685087

research-article2016
SAT0010.1177/1178221816685087Substance Abuse: Research and TreatmentWoo et al

“Don’t Judge a Book by Its Cover”: A Qualitative Study Substance Abuse:

Research and Treatment

of Methadone Patients’ Experiences of Stigma 1–12

© The Author(s) 2017
Reprints and permissions:
Julia Woo1*, Anuja Bhalerao1*, Monica Bawor2, Meha Bhatt3, sagepub.co.uk/journalsPermissions.nav
https://doi.org/10.1177/1178221816685087
DOI: 10.1177/1178221816685087
Brittany Dennis2, Natalia Mouravska4, Laura Zielinski5
and Zainab Samaan2,3,4,6
1Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. 2Department of
Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
3 Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON,

Canada. 4Peter Boris Centre for Addictions Research, St. Joseph’s Healthcare Hamilton,
Hamilton, ON, Canada. 5MiNDS Neuroscience Graduate Program, McMaster University,
Hamilton, ON, Canada. 6Population Genomics Program, Chanchlani Research Centre, McMaster
University, Hamilton, ON, Canada

Abstract

Introduction: Despite its efficacy and widespread use, methadone maintenance treatment (MMT) continues to be widely stigmatized.
Reducing the stigma surrounding MMT will help improve the accessibility, retention, and treatment outcomes in MMT.

Methods: Semi-structured interviews were conducted with 18 adults undergoing MMT. Thematic content analysis was used to identify
overarching themes.

Results: In total, 78% of participants reported having experienced stigma surrounding MMT. Common stereotypes associated with MMT
patients included the following: methadone as a way to get high, incompetence, untrustworthiness, lack of willpower, and heroin junkies.
Participants reported that stigma resulted in lower self-esteem; relationship conflicts; reluctance to initiate, access, or continue MMT; and
distrust toward the health care system. Public awareness campaigns, education of health care workers, family therapy, and community meet-
ings were cited as potential stigma-reduction strategies.

Discussion and conclusion: Stigma is a widespread and serious issue that adversely affects MMT patients’ quality of life and treat-
ment. More efforts are needed to combat MMT-related stigma.

Keywords: methadone maintenance treatment, stigma, substance abuse, opioid use disorder

RECEIVED: September 7, 2016. ACCEPTED: November 29, 2016. gift cards for participants. The study was also supported by a research grant from the
Hamilton Academic Health Sciences Organization (HAHSO).
Peer review: 4 peer reviewers contributed to the peer review report. Reviewers’ reports
totaled 1355 words, excluding any confidential comments to the academic editor. Declaration of conflicting interests: The author(s) declared no potential
conflicts of interest with respect to the research, authorship, and/or publication of this
TYPE: Original Research article.
Funding: The author(s) disclosed receipt of the following financial support for the Corresponding author: Zainab Samaan, Department of Psychiatry and
research, authorship, and/or publication of this article: This study received in-kind support Behavioural Neurosciences, McMaster University, 1280 Main Street West, Hamilton, ON
from the Peter Boris Center for Addiction Research, namely, in the form of reimbursement L8S 4K1, Canada. Email: samaanz@mcmaster.ca

Introduction
In recent years, the increasing ease of access to opioids and action to “escalate the fight against the prescription opioid
overreliance on prescription painkillers have resulted in a global abuse and heroin epidemic.”5
opioid abuse epidemic, with 26.4 million to 36 million people Although opioid use disorder is a complex condition often
suffering from opioid use disorder worldwide.1 Opioid use dis- resistant to treatment, opioid substitution programs have been
order, in turn, brings about serious health, social, and economic shown to be relatively successful, with methadone maintenance
consequences. In the United States alone, prescription opioid treatment (MMT) being the most commonly used treatment.6
abuse results in more than 16 000 deaths1 and $55.7 billion in Methadone is an opioid receptor agonist whose slow onset of
workplace, health care, and criminal justice costs every year.2 action and long half-life allow it to be used in maintenance or
Similarly, in Canada, public programs spend $93 million per detoxification therapy.6 Meta-analyses have shown that MMT
year on opioid addiction treatment.3 Although Canada-wide is more effective than placebo, detoxification, drug-free reha-
statistics on opioid overdose are not available, in the province bilitation, wait-list controls, or buprenorphine in retaining
of Ontario alone opioid overdose led to 1359 deaths between patients and preventing illicit opioid use.7,8
2006 and 2008.4 These statistics are so grim, in fact, that in Despite its efficacy and widespread use, MMT continues
March 2016 President Barack Obama has personally called for to be largely misunderstood and stigmatized. For instance, in
a survey of 1067 randomly selected participants, Matheson
*J.W. and A.B. are co-first authors. et al9 found that the public held strong negative attitudes and

Creative Commons Non Commercial CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-
NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction
and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages
(https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Substance Abuse: Research and Treatment 

doubts over the efficacy of MMT. Similarly, public opinion (4) potential strategies for combating negative stereotypes
polls and surveys in Canada show that while most of the regarding MMT. The relationship between stigma experiences
Canadians support harm-reduction programs, a significant and socioeconomic status (SES) and location was also explored
number of individuals disapprove of harm reduction based on in a preliminary fashion by comparing patient responses
the misguided assumption that such programs promote ille- between 2 cities with large disparity in mean SES.
gal drug use and bring violence into communities.10
Due to the widespread public misunderstanding and dis- Methods
trust toward MMT, patients often experience stigma and dis- This study was approved by the Hamilton Integrated Research
crimination surrounding their treatment.11–14 For instance, a Ethics Board (HIREB #0168).
qualitative study of 24 elderly MMT patients found that stigma
posed a barrier to substance abuse and mental health care.11 As Participants
a result, respondents often tried to conceal their treatment sta-
tus from health care workers, which is extremely dangerous as Participants were recruited from 2 methadone clinics located
it can lead to prescription of interacting medications and opi- in Hamilton and Oakville, ON, between September 2015 and
oid overdose.11 Similarly, Anstice et  al12 and Harris and January 2016. The 2 locations were chosen to diversify the
McElrath13 both reported that institutional stigma is com- study sample, as Hamilton and Oakville are known to have
monly found in MMT programs; institutional stigma refers to vastly different socioeconomic landscapes. Oakville is a rela-
when negative attitudes and beliefs toward methadone are tively affluent, suburban city with a median household income
reflected in organization’s policies, practices, or cultures. For of $118 671 and poverty rate of 8.6%18; however, Hamilton is a
instance, patients reported hearing condescending or distrust- large metropolitan area with a median income of $78 52019 and
ing remarks from pharmacists and other health care workers, poverty rate of 18.8%.20 Due to the large differences between
whereas dispensing spaces often made patients feel humiliated the 2 cities, we hoped to compare participant responses between
and exposed under the public gaze.13 Finally, a survey of 114 Hamilton and Oakville and look for a potential relationship
MMT patients found moderate to high levels of self-stigma between stigma and SES.
and perceived stigma among patients, with higher experiences To be part of the study, participants had to be (1) either cur-
of stigma associated with unemployment, intravenous drug use, rently receiving MMT or enrolled in MMT in the past, (2)
incarceration, and heroin use.14 18 years of age or older, (3) able to understand and speak
Therefore, stigma is a widespread problem in the MMT English, and (4) able to provide informed consent. Saturation
population. This is particularly concerning as accessibility and method was used to determine the sample size, whereby we
retention in MMT tend to be quite low; less than 10% of aimed to continue recruiting participants until no new ideas or
patients requiring treatment worldwide receive it,15 and only themes were being collected in each location.21
about 60% of patients successfully remain in treatment for more Two methods of recruitment were used: flyers and direct
than a year.16 Higher retention, in turn, is linked with positive approach. Flyers were placed in the waiting areas of the clinics,
treatment outcomes such as reduced criminal activity and opi- and patients were encouraged to contact the investigators for
oid use and improved employment and school performance.17 more information regarding the study. In addition, with the
These findings show that there is a need for a framework for permission of the methadone clinic staff, 2 trained study inves-
better understanding and combating MMT-related stigma. tigators ( J.W. and A.B.) approached patients in the waiting
Such a framework would help identify common public miscon- room to seek potential participants. Both written and verbal
ceptions regarding methadone as well as key stigma-reduction consent were obtained from each participant regarding their
strategies. This would, in turn, lead to more effective stigma- willingness to participate in the study and have the interview
reduction strategies that directly target common negative stereo- audio-recorded for data collection purposes. Participants were
types surrounding methadone, thus helping to improve compensated with a $5 coffee shop gift card at the end of each
methadone treatment accessibility, retention, and outcomes. interview.
Therefore, in this study, we conducted semi-structured
interviews with patients undergoing MMT to expand our cur- Demographic questionnaire
rent understanding of MMT patients’ experiences of stigma
Prior to each interview, participants were asked to answer sev-
and create a framework for combating MMT-related stigma.
eral questions regarding their demographic and SES character-
We hoped to build on the existing literature by going beyond
istics such as gender, ethnicity, education, income, employment,
simple categorization of stigma experiences and conducting a
and housing.
more thorough investigation of the exact sources and impact of
stigma. Specifically, we aimed to explore (1) the prevalence,
Semi-structured interview
sources, and types of stigma faced by MMT patients; (2) the
common negative stereotypes associated with MMT; (3) the Two study investigators ( J.W. and A.B.) conducted semi-
impact of stigma on patients’ quality of life and treatment; and structured, in-person interviews with each participant regarding
Woo et al 3

Table 1.  Overall format of the semi-structured interviews.

1. Have you ever experienced stigma related to methadone maintenance treatment?

a. If yes, how frequently do you experience stigma?
2. Based on your experience, what is the most common source of stigma regarding methadone?
3. Could you describe 1 or 2 specific stigma experiences?
4. Could you describe how the general public treats/feels about methadone patients?
a. Could you tell us, on a scale of 1 to 5, how much you agree with these following statements? (1 being you strongly disagree and 5
being you strongly agree)
i. Most people would willingly accept someone who is undergoing methadone treatment as a close friend.
ii. Most people believe that someone who is undergoing methadone treatment is just as trustworthy as the average citizen.
iii. Most people think less of a person who is receiving methadone treatment.
iv. Most employers will hire someone who is receiving methadone treatment if he or she is qualified for the job.
v. Most people would be willing to date someone who is receiving methadone treatment.
b.  How do you think the public perceives the methadone maintenance program?
i. Based on your experience, would you say that most people are aware of what methadone is and how it is used for?
ii. Have you noticed any public misconceptions or misunderstanding regarding methadone? If so, provide specific examples.
iii. Do you believe that the public perceives methadone patients in a more negative manner than individuals undergoing other
addiction treatments like abstinence programs?
5. Do you think some of the negative stereotypes about methadone patients are true?
a.  Do you feel ashamed about being in methadone treatment?
6. Has stigma affected your methadone treatment in any manner?
7. Has stigma affected your daily life in any manner?
8. How do you usually cope with the stigma surrounding methadone?
9. Could you provide some suggestions on how the stigma surrounding drug addiction and methadone could be reduced?
10. If there were one message you would like to give people about drug addiction and methadone, what would it be?

their experiences of stigma surrounding MMT. Prior to the combination of quantitative and qualitative methodologies. In
interviews, both investigators received training from an experi- addition, 5 questions about perceived stigma (Table 1, ques-
enced addiction researcher and psychiatrist (Z.S.) regarding tion 4b) were derived from the 12-item Perceived Devaluation
proper interview methodology and ethics. Each interview ran Discrimination Scale,24 a reliable and validated measure of
for 30 to 60 min and was audio-recorded. individuals’ perception of how the public treats and thinks of
Stigma was broadly defined as any negative stereotype or patients with mental illness.
discrimination surrounding MMT or MMT patients. Following each open-ended question, participants were
Specifically, 3 forms of stigma were addressed through the asked several follow-up questions based on their initial
interviews: public, interpersonal, and self-stigma.22 Public response. As a result, the actual structure and duration of the
and interpersonal stigma refer to negative remarks, attitudes, interviews differed considerably between participants.
or behaviors the participants have heard, witnessed, or expe- Participants were always asked whether there was anything else
rienced from members of the public or through their inter- they wished to add or clarify before moving on to the next
personal relationships. However, self-stigma refers to open-ended question.
negative attitudes and beliefs participants may have toward
themselves.
Thematic analysis
The overall format of the interviews is shown in Table 1.
Participants were asked open-ended questions regarding Interview recordings were transcribed and analyzed using
whether or not they have ever experienced MMT stigma; NVivo. Following each interview, 2 study investigators ( J.W.
common sources, types, and examples of stigma; their percep- and A.B.) independently read and coded each transcript
tion of how the public views MMT patients; strategies used to regarding the 4 main research questions: (1) prevalence,
cope with stigma; the impact of stigma experiences on their sources, and types of stigma; (2) common negative stereo-
quality of life and treatment; and suggestions for reducing types associated with MMT; (3) impact of stigma on daily life
negative stereotypes regarding MMT. Some questions were or treatment; and (4) potential stigma-reduction strategies.
derived from a previous study by Wahl,23 which examined This was followed by a reconciliation process, in which the
mental health care consumers’ experiences of stigma using a investigators discussed any disagreements between their
4 Substance Abuse: Research and Treatment 

Table 2.  Characteristics of study sample.

Hamilton (n = 10) Oakville (n = 8) Overall (n = 18)

Mean age in years (SD) 37.80 (9.51) 34.00 (10.86) 36.11 (10.01)
Gender (% female) 7 (70%) 5 (63%) 12 (67%)
Ethnicity (% white) 9 (90%) 7 (88%) 16 (89%)
Mean annual household income, $ (SD) 35 000 (24 010) 48 750 (29 246) 24 000 (11 005)
Employment
  % on disability benefits 4 (40%) 2 (25%) 6 (33%)
  % employed for wages 4 (40%) 5 (63%) 9 (50%)
  % homemaker/not looking for a job 2 (20%) 1 (13%) 3 (17%)
Education
  % with elementary/high school diploma 6 (60%) 5 (63%) 11 (61%)
  % with college education or higher 4 (40%) 3 (38%) 7 (39%)
Introduction to opioids
  Physician’s prescription 4 (40%) 5 (63%) 9 (50%)
 Friends/family 5 (50%) 3 (38%) 8 (44%)
 Street 1 (10%) 0 (0%) 1 (6%)

coding strategies and decided on a final set of codes. Finally, income ($35 000 vs $48 750) and were more likely to be
the codes were categorized and combined to identify over- employed (40% vs 63%). However, as no statistical tests were
arching themes. conducted, we are unable to determine whether these differ-
ences were statistically significant.

Quantitative analysis
Overview of stigma experiences
The quantitative data were summarized using descriptive sta-
tistics, for instance, by calculating the median score on the per- The proportions of participants in Hamilton, Oakville, and the
ceived public stigma questions or the proportion of participants overall study sample who reported experiencing or being
who reported having experienced MMT-related stigma. The affected by stigma are shown in Figure 1. Overall, most of the
descriptive statistics were, in turn, calculated for each of the participants reported having experienced MMT-related stigma
Hamilton and Oakville sites. However, due to the small size at least once (78%). In general, the prevalence of stigma experi-
and limited power of our sample, no statistical tests were con- ences was higher in Hamilton compared with Oakville. Table 3
ducted to look for significant differences between Hamilton shows participant responses regarding their stigma experiences.
and Oakville. The most commonly cited sources of stigma were friends
(56%), health care workers (44%), family (33%), and commu-
Results nity members (33%).
Characteristics of the study sample
Negative public perception
A total of 18 individuals participated in this study, with 10
from Hamilton and 8 from Oakville. Originally, 2 additional Participant responses regarding perceived public stigma are
participants had consented to be in the study from the Oakville shown in Table 4.
site; however, 1 participant failed to show up for the interview The following overarching themes were identified.
and another participant had to be excluded due to his limited
English-speaking abilities. In total, 16 participants were under- Methadone as a way to get high, not get better.  Although most
going MMT at the time of recruitment. Two participants were interviewees reported that the average person is not aware of
what methadone is and what it is for (72%), they felt that those
receiving Suboxone at the time of recruitment but had received
who do know what methadone is think negatively of MMT
MMT at least 1 year prior.
patients (89%). When asked about the common misconcep-
The sociodemographic characteristics of the study sample tions surrounding MMT, the most commonly reported answer
are shown in Table 2. The mean age of the participants was was the notion that methadone gets patients “high” in the same
36.11 (SD = 10.01) years. Most of the participants were way as other opioids. Although methadone is not known to
female (67%) and white (89%). Compared with the Hamilton induce the feelings of euphoria and intoxication associated
participants, individuals from Oakville had a higher mean with substances such as heroin and morphine, interviewees felt
Woo et al 5

Figure 1.  Proportions of participants who reported experiencing or being affected by stigma surrounding methadone maintenance treatment (MMT).

Table 3.  Number of participants reporting each frequency, stigma Table 4.  Participant responses regarding perceived
source, coping strategy, stigma-reduction strategy, and message for stigma surrounding methadone maintenance treatment
the public (n = 18). (MMT; n = 18).
Frequency of stigma experiences Questions regarding public No. reporting yes
 Never 4 perception

 Rarely 2 Do you think the public thinks 16

negatively of MMT patients?
 Sometimes 6
 Often 4 Do you think people think more 14
negatively of MMT compared with
 Daily 2 abstinence programs?
Sources of stigma Do you agree with some of the 9
 Friends 10 negative stereotypes about MMT
patients?
  Health care workers 8
Do you think the average person 5
 Family 6 knows what methadone is and
  Community members 6 what it is used for?
 Employers/coworkers 3
Statements regarding Median score
Coping strategies perceived stigma (75% interquartile
range)a
 Concealment 11
 Avoidance 10 Most people would willingly accept 4 (3-4)
someone who is undergoing MMT
 Confrontation/education 9 as a close friend
Suggested strategies for reducing stigma Most people believe someone 2.5 (1-3)
  Public awareness campaigns 13 undergoing MMT is as trustworthy
as the average citizen
  Education of health care workers 8
Most people think less of a person 4 (4-5)
  Inviting family to clinic appointments 5 receiving MMT
  Community meetings 2 Most employers will hire someone 2.5 (2-3)
Messages for the public undergoing MMT if he or she is
qualified for the job
 Don’t judge those on methadone treatment without 7
getting to know them first Most people would be willing to 3 (2-3.75)
date someone who is receiving
 Methadone is extremely helpful for many people; it 5 MMT
saves lives
aOn a scale of 1 to 5, where 1 = “strongly disagree” and 5 = “strongly agree.”
 Plea to the public to educate themselves about 4
methadone treatment
  No message 2
that they were simply accessing MMT as a way to get high: “I
  Stay away from methadone treatment 1 always hear people say—you are just replacing one drug with
another drug . . . and that you are still addicted to opioids, you
are just using something else to get high.”
that in the eyes of the public, they were not any different from
illegal drug users. A mother reported that even her motive for Incompetent and untrustworthy. The stereotype that metha-
accessing MMT was often questioned, with others suspecting done causes patients to get “high” led to the notion that MMT
6 Substance Abuse: Research and Treatment 

patients are incompetent and unfit to work. A young working found this generalization particularly unfair and upsetting,
man expressed frustration at the discrepancy between the pub- claiming that she had little control over their situation:
lic’s assumptions and his actual lifestyle:
Maybe they know that you are trying to get better, but they think
Most people think that people who are on methadone don’t have that you’re still a drug addict. You know, I didn’t take these pills by
jobs, they don’t work, they just do nothing all day, get high all day, choice, I actually needed them. Even you, if you were on painkillers
stuff like that. That’s not true, you know. I work full-time, I have an for 6 months you’d also be addicted.
active life, I have a girlfriend.

Impact of stigma
Although interviewees believed that being on methadone
did not make them any less capable or reliable, they reported Self-stigma and lower self-esteem.  Interestingly, 50% of partici-
that most people would consider an MMT patient to be less pants agreed with at least some of the negative stereotypes
trustworthy than the average citizen and that most employers associated with MMT. That being said, most interviewees
believed that the stereotypes applied to other MMT patients
would hesitate to hire someone on MMT even if he or she was
they knew, not directly to themselves. Several interviewees
qualified for the job (Table 4). A woman described how reveal-
admitted that they personally knew of 1 or 2 individuals who
ing her methadone status to her employer led to facing stigma were continuing to use street drugs while on MMT. For
and discrimination in the workplace: instance, a woman stated, “There is some true to the stereotype
that people use it as a free crack house. People do do that some-
I work at a hospital and I take care of people’s medication. So I was
times. When they don’t have money to do other drugs they
on a floor where the boss found out and said, “Well you shouldn’t
be giving out narcotics.” Even though I’ve been working here for a
come here instead.”
long time and I have no interest in stealing narcotics . . . And it was Although some participants directed the stigma toward
really hurtful . . . I love my job and it’s a big part of who I am. Yes, others, 50% reported that the stigma has caused them to
methadone is part of me, but people just assume that I’m going to feel ashamed about being on MMT. This self-stigma often
try to steal drugs just because I’m on methadone . . . my record led to lower self-esteem and feelings of guilt. A woman who
shows that I can be trusted.
almost lost custody over her daughter due to her metha-
done status said about her experience: “It was hard. Because
Lack of willpower.  In all, 78% of interviewees believed that the
I was questioning myself—Am I a drug addict? Am I kid-
public thinks more negatively of MMT compared with other
addiction treatment programs such as abstinence. When asked ding myself? And I was even considering stopping the
to elaborate on why that might be, lack of willpower was fre- medication, and just go through the withdrawal. But I
quently mentioned as a key stereotype associated with MMT couldn’t, because I had a baby.” Similarly, a young man who
patients: “They think that the person who is able to stay away faced difficulties finding an employer willing to accommo-
from everything and doesn’t need any help is stronger than the date for his daily methadone clinic visits described that the
person who needs methadone to help them.” One interviewee stigma left a lasting impact on him: “I felt like shit. I also
commented on how others find it difficult to understand the felt very depressed . . . I lost a lot of weight from like, being
challenges of overcoming opioid use disorder: “They look at depressed over what people’s opinions were of me about
methadone patients and think, ‘Suck it up and go through being on methadone.”
withdrawal!’”
Conflicts with friends and family.  Due to the stigma and mis-
Heroin junkies. The last common stereotype associated with
understanding surrounding methadone, most interviewees
MMT was the myth that all individuals on MMT were first
reported that they try not to disclose their methadone status to
introduced to opioids through illegal, street drugs such as her-
others, including even close friends and family members. This
oin. A young man who was first introduced to opioids at an
habit of avoidance and secrecy led to the feeling that they were
early age showed frustration at people’s tendency to make
forced to hide a major aspect of their lives from their loved
blanket statements about all MMT patients, when in reality
ones, often putting a strain on their relationships. For instance,
each individual has a unique reason for joining the program:
a woman described,
“When they hear you’re on methadone they think you’re a her-
oin addict . . . and they think that methadone users are crimi- I won’t tell a lot of my close friends because I’m fearful they will
nals. But that’s not everybody . . . people sometimes get in shitty judge me . . . That causes curiosity I think. Because I’m like, “I gotta
situations.” In fact, this myth was quite far from the truth, con- go I have an appointment.” And they ask what kind of appointment.
sidering that 50% of the participants were introduced to opi- And I’m like, “Just an appointment.” And they’re like, “Where?
oids through physician’s prescriptions, 44% through friends/ You never tell us.”
family, and only 6% were introduced through street drugs.
This myth was associated with the notion that MMT However, when participants did decide to disclose their
patients have brought this fate upon themselves and that they situation to loved ones, it often led to stigmatizing comments
are responsible for their opioid use disorder. A female partici- and even conflicts. In fact, friends and family were 2 of the
pant who joined MMT due to physician-prescribed painkillers most common sources of stigma, reported by 56% and 33% of
Woo et al 7

participants, respectively. Family and friends often struggled to I started to have withdrawals and got sick and I had to go back up
understand the challenges of getting off of methadone, prompt- again.
ing the patients to lower their dosage or leave the program
altogether: These familial conflicts could get extreme at times, Finally, several participants reported that although the
with a young participant describing how his parents locked stigma caused them to contemplate leaving the program alto-
him up inside his room when they found out that he was think- gether at times, they were never able to put it into action. One
ing of starting MMT, causing him to undergo extreme symp- participant felt that he was not far enough in his recovery to
toms of withdrawal: leave MMT: “I’d probably die if I wasn’t on methadone because
I know I’m not strong enough without it,” whereas another
My parents found out . . . I was hearing about the program, so they man showed resilience and defiance in the face of stigma: “I’ve
kind of locked me up inside my house and they disconnected the thought about leaving. But it’s just too hard to do. And in the
phone from the outside and I wasn’t allowed to leave the house and end I’ve decided that it’s my body, it’s my mind, not theirs.”
I was on house arrest unless my parents let me. My uncle told my
parents if he leaves the house, call the cops right away . . . And I
started feeling the effects, my parents couldn’t handle it because
Distrust toward health care system. Health care workers were
there’s a lot of vomiting . . . One time I picked up the phone when cited as the second most common source of stigma (44%). Par-
my mom put it on and my uncle was saying, “Oh you know you ticipants had faced stigma and discrimination from health care
can’t just let him go on methadone program, he’s just using workers in various settings, ranging from family physicians to
something else instead to get high, he’s going to get addicted to the emergency room. For instance, those who were first intro-
taking something every day.” duced to opioids through physician-prescribed painkillers felt
that their own physicians were unequipped to deal with their
Reluctance to initiate, access, or continue MMT.  In all, 30% of addiction, often laying the blame on the patients to avoid
interviewees reported that the stigma surrounding methadone responsibility. A young woman described the traumatizing
has negatively affected the quality of their treatment. Several effects of this experience:
participants confessed that it took them years between first
hearing about methadone and actually deciding to join MMT I don’t have a family doctor at the time. My family doctor, when I
as they were concerned about the negative stereotypes associ- was 20, was the one who started prescribing me narcotic painkillers.
ated with the program and wished to seek other alternatives And when I told him I wanted to get off of them, and that I was
before turning to MMT as a last resort. Discouragement from going to need either methadone or suboxone to get off of the
medications, he said, “Well that’s because you’re an addict.” And he
friends and family also played a large role in delaying patients’
said if you weren’t an addict, a junkie, that you wouldn’t have this
entry into MMT.
problem . . . and he kicked me out of his practice.
Moreover, even after patients did commence MMT, they
still continued to be extremely wary of accessing it in public, Moreover, numerous interviewees described how they are
lest their friends, family, employers, or neighbors found out. faced with scrutiny and skepticism every time they visit the
Few interviewees confessed that they visited a clinic that was hospital, with health care workers assuming that they are exag-
hours away from their home and avoided clinics within walk- gerating symptoms to access opioids. A woman recounted a
ing distance—in other words, they felt that they would rather story of when she recently visited the emergency room due to
sacrifice hours of their time every day than to risk running into severe abdominal pain a couple of years ago:
somebody they knew. A woman described how the stigma can
make a seemingly simple act such as parking in front of the I told the nurse. I threw up my sleeves and said, “Do you see any
clinic stressful: needle marks on me?” I even had one nurse say to me, “You
probably just came in because you wanted a shot of morphine or
I realized that I have to keep it a secret. I don’t tell people anymore. something” . . . I cried, I sat in the bed and I cried . . . and I ended
Even some of my closest friends. A friend was with us and I had to up with an obstruction and having a surgery, 5 days later . . . So I
come into the clinic to sample and I had to tell my husband to park wasn’t there just for a shot of morphine. . .
way over there so the friend wouldn’t know I was going into the
clinic. And I was like, scared, I was saying, “You have to park down As a result, many participants felt that the greatest impact of
the street. You can’t park in the No Frills parking lot because he stigma surrounding methadone was “just not being able to get
might see me walking across the street.” It was a big deal.
the help that I need from the doctors and nurses. Because they
believe I’m an addict, a drug seeker. That I’m faking my symp-
In addition, the self- and interpersonal stigma surrounding
toms or whatever just to get drugs.” This led many to avoid
methadone led some patients to contemplate lowering their
accessing the health care system unless absolutely necessary, for
dosage prematurely, resulting in withdrawal. The mother
instance, opting to visit walk-in clinics as opposed to making
described her experiences:
regular appointments with a family physician or choosing not
They (my family) want me to go down and get off of this stuff. to visit the emergency room despite extreme pain. Some
But I don’t want to rush it . . . I kind of have tried to go down a reported even concealing the fact that they are on methadone
few times but when I try to go down, I went down really quickly. from health care workers due to fear of stigma.
8 Substance Abuse: Research and Treatment 

Suggested stigma-reduction strategies opioids ineffective, in a way. Right? So I need a much higher dose.
But they don’t understand that. So yeah, some training would be
Public awareness campaigns. The most commonly suggested nice for them.
stigma strategies are shown in Table 3. Public awareness cam-
paigns were suggested by 72% of participants as a potential In addition to providing more education on the mechanisms
stigma-reduction strategy. Specifically, participants wished that and effects of methadone, participants explained that health
there was an easy, accessible way for community members to
care workers should also be trained to be more mindful of any
obtain accurate information about what methadone is its
subconscious biases they might have about the program and
mechanisms, what it is used for, and its positive effects on
patients and society. One interviewee suggested, “it would be encouraged to treat MMT patients in a more empathetic, car-
nice if there was like a website that people can go on,” whereas ing manner. A woman suggested,
others suggested “more pamphlets and TV ads.” Having pam-
phlets in “public areas such as Tim Hortons” was also suggested Healthcare workers should absolutely be educated on how to treat
people who are on methadone or are addicted to drugs, instead of
by 1 interviewee. Another idea suggested by an interviewee was
looking at them in a negative way. Try to reach out and see if there’s
to have a “Methadone user recognition day, something that can any way they can help out. For me, even though I’m on methadone,
celebrate people trying to better their lives . . . something to if I’m not showing any signs that I’m problematic, then they should
bring awareness to the problem.” treat me just the same as everybody else. The medical profession
In addition to providing general information about metha- should really be aware.
done, participants hoped that such campaigns would target
specific stereotypes associated with MMT patients, such as the Inviting family members to clinic appointments.  Greater incor-
notion that all patients are heroin junkies or that they are poration of family members into clinic appointments was
incompetent and untrustworthy. A young worker wished to another suggestion made by 28% of interviewees. As family
spread the message that MMT patients are indeed trying to get and friends were the most commonly cited sources of stigma,
interviewees felt that having the chance to invite their loved
better and overcome their addiction:
ones to their clinic appointments would help clarify any ques-
I think just educating people that they are trying to get healthy and tions and concerns they may have about the program. For
looking towards a better future. They are not druggies or scum of instance, 1 participant discussed how inviting her parent to her
the earth, and that they are actively looking towards turning things psychiatrist appointments truly allowed them to better under-
around and trying to be a productive members of society . . . Our stand the effects of depression and suggested that the same
motivation is good and positive . . . We don’t want the lifestyle that strategy would be helpful for individuals on MMT:
got us where we are, and this is just one of the tools that we have
to assist in getting there. I invited my dad . . . and they [the psychiatrist] explained everything
to my dad, “He can’t control this himself . . . You can’t tell him get
Participants believed that spreading messages such as these off the antidepressants and you’ll be fine. It’s not your brain, it’s
would allow others to approach MMT patients with a more his.” And he understood. But my mom, on the other hand, was at
home. So my mom kept saying the same thing, but then my father
accepting, open-minded manner. One interviewee explained explained it to her. So bringing your parents in . . . is the first step
that fear stems from lack of understanding: “People don’t you should do if you are having arguments at home while on a
know, so they are afraid,” and thus suggested that education program and they are disagreeing . . .
would be the most effective way to target the public’s fear of
methadone. In other words, by discussing the program with the health
care provider, family members may be able to better understand
Educating health care workers.  The second most common strat- the patient’s reasons for remaining in MMT and in turn act as
egy for reducing stigma was education of health care workers, an advocate for the patient.
suggested by 44% of participants. Several interviewees believed
that nurses and physicians who do not frequently see patients
with substance abuse may not fully understand the mecha- Community meetings. Finally, 2 participants—1 from each
nisms and benefits of methadone. Participants suggested incor- site—suggested holding regular community meetings in places
porating substance abuse treatment into the continuing such as churches, as currently “a methadone user can’t go to
education of health care workers through day-long seminars, church on Wednesday night for example, and they can’t sit
workshops, or conferences. For instance, a participant with around and talk about ways to make methadone treatment bet-
medical condition described her frustration at some physicians’ ter.” Such communal meetings would serve a dual purpose. First,
lack of awareness of methadone and how it may affect prescrip- they could create a sense of community for MMT patients and
tion patterns: allow them to support one another through the difficult times
as well as work together to brainstorm ways on how the stigma
Some doctors, I have to explain [methadone treatment] to them. can be reduced. Second, the meetings could also be open to the
When I go in for those vomiting episodes, they only want to give general public and feature MMT patients as well as providers,
me be 2 mg oral hydromorphine. And I’m telling them I need 8 mg helping to answer any questions or misconceptions community
orally, because [methadone] blocks those receptors and renders the members may have about the program.
Woo et al 9

Participants believed that both community meetings and Discussion

public awareness campaigns would be particularly beneficial in Through semi-structured interviews with 18 patients undergo-
neighborhoods that are about to introduce a new methadone ing MMT, we found that the stigma surrounding MMT is a
clinic, as such proposals often face a great deal of backlash from prevalent and serious concern experienced by 78% of partici-
the community members. Four interviewees provided a new pants. The most commonly reported stigma sources were
pain clinic in Burlington as an example: friends, health care workers, family, community members, and
employers/coworkers. Participants reported often engaging in
In Burlington there was a pain clinic that was going to open, and concealment, avoidance, and education/confrontation as cop-
the people living in there were fighting not to have it and they said
ing strategies. These findings are consistent with those of pre-
they didn’t want to have “these” kinds of people around there . . .
And I believe that it is society’s fault by not explaining more to vious studies on MMT patients and generally among those
people. Having pamphlets in here for us guys to read, but there’s utilizing the mental health system.14,23,25
nothing in here for someone who is out on the street and wants to In terms of perceived stigma, participants cited 5 common
come in and wants to learn . . . Just don’t throw methadone at negative stereotypes surrounding MMT: methadone as a way
somebody and here’s a bunch of people without knowing all the
to get high, lack of willpower, incompetence, untrustworthi-
facts about it.
ness, and heroin junkies. Although only participant-perceived
stigma was measured, these findings are consistent with those
Messages for the public from surveys of the general public. For instance, Matheson
When the interviewees were asked about one message to the et al9 conducted a survey on a random sample of 1067 com-
public, similar themes emerged in their answers. Overarching munity members and found that respondents were likely to
themes in the messages are shown in Table 3. The most com- believe that the only way of helping substance abusers was to
mon answer was a request to not judge those on MMT simply make them stop taking drugs altogether and that methadone is
based on their methadone status and to understand that these unhelpful in combating crime and substance abuse. Similarly, a
individuals are simply trying to get better: “Help is help. It’s comprehensive review of public opinion polls between 2003
somebody trying to get better, whether they are doing it wrong and 2007 across Canada found that although most of the
or doing it right.” Many also wanted the public to understand Canadians support harm-reduction programs, some negative
that receiving methadone may not be much different from tak- public views prevailed, such as the notion that such programs
ing any other medication, sending messages such as “we are not promote illegal drug use and bring violent individuals into
any different than the normal person,” “don’t judge a book by its peaceful communities.10
cover,” and “just because you’re on methadone, doesn’t mean Past research in mental illness stigma suggests that these
you are a bad person.” stigmatizing attitudes may arise from the belief that mental
Another common theme was the usefulness of methadone illnesses including addiction are genetic, chronic, and therefore
and its positive effects on patients, with participants calling it difficult—if not impossible—to treat.26 For instance, in a study
“a tool to turn your life around.” “Methadone helps people; it of 202 nurses, physicians, medical students, and patients, a bio-
saves lives,” said one interviewee. medical explanation of schizophrenia was associated with more
The young man who faced backlash from his family regard- stigmatizing attitudes toward patients with schizophrenia,
ing his MMT enrollment explained how methadone allowed compared with environmental explanations.26 Similarly, a sur-
him to drastically improve his life: vey of 85 individuals with severe mental illness and 50 mem-
bers of the public found that among patients, endorsement of
I graduated top of my school and I was the only person on genetic models was correlated with stronger feelings of guilt,
methadone. But if it wasn’t for the methadone, I wouldn’t have fear, and self-stigma.27 Patients reported that the biogenetic
gone to school to begin with. I want people to know that it helps a
model often makes them feel “trapped” and “fundamentally
lot of people. Methadone also helped a lot of people get out of that
addiction and start living a sober life and feeling good about flawed,” as it provides little hope of recovery or being “freed”
themselves again. from the condition.27 Such findings show that a potential
stigma-reducing strategy may be to raise greater awareness of
Participants also requested the public to educate themselves psychosocial explanations for mental illnesses.
regarding MMT, which would also help to reduce the stigma In terms of the impact of stigma, 28% to 56% of interview-
surrounding the treatment. One individual requested others to ees reported that the stigma has adversely affected their daily
“talk to an actual person who is on methadone and get all the life and treatment, leading to lower self-esteem; conflicts with
information from them,” whereas another asked the public to friends/family; reluctance to initiate, access, or continue MMT;
“walk a mile in our shoes.” Finally, a man suggested that those and distrust toward the health care system. What is particularly
in need of treatment for their substance abuse should stay away concerning is that many of these effects seem to take away the
from MMT if possible, as it continues to be widely stigmatized social and emotional support that MMT patients need to suc-
and misunderstood in the public’s eyes. ceed in their recovery. For instance, individuals with substance
10 Substance Abuse: Research and Treatment 

abuse disorder are significantly more likely than the general stigma surrounding MMT—particularly the ones suggested by
population to suffer from other mental illnesses such as depres- the participants: public awareness campaigns, family therapy,
sion and anxiety.28,29 In addition, research has shown that education of health care workers, and community meetings.
patients with stronger social support systems are more likely to Interestingly, the patient-reported strategies seem to cap-
enter and remain in MMT.30,31 Thus, by lowering patients’ self- ture 2 of the 3 key methods frequently used and reviewed in
esteem and causing relationship conflicts, stigma may lead to mental illness stigma literature: educate and contact.37 Brief
even poorer mental health and treatment outcomes overall. courses on mental illness have been proven to reduce stigma
The finding that stigma poses a barrier to MMT accessibil- among variety of populations ranging from the police to high
ity is similar to the findings by Hunt et al,32 who collected data school students.37 Furthermore, research shows that individu-
from 368 current MMT patients and 142 narcotics users. They als who have met and socialized with members of the minority
found that MMT patients were often perceived as incompetent are less likely to stigmatize against the latter.37 Education cou-
and unemployed, while misguided fears about the long-term pled with contact is in fact the most effective method of com-
effects of methadone also prevailed. These perceptions, in turn, bating stigma as it allows the public to dispel misinformation
made individuals reluctant to enroll in the program and, once in while also fostering new, positive perceptions of the minority
MMT, ambivalent about their treatment.32 Similarly, in a survey group.37 In that sense, public awareness campaigns and com-
of 124 physicians, most respondents indicated that the social munity meetings appear to be promising strategies for combat-
stigma surrounding methadone has caused them to be reluctant ing MMT-related stigma.
about prescribing it for chronic pain, and when methadone was Methadone clinics could help organize regular community
prescribed, patients often refused to take it due to the stigma.33 meetings, some of which are exclusive to MMT patients, while
Such findings show that stigma reduction is a key step in others are open to the public. This would help create a safe
increasing accessibility and retention of MMT, a treatment pro- space for patients to discuss the challenges they face in the pro-
gram already suffering with frequent early dropouts.16 gram while also allowing the general public to be more edu-
Perhaps, one of the most alarming findings was that health cated about methadone. In fact, recent studies have shown that
care workers were cited as the second most common source of 12-step, self-help programs similar to Alcoholics Anonymous
stigma. The stigma from health care workers can prevent may lead to reduced opioid use, higher patient satisfaction, as
patients from accessing the health care that they need, which is well as reduced self-stigma among MMT patients.38–41 For
particularly concerning as MMT patients are more likely than instance, a study of 53 heroin addicts on MMT found that the
the general population to experience other mental physical ill- length of time in Methadone Anonymous was correlated with
nesses and report poorer health outcomes.34 Previous studies decreased use of alcohol, cocaine, and marijuana.38 Patients also
have also shown that individuals who perceive higher levels of rated Methadone Anonymous to be more helpful than the
stigma from MMT clinic staff are more likely to drop out early MMT itself, in terms of promoting emotional coping and
from treatment.35 Moreover, the stigma can cause patients to self-acceptance.38
conceal their MMT status from health care workers, which has Moreover, stigma should be more actively incorporated into
serious potential consequences such as prescription of interfer- ongoing methadone treatment and care. MMT providers
ing drugs, opioid overdose, and even death.36 should actively bring up the topic of stigma in clinic appoint-
That being said, it is important not to overgeneralize these ments to determine whether the patient is experiencing MMT-
findings; several participants did note that they have also had related stigma, and if so, whether it is adversely affecting their
positive experiences with helpful and empathetic health care ability to continue in the treatment. If the provider determines
workers. Furthermore, some of the health care workers’ con- that the patient is indeed being stigmatized, an active discus-
cerns regarding MMT patients are understandable, particularly sion should take place between the patient and physician about
in a fast-paced, busy setting such as the emergency department. what steps could be taken to cope with the situation. For
For instance, providers may have valid reasons to be wary of instance, inviting family members to clinic appointments
patients visiting hospitals to access opioids, as this could poten- should be offered to all patients as an option early on in their
tially lead to overdose and further spiral into drug dependence. treatment.
Perhaps, the key is for health care providers to communicate Education of health care workers is another important
these concerns in a more sensitive, empathetic manner to help step in combating stigma. Studies have shown that health
create an environment where patients can feel comfortable care workers’ personal values affect their attitudes toward
about disclosing their MMT status. drug addicts42 and that some practicing physicians and nurses
continue to have little knowledge about methadone and its
effects on patient care.43,44 However, not all hope is lost; edu-
Implications
cation and training regarding harm reduction have been
Considering the widespread prevalence of stigma experiences shown to be effective in improving health care workers’ atti-
and their negative impact on patients’ quality of life and treat- tudes toward and acceptance of MMT.45 Thus, there appears
ment, it is vital that more efforts are made to help reduce the to be benefit in incorporating substance abuse treatment and
Woo et al 11

care into ongoing education of health care workers. For to being asked whether they have experienced each potential
instance, the Registered Nurses’ Association of Ontario has form of stigma or discrimination; it is possible that some par-
published a set of guidelines titled “Supporting Clients on ticipants forgot to mention certain examples, and as a result,
Methadone Maintenance Treatment,” which provides detailed the study may not have captured all relevant stigma experi-
information on the mechanisms and benefits of methadone, ences. Finally, comparisons in responses between Hamilton
MMT-related stigma and barriers to treatment, and ways of and Oakville sites were done in a preliminary fashion, and no
developing a collaborative care plan with the patient.46 Similar statistical tests were conducted due to the small sample size.
guidelines should be provided to all health care workers who Thus, no conclusions can be drawn about the impact of SES
may come in contact with MMT patients, which includes and clinic location on stigma experiences.
anyone working in walk-in clinics, family physician’s offices,
and emergency departments. Future research
Finally, all of the aforementioned strategies must target spe-
cific misconceptions and stereotypes surrounding MMT to be In the future, studies of larger sample sizes are needed to
the most effective. For instance, providing statistics on what increase the generalizability of these findings. This could be
proportion of patients were first introduced to opioids through done by combining quantitative and qualitative methodologies,
prescribed painkillers, and how many patients continue to be similar to the methods used by Wahl.23; quantitative surveys
employed and high functioning throughout their MMT, may could be conducted on a larger sample, followed by in-depth
help dispel the myth that all MMT patients are unemployed, qualitative interviews with a smaller number of participants.
incompetent illegal drug users. Information on the molecular Recruitment should be conducted in a greater number of cities
mechanisms of methadone could also reduce some of the fears and clinics to maximize the diversity of interviewees and their
regarding its effects. Moreover, MMT providers should take experiences. Furthermore, potential determinants of stigma—
the time to explain to frustrated families that it can be extremely such as age, gender, race, income, education, clinic location, and
difficult to be completely independent from methadone, and length of time since initiating MMT—should be explored fur-
that remaining in MMT is not a sign of weakness but rather a ther to determine which patients are at the greatest risk of
desire to get better. experiencing and being adversely affected by stigma. Doing so
would help produce stigma-reduction programs specifically
targeted to each vulnerable group. Moreover, patients’ percep-
Limitations
tions of stigma could be compared with the public’s knowledge
Our findings are limited by several factors. Although our sam- and attitudes and beliefs about MMT to look for potential
ple size reached the saturation point for qualitative analyses, it similarities and differences between perceived and public
was relatively small for quantitative analyses. Thus, the gener- stigma. Finally, self-reported stigma experiences could be com-
alizability of the quantitative findings is limited. Our study was pared with other measures in a longitudinal manner to ascer-
also subject to sampling bias; most of the participants were tain whether stigma truly leads to worse quality of life and
white, and half were unemployed. The latter may be because treatment outcomes over time. For instance, comparing treat-
individuals who were employed were less likely to consent to ment retention, mental well-being, and employment over time
participate in the study, as they were often in a rush to get to between low- vs high-stigma groups may be useful in further
their workplace from the clinic. Thus, it is possible that our elucidating the relationship between stigma and other out-
findings do not adequately capture stigma in the workplace or comes in MMT.
the experiences of cultural and ethnic minorities.
That being said, we did not formally record demographic Conclusion
characteristics of nonresponders and their reasons for declining Our findings show that stigma is a prevalent and serious issue
to participate in the study. As a result, we are unable to compare faced by many MMT patients. Stigma has important negative
characteristics of responders and nonresponders or determine consequences on MMT patients’ mental and physical well-
whether there was a significant difference between the 2 being, relationships, and quality of treatment. More active
groups. Similarly, data regarding how long patients have been measures need to be taken to address the findings of this study
on MMT were also not collected, although this may have been and help reduce the stigma surrounding methadone, for
an important factor in how individuals experience and cope instance, through public awareness campaigns at local levels,
with stigma. continuing education of health care providers regarding sub-
In addition, this study relied entirely on self-reporting of stance abuse treatment, and greater incorporation of family
stigma experiences, making it subject to recall, social desirabil- members into the program. Doing so would not only lead to
ity, and confirmation biases. For instance, individuals may greater accessibility of MMT, higher retention, and better
remember negative experiences more strongly than positive treatment outcomes but may also help ensure that patients
ones, resulting in over-reporting of stigma. Furthermore, par- receive the social and emotional support they need to succeed
ticipants gave examples of their stigma experiences, as opposed in their treatment.
12 Substance Abuse: Research and Treatment 

Acknowledgements hecs-sesc/pdf/pubs/adp-apd/methadone/litreview_methadone_maint_treat.
pdf. Published 2002.
The authors would like to thank the participants for taking the 18. Halton Region. Oakville at a Glance. Oakville, Ontario, Canada: Halton Region;
time to be part of this study. 2011.
19. Statistics Canada. Median Total Income, by Family Type, by Census Metropolitan
Area. Ottawa, Ontario, Canada: Statistics Canada; 2015.
Author Contributions 2 0. Social Planning and Research Council of Hamilton. City of Hamilton: Action on
JW, AB, MBhatt, BD, and ZS conceived and designed the Poverty Profile. Hamilton, Ontario, Canada: Social Planning and Research
Council of Hamilton; 2011.
experiments. JW and AB interviewed participants and col- 21. Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative research.
lected data. JW and AB analyzed data. JW, AB, MBawor, Qual Rep. 2015;20:1408.
22. Vogel DL, Wade NG, Hackler AH. Perceived public stigma and the willingness
MBhatt, BD, LZ, and ZS jointly developed the structure and to seek counseling: the mediating roles of self-stigma and attitudes toward coun-
arguments for the paper. JW and AB wrote the first draft of the seling. J Couns Psychol. 2007;54:40–50
23.
Wahl OF. Mental health consumers’ experience of stigma. Schizophr Bull.
manuscript. All authors reviewed and approved the final 1999;25:467–478.
manuscript. 24. Link BG. Understanding labeling effects in the area of mental disorders: an assess-
ment of the effects of expectations of rejection. Am Sociol Rev. 1987;52:96–112.
25. Earnshaw V, Smith L, Copenhaver M. Drug addiction stigma in the context of
Disclosure and Ethics methadone maintenance therapy: an investigation into understudied sources of
The authors have read and are in agreement with the ICMJE stigma. Int J Ment Health Addict. 2013;11:110–122.
26. Serafini G, Pompili M, Haghighat R, et al. Stigmatization of schizophrenia as
authorship and conflict of interest criteria. The authors also perceived by nurses, medical doctors, medical students and patients. J Psychiatr
confirm that this article is unique and not under consideration Ment Health Nurs. 2011;18:576–585.
27. Rüsch N, Todd AR, Bodenhausen GV, Corrigan PW. Biogenetic models of psychopa-
or published in any other publication and that they have per- thology, implicit guilt, and mental illness stigma. Psychiatry Res. 2010;179:328–332.
mission from rights holders to reproduce any copyrighted 28. Ostacher MJ. Comorbid alcohol and substance abuse dependence in depression:
material. impact on the outcome of antidepressant treatment. Psychiatr Clin North Am.
2007;30:69–76.
29. Davis L, Uezato A, Newell JM, Frazier E. Major depression and comorbid sub-
stance use disorders. Curr Opin Psychiatry. 2008;21:14–18.
30. Kelly SM, O’Grady KE, Schwartz RP, Peterson JA, Wilson ME, Brown BS. The
References relationship of social support to treatment entry and engagement: the Community
1. Volkow N. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Assessment Inventory. Subst Abus. 2010;31:43–52.
Washington, DC: National Institute on Drug Abuse; 2014. 31. Zhou K-N, Li H-X, Wei X-L, Li X-M, Zhuang G-H. Relationships between
2. Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. perceived social support and retention patients receiving methadone mainte-
Societal costs of prescription opioid abuse, dependence, and misuse in the United nance treatment in China mainland. Chin Nurs Res. 2016;3:11–15.
States. Pain Med. 2011;12:657–667. 32. Hunt DE, Lipton DS, Goldsmith DS, Strug DL, Spunt B. “It takes your heart”:
3. Howlett K. How opioid abuse takes a rising financial toll on Canada’s health-care the image of methadone maintenance in the addict world and its effect on re-
system. The Globe and Mail. August 24, 2016. http://www.theglobeandmail.com/ cruitment into treatment. Int J Addict. 1985;20:1751–1771.
news/investigations/opioids/article31464607/. Accessed November 6, 2016. 33. Shah S, Diwan S. Methadone: does stigma play a role as a barrier to treatment of
4. Carter CI, Graham B. Oopid Overdose Prevention & Response in Canada. Ottawa, chronic pain? Pain Physician. 2010;13:289–293.
Ontario, Canada: Canadian Drug Policy Coalition; 2013. 34. Garcia-Portilla MP, Bobes-Bascaran MT, Bascaran MT, Saiz PA, Bobes J. Long
5. Office of the Press Secretary. Obama administration announces additional ac- term outcomes of pharmacological treatments for opioid dependence: does meth-
tions to address the prescription opioid abuse and heroin epidemic. The White adone still lead the pack? Br J Clin Pharmacol. 2014;77:272–284.
House. https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet- 35. Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of dis-
obama-administration-announces-additional-actions-address. Published criminatory treatment by staff as predictors of drug treatment completion: utility
March 29, 2016. Accessed June 29, 2016. of a mixed methods approach. Drug Alcohol Rev. 2010;29:491–497.
6. Stotts AL, Dodrill CL, Kosten TR. Opioid dependence treatment: options in 36. Bohnert AB, Valenstein M, Bair MJ, et al. Association between opioid prescrib-
pharmacotherapy. Expert Opin Pharmacother. 2009;10:1727–1740. ing patterns and opioid overdose-related deaths. JAMA. 2011;305:1315–1321.
7. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy 37. Rusch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, con-
versus no opioid replacement therapy for opioid dependence. Cochrane Database sequences, and initiatives to reduce stigma. Eur Psychiatry. 2005;20:529–539.
Syst Rev. 2003;3:CD002209. 38. Gilman SM, Galanter M, Dermatis H. Methadone anonymous: a 12-step pro-
8. Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus gram for methadone maintained heroin addicts. Subst Abuse. 2001;22:247–256.
placebo or methadone maintenance for opioid dependence. Cochrane Database 39. Hayes SC, Wilson KG, Gifford EV, et al. A preliminary trial of twelve-step fa-
Syst Rev. 2008;2:CD002207. cilitation and acceptance and commitment therapy with polysubstance-abusing
9. Matheson C, Jaffray M, Ryan M, et al. Public opinion of drug treatment policy: methadone-maintained opiate addicts. Behav Ther. 2004;35:667–688.
exploring the public’s attitudes, knowledge, experience and willingness to pay for 4 0. McGonagle D. Methadone anonymous: a 12-step program. Reducing the stigma
drug treatment strategies. Int J Drug Policy. 2014;25:407–415. of methadone use. J Psychosoc Nurs Ment Health Serv. 1994;32:5–9.
10. Law S, Gogolishvili D, Globerman JM. Public Perception of Harm Reduction 41. Ronel N, Gueta K, Abramsohn Y, Caspi N, Adelson M. Can a 12-step program
Interventions. Toronto, Ontario, Canada: Ontario HIV Treatment Network; 2012. work in methadone maintenance treatment? Int J Offender Ther Comp Criminol.
11. Conner KO, Rosen D. “You’re nothing but a junkie”: multiple experiences of 2011;55:1135–1153.
stigma in an aging methadone maintenance population. J Soc Work Pract Addict. 42. Brener L, Von Hippel W, Kippax S, Preacher KJ. The role of physician and nurse
2008;8:244–264. attitudes in the health care of injecting drug users. Subst Use Misuse.
12. Anstice S, Strike CJ, Brands B. Supervised methadone consumption: client is- 2010;45:1007–1018.
sues and stigma. Subst Use Misuse. 2009;44:794–808. 43. Taghva A, Amnollahi F, Khoshdel A, Kazemi MR, Alizadeh K. Cardiologists’
13. Harris J, McElrath K. Methadone as social control: institutionalized stigma and knowledge and attitudes about methadone and buprenorphine maintenance
the prospect of recovery. Qual Health Res. 2012;22:810–824. treatment: a survey study in Tehran, Iran. Thrita. 2014;3:e20689.
14. Etesam F, Assarian F, Hosseini H, Ghoreishi FS. Stigma and its determinants 4 4. Bride BE, Abraham AJ, Kintzle S, Roman PM. Social workers’ knowledge and
among male drug dependents receiving methadone maintenance treatment. Arch perceptions of effectiveness and acceptability of medication assisted treatment of
Iran Med. 2014;17:108–114. substance use disorders. Soc Work Health Care. 2013;52:43–58.
15. World Health Organization. The methadone fix. Bull World Health Organ.
45. Shen Y-M, Lin S-R, Chen C-L, et al. The dual pathway of professional attitude
2008;86:161–240. among health care workers serving HIV/AIDS patients and drug users. AIDS
16. Levine AR, Lundahl LH, Ledgerwood DM, Lisieski M, Rhodes GL,
Care. 2013;25:309–316.
Greenwald MK. Gender-specific predictors of retention and opioid abstinence 4 6.
Registered Nurses’ Association of Ontario (RNAO). Supporting Clients on
during methadone maintenance treatment. J Subst Abuse Treat. 2015;54:37–43. Methadone Maintenance Treatment. Toronto, Ontario, Canada: RNAO. http://
17. Health Canada. Literature Review: Methadone Maintenance Treatment. Ottawa, rnao.ca/sites/rnao-ca/files/Supporting_Clients_on_Methadone_Maintenance_
Ontario, Canada: Health Canada. http://www.hc-sc.gc.ca/hc-ps/alt_formats/ Treatment.pdf. Published 2009.