260-266. doi:10.1097/00001888-199204000-00014 https://doi.org/10.1097/00001888-1992040...	892 medical students	Elective modules and experiences related to drug use	Improved attitudes, responsibility, and knowledge
Gorman et al. (1990)Gorman, D. M., Werner, J. M., Jacobs, L. M., & Duffy, S. W. (1990). Evaluation of an alcohol education package for non-specialist health care and social workers. British Journal of Addiction, 85(2), 223-233. doi:10.1111/j.1360-0443.1990.tb03075.x https://doi.org/10.1111/j.1360-0443.1990...	63 health professionals and social workers	Education, discussions, and role-play	No significant improvement in knowledge and attitudes
Heiligman and Nagoshi (1994)Heiligman, R. M., & Nagoshi, C. T. (1994). A longitudinal study of family practice residents’ attitudes toward alcoholism. Family Medicine, 26(7), 447-451.	43 residents	Classes on dependence and visits to AA	No significant changes in attitudes
Hettema et al. (2009)Hettema, J. E., Sorensen, J. L., Uy, M., & Jain, S. (2009). Motivational enhancement therapy to increase resident physician engagement in substance abuse education. Substance Abuse, 30(3), 244-247. doi:10.1080/08897070903041210 https://doi.org/10.1080/0889707090304121...	9 medical students	Motivational Enhancement Therapy, Education, and SBIRT	No significant changes in attitudes
Junqueira et al. (2015)Junqueira, M. A., Rassool, G. H., Santos, M. A., & Pillon, S. C. (2015). The impact of an educational program in brief interventions for alcohol problems on undergraduate nursing students: A Brazilian context. Journal of Addictions Nursing, 26(3), 129-135. doi:10.1097/JAN.0000000000000086 https://doi.org/10.1097/JAN.000000000000...	120 nursing students	Theoretical and practical classes	Improved knowledge and attitudes; experimental group with greater improvement than control group
Kokotailo et al. (1995)Kokotailo, P. K., Langhough, R., Neary, E. J., Matson, S. C., & Fleming, M. F. (1995). Improving pediatric residents’ alcohol and other drug use clinical skills: Use of an experiential curriculum. Pediatrics, 96(1), 99-104.	44 psychiatric residents	Education, role-play and interviews, participation in drug assessment and intervention programs	Improved general knowledge, interest, specific skills, and trust regarding drugs
Meltzer et al. (2013)Meltzer, E. C., Suppes, A., Burns, S., Shuman, A., Orfanos, A., Sturiano, C. V., ... Fins, J. J. (2013). Stigmatization of substance use disorders among internal medicine residents. Substance Abuse , 34(4), 356-362. doi:10.1080/08897077.2013.815143 https://doi.org/10.1080/08897077.2013.81...	128 medical residents	Knowledge, interactive sessions, lectures on SBIRT, The Brief Negotiated Interview (BNI), and field trip	Increased consideration regarding dependents of alcohol and pain medications
Meng, Rayburn, Ramirez-Cacho and Rayburn (2007)Meng, C., Rayburn, B. B., Ramirez-Cacho, W. A., & Rayburn, W. F. (2007). Effect of a specialized prenatal clinic on medical student attitudes toward women with drinking problems. The Journal of Maternal-Fetal & Neonatal Medicine, 20(3), 217-220. doi:10.1080/14767050601057564 https://doi.org/10.1080/1476705060105756...	117 medical students	Contact with the group	Improved attitudes; increased comfort with pregnant patients with alcohol use disorder
Munro et al. (2007)Munro, A., Watson, H. E., & McFadyen, A. (2007). Assessing the impact of training on mental health nurses’ therapeutic attitudes and knowledge about co-morbidity: A randomised controlled trial. International Journal of Nursing Studies, 44(8), 1430-1438. doi:10.1016/j.ijnurstu.2006.07.024 https://doi.org/10.1016/j.ijnurstu.2006....	49 nurses	Groups, education, evidence-based intervention, ethical issues, and public policies	Improved attitudes in the experimental group
Ockene et al.(1997)Ockene, J. K., Wheeler, E. V., Adams, A., Hurley, T. G., & Hebert, J. (1997). Provider training for patient-centered alcohol counseling in a primary care setting. Archives of Internal Medicine, 157(20), 2334-2341. doi:10.100/archinte.1997.00440410066007 https://doi.org/10.100/archinte.1997.004...	14 doctors, 12 residents, and 5 nursing professionals	Educational strategies, role-play, and counseling skills	Improved confidence, optimism in treatment, and stereotyped beliefs
Oliveira et al. (2013)Oliveira, M. C., Martins, L. F., Richter, K., & Ronzani, T. M. (2013). Evaluation of an intervention to reduce health professional stigma toward drug users: A pilot study. Journal of Nursing Education and Practice, 3(5), 138-148. doi:10.5430/jnep.v3n5p138 https://doi.org/10.5430/jnep.v3n5p138...	95 primary healthcare professionals	SBIRT training for experimental and control groups, anti-stigma training for experimental group, and supervision	No significant differences in the experimental and control groups stigma
Puskar et al. (2013)Puskar, K., Gotham, H. J., Terhorst, L., Hagle, H., Mitchell, A. M., Braxter, B.,... Burns, H. K. (2013). Effects of Screening, Brief Intervention, and Referral to Treatment (SBIRT) education and training on nursing students’ attitudes toward working with patients who use alcohol and drugs. Substance Abuse , 34(2), 122-128. doi:10.1080/08897077.2012.715621 https://doi.org/10.1080/08897077.2012.71...	319 nursing students	ATN-SBIRT Program and education	Greater preparation and responsibility; less motivation to work with patients with alcohol use disorder
Ramirez-Cacho, Strickland, Beraun, Meng and Rayburn (2007)Ramirez-Cacho, W. A., Strickland, L., Beraun, C., Meng, C., & Rayburn, W. F. (2007). Medical students’ attitudes toward pregnant women with substance use disorders. American Journal of Obstetrics and Gynecology, 196(1), 86.e1-5. doi:10.1016/j.ajog.2006.06.092 https://doi.org/10.1016/j.ajog.2006.06.0...	104 medical students	Education and contact in clinical care	Increased comfort in talking about the effects of drugs and related problems
Rose et al. (2006)Rose, A. J., Stein, M. R., Arnsten, J. H., & Saitz, R. (2006). Teaching internal medicine resident physicians about alcoholics anonymous: A pilot study of an educational intervention. Substance Abuse , 27(3), 5-11. doi:10.1300/J465v27n03_02 https://doi.org/10.1300/J465v27n03_02...	36 medical residents	Educational intervention, lecture about the AA, and technical visit	Improved attitudes towards AA; greater belief in its effectiveness
Salvalaggio et al. (2013)Salvalaggio, G., Dong, K., Vandenberghe, C., Kirkland, S., Mramor, K., Brown, T.,... Wild, T. C. (2013). Enhancing screening, brief intervention, and referral to treatment among socioeconomically disadvantaged patients: Study protocol for a knowledge exchange intervention involving patients and physicians. BMC Health Services Research, 13, 108. doi:10.1186/1472-6963-13-108 https://doi.org/10.1186/1472-6963-13-108...	300 doctors	Booklets, online education, workshops, case studies, SBIRT training, and contact	Description of the protocol: methodological care and community challenges
Silins, Conigrave, Rakvin, Dobbins and Curry (2007)Silins, E., Conigrave, K. M., Rakvin, C., Dobbins, T., & Curry, K. (2007). The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers. Drug and Alcohol Review, 26(2), 191-200. doi:10.1080/09595230601184661 https://doi.org/10.1080/0959523060118466...	445 medical students	Lectures, groups, case studies, and contact	Improved attitudes, especially towards smokers; lower hatred towards people who use alcohol
Strang, Hunt, Generated and Marsden (2007)Strang, J., Hunt, C., Gerada, C., & Marsden, J. (2007). What difference does training make? A randomized trial with waiting-list control of general practitioners seeking advanced training in drug misuse. Addiction , 102(10), 1637-1647. doi:10.1111/j.1360-0443.2007.01929.x https://doi.org/10.1111/j.1360-0443.2007...	112 doctors	Training, conferences, and expert supervision	Improved attitudes; increased group support in the treatment for people who use drugs
Vadlamudi, Adams, Hogan, Wu and Wahid (2008)Vadlamudi, R. S., Adams, S., Hogan, B., Wu, T., & Wahid, Z. (2008). Nurses’ attitudes, beliefs and confidence levels regarding care for those who abuse alcohol: Impact of educational intervention. Nurse Education in Practice, 8(4), 290-298. doi:10.1016/j.nepr.2007.10.003 https://doi.org/10.1016/j.nepr.2007.10.0...	181 nursing graduate students	The Brief Negotiated Interview (BNI), didactic training, and role-play	Improved attitudes and beliefs; increased confidence

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[1] Correspondence address: Joanna Gonçalves de Andrade Tostes. Universidade Federal de Juiz de Fora. Instituto de Ciências Humanas. Centro de Referência em Pesquisa, Intervenção e Avaliação em Álcool & Drogas. (CREPEIA). Rua José Lourenço Kelmer, s/n - São Pedro, Juiz de Fora-MG, Brazil. CEP 36.036-900. E-mail: joanna@tostes.org