The purpose of this Funding Opportunity Announcement is to support research applications for commercializable products aimed at reducing stigma around substance use disorders (SUD). Phase I applications are invited to develop and evaluate feasibility of novel digital technologies, services or other interventions to reduce stigma towards SUD in clinical care, including HIV prevention and care settings, clinical training and other relevant settings, and to establish methods to measure stigma reduction. Phase II applications are invited to demonstrate efficacy in decreasing stigma towards SUD and commercialization potential of these products in clinical care, training, and/or other relevant settings, including those providing HIV prevention and care with the goal to remove barriers to SUD prevention, treatment, and support during recovery. Phase II applications focused on HIV prevention and care settings are invited to demonstrate efficacy in decreasing stigma towards SUD and improving health outcomes for people living with HIV and SUD.
Stigma around Substance Use Disorders (SUDs) represents a significant public health problem, despite growing understanding that SUDs are complex brain disorders with behavioral and physiological components. Recent scientific discoveries indicate that susceptibility to the brain changes in SUDs is substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised. Similar to other disorders, medical care is often necessary to facilitate recovery and prevent negative outcomes, including overdose. SUD is a chronic, treatable disease from which patients can recover and lead healthy lives, however stigma limits successful access to care. Nevertheless, stigma can be changed, instilling a sense of hope, and self-efficacy for change that contributes to this recovery.
Stigma is understood as a socially constructed phenomenon that occurs when members of a group experience status loss or discrimination on the basis of some shared characteristic that is deemed undesirable by others. Its effects can occur through attitudes and beliefs internalized by stigmatized individuals (self-stigma), through overt discrimination by others (experienced or enacted stigma), and through the fear of such discrimination (felt stigma). As a result, many people are reluctant to disclose, seek treatment or even talk about substance use disorders, which leads to diminished access to treatment or decreased ability to receive adequate care. There have been promising advances in reducing stigma around other health conditions, for example depression or HIV, making these conditions more acceptable to discuss and breaking down barriers to treatment. Recently, the opioid epidemic impacted all levels of society in the United States and began to shift attitudes about SUD-related stigma as well. The Patient Protection and Affordable Care Act in 2014 has enabled the health care providers to offer reimbursable treatment services for SUDs. However, only 11% of patients that meet the criteria for substance use disorder receive treatment. SUD- related stigma is one of the important factors contributing to this persistent gap; therefore, mitigating stigma will facilitate SUD prevention and care. In addition, addressing SUD stigma will help to improve prevention and care for HIV and other SUD comorbidities such as HCV and sexually transmitted infections (STI).
There is significant evidence that stigma undermines both mental and physical health. It may make people feel badly about themselves, leading to or exacerbating depression, anxiety, and other mental health issues or substance use. Stigma or negative bias among those healthcare providers who perceive a patient’s drug or alcohol problem as the patient’s own fault can lead to substandard care. People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff suspecting drug-seeking behavior. The general public and some in healthcare and the justice system continue to view SUD as a result of moral weakness and people with addiction are continued to be blamed for their disease. Humiliation and rejection experienced by patients stigmatized for their drug use is a powerful social punishment. People with addiction may internalize this stigma, feeling shame and refusing to seek treatment. The health impact of stigma is magnified by the scarcity of available treatment options in rural and low-resource environments. Beyond being a barrier to care, stigma may enhance or reinstate drug use, playing a key part in the vicious cycle of addiction.
SUD-related stigma is often intersectional with negative bias, discrimination, and other forms of stigma. They may include homelessness, socio-economic status, race and ethnicity, gender identify, mental illness, and/ or HIV. Negative bias may prevent parents from talking to their children about risks of substance use, screening for SUD, and seeking out or supporting treatments. Given that SUD and mental health conditions often start to manifest in early adolescence, stigma may result in missing crucial prevention and early treatment steps. Clinics and social care settings may create inhospitable environments to some SUD patients, where stigma can arise from policies and practices, behaviors of insufficiently trained non-clinical staff and sometimes clinical providers. Stigma remains one of the most important barriers to provision and utilization of prevention and care services for HIV and other SUD comorbidities, despite advances in diagnostics, prevention and treatment. Organizational and interpersonal stigma has a disproportionately large impact on access of SUD patients to treatment or life-saving procedures at the time of resource shortage due to disasters, for example the COVID19 pandemic.
Demonstrated similarities in drivers and outcomes of health-related stigma across different domains suggest that successful interventions developed to address stigma in other areas (i.e. HIV, mental health) could provide conceptual support to anti-stigma efforts in the SUD field. Not all anti-stigma interventions are effective (despite demonstrated public reach); they may fail to reduce stereotype agreement, desired social distancing or even “backfire” (increase stigma). It has been suggested that certain personality traits may mediate resistance to anti-stigma campaigns. Focused interventions are required for specific age and cultural background subgroups. For example, cognitive mechanisms influencing messaging efficacy in adolescents may differ from those in adults; culturally appropriate community-based interventions have been critical to connecting American Indian and Alaskan Natives (AI/AN) to mental and behavioral health; and interventions for pregnant and parenting mothers with SUDs had to take into account the legal consequences of seeking SUD treatment.
Recent studies of neural mechanisms of successful quitting campaigns and deeper understanding of neural circuitry underlying behavior change open new opportunities to identify, personalize and optimize anti-stigma interventions. In particular, fMRI activation of medial prefrontal cortex (MPFC) has been demonstrated to be more predictive of the success of selected health promotion messages than self-reports. Non-invasive EEG based classifier has been developed predicting (smoking) treatment success as another example of neural target-based behavior change approach. Intracranial EEG (iEEG) was successfully used in the research environment to describe components of the “brain valuation system”. Ventral striatum, inferior orbitofrontal cortex and ventromedial prefrontal cortex have been identified by an fMRI as components of a valuation system linked to the likelihood of behavior change. Interactive training and behavioral interventions delivered via immersive/ extended reality (XR) technologies are effective in reaching outcomes. This training could be further strengthened by the latest “serious” gaming approaches. This funding opportunity (FOA) seeks to combine novel technologies with evidence-based stigma reduction interventions to reduce stigma around SUD as a primary outcome, leading to reduced barriers to SUD prevention, treatment, and support during recovery long-term.
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