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. Author manuscript; available in PMC: 2025 Jul 1.
Published in final edited form as: J Subst Use Addict Treat. 2024 Mar 21;162:209353. doi: 10.1016/j.josat.2024.209353

The influence of familial networks and stigma on prison-based medication initiation for individuals with opioid use disorder: Clinicians’ perceptions

Maria L Rockett 1, Hannah K Knudsen 2, Carrie B Oser 1
PMCID: PMC11162913  NIHMSID: NIHMS1982258  PMID: 38521351

Abstract

Introduction.

Individuals with criminal legal system (CLS) involvement experience opioid use disorder (OUD) at elevated rates when compared to their non-justice involved counterparts. Medications for opioid use disorder (MOUD) are efficacious but underutilized within this population. Interpersonal relationships and stigma play salient roles in the outcomes of OUD treatment. This study examines prison-based treatment staff perspectives on how familial networks and stigma interact to impact one’s decision of whether to initiate MOUD while in prison in Kentucky.

Methods.

A coding team analyzed qualitative interviews with prison-based clinicians (n=23) and administrators (n=9) collected from the Geographic variation in Addiction Treatment Experiences (GATE) study using NVivo software. The study analyzed excerpts associated with the primary codes of “stigma” and “social networks” and the secondary code of “family” in order to assess the relationship between familial stigma and MOUD initiation from treatment staff viewpoints.

Results.

Arising themes suggest that clients’ families’ lack of MOUD knowledge plays a crucial role in perpetuating related stigma, that this stigma often materializes as a belief that MOUD is a continuation of illicit substance use and that stigma levels vary across MOUD forms (e.g., more stigma towards agonists than antagonists).

Conclusions.

These findings carry implications for better understanding how intervention stigma within one’s familial network impacts prison-based medication initiation decisions. Resulting themes suggest support for continued expansion of efforts by Kentucky Department of Corrections to involve participant families in education and treatment initiatives to reduce intervention stigma and increase treatment utilization.

Keywords: intervention stigma, substance use treatment, medications for opioid use disorder, justice-involvement

The United States opioid epidemic generates a variety of devastating health outcomes, apparent through infectious disease spread and overdose deaths (Dickson-Gomez et al., 2022; McCradden et al., 2019). Many marginalized and disenfranchised groups, including those with CLS involvement (e.g., incarceration experience, community supervision), experience exacerbated rates of opioid use and its related outcomes (NIDA, 2021). In response, correctional entities are encouraged by various organizations, such as the National Institutes of Health and the National Commission on Correctional Health Care, to increase the availability of medications for opioid use disorder (MOUD) (NCCHC, 2021; NIDA, 2021), also referred to as medication-addiction or assisted treatment (MAT), which are a best practice in opioid use recovery (Dickson-Gomez, 2022; McCradden et al., 2019; Witte et al., 2021). The Federal Drug Administration (FDA) currently approves three forms of MOUD (Dickson-Gomez et al., 2022): methadone and buprenorphine, which are agonists/partial-agonists binding to opioid use receptors, and extended-release naltrexone, an antagonist that blocks opioid use receptors preventing biological responses to substance use (SAMHSA, 2018; Mace et al., 2020). Despite their efficacy, MOUD availability and accessibility in prisons remains low (NIDA, 2021), necessitating a better understanding of potential barriers and facilitators to such treatment.

Implementing MOUD in carceral settings is associated with reductions in diversion and prison drug markets (Gryczynski et al., 2021), reduced recidivism rates, increased facility safety, cost reduction, improvements in the continuity of care (Mace et al., 2020; NCCHC, 2018), and reductions in post-release overdose deaths (Green, Clarke, & Brinkley-Rubinstein, 2018; Mace et al., 2020). Some studies estimate that fewer than 1% of correctional facilities within the United States offer MOUD (Mace et al., 2020; Vestal, 2018), and for those that do, initiation remains low (NIDA, 2021). Low MOUD initiation in carceral settings is observed for a variety of reasons. Accessibility issues often make it difficult for incarcerated individuals to initiate medication. Examples of accessibility issues include institutions only offering one form of MOUD, only offering MOUD to specific populations (e.g., pregnant women), and inefficient implementation policies and procedures (Grella et al., 2021).

Outside of institutional and structural impacts, personal perspectives on MOUD, including stigma (both of individuals themselves and others), play a salient role in MOUD uptake (Grella et al., 2021). Stigma is an intricate social construct comprised of stereotypes, prejudice, and discrimination (Sheehan, Nieweglowski, & Corrigan, 2016) and is associated with reduced behavioral health help-seeking behaviors, less service utilization (Golberstein, Eisenberg, & Gollust, 2008; Schnyder et al., 2018; Tucker et al., 2013), an increased concealment of substance use behaviors in healthcare settings (Showers et al., 2021), and reductions in quality healthcare experiences for those with substance use histories (Madden et al., 2021; Showers et al., 2021; Volkow & NIDA, 2021). There are various forms of mental health stigmas (Sheehan et al., 2016), and Madden (2019) proposes the concept of intervention stigma, or stigma towards particular medical interventions, as an extension of condition stigma which occurs when prejudiced perspectives are applied to certain personal characteristics such as substance use behaviors. Although many studies display the association between intervention stigma and MOUD (Cioe et al., 2020; Witte et al., 2021), there is a lack of understanding how such stigmas diffuse through various social networks (e.g., familial) to impact initiation decisions for individuals in prison.

Research suggests that social networks, including families, directly impact individual medical decision-making (Lin et al., 2021), and this has been observed in multiple contexts including in the selection of birth control preferences (Hoopes et al., 2018; Mahony et al., 2021) and the use of PrEP for HIV prevention (Schneider et al., 2021). A systematic review conducted by Kumar et al. (2021) further found that familial networks play a significant role in substance use recovery throughout various stages of the treatment process. In several studies, familial ties with those supporting harm-reduction treatments (e.g., MOUD) were associated with positive outcomes such as reduced substance use (Catalano et al., 1999; Yandoli et al., 2002), increased marital satisfaction (Hoijat et al., 2017), and higher psychosocial functioning (Yandoli et al., 2002). The relevance of one’s social network on individual health decisions and outcomes is evident, although further insight is needed regarding the interaction of specific networks and stigma in relation to MOUD initiation.

Theoretically, this study evaluates MOUD initiation through a relational sociological lens in regard to an understanding of stigma as a social construct which isolates, stereotypes, and oppresses certain individuals (Goffman, 1963; Link & Phelan, 2001). Relational-cultural theory posits that assessing the reification of structural oppression through interpersonal connections is essential in exploring inequities for those living within societal margins (Comstock et al., 2008). Analyzing social networks is one approach to conceptualizing the assertion of structural social elements through a relational lens (Mützel, 2009). The adverse health consequences of stigma (Hatzenbuehler, Phelan & Link, 2012; Link & Phelan, 2006) can thus be assessed through the diffusion of such constructs through one’s social network. Taking a relational approach allows for an increased understanding of the diffusion of intervention stigma through one’s familial network and its consequential impact on medication initiation.

Interviews with prison-based substance abuse program (SAP) treatment staff were collected as part of the Geographic variation in Addiction Treatment Experiences (GATE) study (see Oser et al., 2022 for additional methodological details) for additional methodological details) which aims to robustly characterize MOUD accessibility, uptake, and continuation in Kentucky prisons. Although SAP participants will also be interviewed in later stages of the GATE study, this analysis focuses on the perspectives of the staff. We acknowledge that the lack of voice coming directly from those with lived experience is a limitation to this study, although the perspectives of treatment staff do offer unique insight into families and MOUD stigma within the carceral system. Treatment staff perspectives are utilized to explore research questions in various publications (Aronowitz et al., 2018; Mefodeva et al., 2022; Shoham et al., 2017; Walker et al., 2016; Zubkoff, Shiner, & Watts, 2016), setting a precedent for the efficacy of these data in exploring treatment utilization and programmatic needs. These studies explore barriers to particular mental health treatments (Mefodeva et al., 2022; Zubkoff et al., 2016), involve prison-based staff to better understand the embeddedness of programming in carceral settings (Shoham et al., 2017; Walker et al., 2016), and explore the efficacy of interventions, including various modalities of MOUD treatment (Aronowitz et al., 2018). This study leverages the experiences and perspectives of these prison-based treatment staff in order to better understand how SAP participant familial networks and stigma interact to influence prison-based medication initiation decisions, addressing a gap in the literature and illuminating needs for future efforts in research and intervention.

Methods

The Kentucky Department of Corrections (DOC) offers substance abuse programs (SAP), licensed as alcohol and other drug treatment entities (AODE) through the Cabinet for Health and Family Services, within correctional institutions across the State in an effort to address substance use disorder prevalence within CLS involved populations. These programs are designed based off of the Therapeutic Community Model, which prioritizes the use of peer community structures as recovery mechanisms (De Leon & Unterrainer, 2020), and use the Hazelden A New Direction curriculum which takes a cognitive-behavioral therapeutic approach (DOC, 2021a). SAP participants are housed separately from the general population as they engage with the program which occurs over six months (DOC, 2021a). These prison-based SAP programs are run by a variety of staff, including SAP administrators and clinicians. SAP administrators oversee programming, monitor program adherence, and provide supervision to clinical staff. SAP clinicians offer the bulk of clinical services, including individual and group therapies to SAP participants.

The Kentucky DOC established the Supportive Assistance with Medication for Addiction Treatment (SAMAT) protocol in 2016 in response to the increasing severity of the opioid epidemic (CJKTOS, 2022). This protocol widened the availability of therapeutic treatment options including MOUD within Kentucky correctional institutions (CJKTOS, 2022). The expansion of this protocol was made possible through the passing of Senate Bill 192 and funding allocated through the Kentucky Opioid Response Effort (KORE) (CJKTOS, 2022; Tillson, Winston, & Staton, 2021). At the time of this study, fourteen Kentucky DOC institutions offered extended-release naltrexone (Vivitrol®), and three prisons offered buprenorphine (Sublocade® or Suboxone®) as a SAMAT pilot expansion in 2019; methadone was not available in any Kentucky prisons or jails (CJKTOS, 2022). Individuals within these institutions were eligible to initiate MOUD upon completion of the SAP program if deemed medically and clinically appropriate (CJKTOS, 2019). If eligible, these individuals completed the necessary medical screening and a tolerance trial, and medication was started approximately a month prior to their release (CJKTOS, 2019). Following release, individuals involved with the CLS work with DOC social service clinicians to continue medication treatment in the community and receive good time credit for participating in naltrexone treatment only.

As part of the Geographic variation in Addiction Treatment Experiences (GATE) study (see Oser et al., 2022 for additional methodological details) for additional methodological details), semi-structured interviews and brief demographic surveys were conducted with SAP clinicians (n=23) and administrators (n=9) representing ten prisons, each of which offers at least one form of MOUD. The study conducted SAP administrator interviews from September of 2021 through February of 2022, and SAP clinician interviews from August through December of 2020. The Kentucky DOC provided a list of names and contact information for all SAP administrators and clinicians to the research team. The research team then contacted these staff members by phone and email to schedule interviews. Of the 27 clinicians contacted, 23 enrolled in the study (85% response rate), and nine of the ten administrators participated (90% response rate). The research team received informed consent prior to completing these one-time interviews over the phone or through Zoom due to COVID-19 restrictions. Interviews lasted approximately an hour. No personal information was shared with the Kentucky DOC. In adherence to the Kentucky Executive Branch Ethics Commission, prison-based staff were not able to receive incentives but did receive a small souvenir of appreciation valued less than $10. The study audio-recorded interviews, and the University of Kentucky Institutional Review Board approved all protocols. Further, a federal Certificate of Confidentiality protects participants.

The research team developed the semi-structured interview guides for administrators (see Appendix A) and clinicians (see Appendix B) and included various questions exploring staff training, experiences, and perspectives regarding MOUD (naltrexone, buprenorphine, and methadone) and a brief demographic questionnaire. These interview guides were grounded in a social-ecological theoretical model, which proports that various individual-level outcomes are influenced by multiple realms of experience, including interpersonal and structural factors (Bronfenbrenner, 1992; McLeroy et al., 1988). The guides included specific questions regarding various social-ecological factors influencing SAP participants’ decision of whether to initiate MOUD while in prison. These questions further explored the role of individual (e.g., intrinsic motivation), interpersonal (e.g., social networks, including family and peers), and structural (e.g., DOC policies) factors inhibiting or facilitating prison-based MOUD initiation, although stigma and particular network types (e.g., familial networks, peer networks) were not asked about specifically. In the interview guides, client social networks were defined as “people your clients live, work, or socialize with on a regular basis, including other people who are incarcerated.” Some examples of questions included on the interview guide specifically related to social networks are provided below:

What role does the client’s social network play in initiating Vivitrol® while in prison?

In comparison to social network barriers to initiating Vivitrol® while in prison, in what ways are the social network barriers or facilitators similar or different for prison-based initiation of buprenorphine?

Research staff transcribed the interview recordings and removed identifying information, such as names mentioned, from the transcript. The coding team consisted of two research team members directed by a project manager. The team was trained in qualitative coding and the use of NVivo coding software. First, the coding team reviewed the interview transcripts to construct a codebook. Primary codes addressed overarching concepts related to the social-ecological model, while secondary codes further contextualized sub-themes within the interviews. Once the codebook was finalized, interview transcripts were simultaneously coded using NVivo coding software by both team members, ensuring inter-coder consistency. The coding team and project manager met to discuss each coded transcript and resolved any discrepancies until the team achieved coding consistency, and then the team coded each additional transcript.

After completing the coding process, the team began analysis. Interview excerpts under the primary codes of both “stigma” and “social networks” and the secondary code “family” were selected using NVivo coding software to further analyze staff perceptions of the role of MOUD stigma in familial networks on initiation decisions. The team selected resulting themes after further analyzing the isolated excerpts for recurring and prevalent concepts. Family networks were specifically analyzed in this study due to the prevalence of their importance via SAP staff reports. These data are not currently publicly available to protect the privacy of participants. Further, the authors of this manuscript self-identify as white cis-gendered women and acknowledge how these, among other personal identities, impact our approach to research, analysis, and presentation.

Results

Descriptive statistics for the demographic survey items collected from the SAP clinicians and administrators are in Table 1. SAP clinicians and administrators primarily work in rural settings, are female, white, and around 43 years of age. Almost half of these clinicians hold master’s degrees and/or specific addiction licenses, and about two-thirds maintain independent or temporary addiction counseling certifications. Clinicians have an average of nine years of experience in substance use treatment while administrators have an average of twelve years of experience. SAP clinicians had an average of 32 clients on their caseloads. Administrators reported that their SAP programs averaged about 69 clients, but there was a wide range in program size (i.e., current program census) from 20 to 140 clients, with the 20-bed program being a specialized medical SAP.

Table 1.

Descriptive Statistics of Prison-Based Treatment Program Clinicians and Administrators

Variables Clinicians (n=23) Administrators (n=9)
% or Mean (SD) Range % or Mean (SD) Range
Rural 69.57% 77.78%
Female 65.21% 77.78%
White 91.30% 88.89%
Age 43.00 (9.50) 27.00–63.00 42.22 (7.17) 33.00–55.00
Have Family with SUD 65.22% 66.67%
Master’s Degree 43.48% 33.33%
Certified Addiction Counselor 65.21% 55.55%
Licensed Clinician 4.35% 22.22%
Number of Years in SUD Tx 9.13 (6.78) 1.00–22.00 12.11 (7.93) 0.00–25.00
Number of Years in Current Position 4.38 (4.05) 1.00–13.00 2.67 (2.45) 0.00–7.00
Number of Clients 32.30 (16.94) 2.00–80.00 -- --
Size of Program -- -- 68.89 (36.41) 20.00–140.00
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SAP staff clearly articulate the influential role of one’s social network, particularly family members, on the decision of whether to initiate MOUD while in prison. SAP staff have varying levels of contact with participant families, basing their perspectives on this direct contact as well as their communication and observations of participants themselves. SAP Clinician #017 asserts their view on the influence of family in MOUD initiation:

A lot of times just, people who are incarcerated, they’re very worried about their family…we ask …how would your family feel about medically assisted treatment and stuff like that. Some answers I see are things where it seems like, especially if that’s the only person who’s battling addiction in their family, their family just doesn’t understand why they can’t just kick it on their own. So they think that their family would look down on them for doing that, and not doing the work of just quitting on their own. Some people, I think there’s a little bit of family stigma.

The interacting role of familial networks and stigma on one’s decision to initiate MOUD while in prison is evident across transcripts, even though stigma- and family-specific questions were not included in the interview guides. Three themes appear in the interview excerpts related to stigma and familial networks. The first and overarching theme is that a lack of familial knowledge regarding MOUD contributes to the perpetuation of stigma. The second and third themes indicate that MOUD stigma, rooted in a lack of knowledge, manifests as a belief that MOUD is synonymous to illicit opioid use and that stigma varies across MOUD forms (i.e., more stigma towards agonist medications).

Lack of Familial MOUD Knowledge Perpetuating Stigma

SAP staff assert that a lack of MOUD education, understanding, and knowledge by SAP participants’ families perpetuate stigmatizing views of such treatments. SAP Clinician #022 discusses the gap in MOUD education, particularly regarding naltrexone (e.g., Vivitrol®):

People don’t understand Vivitrol®, like I said, when I first heard about it, I was like, “Wow, okay. This is a magical thing that…” But people don’t understand it. If you’re not in addiction or you don’t work in addiction, then you don’t really have a reason to know about it, necessarily. So, it’s not something that’s just common knowledge.

SAP staff often cite this lack of understanding or education as a barrier in stigma reduction, further inhibiting prison-based MOUD initiation and the ability to improve OUD treatment outcomes upon re-entry.

SAP staff report that offering educational materials to SAP participants’ families could support stigma reduction and thus act as a facilitator to prison-based MOUD initiation. SAP Clinician #009 discusses the need for family education in regard to naltrexone (e.g., Vivitrol®) in order to combat the belief that MOUD is morally equivalent to illicit substance use:

There’s so many families that are completely against medical assisted treatment, they don’t understand it, they see it substituting one drug for another. So, any kind of information that could be sent home to the families would be huge, because their biggest factors and our biggest hinderance are the family members, because they only thing they understand is replacing one drug for another. So, if we get the family members on board to be supportive, that’s huge. Educating the family members are huge.

SAP staff identify a lack of MOUD education and understanding as a contributing factor to the perpetuation of related stigma, while also acknowledging the potentially supportive role that family-targeted education could play in prison-based initiation for SAP participants.

Family Equivalence of MOUD to Illicit Opioids

SAP staff report that many families equate MOUD use to the use of illicit opioids, often believing that MOUD is simply replacing one drug for another. SAP Clinician #003 summarizes this perspective while discussing the role of families on MOUD initiation, stating “There’s usually a few that don’t like it. They, you know, you’re just trading one addiction for another, that seems to be the common complaint.” Through this perspective, families fail to acknowledge MOUD as a legitimate form of medication based in clinical evidence and rather view it as a continuation of previous illicit substance use. SAP Clinician #002 elaborates on this perspective:

Yeah, I think with their, like, family members, and friends, and whatever, there’s still a little bit like stigma, negative connotation, when it comes to medication assisted treatment. You know, there’s the old, I guess, ideology that you’re just replacing one with another. I think that influences some people into not wanting to do it.

SAP staff further establish that these family-held perceptions influence SAP participants’ decisions regarding MOUD initiation while in prison. SAP Clinician #022 builds upon this assertion stating, “The stigma is really big as well. Because their family members will see it as a cop-out, or they see it as just another way to get high or whatever. So, I think that can be discouraging to them. Definitely.”

SAP staff further report familial preferences towards abstinence-based treatment models. SAP staff assert that many participants’ families believe and communicate that recovery cannot be attained with the use of MOUD. This perspective acts as a further barrier to the prison-based initiation of MOUD for SAP participants. SAP Clinician #012 identifies the role of family preferences for abstinence-based recovery models in initiation decisions:

But I think that some of them have, their family or themselves, they have like a stigma about any type of medication ‘cause they feel like they should just be abstinent, you know, 100 percent sober and not take any medication or anything.

SAP staff identify that abstinence-based preferences, resulting in further MOUD stigmatization, likely originate from traditional 12-Step recovery formats. SAP Clinician #016 discusses the distinct role of traditional recovery support groups, abstinence-based treatment biases, and MOUD initiation:

There are a lot of people in recovery support groups who are against medication assisted treatment, and that can have a big impact on clients where they think, “Well, you can’t be in recovery if you’re taking any type of medication.” So that can play a role to in their decision whether or not to take medication assisted treatment.

SAP staff repeatedly discuss the impact of SAP participants’ family’s perceptions that MOUD is equivalent to illicit substance use and that recovery must be abstinence-based, inhibiting prison-based MOUD initiation.

Variation of Familial Stigma Based on Type of MOUD

SAP staff indicate throughout their interviews that stigmatizing familial perspectives of MOUD vary based on the form of medication being discussed (e.g., agonists, partial agonists, antagonists). Specifically, staff assert that stigma is more salient in regard to agonist (i.e., methadone) and partial agonist (i.e., buprenorphine/Suboxone®) medications when compared to antagonists (i.e., naltrexone/Vivitrol®). On one hand, SAP staff acknowledge the manifestation of this bias as familial preference for antagonist medications, encouraging SAP participants to initiate naltrexone/Vivitrol®. SAP Administrator #005 discusses this observation further:

A lot of them are like, “My family would prefer that I participate in Vivitrol® or an abstinence-based program,” because again, I feel like everybody knows somebody that was not successful and it is very hard to provide the proper education on that level and provide examples of success because, you know, I think they’ve seen a lot of failures on it.

On the other hand, SAP staff report that many families translate negative experiences or feelings towards agonist and partial agonist misuse to their perceptions of antagonist medication (i.e., naltrexone/Vivitrol®). This often results in a lack of family support for all forms of MOUD, despite the differences in misuse potential. SAP Administrator #009 describes how families equate all forms of MOUD with one another, often creating barriers to initiation for SAP participants:

I have seen like a guy came to me and said, “Oh, my family, I need to talk to my family about it,” and then when he came back, he was like, “My family doesn’t really want me to do this, so I’m not going to do it.” So yeah, there are cases where the family talks them out of it because you know, I mean, in all honestly medication assistance has a bad rap out there on the street, like we have so much judgement, and honestly, I think Suboxone® and methadone created that when they came up with a drug that can be abused and there’s a street value on it. Most people think now that all medication assistance is a joke.

Throughout their interviews, SAP staff acknowledge that family stigma towards MOUD varies depending on the form of medication, with increased portrayals of stigma related to agonist and partial agonist medications. SAP staff discuss how this variation can either manifest as family support for antagonist forms of MOUD or as family dissuasion towards any form of prison-based MOUD initiation.

Discussion

This study contributes to understanding how the diffusion of MOUD intervention stigma through family networks may impact prison-based initiation decisions by leveraging the perspectives of prison-based treatment staff. All three themes found within this study are interrelated based on their connection to MOUD knowledge. Many studies establish that MOUD treatment is often perceived as a continuation of illicit substance use (Madden et al., 2021; Witte et al., 2021), although usually these observations are documented in regard to providers rather than families. It is likely that this stigmatizing perspective is rooted in a fundamental lack of understanding regarding how MOUD neurologically functions and how such medications differ from illicit opioids (e.g., heroin). Ultimately, these findings suggest network-targeted interventions aimed at increasing MOUD knowledge and visibility could bolster initiation within prisons.

Currently, the DOC offers a six-part series to SAP participant families on various aspects of substance use treatment, including MOUD. Families that participate in at least two of these sessions receive extended visitation as an incentive. These sessions began during the COVID-pandemic and are offered virtually. In order for families to participate, in compliance with HIPAA laws, participants must consent and provide a release of information for family participation. DOC also offers information about MOUD on their website. Although some of our interviews occurred prior to the implementation of this DOC program, no SAP treatment staff discussed the program in their interviews, potentially indicating a need to further promote, evaluate, and bolster this program. Also, although MOUD is an aspect within this family program, it is not the sole purpose. Specific programs targeted towards MOUD for families could assist in increasing their efficacy. Continuing to expand and further promote Kentucky DOC-facilitated family education programs regarding MOUD may be effective in increasing knowledge and decreasing stigmatizing associations with such medications.

In addition to expanding the educational curriculum regarding MOUD for SAP participant families, the third theme in this study indicates a need for education which specifically addresses the variation of MOUD forms and their differences. SAP staff reported familial stigma was more prevalent towards agonist forms of MOUD (e.g., methadone, buprenorphine) when compared to antagonists (e.g., naltrexone). This stigma variation is also observed in the literature and tied to a lack of understanding regarding agonist MOUD which are more heavily associated with illicit substance use (Witte et al., 2021). Agonist medications have more research supporting their efficacy with opioid use disorder when compared to naltrexone (Dickson-Gomez et al., 2022), and naltrexone often yields increased initiation barriers as it requires opioid abstinence and displays poorer overdose outcomes after medication cessation when compared to agonists (Mace et al., 2020; SAMHSA, 2018). However, naltrexone is more widely available in carceral settings (Scott et al., 2021), including Kentucky jails and prisons (CJKTOS, 2022), and results from this study suggest that families may be more supportive of naltrexone treatment when compared to other forms of MOUD. Targeted education on the varying forms of MOUD could either bolster support for agonist medications or build upon familial preferences for naltrexone. More research into this dichotomy is needed in constructing a comprehensive MOUD education program.

Although research regarding family MOUD education programs is sparse, many studies display the benefits of family involvement and education across treatment outcomes. A randomized controlled trial in China found that schizophrenia knowledge and symptom scores were significantly improved for individuals receiving psychotropic medication following participation in a nurse-led education program with their families (Li & Arthur, 2005). Several studies find that the inclusion of families in prison-based mental health treatment yields advantageous outcomes such as reducing depression, anxiety, substance use, and recidivism (Garofalo, M., 2020; Hofmann et al., 2012; Kolko et al., 2014). Some researchers found MOUD education programs resulted in reduced MOUD stigma scores across all three forms of medication for mental health treatment staff (Sulzer et al., 2021) and greater acceptability of MOUD for re-entry service staff (Friedmann et al., 2015). These findings highlight the potential efficacy of expanding an MOUD-specific education program geared towards participant families.

Continuing and expanding these efforts within existing DOC structures could further combat MOUD stigma and bolster recovery outcomes. Corrigan et al. (2016) discuss multiple approaches to stigma reduction. First, education approaches should employ a variety of informational materials such as flyers, videos, and pamphlets (Corrigan et al., 2016). Kentucky DOC currently offers virtual information regarding MOUD on their website, and continuing to promote these materials through physical copies or mailings could increase their visibility to participant families. These materials could be further disseminated in existing programming events as well, such as the Reentry Family Engagement Q&A sessions in which families of incarcerated individuals are invited to ask questions regarding various aspects of incarceration and re-entry (DOC, 2021b). Additionally, some stigma-reduction efforts suggest a more sustained effect when contact methods are used in conjunction with education (Corrigan et al., 2016). Contact methods involve actual interactions with stigmatized individuals (Corrigan et al., 2016), and in this case could involve in-person and video presentations of SAP peers and mentors finding success with MOUD treatment. DOC-hosted family education programs could implement contact methods to reduce stigma in the form of presentations from SAP alumnus’ experiences with MOUD.

In addition to offering family education programs, continuing to integrate families in direct treatment could advance recovery outcomes. Multiple forms of family therapies in carceral settings, including cognitive-behavioral family therapy, display efficacy in supporting positive mental health outcomes upon re-entry (Garofalo, M, 2020; Hofmann et al., 2012). The integration of family therapies in the SAP program could include psychoeducation on substance use and MOUD treatment in order to support advantageous therapeutic outcomes, although SAP participants would need to provide consent and a release of information in order to abide by HIPAA regulations. Moreover, transportation may be a barrier for families to engage in family therapy in-person, but telehealth platforms may be an option. However, it should also be noted that substance use is often prominent within families of people who are incarcerated; thus, family therapy may not be appropriate for all clients (Negash, Chung, & Oh, 2022). These are just several suggestions of how DOCs across the United States could further integrate families in their substance use treatment programs in order to increase MOUD treatment knowledge and aid in recovery successes.

Although this study focuses on interpersonal aspects of intervention stigma, one should also consider individual and structural level components to stigma reproduction. An effective stigma reduction effort should be multifaceted and target individual, interpersonal, and structural elements of intervention stigma (McCradden et al., 2019). Individual efforts may include programming to bolster the self-esteem and self-efficacy of those in recovery, given that self-stigma is associated with reductions in mental health help-seeking behaviors (Schnyder et al., 2018; Tucker et al., 2013).

Since the collection of the data in this study, the SAMAT protocol within prisons is no longer active, and procedural changes to further expand MOUD availability in Kentucky prisons are currently underway. These procedural changes will permit the prescribing and use of MOUD for any individuals (not only SAP participants) that are medically and clinically deemed eligible, and MOUD will be available during incarceration as opposed to only pre-release induction. On a structural level, all three forms of MOUD should be widely available and accessible in correctional institutions in order to increase successful recovery outcomes and to achieve compliance with policies such as the ADA and Eighth Amendment (Mace et al., 2020; Mette, 2019). Scott et al. (2021) found that although most states have at least one correctional facility offering MOUD, only 7% across the nation offer all three forms. Further, naltrexone is more frequently offered than buprenorphine or the even lesser available methadone, often due to restrictive regulatory requirements (Scott et al., 2021). Commonly cited explanations for the lack of MOUD availability in jails and prisons are funding (Scott et al., 2021) and concerns regarding diversion (Doernber et al., 2019; Evans et al., 2022; Gryczynski et al., 2021), although diversion concerns are often out of proportion to the actual frequency of such incidences (Dickson-Gomez et al., 2022). Restrictive policy and regulations regarding MOUD, particularly agonist medications, perpetuates intervention stigma and should be addressed (Madden et al., 2021). Also, the criminalization of substance use behaviors must be critically challenged in regard to reproducing condition and intervention stigmas (Volkow & NIDA, 2021). Although outside of the scope of this study, individual (e.g., self-stigma) and structural (e.g., substance use criminalization, MOUD availability) elements to intervention stigma should be further explored.

Several considerations for future directions arise from this study. Stigma is complex and pervasive on multiple levels of the socio-ecological model, enacted internally, through individual interactions, and through larger systemic structures (Link & Phelan, 2001). There is a large body of research exploring stigmatizing views of MOUD held by healthcare practitioners (Madden et al., 2021) and MOUD stigma is observed through regulations and policy (Scott et al., 2021). Given that prison-based treatment involves individuals, their social networks, prison and treatment staff, medical providers, and larger structures influenced by policy, we presume that MOUD stigma among all these levels are interacting to influence medication accessibility and initiation. More expansive stigma research related to MOUD within prisons could clarify some of these mechanisms of stigma, illuminating further areas for intervention. We understand how various conflating stigmas may have influenced the results in this study and advocate for expansive stigma reduction efforts. DOC, if they have not already done so, could consider implementing a uniform standard operating procedure for disseminating information and discussing MOUD with participants and their families in order to combat any institutional discrepancies.

This study is not without limitations. First, only prison-based treatment staff perceptions are evaluated due to the scope of the project and data limitations. Although this offers a broader perspective of the relevant themes of this study, the inclusion of participants’ lived experiences should be prioritized in future research, and qualitative interviews with participants in the GATE study will be completed at later stages of the study. Second, the qualitative interview guide asks specific questions regarding participant social networks, but does not differentiate between network types (e.g., family, friends, SAP peers, etc.) or ask specifically about stigma. Future studies should further explore the various types of networks in regard to stigma and medication initiation decisions. Third, given that this study focuses on prison-based staff accounts of familial stigma regarding MOUD, it’s important to note that staff perspectives influence how they perceive the role of familial stigma. Although staff widely cite a lack of familial MOUD knowledge or education, clinician perceptions could be influencing these observations; and, if so, the validity of family and individual treatment preferences could be undermined. Further studies should explore staff recall processes and perceptions. This study also did not explore the variation of familial MOUD stigma among different identities of clients (e.g., race, gender, age), which would contribute greatly to the literature. Additional studies exploring these limitations are essential in better understanding familial MOUD stigma and prison-based medication initiation decisions.

Despite these limitations, this study contributes to the substance use treatment and stigma literature. Condition stigma towards substance use and its manifestation as intervention stigma towards MOUD has a negative impact on recovery outcomes (Dickson-Gomez et al., 2022; McCradden et al., 2019). Prison-based staff from this study clearly establish the connection between family perceptions of MOUD and SAP participants’ decisions regarding prison-based medication initiation. Staff in this study report that many families view MOUD as a continuation of illicit substance use, that stigma levels vary among MOUD forms, and that a lack of family education or MOUD understanding perpetuates such stigmas. These findings suggest that a targeted MOUD education program for SAP participant families in the justice-system could reduce stigma and the associated barriers to medication initiation. In doing so, more SAP participants may decide to initiate MOUD, which is associated with positive outcomes on the individual, interpersonal, and community levels (Witte et al., 2021). Ultimately, reducing familial intervention stigma towards MOUD is a crucial step in widening treatment utilization to address the overrepresentation of opioid use disorder within populations involved with the CLS.

Supplementary Material

Appendix A
Appendix B

Acknowledgments

This work was supported by the National Institute on Drug Abuse (NIDA) under award number R01-DA48876. The contents of this presentation are solely the responsibility of the authors and do not represent the official views of NIDA or the Kentucky Department of Corrections. The authors have no conflicts of interest to disclose. The authors of this manuscript self-identify as white cis-gendered women and acknowledge how these, among other personal identities impact our approach to research, analysis, and presentation. Efforts were made in this manuscript to represent various identities of researchers in the citations. Data used in this analysis are not currently publicly available to protect the identities of the participants. The authors also thank the participants of this study for their participation and insights.

Footnotes

Conflicts of Interest

The authors have no conflicts of interest to disclose.

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Supplementary Materials

Appendix A
NIHMS1982258-supplement-Appendix_A.doc (385.5KB, doc)
Appendix B
NIHMS1982258-supplement-Appendix_B.doc (390.5KB, doc)

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