Substance use, stigma, and coping in treatment: A qualitative study of participant perspectives

Background

This study explores experiences of stigma in substance use treatment, coping strategies, and the contexts in which individuals feel stigmatized due to current or past substance use. Semi-structured interviews were conducted with 55 individuals enrolled in substance use treatment programs within two distinct geographical areas of the U.S., Northeast and Southeast. Data were collected from February to October 2023. Themes were organized by the Health Stigma and Discrimination Framework. Five themes were identified: 1.) Interpersonal drivers of stigma participants described feeling stigmatized by treatment staff, healthcare practitioners, and family; 2.) Substance- and method-specific stigmatization: participants reported feeling greater stigma from the use of criminalized substances and substances used intravenously, compared to non-criminalized substances and non-injection use methods; 3.) Coping approaches: participants identified active (e.g., prayer, meditation, exercise) and avoidant (e.g., laughing it off) strategies to manage stigmatizing experiences; 4.) Rejection of stereotypes: participants described empathetic views of people who use substances, even as they acknowledged that treatment environments often reinforce stigmatizing practices; 5.) Recovery-oriented care: participants felt less stigmatized and more comfortable with treatment providers with lived experience. Data for this study did not indicate differences by study site. Recommendations include prioritizing providers with lived experience, training healthcare workers in culturally responsive care, and integrating coping strategies and harm reduction into treatment to reduce stigma.

Highlights

• •Participants experienced stigma shaped by substance type and substance use method.
• •Participants reported stigma from both providers and family within treatment settings and familial spaces.
• •Coping mechanisms varied, with participants engaging in active, avoidant, and a combination of active and avoidant strategies.
• •Participants advocated for recovery-oriented care in reducing substance use stigma.

1. Introduction

Globally, stigma toward individuals who use substances is recognized as a significant barrier to care and a contributor to negative health outcomes. (Manthey et al., 2022). In 2023, 48.5 million individuals aged 12 or older in the United States had a substance use disorder (SUD), yet only 24 % received treatment (SAMHSA, 2024). Stigma is a frequently reported barrier to treatment (SAMHSA, 2024), discouraging help-seeking behavior and creating structural barriers to accessing care, including limited availability of services, and broader policies that prioritize punishment over treatment (Anvari et al., 2022, Avery and Avery, 2019, Lerman Ginzburg et al., 2017).

Stigma refers to negative attitudes, stereotypes, discrimination, and social exclusion, often leading to adverse physical, psychological, social, and professional outcomes (Avery and Avery, 2019, Cernasev et al., 2022, Woods and Avery, 2024). Stigma operates as a sociocultural and political process through which individuals with socially discredited health conditions, such as those with SUDs, are devalued and marginalized (Ahern et al., 2007, Link and Phelan, 2001, Livingston et al., 2012). Individuals with SUDs are frequently perceived as morally deficient or lacking willpower, in part due to the widespread belief that SUDs are a personal choice rather than a health condition (Carl et al., 2023a, Crawford et al., 2012, Frank and Nagel, 2017, Krendl and Perry, 2023). Stigma is not uniform across SUDs but varies by substance; for example, although alcohol is legal and socially accepted, individuals with alcohol use disorder (AUD) still face stigma rooted in shame and personal blame. In contrast, people who use criminalized substances often face structural exclusion shaped by punitive drug policies that limit access to care (Hammarlund et al., 2018, Lerman Ginzburg et al., 2017, Schomerus et al., 2011). Stigma remains a persistent public health issue associated with long-term negative health outcomes and barriers to housing, employment, and supportive social networks (Avery and Avery, 2019, Carl et al., 2023a, Krendl and Perry, 2023, Sibley et al., 2024, Woods and Avery, 2024).

Stigma, as understood through the Health Stigma and Discrimination Framework (HSDF), manifests across multiple levels (Stangl et al., 2019), including self-stigma, peer/interpersonal stigma, and societal/structural stigma (Davis et al., 2022, Kulesza et al., 2017, Link et al., 1997, Sibley et al., 2024, Stangl et al., 2019, Vakharia, 2024). Self-stigma refers to a subjective process in which individuals internalize negative beliefs and stereotypes about a stigmatized condition, thus leading to diminished self-worth and self-efficacy (Anvari et al., 2022). This may involve negative feelings about oneself or the endorsement of harmful stereotypes, often rooted in lived experiences, perceptions, or anticipation of judgment (Crawford et al., 2012, Paquette et al., 2018, Sibley et al., 2024, Stangl et al., 2019, Tsai et al., 2019, Vakharia, 2024). Interpersonal stigma can occur during interactions that convey judgment, prejudice, or disapproval (Davis et al., 2022, Sibley et al., 2024, Stangl et al., 2019). Structural stigma is embedded in laws, policies, and institutional practices, such as punitive drug laws that systematically disadvantage people with SUDs (Sibley et al., 2024, Stangl et al., 2019). These forms of stigma are not experienced passively (Stangl et al., 2019). Individuals actively manage and navigate stigma; however, there is limited qualitative research focused on how people with SUDs experience and respond to stigma while in treatment, and how these experiences impact their recovery process.

Stigma from healthcare and substance use treatment providers is common. Many patients on methadone, for example, report that they hear negative comments about medications for opioid use disorder from providers (Kulesza et al., 2017). A recent study on patient experiences showed that negative interpersonal interactions, lack of cultural humility, and rigid program structures undermine trust and satisfaction in treatment programs (Carl et al., 2023a). Recent studies have shown that stigma prevents those with a SUD from engaging in treatment and harm reduction efforts (Frank and Nagel, 2017, Paquette et al., 2018, Sibley et al., 2024, Vakharia, 2024, Woods and Avery, 2024). While previous studies provide critical insight into the consequences of stigma during treatment, they tend to rely on patient satisfaction measures and other quantitative approaches, leaving a gap in understanding how individuals perceive, navigate, and respond to stigma during their treatment journeys (Choi et al., 2025).

The current study seeks to qualitatively explore and describe the experiences of stigma faced by individuals undergoing treatment for SUDs and understand the personal narratives of participants regarding societal, peer, and self-stigmatization. We sought to understand the opinions and feelings of individuals towards themselves and others in treatment, explore sources of stigma, and evaluate their impact on treatment experiences and recovery journeys.

2. Methods

The research team enrolled participants from the parent study, Project RENEW (R01AA025954), designed to understand the role of place and social networks on triggers to use among individuals in treatment for SUDs. The research team developed the study in partnership with a community advisory board consisting of individuals with lived experience. This study recruited individuals in the Northeast and Southeast. Recruitment methods and eligibility criteria were consistent across both sites. The team used regional treatment programs for recruitment. Inclusion criteria were: 1) fluency in English, 2) being 18 years of age or older, 3) having entered a formal treatment program within the last 12 months, 4) access to and ability to comfortably use a smartphone, and 5) drinking alcohol during the previous 12 months. The research team recruited participants through social media, flyers, in-person recruitment at health clinics, referrals from partnering treatment centers, and peers. Participation in the parent study included quantitative surveys every three months, daily and geographic ecological momentary assessments, and opportunities to participate in optional qualitative interviews scheduled at the participant's convenience.

The research team conducted qualitative interviews for this analysis from February 2023 until data saturation was reached in October 2023. The research team regularly reviewed transcripts and identified emerging patterns and assessed thematic stability and the point of data saturation. The study team determined saturation based on the homogeneity of the experiences and themes and reaching thematic stability (Bielenberg et al., 2021, Guest et al., 2006). Eligible participants signed informed consent. Interviews ranged from 30 to 60 min. and were paid $40. The team uploaded interview audio into Trint software for transcription. At least two research team members reviewed and edited each transcript for accuracy. All procedures were approved by Central Yale WCG IRB (1280127).

3. Data collection

We conducted 55 semi-structured interviews where participants were asked about their experiences in substance use treatment programs and their experiences with stigmatization. These questions explored where participants experienced stigmatization, the context surrounding it, and how they managed experiences of stigmatization related to their substance use and treatment journeys. Participants were asked to reflect on their thoughts and feelings towards others who use substances, probing whether these views have changed over time and how they perceived others who use substances in different contexts, such as those in treatment or recovery groups, versus those with whom they used substances. See Appendix A for the complete semi-structured interview guide.

4. Theoretical framework

The HSDF was used to guide both the development of our interview questions and our data analysis (Stangl et al., 2019). The HSDF conceptualizes stigma as a dynamic, multi-level process that shapes individual and organizational outcomes. It emphasizes how individuals may experience and contribute to stigma, with intersecting identities of privilege and marginalization (Stangl et al., 2019). To align with the framework, the interview guide was designed to explore participants’ experiences with self-stigma, interpersonal stigma, and structural stigma. The HSDF also informed the analytical approach by offering a structured lens to interpret how stigma manifests and is managed during treatment.

5. Data analysis

Interviewers and coders were trained in qualitative research methods by senior team members who brought both lived experience with substance use and experience in qualitative research data collection and analysis. Our training curriculum included practical exercises in interviewing techniques, coding procedures, and thematic analysis, and was designed to standardize methodological approaches across team members regardless of their prior experience. Those conducting the interviews included five individuals: two PhD students in Georgia and three MPH students and alumni based in Connecticut. All interviewers had prior experience with qualitative methods through academic coursework and applied research. In addition to initial training, the team engaged in ongoing discussions throughout the data collection phase to ensure consistency in interviewing approach and reflexivity across the project.

We conducted thematic analysis informed by both deductive and inductive approaches (Braun and Clarke, 2006). We began with a deductive stance, applying the predefined categories of the HSDF to organize and interpret the data. As the analysis progressed, inductive reasoning was used to identify and integrate new themes that extended beyond the original framework. This process evolved through active interaction with the data, where emerging patterns and themes were noted (Saldaña, 2020).

Codebook development was initially grounded in the HSDF, which, alongside the interview guide, served as the foundational method for code creation. Examples of some of those codes were Facilitators, Organizational Stigma practices, Drivers of Stigma, and Intersectional Stigma. These codes captured the multi-level social and structural mechanisms of stigma as outlined in the framework. Some codes were developed to address specific elements of stigma that arise in the context of substance use treatment such as Substance-Specific Stigma, Substance-Method Specific Stigma, Manifestations of Stigma, Stigma Outcomes, and Internal Conflict.

The initial version of the codebook was collaboratively drafted by research team members KC and AO, who were deeply involved in both the data collection and transcription phases. The research team workgroup refined the codebook through a process of iterative editing and feedback, thus utilizing multiple perspectives to ensure the framework accurately reflected the data and theoretical support (Leavy, 2020).

Throughout this process, analytic memos documented evolving thoughts and preliminary conclusions, helping to track the application and refinement of codes as data analysis progressed (Saldaña, 2020). The research team formulated the codebook through regular meetings until the group reached consensus. The coding team performed five rounds of intercoder reliability testing in Dedoose (Version 9.0.17), a cloud-based application for managing and analyzing qualitative research data (Dedoose, 2025). This involved double-coding 20 % of the transcripts and refining the codebook until agreement was achieved. Coding criteria was a pooled Cohen’s Kappa of 0.75; all coders achieved above 0.80 or higher, ensuring the reliability of the coding scheme (Saldaña, 2020). Coders then independently coded the remaining 44 transcripts.

6. Reflexivity

Collectively, members of the interviewing and coding teams were diverse in their personal and professional experience with substance use and individuals who use substances. All members of the interviewing teams were affiliated with Yale School of Public Health and University of Georgia. All members of the team were aware of the power dynamics inherent in the researcher-participant relationship and strived to mitigate these by fostering a collaborative and respectful research environment. Interviewers emphasized participant expertise in their own experiences and provided participants with opportunities to skip questions or stop the interview at any time. Interviews were conducted in a conversational tone, and participants were reminded that there were no right or wrong answers. When possible, interviewers with lived experience were matched with participants to build rapport. Our commitment to reflexivity requires us to continuously examine how our positionality influences the research process and outcomes. This was reinforced during all steps in the process, including interviews, codebook development, coding, and analysis.

7. Results

Demographic characteristics of the 55 participants are presented in Table 1. The largest age category was 28–38 years (37.0 %). The majority identified as White (56.4 %), cisgender men (63.6 %), and heterosexual (94.5 %). In terms of education, the largest group of participants (38.2 %) had a high school diploma or GED. Regarding substances addressed in treatment, most participants (78.2 %) reported addressing multiple substances. Alcohol was the most addressed (81.1 %), followed by cannabinoids (76.0 %), stimulants (40.0 %), and opioids (21.8 %). The majority received inpatient treatment (74.5 %). Just over half (50.9 %) were legally required to attend treatment. A significant proportion had a history of arrest (80.0 %) and previous incarceration (67.3 %). Geographically, most participants were from the Southeast (65.5 %).

Table 1.

Participant demographics (N = 55).

N (%)
Age Category⁎
18–28 28–38 38–48 48–58 58–68 68 + No Answer	8 (14.8 %) 20 (37.0 %) 14 (25.9 %) 8 (14.8 %) 4 (7.4 %) 0 (0.0 %) 1 (1.8 %)
Race
American Indian or Alaska Native Black or African American Hispanic/Latino White Other	2 (3.6 %) 20 (36.4 %) 1 (1.8 %) 31 (56.4 %) 1 (1.8 %)
Gender
Transgender Man Woman Man	1 (1.8 %) 19 (34.5 %) 35 (63.6 %
Sexual Orientation
Bisexual Queer Heterosexual	2 (3.6 %) 1 (1.8 %) 52 (94.5 %)
Highest Attained Educational Level
Completed graduate or professional school Graduated from college High school or GED Less Than High School Some college Some graduate or professional school	4 (7.3 %) 4 (7.3 %) 21 (38.2 %) 7 (12.7 %) 15 (27.3 %) 4 (7.3 %)
Employment
Not working Working full-time Working part-time	32 (58.2 %) 11 (20.0 %) 12 (21.8 %)
Substances Addressed in Treatment⁎⁎
Opiates Stimulants Depressants Alcohol Hallucinogens Benzodiazepines Cannabinoids Other Substances	12 (21.8 %) 22 (40.0 %) 11 (20.0 %) 45 (81.1 %) 4 (7.2 %) 11 (20.0 %) 42 (76.0 %) 2 (3.6.0 %)
Concurrent Substance Use
Alcohol Only Polysubstance Use	10 (18.2 %) 45 (81.8 %)
Treatment Type
In-patient Outpatient	41 (74.5 %) 14 (25.5 %)
Legally Required to Attend Treatment
No Yes	27 (49.1 %) 28 (50.9 %)
Previous Arrest⁎⁎⁎
No Yes Missing/Declined to answer	10 (18.2 %) 44 (80.0 %) 1 (1.8 %)
Previous Incarceration
No Yes Missing/Declined to answer	17 (30.9 %) 37 (67.3 %) 1 (1.8 %)
Location
Northeast Southeast	19 (34.5 %) 36 (65.5 %)

^⁎Age groups are inclusive of the lower bound and exclusive of the upper bound

^⁎⁎Note: Participants could select more than one substance.

^⁎⁎⁎This variable is any arrest, not necessarily related to substance use.

Five themes were identified: interpersonal sources of stigma, substance- and method-specific stigmatization, coping approaches, rejection of stereotypes, and recovery-oriented care. Despite regional variation in alcohol culture and treatment infrastructure, no meaningful thematic differences emerged between the sites in qualitative analysis.

Theme 1: Interpersonal sources of stigma

Subtheme 1: Stigma from family

A form of interpersonal stigma in the data was stigma from family. Participants felt familial stigma deepened feelings of alienation.

“I went for…a family gathering and I just decided to take a little [substance]… [A family friend] was like, "… why are you looking so untidy? Why look the way your eyes is, you look so raw. She looks so dirty…can you ever do anything useful with your life?…" But she doesn't know the struggles I'm going through… And she was like, " …who on earth will have anything to do with someone like you?".” Participant 38, Age 38–48, Woman, Black, Inpatient

Subtheme 2: Stigma from medical personnel

An additional form of interpersonal stigma was the experience of stigma from medical personnel.

“I was at the hospital because I was passing kidney … [Medical personnel] said, ‘Oh, she's just looking to get something to get high off of.’ …Because I guess it's in my medical history… I said I wasn't here for the opiate, though…And then they called security and the whole nine yards.” Participant 47, Age 28–38, Woman, White, Inpatient

Theme 2: Substance- and method-specific stigmatization.

Participants discusses how alcohol is seen as a ‘lower level’ substance compared to other substances like methamphetamine and opioids.

“I think that, depending on what the drug type is, it comes with its own stigmatism and with that people shame not only the drug that is being used, but the person who was using that. But I think alcohol is at a lower level than someone who does, you know, like crack or meth as an example.” Participant 44, Age 18–28, Transgender Man, Black, Inpatient

Participants noted their frustration with judgment placed on the type of substance because, to them, all substances can have negative consequences.

“A lot of true-blue alcoholics like myself feel that they are somewhat superior or whatever because they've never smoked crack or done other drugs. I've seen it the other way, too. ‘Well, I just took pills, I didn't shoot heroin, you know, I never use a needle or anything like that. So, just because I was snorting and smoking heroin, I never shot up heroin. So I'm better than that, you know?’” Participant 24, Age 28–38, Man, White, Inpatient

The following participant describes how stigma attributed to a substance was often tied to its legality. Substances that are criminalized were perceived as carrying higher risks because of the implicit legal consequences.

“Obviously like with drinking, it's different. With drugs, it's a whole different category. …I know they're both substances and they're both very harmful to your body, but drinking is a little different because it's more legal … whereas drugs is not legal. …Like, people look at drugs way differently than they do at alcohol.”

Participant 48, Age 28–38, Woman, White, Inpatient

The participant described how they had once perceived certain substances as having less social acceptance than others. Now, having experienced an SUD themselves, their perspective on using specific substances has evolved, leading to greater empathy.

“I guess, I used to judge people for using that drug- using crack because I was taught and I was brought up that it was nasty and for trashy people and whatnot. But my ideas have changed about that because I would be considered one of those same people because of my experience. Now, I never thought that I'd have use of drugs, but things change”

Participant 11, Age 48–58, Man, White, Outpatient

The following participant highlights the stigma associated with injection drug use. This stigma was linked to the visibility of injection-related signs, such as track marks, which publicly marked them as individuals who use substances.

“Injection users, they're gonna have more bodily damage… So yeah, injection users are looked at a little differently if they admit they were an injection user or have track marks.” Participant 1, Age 18–28, Woman, White, Inpatient

Theme 3: Coping approaches active, avoidant, and both

Participants described using both active and avoidant coping strategies in response to stigma.

“before I got here, I used to get upset, and I would just say to heck with them and just keep going off doing my thing. They they think I'm messed up, I'm going to show them messed up, you know? And I'd go out there and go even harder.” Participant 10, Age 28–38, Man, White, Inpatient

Participants shared feelings of being upset or emotionally exhausted from repeated experiences of stigmatization. In some cases, these negative emotions acted as a catalyst for change, prompting a shift from avoidant to active coping strategies. This shift often manifested in ways that were ultimately unhelpful in managing their SUD, such as increasing substance use to cope with the distress caused by stigma. Negative comments from others reinforced feelings of worthlessness, perpetuating cycles of harm driven by stigma's emotional and psychological impact.

Religion and prayer were commonly used active coping strategies, focusing on transforming pain into purpose.

“Number one prayer. Prayer. And my relationship with Jesus Christ was number one. I know that what people think about me is not key to my survival.” Participant 46, Man, Age 28–38, Black, Inpatient

However, participants mentioned using prayer as an avoidantstrategy as well, aimed to deflect stigma and avoid internalizing it. Avoidance was frequently discussed, including behaviors such as withdrawing from stigmatizing situations or choosing not to dwell on harmful experiences.

“Actually, I just let it go…. You can't hold stuff like that. Because if you do it, it'll have a tendency to bother you… I pray every day and I'll leave it in the hands of the Lord. That's how it is.” Participant 15, Age 28–38, Woman, Black, Inpatient

Other participants described avoidant strategies such as retreating into isolation to avoid judgment.

“When I drank, I didn't want to talk to nobody. I was like, in the house drinking and… the phone would ring and I wouldn't answer. Like, I like secluded myself when I was drinking… Cause of embarrassment. And I just didn't want to be bother with nobody because they're going to say, "Oh, you're drunk or you're drinking." And I didn't want to hear that.” Participant 49, Age 28–38, Woman, Black, Inpatient

Theme 4: Rejection of stereotypes.

Despite acknowledging that different substances and modes of use were subject to varying levels of stigma, participants largely rejected the notion that these distinctions reflected a person’s moral character or worth. They emphasized that people in treatment were not in a position to judge others and advocated for compassion and solidarity across substance types. While they recognized that treatment experiences and societal responses often varied based on the substance used, participants endorsed a more unified and nonjudgmental approach to recovery.

“Like there's different degrees of being excuse my language, like different degrees of being fucked up. If you're, you're an addict, you're an addict. There's no like addict A, addict B, you know what I mean like, addicts are addicts. But people, people like to judge people. I feel like all the drugs are equally bad.”

Participant 51, Age 38–48, Man, Black, Inpatient

Theme 5: Recovery-oriented care.

Participants felt more connected and supported by those who experienced SUD themselves rather than by professionals who only have theoretical knowledge. Participants discussed wanting staff who had prior lived experience with SUDs.

“When I go to church or something like that and I'm listening to a testimony, I feel more, I feel more attached in connection with that testimony as somebody who's been through what I've been through in some sort of way and they're doing much better. I feel more attached to that than I would a person that's a counselor with a diploma who is trying to tell me what I'm doing wrong and right.” Participant 1, Age 18–28, Woman, White, Inpatient

Participants noted the community aspect of recovery programs, where many staff members have ‘lived experience with SUDs. The community formed by these shared experiences was described as crucial for truly grasping the nature of SUDs beyond what can be learned in an academic setting.

“They're hearing our stories and, you know, they're sharing theirs. So, it's an amazing community of people who truly get addiction at its core and not just are book taught.” Participant 44, Age 18–28, Transgender Man, Black, Inpatient

Participants discussed how treatment centers can be a place of feeling judged, especially in relation to their recovery journey. This participant noted that the only support system she currently had were people in treatment, and that she wished she did not feel judged. Participants wanted a focus on empathy and understanding in the treatment and recovery environment.

“My family completely looks down on me. I don't talk to any of them. Here in the program, I'm judged daily. You know, you have people at all different levels here, so, you know, you have the ones that come in and they think you're too good because you've already finished the program. And then you have ones that finish the program with you. And it's a matter of people just looking at you like, "Oh, well, when is she going to relapse or is she going to fall back?". So it's it's it's constantly feeling like you're judged. Participant 30, Age 48–58, Woman, White, Outpatient

Participants discussed the need for providers to have more empathy when working with those who are using substances or in treatment. Participants described situations where lack of empathy was rooted in misinformed beliefs about SUD. Participants noted wanting to feel like the goal of the treatment center was to help them in their recovery journey and to not feel like an inconvenience.

“When you go to detox or rehab, they kind of like, some of the people [treatment staff] there will like have an attitude toward you or not like, be a little bit tougher on you and not show any sympathy or empathy towards you.” Participant 35, Age 28–38, Woman, American Indian or Alaska Native, Inpatient

8. Discussion

The themes highlight the complexity of substance use stigma. The HSDF offers a valuable framework for understanding and addressing the nuanced nature of health-related stigma and moving beyond rigid categories of “stigmatized” and “stigmatizer” (Stangl et al., 2019). This means recognizing that criminalized substances and injection substance use often carry heightened stigma. As a result, providers and peer-support programs working with these populations may require enhanced de-stigmatizing messaging and training. Efforts should prioritize reducing stigma across all substance types and methods of use to promote equitable and effective care.

A recurring theme in the literature is that individuals with SUDs often encounter discrimination in healthcare settings, leading to a lower quality of care (Ahern et al., 2007, Cernasev et al., 2021, Livingston et al., 2012, Olsen and Sharfstein, 2014). For example, healthcare and treatment facilities frequently use pejorative or stigmatizing language (Kelly et al., 2016). Such language can perpetuate stigma and lead individuals to feel less capable of changing their substance use (NIDA., 2021, Olsen and Sharfstein, 2014). Despite the implementation of interventions aimed at reducing stigma, research indicates that healthcare providers remain a significant source of stigma toward people with SUDs (Carl et al., 2023b, Livingston et al., 2012, Paquette et al., 2018).Similarly, participants in the current study emphasized the pervasiveness of stigma in healthcare settings, along with treatment centers and family environments.

An overwhelming majority of participants discussed the harmful stigma associated with specific substances and their method of use. Participants perceived a societal/social tendency to differentiate between individuals who use substances based on their substance of choice, assigning varying levels of stigma to each. Participants noted their frustration with judgment placed on the type of substance, because they feel all substances can have negative consequences. This supports previous research, stating that opioids, methamphetamines, and crack cocaine are more stigmatized (Davis et al., 2022, Goodyear et al., 2022; M. R. Khan et al., 2023) as well as injection substance use (Paquette et al., 2018). Harm reductionists advocate for understanding risk associated with using a substance while de-stigmatizing the substance itself (Vakharia, 2024). Participants similarly discussed that while stigma is pervasive and amplified for some substances and modalities, it is not valid and should be dismantled to reduce the overall stigma experienced by those with SUDs.

Our participants frequently cited the criminalization of specific substances as a central source of stigma, which reflects their lived experiences: 80 % had a prior arrest, 67 % had been incarcerated, and 50 % were court-mandated to attend treatment. Substances that are criminalized were perceived as carrying higher risks because of the implicit legal consequences. Historically, people who use specific substances are marginalized based on how they are categorized under the law (Vakharia, 2024). Marijuana, which was once heavily stigmatized and associated with “reefer madness” or drug-induced psychosis, is now often viewed as “good” or therapeutic following its legalization in much of the U.S. (Vakharia, 2024).

Coping strategies for experiencing stigma included both active and avoidant approaches. Active coping strategies primarily involve spiritual practices, which is expected given the strong religious and spiritual underpinnings of many treatment programs and abstinence-based social groups, such as 12-Step programs. Previous research has shown that spiritual well-being may help in post-treatment recovery outcomes, including reduced frequency of substance use during early recovery (Kane et al., 2024). Spiritual well-being may provide individuals with tools to handle the stressors of transitioning out of treatment and managing recovery challenges (Kane et al., 2024). In contrast, avoidant strategies were employed by participants to sidestep directly confronting or addressing stigma. This behavior is supported by previous research suggesting that individuals might avoid people or situations where they expect to face stigma or discrimination (Ahern et al., 2007). While avoidant strategies might offer temporary relief by reducing immediate distress, they are typically ineffective for long-term coping (Suls and Fletcher, 1985). Moreover, substance use has been documented as a method for individuals to manage trauma and stress (Bountress et al., 2019). Thus, the finding that participants increased their substance use as a coping mechanism for stigma aligns with these prior studies.

Current literature states that much of substance use stigma is internalized into self-stigma, (Kulesza et al., 2017, Sibley et al., 2024) which negatively affects the mental health and well-being of those with SUDs (Kulesza et al., 2017, Sibley et al., 2024). When participants in the current study were asked about stigmatizing beliefs, there was a theme of rejecting commonly held stereotypes placed on folks who use substances. Their experiences fostered a non-judgmental attitude towards others facing similar struggles, advocating for a more compassionate approach to SUDs. The theme of rejecting stereotypes created an interesting dichotomy between participants' experiences of stigma and their own beliefs about such stigma. While stigma is pervasive in treatment centers and healthcare environments, participants did not hold these stigmatizing beliefs. This suggests that participants are actively challenging these stereotypes and making efforts to combat stigma. This finding might be because participants of this study were already in a substance use treatment program, and those who may be experiencing self-stigma are less likely to enroll or participate in a treatment program (Kulesza et al., 2017, Sibley et al., 2024).

Participants emphasized the importance of recovery-oriented care as it pertains to preferring providers with lived experience and more empathy in treatment and recovery environments. Participants assessed the care from providers without lived experience being of a lower quality due to the lack of ‘true’ empathy, even if the provider was well-meaning. This finding is consistent with the literature stating that recovery-oriented care with facilitators who have lived experience is successful in retention, overdose prevention, and mental health outcomes (Park et al., 2023). Peer support workers can provide advocacy and a voice for people who use substances and may help buffer or protect individuals from the negative impacts of enacted stigma in treatment settings (Anvari et al., 2022, Corrigan and Nieweglowski, 2018, Davis et al., 2022).

9. Conclusion

Themes from the study underscore the necessity for integrated approaches in treatment and support systems that actively confront both substance and method-specific stigma. Although various stigma-reduction strategies for providers have been tested, results have been mixed (Bielenberg et al., 2021, Livingston et al., 2012). The current study recommends a multifaceted approach to stigma reduction that centers harm reduction and includes provider stigma reduction training, expanding peer support networks, prioritizing providers with lived experience, policy reform, and helping those with SUD build coping strategies for managing stigma. By addressing stigma at multiple levels, treatment settings can become healing spaces rather than further marginalization sites.

Limitations

While our analysis does not include an examination of race, ethnicity, or class, these factors undoubtedly intersect with how stigma is produced and experienced and should be explored in future research. Due to the parent study's focus, there may have been other thematic content that could have emerged if the sample included people who did not drink alcohol in the past year, particularly among people who use substances other than alcohol. Given that only 23.6 % of individuals who identify as having a SUD seek treatment, our themes likely differ from the stigma experienced of people who have never sought treatment (SAMHSA, 2024). Despite these limitations, this study contributes to the larger body of knowledge on stigma and substance use. This research should inform future stigma reduction interventions and provide insights for healthcare workers and families of individuals with SUD, helping them better understand the stigma faced by those who use substances.

Author disclosure statement

No conflict of interest to report.

CRediT authorship contribution statement

Carson F. Ferrara: Conceptualization. Cathy Jian: Data curation. Trace Kershaw: Writing – review & editing, Visualization, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Jessica Muilenburg: Writing – review & editing, Validation, Supervision, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Charles Ashley Warnock: Writing – review & editing, Methodology, Conceptualization. Kaylia Carroll: Writing – review & editing, Writing – original draft, Visualization, Supervision, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Griffith Frances: Writing – review & editing, Methodology. Ondrusek Ashlin R: Writing – review & editing, Formal analysis, Data curation, Conceptualization. Noah Hopkins: Conceptualization. Adam Viera: Methodology, Data curation. Carmen Muniz-Almaguer: Data curation.

Funding sources

R01AA025954, and T32DA019426.

Declaration of Competing Interest

There are no conflicts of interest to report.

Appendix A. Qualitative interview questions

1. What thoughts/feelings do you have about others who use drugs?  If they say none, have you always felt that way?  Us vs them, but in treatment?  [probe] Think about the people who you were in treatment with, or recovery groups– what were your opinions of them and their use?  [probe] Think about the people you might’ve used with– what were your opinions of them and their use? i. Can you give me an example of what you mean? 2. What opinions do people have about individuals who use substances (including drugs and alcohol)?  Probe: IV drug use, vs. meth, vs. etc.  Where do you think that opinion comes from for you? 3. Tell me about the last time you felt judged, stigmatized, or treated poorly due to your status as someone in treatment or someone who uses or used to use drugs?  If yes, could you tell me about what happened? i. Who made you feel this way? ii. What was that experience like? à where did it happen/ what was the context? iii. How did you cope with this?  If no, have you ever seen something like that during your treatment experience? i. If yes, what was it related to? ii. What was that experience like? 4. Have you ever felt like you or your health concerns/experiences were not taken seriously or treated differently by staff, healthcare providers?  Do you think stigma surrounding different drugs can affect the level of care in treatment? (yours vs. others)  Can you tell me a little bit about this experience? What was it related to? How did you cope with this while in treatment?  Have you ever seen or heard of something like this?  What impact did this have on your treatment experience or the treatment experience of the people who you saw experience it? 5. Have you ever felt like you or your health concerns/experiences were not taken seriously by others in treatment while in treatment?  Can you tell me a little bit about this experience? What was it related to? How did you cope with this while in treatment?  Have you ever seen or heard of something like this?  What impact did this have on your treatment experience or the treatment experience of the people who you saw experience it? 6. Have you noticed any patterns or common themes in how you or others were treated in treatment? 7. What suggestions do you have for improving the treatment experience for others?