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Strategies used by people who inject drugs to avoid stigma in healthcare settings
Open accessAbstract
Background People who inject drugs (PWID) have limited engagement in healthcare services and report frequent experiences of stigma and mistreatment when accessing services. This paper explores the impact of stigma against injection drug use on healthcare utilization among PWID in the U.S. Northeast.Methods We recruited PWID through community-based organizations (CBOs; e.g., syringe service programs). Participants completed brief surveys and semi-structured interviews lasting approximately 45 min exploring HIV risk behaviors and prevention needs. Thematic analysis examined the emergent topic of stigma experiences in relation to healthcare utilization.Results Among 33 PWID (55% male; age range 24-62 years; 67% White; 24% Latino), most used heroin (94%) and injected at least daily (60%). Experiences of dehumanization in healthcare settings were common, with many participants perceiving that they had been treated unfairly or discriminated against due to their injection drug use. As participants anticipated this type of stigma from healthcare providers, they developed strategies to avoid it, including delaying presenting for healthcare, not disclosing drug use, downplaying pain, and seeking care elsewhere. In contrast to large institutional healthcare settings, participants described non-stigmatizing environments within CBOs, where they experienced greater acceptance, mutual respect, and stronger connections with staff.Conclusions Stigma against injection drug use carries important implications for PWID health. Increased provider training on addiction as a medical disorder could improve PWID healthcare experiences, and integrating health services into organizations frequented by PWID could increase utilization of health services by this population.
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“Building rapport and trust through low-threshold, non-stigmatizing services in community-based organizations, rather than in large institutional clinics, helps mitigate the anticipated discrimination that often deters these patients from seeking care [46].”
From Psychosocial Interventions for Improving Treatment Adherence in Tuberculosis Patients: A Scoping Review of Evidence-Based Approaches. (2026) · cites this paper as [46]
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BackgroundResultThe Past, Present, and Future of PrEP implementation Among People Who Use Drugs
Biello, K. B., Mimiaga, M. J., Valente, P. K., Saxena, N., & Bazzi, A. R. (2021) · Current HIV/AIDS Reports · doi:10.1007/s11904-021-00556-z · Cited by 57
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“PWID are typically under-represented in primary health care [14], with access to COVID-19 vaccination likely to be constrained by concerns about stigma and discrimination [15], costs associated with receipt of a vaccine [16], including transportation [17], the complexity of booking systems [4], and a lack of trust in…”
BackgroundConsidering the Potential Benefits of Over-the-Counter Naloxone
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Bartholow, L. A. M., & Huffman, R. T. (2021) · Journal of the American Psychiatric Nurses Association · doi:10.1177/10783903211036496 · Cited by 46
“The less likely they are to feel stigmatized and dehumanized, the more likely they are to return promptly on a recurrence of disease symptoms (Biancarelli et al., 2019).”
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“Furthermore, SSPs have been identified as non-stigmatizing environments, which could lessen the barrier of stigma that PWID experience in healthcare settings (Ahern et al., 2007; Biancarelli et al., 2019).”
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“Although long-acting injectable PrEP could reduce the need for this level of daily outreach, frequent contact with patients can also help retain patients in care, enable referrals to other services, and support the trusting patient-provider relationships that are critical for this often-stigmatized population.(25) Lim…”
BackgroundExperiences of stigma and subsequent reduced access to health care among women who inject drugs
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“To avoid stigma, PWID presenting to healthcare with non–IDU-related problems may not disclose their IDU [23].”
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“Negative attitudes toward people who use drugs are pervasive in medicine [44, 45], and individuals who use drugs commonly report having experienced unfair, dehumanizing treatment by providers during past medical encounters because of their drug use [46, 47].”
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“Stigmatization of PWID can disincentivize persons from engaging in positive health-seeking behaviors (Biancarelli et al., 2019; Paquette et al., 2018).”
BackgroundMattocks, K. M., Moore, D. T., Wischik, D. L., Lazar, C. M., & Rosen, M. I. (2022) · Journal of Substance Abuse Treatment · doi:10.1016/j.jsat.2022.108777 · Cited by 24
“, 1993) and the stigma they anticipate from others (Biancarelli et al., 2019; Brener et al., 2010) have both been associated with less engagement in treatment.”
Interventions to reduce self-stigma in people who use drugs: A systematic review
Sibley, A. L., Colston, D. C., & Go, V. F.-L. (2023) · Journal of Substance Use and Addiction Treatment · doi:10.1016/j.josat.2023.209284 · Cited by 28
Cahn, B. A., Bartholomew, T. S., Patel, H. P., Pastar, I., Tookes, H. E., & Lev‐Tov, H. A. (2021) · International Wound Journal · doi:10.1111/iwj.13572 · Cited by 24
Ogden, S. N., Harris, M. T. H., Childs, E., Valente, P. K., Edeza, A., Collins, A. B., Drainoni, M., Mimiaga, M. J., Biello, K. B., & Bazzi, A. R. (2021) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2021.103285 · Cited by 25
Broman, M. J., Pasman, E., Brown, S., Lister, J. J., Agius, E., & Resko, S. M. (2022) · Addiction Research & Theory · doi:10.1080/16066359.2022.2101640 · Cited by 24
“Because stigma reduces help-seeking (Keyes et al. 2010; Biancarelli et al. 2019) and may reduce social support, psychosocial interventions are necessary to make it feel less threatening to seek treatment.”
BackgroundGoodman‐Meza, D., Tang, A. B., Aryanfar, B., Vazquez, S., Gordon, A. J., Goto, M., Goetz, M. B., SHOPTAW, S. J., & Bui, A. A. T. (2022) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofac471 · Cited by 24
Gaps and barriers in drug and alcohol treatment following implementation of the affordable care act
Tomko, C. A., Olfson, M., & Mojtabai, R. (2022) · Drug and Alcohol Dependence Reports · doi:10.1016/j.dadr.2022.100115 · Cited by 24
“In contrast, community-based organizations are often preferred sources of care for people who use drugs, including SUD treatment, because of the non-stigmatizing environment (Biancarelli et al., 2019; McNeil et al., 2014).”
A qualitative study of a publicly funded pharmacy-dispensed naloxone program
Antoniou, T., Pritlove, C., Shearer, D., Martins, D., Tadrous, M., Munro, C., & Gomes, T. (2021) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2021.103146 · Cited by 26
Moe, J., Chong, M., Zhao, B., Scheuermeyer, F. X., Purssell, R. A., & Slaunwhite, A. (2021) · CMAJ Open · doi:10.9778/cmajo.20200169 · Cited by 23
Tookes, H. E., Bartholomew, T. S., Suarez, E., Ekowo, E., Ginoza, M., Forrest, D. W., Serota, D. P., Rodriguez, A. E., Kolber, M. A., Feaster, D. J., et al. (2021) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2021.109124 · Cited by 22
Norris, W. K., Allison, M. K., Fradley, M. F., & Zielinski, M. J. (2022) · Health & Justice · doi:10.1186/s40352-022-00166-w · Cited by 22
Boucher, L. M., Shoemaker, E. S., Liddy, C. E., Leonard, L., MacPherson, P. A., Presseau, J., Martin, A., Pineau, D., Lalonde, C., Diliso, N., et al. (2022) · Qualitative Health Research · doi:10.1177/10497323221083353 · Cited by 22
“Marginalized people who use drugs (PWUD) tend to experience complex health conditions characterized by chronicity and multimorbidity, as well as intersectional stigma and disparities related to social determinants of health (Biancarelli et al., 2019; Boucher et al., 2017; Dassieu et al., 2020; Degenhardt et al., 2013;…”
BackgroundSumnall, H. R., Hamilton, I., Atkinson, A. M., Montgomery, C., & Gage, S. H. (2020) · Drugs Education Prevention and Policy · doi:10.1080/09687637.2020.1820450 · Cited by 22
“…and experiences of public and internalised stigma can lead to reduced self-worth and label avoidance, and act as a barrier to treatment seeking and recovery (Biancarelli et al., 2019; Birtel et al., 2017; Chan Carusone et al., 2019; Luoma et al., 2007; Neale et al., 2011; Stringer & Baker, 2018).”
BackgroundEarlywine, J. J., Bazzi, A. R., Biello, K. B., & Klevens, R. M. (2020) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2020.09.011 · Cited by 20
Saunders, E. C., Moore, S. K., Walsh, O., Metcalf, S. A., Budney, A. J., Cavazos‐Rehg, P. A., Scherer, E. A., & Marsch, L. A. (2021) · Addiction Science & Clinical Practice · doi:10.1186/s13722-021-00213-1 · Cited by 21
“This opinion echoes findings of a recent qualitative study [105] in which people who injected drugs thought addiction medicine specialists were more empathetic and helpful than general medical providers.”
BackgroundWard, K., McCormick, S. D., Sulkowski, M., Latkin, C. A., Chander, G., & Falade-Nwulia, O. O. (2020) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2020.103019 · Cited by 19
“Consequently, PWID internalize a feeling of undeservingness and subsequently modify their behavior during interactions with healthcare providers, including delaying presentation, not disclosing or underrepresenting drug use, or obtaining care from somewhere else (Biancarelli et al., 2019; Madden et al., 2018).”
BackgroundWalters, S. M., Kral, A. H., Lamb, S., Goldshear, J. L., Wenger, L. D., & Bluthenthal, R. N. (2021) · Journal of Urban Health · doi:10.1007/s11524-020-00494-y · Cited by 19
Djordjevic, F., Ryan, K., Gunn, J., Brener, L., O’Keefe, D., Draper, B. L., Schroeder, S., Gold, J., Treloar, C., Broady, T. R., et al. (2021) · Journal of Viral Hepatitis · doi:10.1111/jvh.13612 · Cited by 20
Dahl, R. A., Vakkalanka, J. P., Harland, K. K., & Radke, J. B. (2022) · Journal of Addiction Medicine · doi:10.1097/adm.0000000000000970 · Cited by 23
“PWUD have reported delaying healthcare visits to avoid facing stigma, which results in presenting with advanced disease and use of a higher proportion of emergency medical services.(3,6,9,10) PWUD are vulnerable to nutritional, mental health, immune, and infectious disorders,(11) and so there is a critical need for th…”
BackgroundAcceptability of a HIV self-testing program among people who use illicit drugs
Peiper, N. C., Shamblen, S., Gilbertson, A., Guest, G., Kopp, M., Guy, L., & Rose, M. (2022) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2022.103613 · Cited by 20
Edeza, A., Bazzi, A. R., Salhaney, P., Biancarelli, D. L., Childs, E., Mimiaga, M. J., Drainoni, M., & Biello, K. B. (2019) · Substance Use & Misuse · doi:10.1080/10826084.2019.1673419 · Cited by 21
“…many PWID in this sample reported stigma and discrimination from clinical care providers for reasons relating to their injection drug use overall (Biancarelli et al., 2019), which may limit candid discussions between PWID and healthcare providers about HIV risk, particularly sexual risk, and…”
BackgroundStudent-Run Free Clinic at a Syringe Services Program, Miami, Florida, 2017–2019
Ginoza, M., Tomita‐Barber, J., Onugha, J., Bullock, C., Bartholomew, T. S., Tookes, H. E., & Serota, D. P. (2020) · American Journal of Public Health · doi:10.2105/ajph.2020.305705 · Cited by 20
Beyond clinical outcomes: the social and healthcare system implications of hepatitis C treatment
Torrens, M., Soyemi, T., Bowman, D., & Schatz, E. (2020) · BMC Infectious Diseases · doi:10.1186/s12879-020-05426-4 · Cited by 19
“A possible reason for this is that PWID visit community-based organisations more regularly than other healthcare settings [37].”
BackgroundBrener, L., Caruana, T., Broady, T. R., Cama, E. J., Ezard, N., Madden, A., & Treloar, C. (2021) · Addictive Behaviors Reports · doi:10.1016/j.abrep.2021.100398 · Cited by 19
Ciaccio, M. D., Villes, V., Perfect, C., Kaim, J. L. E., Klinger, M. D., James, C., Easterbrook, P., & Delabre, R. M. (2023) · Harm Reduction Journal · doi:10.1186/s12954-023-00743-8 · Cited by 19
“Community-based HCV services, which engage all stakeholders affected by HCV, could be well placed to identify and respond to the specific needs of people who inject drugs and address stigma issues [17, 25].”
BackgroundA national survey of law enforcement post-overdose response efforts
Ray, B. R., Richardson, N. J., Attaway, P. R., McDonald, H. S., Davidson, P. J., & Kral, A. H. (2023) · The American Journal of Drug and Alcohol Abuse · doi:10.1080/00952990.2023.2169615 · Cited by 19
Galarneau, L. R., Scheuermeyer, F. X., Hilburt, J., O'Neill, Z. R., Barbic, S. P., Moe, J., Buxton, J. A., Orkin, A. M., Kaczorowski, J. A., Dong, K. A., et al. (2023) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2023.02.007 · Cited by 19
Applying the Infectious Diseases Literature to People who Inject Drugs
Serota, D. P., Chueng, T. A., & Schechter, M. C. (2020) · Infectious Disease Clinics of North America · doi:10.1016/j.idc.2020.06.010 · Cited by 19
“…used for the treatment of severe infections Stigmatization by health care system • Many report experiences of dehumanization and discrimination 89 • Experiences of trauma during prolonged hospitalization 28 • Associated with delay in presenting for health care, self-treatment attempts, and…”
BackgroundTelehealth for people who inject drugs: An acceptable method of treatment but challenging to access
Delisle-Reda, S., Bruneau, J., & Martel‐Laferrière, V. (2022) · Journal of Addictive Diseases · doi:10.1080/10550887.2022.2035166 · Cited by 19
Stigma Communication Surrounding Nonmedical Opioid Use Among Affected Family Members
Pasman, E., O’Shay, S., Hicks, D. L., Resko, S. M., Agius, E., & Brown, S. (2023) · Health Communication · doi:10.1080/10410236.2023.2167588 · Cited by 17
“…communication, the ways in which families frame conversations about NMOU have potential to affect perceptions of NMOU (Goodyear et al., 2018), strategies for addressing NMOU (Kelly et al., 2010), help-seeking (Biancarelli et al., 2019), and treatment and recovery outcomes (Crapanzano et al., 2018).”
BackgroundKapadia, S. N., Katzman, C. L., Fong, C., Eckhardt, B. J., Guarino, H., & Mateu‐Gelabert, P. (2020) · Journal of Viral Hepatitis · doi:10.1111/jvh.13437 · Cited by 18
Cohort profile: The provincial substance use disorder cohort in British Columbia, Canada
Homayra, F., Pearce, L. A., Wang, L., Panagiotoglou, D., Sambo, T., Smith, N., McKendry, R., Wilson, B., Joe, R. S., Hawkins, K., et al. (2020) · International Journal of Epidemiology · doi:10.1093/ije/dyaa150 · Cited by 17
Bryant, J., Caluzzi, G., Bruun, A., Sundbery, J., Ferry, M., Gray, R. M., Skattebol, J., Neale, J., & MacLean, S. J. (2022) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2022.103631 · Cited by 18
Opioid Use Disorder Diagnosis and Management
Wakeman, S. E. (2022) · NEJM Evidence · doi:10.1056/evidra2200038 · Cited by 17
Implementation and evaluation of a syringe vending machine trial in Tbilisi, Georgia
Otiashvili, D., Kirtadze, I., Mgebrishvili, T., Beselia, A., Tabatadze, M., Vardanashvili, I., & Ober, A. J. (2022) · International Journal of Drug Policy · doi:10.1016/j.drugpo.2022.103649 · Cited by 17
The Opioid Epidemic and the State of Stigma: A Pennsylvania Statewide Survey
Kaynak, Ö., Whipple, C. R., Bonnevie, E., Grossman, J. A., Saylor, E., Stefanko, M., McKeon, C., Smyser, J., & Kensinger, W. S. (2022) · Substance Use & Misuse · doi:10.1080/10826084.2022.2064506 · Cited by 19
“Stigma also can lead individuals to delay healthcare, avoid disclosing drug use or downplay pain to medical staff, or request to be discharged against medical advice (Biancarelli et al., 2019; Simon et al., 2020).”
Background
Metadata
- Authors
- Biancarelli, D. L., Biello, K. B., Childs, E., Drainoni, M., Salhaney, P., Edeza, A., Mimiaga, M. J., Saitz, R., & Bazzi, A. R.
- Affiliations
- Boston University (US)
- Brown University (US)
- Corresponding author
- Bazzi, Angela R.
- ORCID
- Venue
- Drug and Alcohol Dependence
- Publisher
- Elsevier BV
- Published
- 2019-05
- Volume
- 198
- Pages
- 80-86
- ISSN
- 0376-8716 (ISSN-L)
- PMC
- PMC6521691
- OpenAlex
- W2921016611
- Cited by
- 524
- References
- 79
- Citations by year
- 2026: 51 · 2025: 92 · 2024: 109 · 2023: 79 · 2022: 73 · 2021: 69 · 2020: 42 · 2019: 8
- FWCI
- 36.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Drug and Alcohol Dependence (acceptedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Providence/Boston Center for AIDS Research (P30AI042853)
- NIH/NIDA (K01DA043412)
- BU Peter Paul Career Development Professorship
- Topics
- Health Sciences › Medicine › Epidemiology › HIV, Drug Use, Sexual Risk
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- people who inject drugs, stigma, health care utilization, dehumanization, community organizations, syringe services programs, HIV risk behavior, provider training, integrated care
- MeSH terms
- Adult, Female, Health Personnel, Humans, Male, Middle Aged, New England, Patient Acceptance of Health Care, HIV Infections, Substance Abuse, Intravenous, Drug Users, Young Adult, Social Stigma
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