Running head: REDUCING OPIOID BIAS

Reducing Opioid Bias is Necessary (ROBIN):

An Educational Program to Reduce Addiction Stigma

Carrie L. Brannock, DNP(c), MSN, RN, FNP-C

University of Alabama, Tuscaloosa, AL, USA

Corresponding author details:

Carrie L. Brannock
17 Brielle Way, 19962, Magnolia, DE, USA.
Telephone number, 302-222-8006
E-mail address: clbrannock@crimson.ua.edu

The authors have no conflict of interest or disclosures.

I would like to acknowledge my clinical advisor, Jo Ann Baker, DNP, MSN, RN, FNP-C and
faculty advisor Justin White, DNP, PHMNP-BC, LCSW for their guidance and support. I would
also like to acknowledge and thank Peter Stomieroski for his assistance with statistical analysis
of the data presented in this research.
REDUCING OPIOID BIAS

Abstract

Heroin use and addiction is a local, national, and worldwide epidemic plaguing over eleven

million people. Current literature about bias toward individuals with substance use disorder

(SUD) focuses on studies among practicing healthcare professionals and first responders with

limited information and studies specific to substance use done among the general adult

population. Many studies reviewed had a focus on mental health bias with a portion contributing

to the investigation of substance use. Attitudes toward substance use is highlighted as an area

that needs to be further investigated and addressed. The purpose of the project was to develop an

educational program to reduce bias toward individuals with opioid use disorder among voluntary

adult participants, over the age of 18, from the public and healthcare work force. Educational

strategies included theoretical background on the disease of addiction, treatment methods, and

common behaviors of these individuals. Audio visual and real experiences were included to help

participants understand the human side of addiction. Methods for data collection included

demographic information, a survey on their level of familiarity with individuals addicted to

opioids, an attitude questionnaire attached to a vignette of an individual who injects heroin, and a

before and after questionnaire on drug and drug problem perceptions to measure the overall

effect of the Reducing Opioid Bias is Necessary (ROBIN) educational project on the

participants’ bias.

Keywords: addiction, substance use, opioid use, bias, attitudes, stigma

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REDUCING OPIOID BIAS

Reducing Opioid Bias is Necessary (ROBIN):

An Educational Program to Reduce Addiction Stigma

Heroin abuse and addiction is a local, national, and worldwide epidemic plaguing over

eleven million people (World Health Organization, 2009). Despite the dangers of overdose,

addiction, and multiple social and psychological dangers, usage continues to increase among the

population. In 2014, approximately 435,000 individuals were using heroin. Heroin usage has

doubled among people age 18 to 25 (Center for Behavioral Health Statistics and Quality, 2015;

Centers for Disease Control and Prevention, 2015). Addiction encompasses individual

characteristics (demographics, developmental attributes, biological factors, and psychological

factors), as well as, environmental characteristics which include social or physical factors that

are present in the individual’s situation (Ferrans, Zerwic, Wilbur, & Larson, 2005). There are

many areas of substance abuse that need research and the epidemic cannot be eradicated by one

specific intervention.

Healthcare providers and first responders have contact with individuals suffering from

opioid use disorder (OUD), however, many have insufficient education to reduce bias and

stereotype of the biology of the disease or the resources that are available to help. Current

literature has focused on studies among practicing healthcare professionals and first responders

with limited information and studies specific to substance use disorder (SUD) done among entry

level healthcare providers and the public. Many of the studies reviewed had a focus on mental

health bias with a portion contributing to the investigation of substance use. Attitudes toward

individuals with a SUD were highlighted as an area that needs to be further investigated and

addressed (McKenna et al., 2012).

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Among social workers and counselors that were studied by Warren, Cisler, Weatherford,

& Syamilah Zakaria (2013), more than half of participants studied did not feel they had sufficient

training in substance use and the study indicated more research was needed on education that

would enhance constructive non-bias attitudes when encountering individuals with SUD.

Another study conducted on health care professionals’ provision of care among individuals with

SUD, found the need for education and training programs to address affective responses and

empathy in providing care among this vulnerable population (Skinner, Feather, Freeman, &

Roche, 2007; Warren, Cisler, Weatherford, & Syamilah Zakaria, 2013).

A systematic review of thirteen studies evaluating the effectiveness of interventions

(education, group sharing, and structured interview) to reduce stigma related to SUD and OUD

produced mixed results, small sample sizes, and uncontrolled study designs. The authors noted

the need for replication of the studies and more evidence concerning interventions to help reduce

stigma. The studies were conducted using participants in criminal justice, the public, and medical

students (Livingston, Milne, Fang, & Amari, 2012).

A qualitative study in Norway was conducted by Thorkildsen, Eriksson, & Råholm

(2015) on the core of love when caring for patients with SUD. The study was limited by the

sample size of four nurses interviewed who worked in a rehabilitation facility, however, even

with the limitation, the study uncovered important areas that needed to be considered in future

research designs. Their study found the concepts of empathy, love, compassion and emotion are

strong indicators in building a trusting relationship among individuals with SUD. Poor trust

between the patient and the healthcare worker inhibit the ability to communicate and see the

underlying individual behind the disease.

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REDUCING OPIOID BIAS

Roussy, Thomacos, Rudd, & Crockett (2015) found through their research that training

which included both a clinician and an individual recovering from substance abuse was

associated with an increase in understanding SUD and positive changes among individuals’

attitudes. This approach was considered promising for individuals to overcome stigma and

judgmental attitudes, as well as, improving access and services to individuals with SUD.

Choosing language that respects the worth and dignity of the individual with SUD, focuses on

the medical nature of the disease, promotes recovery, and avoids using slang can promote a

therapeutic and trusting environment. Proper use of therapeutic communication and considerate

choice of words impacts the openness of individuals with SUD to receive treatment (Broyles et

al., 2014).

In the current research project, the Dorothy Johnson’s Behavioral System Model

(Johnson, 1980) was used to guide the exploration of feelings and bias attitudes related to opioid

abuse. In using the model, an educational program was developed for voluntary adult

participants. Participants were recruited from the public and from healthcare fields. The

educational program was designed to help participants gain knowledge to provide a nurturing

environment, free of judgement and bias toward individuals with OUD. The intervention

completed was entitled, “Reducing Opioid Bias is Necessary (ROBIN).” The educational

program contained a theoretical presentation on the disease of addiction, treatment methods, and

common behaviors of these individuals. Audio visual aids and a video documentary depicting

individuals with OUD were included to help participants understand the human side of addiction,

the effects on the family, and the effects on the community. Combined consumer-led and

clinician-led education has shown to be an effective approach in reducing bias and stigma, as

well as, promoting understanding and knowledge of substance use (Roussy et al., 2015).

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REDUCING OPIOID BIAS

Method

Study Design

This design was a quasi-experimental controlled before and after study of a pilot

educational program designed by the researcher. Methods for data collection included a

demographic form designed by the researcher, a survey on their Level of Familiarity (LOF) with

individuals addicted to opioids developed by Corrigan, Edwards, Green, Diwann, & Penn

(2001), and a modified version of the Attitudes to Mental Illness Questionnaire (AMIQ) attached

to a vignette of an individual who injects heroin originally developed by Cunnigham, Sobell, &

Chow (1993) and modified by Luty, Fekadu, Umoh, & Gallagher (2006). The Drug and Drug

Problems Perceptions Questionnaire (DDPPQ) was used before and after the education to

measure the overall effect of the intervention on the participants bias. The DDPPQ was

developed by Watson, Maclaren, & Kerr (2007) .

Demographics and the LOF were used to help determine if there was a causal impact on

participants’ attitudes and bias toward individuals with OUD. Use of a modified version of the

AMIQ was compared with the LOF as part of the baseline for participants perceived bias. The

DDPQ pre- and post-questionnaire were compared to determine if there was a change in

participants’ perceptions after the ROBIN educational program.

At the completion of the education, participants were asked to complete a guided

reflective writing. Participants were also asked to volunteer to attend a one-hour focus group

about the program two months after the completion of the program to discuss if their perceptions

were improved or stayed the same. This qualitative data was sorted by theme and utilized to

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improve the program for future use, add to existing literature, and identify areas for future

research.

Participants

After full institutional review board (IRB) approval was received from the University of

Alabama, a convenience sample of adult volunteers from the public and healthcare sector were

recruited via brochures posted in public areas throughout Kent County, Delaware. Participants

volunteered consent to attend and participate in the four-hour educational course on one of two

dates that were chosen for the program. Participants included multicultural males and females.

There was no exclusion based on race, gender, religion, or socioeconomic status. Individuals

under the age of eighteen were excluded from the study. The educational program and data

collection occurred on two dates in November 2018 at Delaware Technical Community College,

Downes Lecture Hall. There was no cost to the participants and they received no compensation.

Light refreshments and non-alcoholic beverages were provided and available throughout the

program. The total number of participants from both offerings was twenty-one (n=21). No one

was excluded or voluntarily revoked consent.

Measures

Measures to collect data included researcher developed demographic information

provided by participants and use of a modified LOF with validity and reliability supported by

three studies (Corrigan, Edwards, Green, Diwann, & Penn, 2001; Corrigan, Green, Lundin,

Kubiak, & Penn, 2001; Holmes, Corrigan, Williams, Canar, & Kubiak, 1999). The AMIQ was

modified and included a vignette of an individual with a heroin use disorder. This is a valid and

reliable tool initially created to evaluate attitudes toward mental illness (Cunnigham, Sobell, &

Chow, 1993) and modified by Luty, Fekadu, Umoh, & Gallagher (2006). The Drug and Drug

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REDUCING OPIOID BIAS

Problems Perceptions Questionnaire was used as a pre- and post-test. This questionnaire was

considered by the developers to be a valid and reliable tool through psychometric analysis of

test-retest reliability, internal consistency, and content validity (Watson et al., 2007). Using the

LOF, the researcher was able to determine if there is a difference in bias and impact of the

educational program related to the amount of familiarity or personal experience the participants

had with OUD. The data was entered into an Excel database and analyzed with the help of a

statistician using descriptive statistics, Spearman’s rank correlation coefficient, and t-test.

Qualitative data collected from the reflective writings and focus group were analyzed for themes

and used to make modifications to the ROBIN educational program for future use and to propose

areas needed for future research.

The demographics form consisted of age, gender, marital status, annual income category,

ethnic category, spiritual belief, and whether the participant worked in healthcare. Participants

filled out this information after signing the voluntary consent to be part of the research.

The LOF scale contains eleven statements relate to contact with an individual with OUD.

Participants are asked to select the statements that apply to them. The scale is a ranking of the

questions from 1 – 11, with 1=little familiarity, 7=medium familiarity, and 11=most familiar

with a person with OUD. The scale originally was designed to determine an individual’s

familiarity with mental illness (Corrigan, Edwards, Green, Diwann, & Penn, 2001; Corrigan

Green, Lundin, Kubiak, & Penn, 2001; Holmes, Corrigan, Williams, Canar, & Kubiak, 1999).

The researcher replaced the words “severe mental health illness” with “opioid use disorder.”

The DDPPQ uses a 7-point Likert scale to rate the participants level of agreement with 22

statements. The scale ranges from 1=strongly agree to 7=strongly disagree. Item numbers 15,16,

17, and 18 are worded negatively so the scores are reversed. A lower score indicates a positive

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REDUCING OPIOID BIAS

attitude toward individuals with OUD, whereas a higher score indicates negative attitudes. The

minimum score a participant can obtain is a 22 and the highest score obtainable is 154 (Watson

et al., 2007).

In this research, the AMIQ used a vignette about an imaginary person who injected

heroin daily. Participants were asked to answer five questions on a 5-point Likert scale ranging

from +2=strongly agree to -2=strongly disagree. Neutral answers or “I don’t know” were given a

zero. The total score for the AMIQ vignette ranged from -10 to +10. The higher the score for this

scale, the more positive the participants attitude was toward individuals with OUD (Cunnigham,

Sobell, & Chow, 1993; Luty, Fekadu, Umoh, & Gallagher, 2006).

The last two instruments used were a reflective writing and a focus group to collect

qualitative data. Both instruments were designed by the researcher and required short answers

concerning the participants thoughts and feelings on the presentation, what they felt was learned,

and areas of improvement. The focus group questions discussed if participants might act

differently in speaking to or about individuals with OUD.

Procedure

The total number of participants who attended and met the criteria for the research study

was twenty-one (n=21). Participants were welcomed and introduced to the research study. They

volunteered consent by signing and returning the consent form. Participants chose a number from

a deck of cards that they would use to identify paperwork so that no names would be identifiable

by the researcher during data analysis. They were then asked to complete the demographics form

and the LOF scale. Research participants then completed the DDPPQ pre-test and the AMIQ.

Once the forms were completed and collected, the researcher began the educational program.

The program consisted of theoretical information on addiction as a disease, statistical

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REDUCING OPIOID BIAS

information collected from the local and national level, risk factors, treatment options, and ways

to recognize and reduce bias toward individuals with OUD. During the education, audiovisual

information was utilized to enhance the information provided and integrate real-life experiences

from those suffering with OUD, their families, and the community. After the educational

program, participants completed the DDPPQ post-test and completed a self-reflective writing for

collecting qualitative data. There was a sign-up sheet provided for participants who wanted to

volunteer to be part of the focus group for qualitative data collection two months after the

completion of the educational program. Nine (n=9) participants returned for the focus group

which was led by the researcher to discuss how they felt their attitudes had changed, if they felt

any of their interactions with OUD individuals had changed since the ROBIN education

program, and suggestions for the improvement of the program for future use.

Results

Participants ranged in age from 19 to 68 years with a mean age of 34 years (s.d.=16.7).

Females made up 81% of the sample, 81% were single, divorced, or widowed, 72% were

Caucasian, and 67% believed in a higher power. The sample was almost even in those who

worked in healthcare and those who did not. Eleven of the participants made less than $30,000

annually and seven made greater than $50,000.

Spearman’s rank correlation coefficient was calculated to determine if there was any

relationship between a participant’s LOF and their bias toward individuals with OUD using the

AMIQ. Spearman’s rank rho=0.947 (p<0.05) indicated a strong positive correlation. The less

familiar the participant was with OUD individuals the more biased they were toward these

individuals.

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REDUCING OPIOID BIAS

A paired-sample t-test was conducted to compare scores on the DDPPQ before the

ROBIN educational program and after the educational program. There was a significant decrease

in participants bias determined by the DDPPQ post-test (M=59.33, SD=16.48) when compared

to the pre-test (M=74.86, SD=19.38); t(20)=5.17, p=0.00002.

Qualitative results from the reflective writings were collected and sorted for themes. Prior

to the presentation, participants most common thoughts toward the opioid epidemic fell into one

of two categories; either it was a choice or a disease. After the presentation, participants

responses included a better understanding of the epidemic, awareness of its effect in their

community, awareness of addiction as a brain disease and mental illness that is chronic and

lifelong, awareness of treatments, gaining empathy, being less judgmental, and the importance of

education to help prevent OUD. One participant stated continued bias toward individuals with

OUD. Participants cited the most interesting parts of the presentation being the statistics, videos,

brain images, and real-life experiences. Areas that were cited to be disliked by participants

included some medical terminology that was hard to understand, and that the presentation overall

was long. The majority (n=20) of participants stated they would use the knowledge they gained

to be less bias in understanding, interacting and being compassionate toward individuals with

OUD. One participant felt they had a firm understanding of OUD before the presentation. In the

final question of the reflective writing, participants were given the opportunity to make

recommendations for improvement in the program. The most common response indicated no

change in the program and that it should continue to be used to educate the community. Two

participants recommended shortening some of the theory slides to shorten the presentation.

Two months after the ROBIN program, participants were invited to attend a focus group

session. The results of the qualitative data from 6 discussion questions was sorted for themes. In

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REDUCING OPIOID BIAS

response to the participants overall thoughts about the program, there was an overwhelming

reply that they liked the entire program. Information that the participants found most impactful

included the statistical data related to opioid prescriptions in the country, the local statistics of

the opioid epidemic, the audiovisual presentations, the personal information shared through

letters from an individual with OUD, and the program development showing the history, biology,

risk factors, and impact of substance use. Participants felt the design hit on all the topic areas to

bring a full picture of the disease. Participants did not feel anything should change about the

program. They felt engaged the entire time and shared encouraging views that more individuals

should see this presentation. One participant added the opinion of sharing this with a larger

population that may have no experience or familiarity with OUD to grow the research on

whether perspectives are changed even more among this population. Changes in interactions

with OUD individuals by participants included feeling more sympathy for these individuals,

wanting to advocate more for their treatment, realizing they are human beings who deserve care,

and a desire to promote education on this topic. Positive changes participants had made since the

education included advocacy, feelings of empathy for individuals with OUD, wanting to speak to

people with this disease on options for treatment, not giving up on helping individuals access

care even if they say they do not want it or have relapsed from past treatment, and treating

legitimate pain without bias or feeling that people are only looking for drugs. The final

discussion for participants included what they would tell individuals about the program if they

only had a minute. Participants all strongly agreed that they would tell people they needed to see

the program and that it would change their perspective regardless whether they knew little or a

lot about OUD.

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REDUCING OPIOID BIAS

Discussion

This project found education on theoretical knowledge, treatments, and real-life

experience of individuals with OUD can reduce bias among community and healthcare members.

The data concluded that even for individuals with familiarity on the topic of OUD, their personal

bias could still be reduced after education. Education was provided to explain OUD and its

effects on the individual, their health, the families, and the communities. This approach has

shown a reduction in bias through multiple studies. Using theoretical information alone on the

biology of the disease, methods of treatment, and risk factors contributed to only minimal

positive changes in attitudes (Warren et al., 2013). In combining both theoretical lecture with

films and true experiences of individuals with OUD, the effect of change in attitudes is more

significantly positive (Crapanzano, Vath, & Fisher, 2014). Information from this study in

combination with previous literature can be utilized to promote the continued improvement of

this educational activity or similar programs for the public and healthcare workers. This shows

promise in adding to the body of literature on the importance of education in preventing and

understanding OUD, however, the small sample size gives some limitation on making a broader

population assumption. Developing education for the public and providers who have contact

with OUD individuals is only a portion of what can be done. Many comments in the qualitative

findings echoed the frustrations with lack of treatment and aftercare planning to prevent relapse.

Bias can cause barriers to seek help and access healthcare for individuals with addiction

disorders. Research is necessary in this and many areas to combat this growing epidemic. The

more people who can be reached with education on this topic will lead to reducing the bias,

stigma, and shame that has become a pillar of this disease.

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REDUCING OPIOID BIAS

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