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. Author manuscript; available in PMC: 2026 May 12.
Published in final edited form as: Subst Use Misuse. 2025 May 12;60(10):1424–1433. doi: 10.1080/10826084.2025.2501171

Preference for Abstinence-Based Recovery and Public Stigma toward Substance Use

Diamond C Meadows 1, Kelly E Moore 1, Bruce Taylor 2, Phoebe Lamuda 2, John Schneider 3, Harold Pollack 4
PMCID: PMC12224421  NIHMSID: NIHMS2079966  PMID: 40354350

Abstract

Stigma toward substance use disorders (SUDs) is pervasive in the United States (U.S.) and often hinders the effective treatment of addiction. Although it is well-documented that the general public holds negative attitudes about SUDs (Mannarini & Bofo, 2015), there is limited research investigating public stigma towards the use of specific substances. Additionally, the role of perceived dangerousness of a substance needs to be further explored in order to understand how it can impact attitudes towards SUDs. As harm reduction approaches begin to grow in the U.S., it is important to understand how perspectives about recovery relate to public stigma. Understanding stigma related to SUDs and its relationship to recovery perspectives is important for reducing barriers to substance use treatment and preventing overdose deaths. The present study drew from an AmeriSpeak® national survey (n = 6,515) to examine public stigma towards different substances and the relationship between preferences for abstinence-based recovery and stigma toward each substance. It also explored whether perceived dangerousness of substances moderates the relationship between preferences for abstinence-based recovery and public stigma. The results indicate that the general public has greater stigmatizing attitudes towards methamphetamine use disorder than it does towards cocaine use disorder, opioid use disorder, and alcohol use disorder. Furthermore, a preference for abstinence-based recovery was associated with greater stigmatizing attitudes toward all SUDs. The perceived dangerousness of a substance did not moderate the relationship between preference for abstinence-based recovery and stigmatizing attitudes towards SUDs. Results have implications for creating public stigma interventions for the general public, which can be adapted for abstinence-based settings.

Keywords: public stigma, abstinence-based recovery, harm reduction, dangerousness

Introduction

The Substance Abuse and Mental Health Services Administration (SAMHSA, 2023) estimates that 46.3 million Americans were impacted by substance use disorders (SUDs) in 2021. Within the United States, recovery from SUD has traditionally been conceptualized as stopping the use of all substances, also known as “abstinence-based recovery” (Laudet, 2007; Marlatt et al., 2002). Many substance use treatment facilities operate on abstinence-based principles (Hoffmann et al., 1992; Paquette et al., 2022). Harm reduction strategies, on the other hand, encompass recovery approaches that aim to reduce substance use or the harmful consequences of use (Marlatt et al., 2010). While the general public has been reluctant to embrace harm reduction approaches to recovery (Sulzer et al., 2021), it is unclear whether preferences for abstinence-based recovery approaches are associated with stigmatizing attitudes toward SUDs. Support for abstinence-based over harm reduction approaches may contribute to negative perceptions of SUDs, especially for those perceived as dangerous (e.g., methamphetamine). The present study aims to address this gap by examining how preferences for abstinence-based recovery relate to public stigma toward different substances, and whether this relationship is impacted by the perceived dangerousness of each substance. Understanding how preferences for abstinence-based recovery relate to public stigma is critical to improving access to evidence-based SUD care, especially given that harm reduction may be more broadly applicable in treating SUD. Support for abstinence-based approaches and stigma towards SUD can negatively impact an individual’s likelihood of engaging in substance use treatment services. Moreover, people who prefer certain recovery approaches, such as the belief that people with addiction must achieve total abstinence (i.e., abstinence-based recovery), may be more likely to endorse stigmatizing attitudes.

Public Stigma toward Substance Use Disorders

SUDs are associated with a great deal of public stigma, which is expressed as negative public opinions and discriminatory practices toward minoritized social groups (Goffman, 1986; Sattler et al., 2017; Link et al., 2001). Many people blame addiction on the individual, deeming people with SUDs as weak-willed (Foddy, 2011). People with SUDs are also commonly stereotyped as violent (Link et al., 1999; Witte et al., 2019), unpredictable (Link et al., 1999; Yang et al., 2017), and dangerous (Richter et al., 2019; Yang et al., 2017). Further, people with SUDs are labeled as “addicts,” “junkies,” and “crack heads” (Werder et al., 2022). Public stigma can impact housing, jobs, education, treatment, and other resources that people with SUDs need as part of recovery (Becton et al., 2017; Roche et al., 2019; Sattler et al., 2017).

Several studies have shown differences in public stigma depending on which substance an individual uses, with several studies showing greater public stigma toward stimulants (e.g., methamphetamine, cocaine; Hengartner et al., 2013; Link et al., 1999). In addition, several studies show greater levels of public stigma toward heroin or injection drugs compared to others (Janulis et al., 2013; Luo et al., 2014; Power et al., 1996). However, many of the preceding studies used limited measures of public stigma and are out of date, suggesting the need for more current research on public stigma toward different substances with larger nationally representative samples. Furthermore, it is unclear whether differences in public stigma can be explained by preferences for abstinence-based recovery approaches.

Recovery and Stigma

Abstinence-based recovery has been defined as entirely refraining from using substances. This type of recovery is largely represented by 12-step recovery programs like Alcoholics Anonymous (AA)and Narcotics Anonymous (NA) (Adelman-Mullally et al., 2021; Laudet, 2008). On the contrary, harm reduction is defined as a lessening in the frequency or amount of substances used, experiencing fewer negative issues related to using, or being in control of initiation and cessation of use (Davis et al., 2017). Harm reduction recovery strategies that effectively address SUD include needle and syringe programs (Clarke et al., 2016; Hunt et al., 2003), psychoeducation, fentanyl test strips (Goldman et al., 2019; Park et al., 2021), and safe injection/consumption sites (Hunt et al., 2003; Levengood et al., 2021), as well as pharmacotherapy (Fullerton et al., 2014). Despite its benefits, harm reduction can be a difficult concept for the public to support, with research suggesting that this is intertwined with public stigma and preferences for an abstinence-based approach to recovery. For example, safe consumption sites are thought to increase crime rates, promote injection, and increase substance use (Strike et al., 2014; McGinty et al., 2018). Medications for opioid use disorder (MOUD) are often viewed as substituting one drug for another by the broader society (Boyd et al., 2012; Furr-Holden et al., 2016), health professionals (Hyshka et al., 2019), and peers in recovery (McGonagle, 1994; Suzuki & Dodds, 2016).

The perspective that abstinence-based recovery is the only “true” recovery likely contributes to negative perceptions about SUDs. One study showed that the more negative attitudes about syringe exchange programs were associated with more concerns about “purity” (Christie et al., 2019, p. 231), which is rooted in abstinence-only beliefs. Indeed, people who advocate for abstinence-only forms of substance use recovery, as opposed to harm-reduction approaches, have been found to have more stigmatizing attitudes and behaviors toward people with SUDs (Hyshka et al., 2019; Luoma et al., 2008). It may be difficult for many people to imagine that the recovery goal of manageable substance use can be effective, further exacerbating their negative perceptions of people who continue to use substances.

Perceptions of Dangerousness

An ongoing theme and driver of public stigma toward SUDs is dangerousness. There are several factors that influence the perceived dangerousness of a substance. Dangerousness is conceptualized as the long-term health effects of a substance and aggressive and uncontrolled conduct toward others when under the influence (Room, 2006; Roques, 1999). Perceptions of dangerousness are also influenced by how substances are scheduled by the Drug Enforcement Administration (DEA) and the Food and Drug Administration (FDA), including their “abuse liability,” which refers to their medical purpose and addictiveness (Burke-Shyne et al., 2017; Room & Lubman, 2010). Currently, methamphetamine, cocaine, and prescription opioids are classified as Schedule II drugs, indicating a high potential for abuse and harm. Alcohol and tobacco are not scheduled substances (Room & Lubman., 2010). Substances that are classified in the scheduling system are presumed to be more dangerous (Amigó, 2021). Public perceptions of substance dangerousness also stem from how these substances are portrayed in media coverage, which emphasizes stories related to illicit use (i.e., methamphetamine, cocaine, and opioids) instead of alcohol and tobacco (McGinty et al., 2019). The media frequently portrays people with SUDs as violent. For example, stigma toward methamphetamine could be attributed to media sensationalism and crisis framing associated with the impact of methamphetamine use on people and communities (Jones et al., 2020). The “meth epidemic” paved the way for labels to be created about methamphetamine, like “the most dangerous drug problem of small-town America” and even a diagnosis called “meth mouth,” which has likely fueled negative perceptions about MUD (Murakawa, 2011, p. 219).

Perceptions of how dangerous a substance is likely contributed to public stigma toward SUDs. The perception of substance use as hazardous has been associated with greater public stigma toward people with SUDs (Lloyd, 2013). Even when the type of substance used is unclear, the belief that people with SUDs are dangerous persists, and interpersonal relationships with them are to be avoided (Mannarini et al., 2015). Believing that a substance is dangerous may strengthen the relationship between preferences for abstinence-based recovery and stigmatizing attitudes toward that substance because substance use, even in moderation, may be seen as harmful or unacceptable. People who prefer abstinence-based recovery and believe substances are dangerous may have particularly negative attitudes about SUD.

Present Study

Although research shows that people generally have negative attitudes about SUD, there are limited U.S. studies comparing public stigma toward different substances, and there is little research on how preferences for abstinence-based recovery relate to public stigma. In addition, it is important to identify whether perceived dangerousness influences the relationship between preferences for abstinence-based recovery and public stigma toward different substances. This study seeks to examine whether preferences for abstinence-based recovery are related to increased public stigma towards different substances. This study also seeks to determine whether perceptions of substance dangerousness moderate the relationship between preference for abstinence-based recovery and public stigma.

Methods

Participants and Procedures

Participants were drawn from the AmeriSpeak® survey, which was collected in Fall 2021. Funded and operated by NORC at the University of Chicago, AmeriSpeak® is a probability-based panel survey that has been conducted since 2015 and is designed to be representative of the U.S. household population. Randomly selected U.S. households were sampled using area probability and address-based sampling, with a known, nonzero probability of selection from the NORC National Sample Frame. Households were contacted primarily by U.S. mail and telephone. The AmeriSpeak® panel represents approximately 97% of the U.S. household population. Surveys were completed online (or telephone for households without internet access). AmeriSpeak® panelists participate in NORC studies on behalf of governmental agencies, academic researchers, and media and commercial organizations. The recruitment rate for AmeriSpeak® overall, which includes a second stage of recruitment for initial non-responders to capture harder-to-reach populations, is 37%. This is one of the highest rates for comparable national probability-based household panels (Montgomery et al., 2016). With an annual panel attrition rate of about 15% (Dennis, 2019), research shows only minor differences, on average under 1.5%, by key demographic factors (i.e., sex, age group, race/ethnicity, education, marital status, employment, income, region, and home Internet access) between the AmeriSpeak® panelists compared to the US Census American Community Survey (Bilgen et al., 2018). Panelists provide informed consent as part of the panel registration process and select their preferred mode of participation in future surveys.

For this study on drug use, a randomly selected group of AmeriSpeak® participants were emailed with a description of the study and an invitation to complete this survey. The survey was offered in English and Spanish. Study participants who did not respond to the first invitation were contacted by email and phone multiple times over a 1.5-month period. Participants received an incentive worth USD 25 for completing the survey. Of the 17,075 individuals contacted, 6,515 (38%) completed the survey, which compares favorably with competing national panel response rates (Montgomery et al., 2016). The weighted American Association for Public Opinion Research Response Rate III (AAPOR RR III) for the AmeriSpeak® panel recruitment was 19.1%. The weighted AAPOR RR III for the AmeriSpeak® panel recruitment corresponds to the recruitment cohorts sampled for the study. A recruited household is a household where at least one adult successfully completed the recruitment survey and joined the panel.

Data are weighted to US census benchmarks, accounting for demographic selection probabilities and nonresponse. More specifically, we weighted the survey data to better represent the overall US population, using US Census data, with respect to age, gender, census division, race/ethnicity, education, housing tenure, and household phone status. Panel based sampling weights for all the sampled housing units were computed as the inverse of the probability of selection from the NORC National Frame (the sampling frame used to sample housing units for AmeriSpeak®). With many panel members not responding to our survey request, we also made a statistical adjustment for survey non-response. All descriptive statistics are weighted to national US Census benchmarks, accounting for selection probabilities (balanced by sex, age, education, race/ethnicity, and region) and non-response. Specifically, we employed a response propensity approach to calculate the conditional probability that a particular respondent completed the survey given observed covariates (Bethlehem et al., 2011). This method helps reduce potential non-response bias by ensuring that respondents who participated in the survey are demographically representative of the broader U.S. population. The study sampling weights were derived using a combination of the final panel weight used in all studies using the AmeriSpeak platform and the probability of selection associated with the sampled panel member into our specific study covered in this paper. Since not all sampled panel members responded to our survey request, an adjustment was needed to account for and adjust for survey non-respondents. This adjustment decreases potential nonresponse bias associated with sampled panel members who did not complete the survey interview for the study. Thus, the nonresponse adjusted survey weights for the study are adjusted via a ranking ratio method to general population age 18 and older population totals associated with the following topline socio-demographic characteristics: age, sex, education, race/Hispanic ethnicity, and Census Division.

Participants included anyone who completed the items covering substance use stigma, recovery, and dangerousness (n= 6,515) (See Table 1). Age was self-reported and coded as 18–29 (18.7%), 30–44 (26.0%), 45–59 (24.2%), and 60+ (31.1%). Participant were majority white, non-Hispanic (62.8%), Black, non-Hispanic (12.1%), other, non-Hispanic (1.0%), Hispanic (16.6%), 2+ races non-Hispanic (2.3%), and Asian, non-Hispanic (5.2%). The sample largely included cisgender females (52.5%), followed by cisgender males (46.8%), and transgender/neither male nor female (0.7%). Most participants reported receiving their education at a vocational/technical school or had some college/associate’s degree (27.7%), followed by high school graduate or equivalent (27.3%), bachelor’s (20.8%), post-graduate study/professional degree (15.2%), and less than high school diploma (9.1%). Household income was self-reported and coded as less than $30,000 (26.5%), $30,000 to under $60,000 (26.0%), $60,000 to under $100,000 (23.6%), and $100,000 or more (24.0%).

Table I.

Descriptive Statistics of the Study’s Variables*

Variable n (%)
Age
  18–29 1,219 (18.7%)
  30–44 1,696 (26.0%)
  45–59 1,574 (24.2%)
  60 Plus 2,027 (31.1%)
Race and Ethnicity
  White 4,094 (62.8%)
  Black 790 (12.1%)
  Hispanic 1,080 (16.6.%)
  Other, non-Hispanic 67 (1.0 %)
  2+ races 147 (2.3%)
  Asian 337 (5.2%)
Household Income
  Less than $30,000 1,724 (26.5%)
  $30,000– $60,000 1,692 (26.0%)
  $60,000– $100,000 1,534 (23.6%)
  $100,000 or more 1,564 (24.0%)
Education
  Less than High School 591 (9.12%)
  High School Diploma 1,776 (27.3%)
  Vocational Degree/Some college 1,806 (27.7%)
  Bachelor’s Degree 1,354 (20.8%)
  Post Grad Study/.Professional Degree 989 (15.2%)
Sex
  Male 3,049 (46.8%)
  Female 3,421 (52.5%)
  Transgender 46 (0.7%)
Abstinence 6,411 (98.4%)
  Yes 2,569 (39.4%)
  No 3,842 (59.0%)
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*

Weighted statistics.

Measures

Preference for Abstinence-based Recovery

Participants were asked to rank statements reflecting different types of recovery from 1 (i.e., “most closely corresponds to your personal definition of substance use recovery”) to 10 (i.e., “least corresponds to your personal definition of substance use recovery”). Recovery statements included the following: 1. Religious in nature, 2. Spiritual in nature, 3. Physical and mental in nature, 4. Living a life that contributes to society, 5. Enhanced quality of life, 6. Seeking professional help, 7. Having a sense of purpose in life, 8. Moderate/controlled use of any substance (drugs and/or alcohol), 9. No use of any drug and moderate/controlled use of alcohol, 10. No use of any substance (drugs or alcohol). People who reported a 1 (i.e., indicating that this most closely corresponded to their personal definition of recovery) on statement 10 were coded a “1” on our variable “preferences for abstinence-based recovery” (n= 4,179 coded as 0, 2,229 coded as 1). People who assigned statement 10 a score of anything greater than 1 were coded as a 0 on the abstinence-based recovery variable.

Stigma toward Substance Use Disorders

A 10-item measure for each substance was used to assess stigma toward people with different types of SUDs (i.e., methamphetamine, crack cocaine, alcohol, opioids), which were based on scales from Yang et al. (2019) and Kennedy-Hendricks et al. (2017). Response choices ranged from 1, Strongly disagree, to 5, Strongly agree. Example items included “A person who currently has an alcohol use disorder would be willing to steal money or valuable items out of desperation to get drugs” and “A person who currently has an alcohol use disorder cannot be trusted.” We created one continuous stigma scale for each SUD: alcohol use disorder stigma scale (α = .82), methamphetamine use disorder stigma scale (α = .86), cocaine use disorder stigma scale (α = .86), the opioid use disorder stigma scale (α = .84).

Perceived Dangerousness of Substances

The AmeriSpeak® survey used a two-part question to assess participants’ beliefs about the dangerousness of alcohol, cocaine, methamphetamine, and opioids. Of note, heroin and prescription opioids were asked about separately in these items. The first question asked, “Do you believe that people are more or less dangerous depending on the type of substance they use?” The response options were “Yes, how dangerous a person is will determine which substance(s) they use,” “Yes, different substances make people more or less dangerous,” and “No.” The second question asked, “If yes, please rank the following statements in order from most dangerous to least dangerous.” The response options were “people with opioid prescription pain medication use disorder,” “people with heroin opioid use disorder,” “people with cocaine use disorder,” “people with methamphetamine use disorder,” and “people with alcohol use disorder.” Five variables were created (i.e., meth dangerousness, prescription opioids dangerousness, heroin dangerousness, alcohol dangerousness, cocaine dangerousness) reflecting how dangerous (ranging from 1 to 5) participants thought that people using each substance was relative to the others. Each variable was reverse coded to range from 5 to 1 so that higher scores indicated greater perceptions of dangerousness. For example, if a participant believed a person with methamphetamine use disorder (MUD) was the most dangerous and a person with cocaine use disorder (CUD) was the next most dangerous, they would rank MUD as 1, CUD as 2, and rank the remaining SUDs in order from most to least dangerous. During the MUD analysis, this participant’s score on MUD dangerousness would be 1, indicating that they believed it posed the greatest danger, and during the CUD analysis, this participant’s score on CUD dangerousness would be 2 indicating they believed it posed the next greatest amount of danger.

Data Analysis Plan

Data were analyzed using IBM SPSS Statistics version 28.0, with weights applied to account for the AmeriSpeak® sampling strategy. Bivariate correlations were examined for all study variables (See Table 2). Point-biserial correlations were conducted between continuous and dichotomous variables. For all tests, statistical significance was indicated by a p-value of less than .05, along with an examination of effect sizes.

Table II.

Bivariate Correlations among Primary Study Variables*

1 2 3 4 5 6 7 8 9 10
1. aAlcohol Stigma --
2. bCocaine Stigma .537** --
3. cMeth Stigma .513** .805** --
4. dOpioid Stigma .552** .625** .617** --
5. eAlcohol Danger −.002 −.110** −.107** −.104** --
6. fCocaine Danger .024 .013 −.032* −.029* −.272** --
7. gHeroin Danger .035* .073** .045** .077** −.588** −.004 --
8. hMeth Danger −.057** .044** .118** −.020 −.225** −.227** −.127** --
9. iPrescription .005 −.008 −.020 .084** −.103** −.302** −.163** −.454** --
Opioid Danger
10. jAbstinence .108** .147** .119** .129** −.015 .008. .023 .011 −.027 --
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*

p < .05

**

p < .01

***

p < .001.

a

Alcohol stigma= AUD stigma

b

Cocaine Stigma= CUD stigma

c

Meth stigma= MUD stigma

d

Opioid stigma= OUD stigma

e

Alcohol danger= alcohol dangerousness

f

Cocaine danger= cocaine dangerousness

g

Heroin danger= heroin dangerousness

h

Meth danger= methamphetamine dangerousness

i

Prescription opioid danger= prescription opioid dangerousness

j

Abstinence= preference for abstinence-based recovery

*

Weighted statistic

First, descriptive statistics were used to compare the general public’s mean levels of stigmatizing attitudes toward cocaine, methamphetamine, alcohol, and opioids. To determine whether a preference for abstinence-based recovery (vs. other forms of recovery) was related to stigma toward different substances, linear regression models for each stigma scale were conducted. Effect sizes for coefficient β were evaluated as = 0.10–0.29 (small), 0.30–0.49 (medium), and 0.50 or greater (large) (Cohen, 2013). PROCESS version 3.8.0 Model 1 was used to test whether perceived dangerousness moderated the relationship between support for abstinence-based recovery and stigmatizing attitudes. As is the default in PROCESS, all variables were centered to reduce multicollinearity (Aiken & West, 1991). Interactions significant at the p < 0.05 level were probed using simple slopes analysis to examine the relationship between preferences for abstinence-based recovery and stigma toward each substance at low (1 SD below the mean), mean, and high (1 SD above the mean) levels of dangerousness. Missing data were handled using listwise deletion. Missing data for the stigma variables was less than 3% and around 29% for dangerousness variables because a portion of respondents answered no to the first question. The sample size for each analysis is specified throughout the results and tables.

Results

Public stigma was the highest toward MUD (M = 3.75, SD = 0.69) and CUD (M = 3.70, SD = 0.70), followed by OUD (M = 3.30, SD = 0.66) and AUD (M = 3.14, SD = 0.64) (Table 3). Regression analyses (Table 4) showed that a preference for abstinence-based recovery predicted stigma toward AUD (n= 6,382, b = .15, p <.001, effect size = .11), CUD (n= 6,385, b = .22, p <.001, effect size = .15), OUD (n= 6,509, b = .18, p <.001, effect size= .13), and MUD (n= 6,383, b = .18, p < .001, effect size = .12).

Table III.

Descriptive Statistics of Stigma Variables*

N Mean SD Range Skew Kurtosis
Alcohol Stigma 6,382 3.14 .64 1–5 −.04-.03 .89-.06
Cocaine Stigma 6,385 3.70 .70 1–5 −.39-.03 .49-.06
Meth Stigma 6,383 3.75 .69 1–5 −.41-.03 .51-.06
Opioid Stigma 6,509 3.30 .66 1–5 −.20-.03 .54-.06
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*

Weighted statistics

Table IV.

Regression of Stigma Variables on Preference of Abstinence-Based Recovery*

Variable B SE β p 95% CI of B N
Alcohol Stigma
aAbstinence .15 .02 .11 <.001 [.11, .18] 6,382
Cocaine Stigma
aAbstinence .22 .02 .15 <.001 [.18, .25] 6,385
Meth Stigma
aAbstinence .18 .02 .12 <.001 [.14, .21] 6,383
Opioid Stigma
aAbstinence .18 .02 .13 <.001 [.15, .21] 6,509
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a

Abstinence = preference for abstinence-based recovery

*

Weighted statistics

Moderation by Perceived Dangerousness

Moderated regression analyses are displayed in Table 5. In the regression model, alcohol dangerousness (n= 4,503) accounted for 0.56% of the variance in AUD stigma. There was a significant relationship between preference for abstinence-based recovery and AUD stigma b = 0.09, t = 2.40, p = 0.016. Perceived alcohol dangerousness was unrelated to AUD stigma (b = 0.005, t = 0.61, p = 0.54) and the interaction of preferences for abstinence-based recovery x perceived alcohol dangerousness was not significant (b = 0.00, t = 0.20, p = 0.88).

Table V.

Regression analyses examining perceived dangerousness as a moderator of the relationship between abstinence-based recovery and stigma scales*

Model b 95% CI of b SE B t p R-sq N
Abstinence .09 [.02, .16] .04 2.40 .016 .0056 4,503
Alcohol Danger .00 [−.01, .02] .01 .61 .543
Abstinence x Alcohol Danger .00 [−.02, .03] .01 .20 .838
Abstinence .18 [.07, .28] .06 3.14 .002 .0119 4,495
Cocaine Danger .03 [.01, .05] .01 2.94 .003
Abstinence x Cocaine Danger −.05 [−.05, .02] .02 −.90 .367
Abstinence .12 [.00, .23] .06 1.97 .049 .0185 4,492
Meth Danger .05 [.04, .07] .01 6.08 .000
Abstinence x Meth Danger −.00 [−.03, .02] .01 −.287 .774
Abstinence .06 [−.02, .14] .04 1.55 .122 .0162 4,588
Opioid Danger .04 [.02, .05] .01 4.16 .000
Abstinence x Opioid Danger .02 [−.01, .05] .02 1.58 .113
Abstinence .11 [−.01, .22] .06 1.80 .072 .0132 4,591
Heroin Danger .04 [.02, .06] .01 4.20 .000
Abstinence x Heroin Danger .00 [−.03, .03] .02 .05 .962
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Alcohol danger= alcohol dangerousness

Cocaine danger= cocaine dangerousness

Heroin danger= heroin dangerousness

Meth danger= methamphetamine dangerousness

Opioid danger= prescription opioid dangerousness

Abstinence= preference for abstinence-based recovery

*

Weighted statistics

In the cocaine regression model, cocaine dangerousness (n= 4,495) accounted for 1.19% of the variance in CUD stigma. There was a significant positive relationship between preference for abstinence-based recovery and cocaine stigma (b = 0.18, t = 3.14, p = 0.002). Cocaine dangerousness was positively related to CUD stigma (b = 0.03, t = 2.94, p = 0.003), but the interaction of preference for abstinence-based recovery x perceived cocaine dangerousness was not significant, b = −0.02, t = −0.90, p = 0.37.

In the opioid regression model (n= 4,591), opioid dangerousness accounted for 1.32% of the variance in OUD stigma. Preference for abstinence-based recovery was unrelated to OUD stigma, b = 0.11, t = 1.80, p = 0.07. There was a significant positive relationship between perceived heroin dangerousness and opioid stigma, b = 0.04, t = 4.20, p < 0.001, but the interaction for preference for abstinence-based recovery x perceived heroin dangerousness was not significant, b = 0.00, t = 0.05, p = 0.96. In the prescription opioid regression model (n= 4,588), prescription opioids accounted for 1.62% of the variance of OUD stigma. Preference for abstinence-based recovery was unrelated to OUD stigma (b = 0.04, t = 6.08, p = 0.12), but there was a significant main effect for perceived prescription opioid dangerousness on OUD stigma (b = 0.04, t = 4.16, p < 0.001). The interaction of preference for abstinence-based recovery x perceived opioid dangerousness was not significant, b = 0.02, t = 1.59, p = 0.11.

In the methamphetamine model (n= 4,492), methamphetamine dangerousness accounted for 1.85% of the variance in MUD stigma. There was a significant positive main effect for preference for abstinence-based recovery (b = 0.12, t = 1.97, p = 0.05) and perceived methamphetamine dangerousness (b = 0.05, t = 6.08, p < 0.001) on MUD stigma. The interaction for preference for abstinence-based recovery x perceived methamphetamine dangerousness was not significant, b = −0.00, t = −0.29, p = 0.77.

Discussion

Abstinence-based recovery has been the standard recovery approach used throughout treatment services in the U.S. but may contribute to public stigma toward SUDs and thereby influence the public’s support for alternative SUD treatment strategies. This study investigated the relationship between preference for abstinence-based recovery and public stigma toward opioid, cocaine, methamphetamine, and alcohol use disorder, as well as the impact of perceived dangerousness of people with these SUDs on the relationship between preferences for abstinence-based recovery and public stigma. Results partially supported our hypotheses.

It was hypothesized that a preference for abstinence-based recovery would be associated with greater stigma towards opioids, methamphetamine, cocaine, and alcohol. This hypothesis was supported because the results suggest that negative attitudes towards people with SUDs co-occur with beliefs that abstinence is the best approach to recovery. The perception of abstinence as the only true form of recovery can contribute to the lack of acceptance and understanding of people with SUDs, which could potentially lead to bias against people in active use or those utilizing harm-reduction methods. This aligns with intervention public stigma research on medications for opioid use disorder, revealing that there are negative attitudes and feelings toward methods of recovery that are not abstinence-based (Madden et al., 2021). The data contributes a clearer understanding that preference for abstinence-based recovery could be potentially stigmatizing and contribute to barriers individuals with SUDs face when seeking services, completing treatment, and finding support systems.

It was hypothesized that public stigma toward methamphetamine would be the highest compared to opioids, cocaine, and alcohol. This hypothesis was supported, which is consistent with prior research that indicates social stigma is heightened toward individuals with MUD (Flores et al., 2023; Semple et al., 2005). This study failed to find evidence of moderation based on how dangerous people with each SUD are perceived to be. Thus, the perception of people with SUD being dangerous did not strengthen the relationship between abstinence-based recovery preferences on stigmatizing attitudes. It is possible that individuals who prefer abstinence-based recovery do not factor in dangerousness when developing stigmatizing attitudes towards drug use. Of note, several main effects suggested that perceived dangerousness is a factor in public stigma towards people with cocaine, methamphetamine, opioids use disorders, but not alcohol use disorder. This makes sense, as the belief that people with SUDs are dangerous is closely tied to other negative attitudes toward people with SUDs. Substances that people are less familiar with are perceived as more dangerous (i.e., heroin, amphetamine, and cannabis compared to alcohol, tobacco, gambling, and Internet use) (Koski- Jännes et al., 2012). This could explain why alcohol was the only substance in which perceived dangerousness was unrelated to stigmatizing attitudes.

Limitations

It is important to note that this study was cross-sectional, which limits the ability to make casual statements. There are general limitations regarding the use of self-report of stigmatizing attitudes, including the social desirability to align with social norms. A limitation of this study was that the preference for abstinence-based recovery question was assessed through a rank variable, making it difficult to determine the most meaningful way to assess recovery beliefs. Specifically, one of the answer choices was “Religious in nature,” which is often associated with abstinence-based recovery. Therefore, it is possible that people who believe in abstinence-based recovery could have chosen this response instead of the “No use of any substance” response. Future research should consider capturing preferences for abstinence-based recovery using two questions. One question could inquire about preferences for recovery approaches that are characterized by: “Religious in nature,” “Spiritual in nature,” “Physical and mental in nature,” “Living a life that contributes to society,” “Enhanced quality of life,” “Seeking professional help,” and “Having a sense of purpose in life.” A second question could capture preferences for recovery approaches that are characterized by: “Moderate/controlled use of any substance (drugs and/or alcohol),” “No use of any drug and moderate/controlled use of alcohol,” and “No use of any substance (drugs or alcohol).”

Another limitation of the study is the restricted focus on abstinence and harm reduction approaches without consideration of behavioral therapies for substance use disorders. The study did not take into consideration contact with people who use drugs or alcohol, and beliefs about controllability of use as potential factors that may influence stigmatizing views. These factors should be considered in future research.

Implications and future directions

The findings from this study have implications for developing stigma training programs for the general public as well as anyone who works with people with SUDs. It is critically important to address public stigma that may negatively impact an individual’s ability to receive substance use treatment. People may not realize how preferring abstinence-based recovery is tied to negative beliefs about SUDs. Similarly, for some people, it may be difficult to see how preference for abstinence-based recovery perpetuates cycles of addiction, because it impacts institutions and policies that are meant to help people with SUDs. Stigma-reduction efforts should acknowledge the harms caused by SUD, while simultaneously increasing knowledge and acceptance of harm reduction approaches (Pollack, 2023). Further, stigma-reduction efforts should use a culturally competent approach that involves peer navigators, health professionals, and other supports involved in substance use treatment (Pollack et al., 2023). Professionals should consider utilizing existing public stigma reduction interventions for training purposes, such as the recent online intervention aimed at reducing public stigma related to blood borne viruses (Broady et al., 2021).

Because methamphetamine may be more stigmatized than other substances, it is important to identify ways to reduce public stigma around MUD. Changing the narrative that recovery is not possible for people with MUD is pertinent for people seeking treatment. It is also important to increase resources for MUD research to find an effective pharmacological treatment. Additionally, it is necessary to increase access to existing approaches, such as contingency management (Brown et al., 2020). This may be relevant to increasing the number of peer support specialists to provide support for this specific population at treatment centers.

There are several directions for future research. Prior research on opioid stigma has concluded that demographic variables and proximity to people with OUD have an impact on stigmatizing attitudes (Lin et al., 2022), which could also be relevant to people with a preference for abstinence-based recovery. Further research should examine whether exposure to people with SUDs decreases public stigma. In addition, the characteristics that may predict preferences for abstinence-based recovery should be considered. This would help identify how to tailor training materials to decrease public stigma, which could later be adapted for various settings. When using a sample of treatment providers, we also recommend exploring whether personnel in abstinence-based treatment settings have different attitudes when compared to the public since they have increased contact with people with SUDs but operate under an abstinence approach. Understanding these factors can help facilitate advancing policies and laws related to drug regulation, treatment services, and criminal offenses.

Conclusion

Individuals who prefer abstinence-based recovery over harm reduction approaches are more likely to have stigmatizing attitudes towards OUD, CUD, MUD, and AUD. Perceived dangerousness does not moderate the relationship between preference for abstinence-based recovery and stigmatizing attitudes towards OUD, CUD, MUD, HUD, and AUD. However, the perception that substances (except alcohol) are more dangerous is linked to greater stigmatizing attitudes. Stigma toward SUD, and MUD in particular, must be addressed alongside increasing awareness of harm reduction approaches to SUD treatment.

Acknowledgments

This work was supported by the MAARC under Grant U2CDA050098.

Footnotes

Declaration of Interest Statement

The authors report there are no competing interests to declare.

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