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Objective: Opioid use disorder (OUD) remains a major public health problem within Canada and worldwide. Increasing our understanding of psychiatric comorbidity in this population is the focus of this thesis. Methods: We used observational cohort data from two prospective studies of individuals with OUD receiving opioid agonist treatment (OAT). These data allowed us to examine risk factors for psychological symptoms and psychiatric comorbidities, to examine differences between youth and adults, and to assess the sensitivity and specificity of self-reported diagnoses against those made using a validated tool. We linked cohort data to Provincial health administrative data holdings to explore mental healthcare service use and associated costs. Discoveries: This work provides new information on psychiatric comorbidity among individuals receiving treatment for OUD and carries implications that can inform future research to shape clinical care. The main conclusions drawn from this work were: 1) routine assessment of psychological symptoms, including suicidal ideation, in this population is warranted; 2) self- report of psychiatric disorders is not sufficiently sensitive to identify psychiatric comorbidity and other methods such as validated tools should be considered; 3) trauma and post-traumatic stress disorder are common in individuals with OUD and their impact may not be captured by solely measuring substance-related outcomes in treatment; 4) youth with OUD differ from adults in their health risk behaviours and psychiatric comorbidities and likely require distinct services and supports; and 5) outpatient non-substance-related mental healthcare for individuals with OUD is provided largely by primary care physicians for whom increased resources and training are needed, and emergency department visits and hospitalizations (which are costlier to the system) are not uncommon. Conclusion: Psychiatric comorbidity is prevalent in OUD and integrated mental health and addictions treatment requires clinical and research attention. Future studies are needed to test interventions and build an evidence base to inform clinical management. / Thesis / Doctor of Philosophy (PhD) / Opioid addiction has led to the deaths of tens of thousands of Canadians and many more people worldwide. Many individuals with opioid addiction also have other mental health problems that can be barriers to recovery from opioid use. Our current healthcare services are disconnected, and most people do not have access to treatments that can help with both addiction and other mental health problems at the same time. We conducted five studies looking at mental health problems within people who have opioid addiction. We focused on understanding risk factors, diagnoses, treatment, and use of mental healthcare services for individuals with opioid addiction and other mental health problems. Our findings provide new information on unmet mental health needs for people with opioid addiction. This information will help treatment programs, doctors, and policy makers better understand who needs more supports and consider how to improve services.

Stigma in the healthcare system is widely documented. A significant medium through which stigmatizing thoughts, opinions, and attitudes are propagated is language. Stigmatizing language can create barriers to care, while inclusive non-stigmatizing language has the ability to highlight a patient’s strengths, humanity, and potential for recovery. While several institutions have implemented campaigns and interventions aimed at reducing stigma in healthcare, research examining the impact of these interventions is limited. Specifically, no studies have examined the effects of language-focused campaigns on patient outcomes. This paper reviews the current literature on stigma and stigmatizing language in healthcare and proposes a hypothetical study designed to assess the effects of a clinician-facing training that emphasizes the use of non-stigmatizing language on opioid abstinence in patients newly diagnosed with opioid use disorder. Potential limitations in study design and data analysis, along with possible implications of study results, are discussed. / Urban Bioethics

Motherhood has been set up as an institution of control over women by the patriarchy. Dominant ideas of motherhood and what constitutes being a good mother are steeped in patriarchal ideals and conceptual thoughts. What is absent from ideas of motherhood is the female lived experiences of mothering. Mothering, by contrast, is the conceptual understanding of what it means to be a mother from a women-centered perspective. Under the dominant discourse of motherhood, mothers are self-sacrificing, generous, calm, patient, and loving. Those mothers who do not meet these standards are constructed as "bad mothers," reinforcing a binary understanding of mothers. This paper challenges the good/bad mother binary by drawing on the lived experience of one mother who uses substances to demonstrate the judgmental road mothers are forced to walk. This thesis takes a feminist-based approach to explore Ruth's story: a mother who engages in substance use. This research is produced through a feminist ontology to add to a body of scholarship that works to create a counter-discourse for mothers from mothers against dominating patriarchal norms of motherhood. A Narrative case study methodology is applied to Ruth's story to extrapolate the complex realities Ruth faces as she attempts to make sense of her mothering identity within the patriarchal definition of the "good mother." While engaging in substance use, Ruth's mothering story produced four themes that facilitate understanding mothering from a holistic, women-centric lens. First, this research emphasizes the barriers Ruth experiences in building, understanding and maintaining her sense of self. Second, Ruth's story illuminates the impact of the dominant "good" motherhood discourse on how women like Ruth conceptualize themselves as a mother. Third, Ruth's story enables the exploration of the intersectional identities of mothering and substance use in a way that creates space for both identities to work together rather than in opposition. Lastly, reflecting on the surveillance Ruth has endured in relation to her family and interactions with child welfare, her story reveals how discourses of risk are connected to and associated with substance use. Through the exploration of Ruth's mothering experiences, a narrative is produced to challenge and disrupt the oppressive institution of motherhood. / Thesis / Master of Social Work (MSW)

The purpose of this qualitative study was to identify salient beliefs about disclosing drug use to healthcare providers among a convenience sample of adults who use drugs in the United States. This study differs from previous research by using the Reasoned Action Approach as the theoretical framework which allows the intention to disclose to be explored. A sample of 5 adults were recruited from Bluelight.org, with ages above 35 years for all participants. Primary drugs differed among the sample with two participants using primarily opioids, heroin as the primary drug for one participant, and stimulants as the primary drug for two participants. Data was collected using an open-ended web survey. Content analysis was performed on the data using a pragmatic worldview. Data was analyzed using the Reasoned Action Approach concepts relating to behavioral beliefs, normative beliefs, and control beliefs. Among the sample, advantages to disclosing drug use included improved healthcare and finding help while disadvantages primarily included discrimination and stigmatization. When asked about normative referents that would encourage disclosure, family and healthcare providers were provided most. However, those who would discourage disclosure were people who know the consequence, pain patients, and support groups. Stigma and discrimination appeared again as response to a question about groups or people who would be least likely to disclose. When asked about factors that would increase the likelihood of disclosure, being listened to without consequences and a variety of healthcare provider qualities (e.g., caring, trustworthy, etc.) were provided most often. Factors that would decrease the likelihood of disclosure were less conclusive and diminished health/healthcare was the only salient belief identified. The findings of this study align with previous literature on the consequences of stigma and discrimination while also providing a base of literature for future research on the topic using the Reasoned Action Approach.

The development of multiple theoretical models and measures of impulsivity has led to inconsistent use of this term and disagreement regarding the most salient predictors of alcohol-related outcomes. The present study examined whether self-report and behavioral measures of impulsivity measure the same construct and how eight conceptually distinct facets of impulsivity relate to alcohol-related outcomes. Participants completed measures and tasks to assess alcohol use, alcohol problems, trait impulsivity, and behavioral impulsivity. The UPPS-P and behavioral measures of impulsivity were largely uncorrelated with each other. Negative urgency and alcohol use emerged as direct predictors of alcohol-related problems. Lack of premeditation demonstrated an indirect effect on alcohol-related problems. Results support previous research suggesting behavioral and self-report measures of impulsivity do not assess the same construct. Further, results suggest that negative urgency may be the most predictive of alcohol-related problems when accounting for self-report and behavioral components of impulsivity.

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