BACKGROUND: Substance use disorders are highly prevalent and highly stigmatized. They are defined as conditions in which the use of one or more substances, in spite of negative consequences, leads to a clinically significant impairment or distress. Stigma is a characteristic deemed undesirable by society. Stigma is dependent on the relationship between the specific discrediting or undesirable characteristic and the social context. LITERATURE REVIEW FINDINGS: The various manifestations of stigma include public or external stigma, provider stigma, and internal stigma. External stigma is the negative beliefs that society holds about people in stigmatized groups, for example patients with substance use disorders or HIV. Another type of stigma is provider stigma, referring to the negative beliefs that providers hold about patients belonging to these stigmatized groups. Internal stigma is defined as the devaluation that people in stigmatized groups hold about themselves in relation to society. Stigma is continued when there is a lack of familiarity and education with a stigmatized condition or group. PROPOSED PROJECT: The proposed project aims to address and decrease provider stigma in physician assistant trainees before they begin their clinical training through an educational intervention. This thesis will propose the development and evaluation of a new curriculum to educate physician assistant students on substance use disorders and their treatments, frame substance use disorders as chronic diseases, and aid physician assistant student trainees on recognizing their attitudes and biases, or prejudices, toward working with patients with substance use disorders. The project will assess attitudes before and after the education intervention to analyze if attitudes toward patients with substance use disorders have changed as a result of the educational intervention. The goal of the educational curriculum is to improve physician assistant student attitudes toward working with patients with substance use disorders before they encounter this population in clinical practice. SIGNIFICANCE: Physician assistants are clinicians who diagnose illness, develop treatment plans, manage their own patients, and often serve as the primary clinician for patients. Physician assistants will encounter a number of patients with substance use disorders throughout the course of their careers. Addressing provider stigma in this group will help improve treatment outcomes in this patient population and give the students the confidence and knowledge to manage patients with substance use disorders. As a result of completing this curriculum, physician assistant students will have decreased stigma and better attitudes toward working with patients with substance use disorders.

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The increasing prevalence of substance use disorder (SUD) is a major public health crisis in the Unites States. Adolescence is an ideal period for early intervention to reduce the risk of SUDs in adulthood, as research has shown that up to 60% of adult SUD could have been avoided by early intervention in youth. Prior research has typically focused on urban metropolitan areas when describing adolescent substance use. However while the data is varied, several studies have shown that the prevalence of rural adolescent substance use is equal or greater than that of their urban peers, particularly alcohol, tobacco, and prescription drug use, and begin use at an earlier age. There are several methods of treatment for adolescent substance use and SUD, centered on evidence-based practices, which have been shown to be moderately effective at reducing substance use. Despite the existence of these treatment strategies, substantial disparities exists with respect to the number of adolescents who could potentially benefit and the number who actually enroll in treatment. It has been estimated that 90% of adolescents in need of treatment are not able to succeed in receiving it. This highlights the importance of understanding the circumstances in which youth initiate drug use and the unique barriers they must overcome to receive treatment when these behaviors develop into a pattern that impacts daily life. With this information, interventions can be targeted to reduce the magnitude of the most significant barriers in order to increase treatment utilization, especially in rural areas where adolescents face unique challenges to treatment access as a consequence of their remote locations. A literature review was conducted and found the major barriers in access to substance use treatment for adolescents to be a lack of available treatment programs, lack of treatment options including medication treatment, lack of perceived need or motivation for treatment, social stigma, socioeconomic status (SES), familial relationships, and referral services. These studies were all conducted in the United States and published from 2011-2020. The aim of this thesis is to propose a protocol for the completion of a systematic review to determine which barriers exist to adolescents receiving substance use treatment and to examine them in the context of rurality. Healthcare decisions and policy are informed by the best available evidence from systematic research and incorporated into evidence-based practices. A systematic review will summarize the findings of all relevant studies thereby making the key information more accessible to decision makers, including clinicians and policy makers, in order for substance use treatment to become more accessible to adolescents.

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INTRODUCTION: Drug overdose death is now the leading cause of mortality among homeless adults in Boston, with opioids implicated in a majority of those deaths. Harm reduction interventions help minimize the risks associated with substance use, and are critical in supporting individuals with substance use disorder. Medical monitoring programs are an effective harm reduction strategy that work to prevent fatal drug overdoses and keep people safe while still actively using. METHODS: Visit data from the Supportive Place for Observation and Treatment (SPOT) was compiled and analyzed. The two measures of interest were the count of referrals to substance use disorder treatment and the count of visits prior to the first referral to treatment. Chi-square tests of independence, odds ratios, and binary logistic regression models were used to describe the association between factors of interest and referrals to substance use disorder treatment. RESULTS: Gender and age did not show any significant association to a connection to treatment. Overdose history (Adjusted Odds Ratio 6.59), reported stimulant use (AOR 2.59), and documented health or harm reduction education (AOR 5.14) were all associated with increased odds of being referred to substance use disorder treatment. Heavy sedation (AOR 0.55) was associated with decreased odds of a treatment referral.When examining factors associated with rapid connection to treatment, male gender (OR 1.87) was associated with increased odds, while overdose history (AOR 0.42) was associated with decreased odds. DISCUSSION: The two most impactful factors associated with increased odds of connecting to substance use disorder treatment were reported overdose history and documented education. Both of these factors suggests that a strength of SPOT is its ability to form and maintain meaningful connections with participants. One way that SPOT could improve referral outcomes would be to increase its ability to engage participants, such as through the recruitment of more harm reduction specialists or peer recovery coaches.

Substance Use Disorder (SUD) has plagued families of rural Appalachia for many years, perpetuating involvement in the criminal justice system as well as generational trauma for people diagnosed with SUD as well as their children. This points to the necessity of a trauma-informed, restorative-justice based framework for rehabilitative services to most effectively heal families, address trauma, and re-integrate people diagnosed with SUD into society. A restorative justice-based program would provide health care services for addiction and any comorbid mental health disorders as well as teach parents how to properly provide for themselves and their families, manage finances, obtain employment, and further education. Current rehabilitative program structures were evaluated in the literature, and it was found that typically, rehabilitative programs provide either strictly addiction services or mental health services, but not both. It was also found that the criminal justice system tends to sentence to 28-day inpatient rehabilitative services, which provides people diagnosed with SUD an opportunity to achieve sobriety and establish some stability; however, with little or no follow up, these people are significantly more likely to relapse. These findings were compared with the structure of Ballad Health Strong Futures, an outpatient addiction services and behavioral health clinic located in Greeneville, TN. It was found that rehabilitative care structures that addresses trauma, addiction, and aspects of daily living such as parenting, finances, education, and employment provides clients with the tools and stability they need to be successful in their respective recovery journeys. This work will provide significant insight for the creation and implementation of other substance use clinics across the country and encourage them to address addiction, mental health, and aspects of daily living to promote clients' success and break cycles of generational trauma.

Empathy is one of the most important skills a mental health counselor can have. For instance, empathy plays a key role in retention and engagement in therapy for substance use disorder (SUD), which leads to improved client outcomes. Historically, SUD treatment has been provided by those in recovery with little formal education about counseling. Currently, academic requirements for SUD counselors vary, and most master'€™s level education programs rarely address SUDs. To determine whether SUD experience alone is related to empathy, a 2x2 factorial ANOVA was used in this study to examine the relationship between two independent variables (education status and recovery status) against the dependent variable of empathy for 607 SUD counselors. Findings showed that recovery status was not indicative of SUD counselor empathy, and graduate level education was associated with empathy in SUD counselors. As the epidemic of addiction continues to grow, having a competent workforce of licensed/credentialed SUD counselors is imperative, and this research shows that having a master'€™s degree in counseling may influence empathy in SUD counselors. Thus, the results of this research have the potential to shape licensure/credentialing processes for those seeking a career in the SUD field and improve outcomes for individuals with a SUD.

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