Interventions to Reduce Self-Stigma in People Who Use Drugs: A Systematic Review

Abstract

Background:

Substance use stigma is a key barrier to treatment and harm reduction engagement among people who use drugs (PWUD). Previous systematic reviews have focused on interventions to reduce stigma in healthcare providers and the public; less is known about interventions to address self-stigma among PWUD. The purpose of this review is to evaluate the evidence for substance use self-stigma reduction interventions.

Methods:

We reviewed English-language studies published between 2011 and 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO #CRD42022321305). We searched seven bibliographic databases (PubMed; SCOPUS; APA PsycInfo; CINAHL; Social Work Abstracts; Sociological Abstracts; ProQuest Dissertations & Theses). Studies were included if 1) they evaluated the effectiveness of a psychosocial intervention, 2) participants were PWUD, 3) authors reported self-stigma as a primary outcome, 4) the study design was experimental or quasi-experimental. Intervention characteristics and effectiveness were reviewed, interpreted, and reported using narrative synthesis. Study quality was assessed with the Downs & Black checklist.

Results:

Among 1,195 screened studies, 15 met the inclusion criteria (N=2,280 PWUD). We categorized the interventions according to three approaches: psychotherapeutic (n=8), psychoeducational (n=5), and multimodal (n=2). Most interventions were delivered in clinical settings (n=11) and in a group format (n=13). Study quality was fair-to-good and included nine randomized controlled trials (RCTs) and six quasi-experiments. Measurement heterogeneity was high, with 11 different stigma-related scales used across the 15 studies. Eleven studies showed significant favorable effects in at least one stigma measure. Six of these demonstrated positive effects in all stigma measures. Evidence was mixed for all three intervention categories; however, Acceptance and Commitment Therapy, a form of group psychotherapy, demonstrated effectiveness in four of five RCTs incorporating this approach.

Conclusions:

Overall, there is promising evidence for the effectiveness of substance use self-stigma interventions, although more studies are needed to determine which approaches are most effective. Consistent conceptualization and measurement of self-stigma across studies will improve comparability in future intervention trials. Current offerings are largely limited to clinical settings and group-based formats; self-help interventions, available for other stigmatized conditions, could be developed to serve the majority of PWUD not engaged in treatment.

1. Introduction

More than one million Americans have died from drug overdose in the past two decades, and mortality exceeded 100,000 individuals in 2021 and 2022 (Centers for Disease Control & Prevention, 2023). Substance use disorder (SUD) stigma is a primary barrier to ending the opioid epidemic. SUDs remain highly stigmatized compared with other health conditions (Kulesza et al., 2013). For instance, the general public sees people who use drugs (PWUD) as significantly more blameworthy and dangerous than people with mental illness, and drug-related stigma is higher than HIV stigma among individuals living with both conditions (Barry et al., 2014; Corrigan et al., 2009; Li et al., 2020). SUD stigma prevents uptake of and retention in treatment and harm reduction services among PWUD, contributing to needless morbidity (e.g., infectious disease) and mortality (e.g., overdose deaths) (Biancarelli et al., 2019; Latkin et al., 2019; van Boekel et al., 2013; von Hippel et al., 2018). Though key federal agencies have identified stigma reduction as a strategic priority in the opioid epidemic, researchers know much less about how to address SUD stigma as compared with other health conditions, such as mental illness and HIV/AIDS (Corrigan et al., 2017; Corrigan & Nieweglowski, 2018; Earnshaw, 2020; Yang et al., 2017).

Livingston and colleagues (2012) published the first systematic review of substance use stigma interventions. Notably, among the 13 studies included in the review, 10 targeted social or structural stigma, attempting to change attitudes or behaviors in the general public or stakeholder groups like medical students. Only three interventions targeted self-stigma, two of which were published before 1980. Self-stigma is the process by which a stigmatized group member identifies, internalizes, and responds to public stigma, and often involves accepting and applying negative societal beliefs to oneself (Corrigan & Rao, 2012; Stangl et al., 2019). Self-stigma includes two cognitive and two behavioral components: self-devaluation (e.g., internalized stereotypes, judgements, and shame), fear of experiencing stigma in the future, avoiding stigmatizing thoughts and situations, and disengaging from personal values (Luoma et al., 2013). Self-stigma leads to the “why try” phenomenon in which the stigmatized are disempowered from pursuing life goals (Corrigan et al., 2019). SUD self-stigma is positively associated with numerous adverse psychosocial outcomes (e.g., depression, anxiety, diminished quality of life, maladaptive coping), leads to delays in substance use treatment and harm reduction seeking and retention, and ultimately increases the risk of overdose (Benz et al., 2021; S. A. Brown et al., 2015; Hammarlund et al., 2018; Kulesza et al., 2017; Latkin et al., 2019; Luoma, 2011; Rivera et al., 2014). Reducing self-stigma directly, known as the ‘self-worth agenda,’ is a necessary complement to prevailing efforts to reduce stigma in the public (Corrigan & Nieweglowski, 2018; Kundert & Corrigan, 2022).

Compared with public stigma interventions, self-stigma reduction is likely an underutilized approach, despite its potential advantages. Practically speaking, no amount of intervention can entirely erase the public stigma of substance use nor its experience by PWUD (i.e., received, perceived, and anticipated stigma). PWUD should thus be equipped with strategies to manage, deflect, and react to public stigma. Evidence suggests that self-stigma mediates the effect of received, perceived, and anticipated stigma on numerous health outcomes, including mental health, help-seeking, quality of life, and general health (Birtel et al., 2017; Blais & Renshaw, 2014; Kao et al., 2016; Picco et al., 2017; van der Kooij et al., 2021). Addressing self-stigma directly may thus block the harmful effects of public stigma, providing a complementary approach to public-facing interventions. Positive evidence from self-stigma reduction interventions in related stigmatized conditions like HIV/AIDS and mental illness point to the promise of this approach for PWUD (Earnshaw, 2020; Ma et al., 2019; Mittal et al., 2012; Yanos et al., 2015).

At least two systematic reviews of substance use stigma interventions have been conducted since Livingston et al. (2012), yet neither included self-stigma interventions. Bielenberg and colleagues (2021) focused their review on stigma among healthcare professionals. Tostes and colleagues (2020) employed a broader search strategy, including any substance use stigma intervention, yet all 28 included studies targeted prospective stigmatizers (e.g., medical students, doctors, nurses, and caregivers) rather than the stigmatized.

There is thus a critical need for rigorously evaluated strategies that PWUD may use to reduce, resist, or cope with stigma. The purpose of this review is to systematically identify and evaluate substance use self-stigma interventions published since the Livingston (2012) review. The review is guided by three central questions.

1. What are the approaches and design features of self-stigma reduction interventions among PWUD?

2. Are self-stigma reduction interventions effective among PWUD?

3. How does effectiveness vary by intervention approach?

2. Methods

This systematic review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Page et al., 2021). The first author developed a protocol, including research questions, bibliographic databases to search, inclusion/exclusion criteria, and search terms prior to conducting the review (Appendix A). The protocol was registered with PROSPERO (#CRD42022321305), a prospective register of systematic reviews coordinated by the National Institute for Health Research in the United Kingdom.

2.1. Eligibility Criteria

We included intervention studies targeting self-stigma in PWUD. Specifically, studies included in this review met the following criteria: 1) the purpose of the study was to test the efficacy or effectiveness of a psychosocial intervention, 2) participants in the intervention were PWUD (i.e., people with a diagnosed substance use disorder, people with self-reported problematic use, or people accessing substance use programs such as treatment facilities, detoxification units, or harm reduction programs), 3) authors reported self-stigma as the primary outcome (or as a secondary outcome only if stigma reduction was an evident component of the intervention protocol), and 4) the study design was experimental or quasi-experimental (e.g., randomized controlled trial, non-randomized trial with a comparison group, one-group pre-post design) (Shadish et al., 2001). Studies targeting multiple types of stigma (e.g., HIV or mental health and substance use) were included only if substance use stigma outcomes were measured and reported.

We excluded studies for the following reasons: 1) participant substance use was not problematic, habitual, or clinically diagnosed (e.g., participants who are occasional drinkers), 2) the study design was pre-experimental or qualitative (Shadish et al., 2001), 3) only stigma relating to another condition (e.g., HIV or mental health) was measured and reported, and 4) the paper was not published in English.

2.2. Search Strategy

We conducted our initial literature search on May 26, 2023 using seven bibliographic databases: PubMed; SCOPUS; APA PsycInfo, CINAHL, and Social Work Abstracts via EBSCO; and Sociological Abstracts and ProQuest Dissertations & Theses Global via ProQuest. Searches included only studies published after January 1, 2011 (the search date in Livingston et al., 2012). Only titles, abstracts, and keywords were queried using each database’s respective filter (e.g., PubMed: TIAB, SCOPUS: TITLE-ABS-KEY, EBSCO: AB, ProQuest: NOFT). Search terms were unique to each database depending on available Boolean operators but in each case focused on a combination of three subject areas: stigma (e.g., “self-stigma” OR “internalized stigma” OR “stigma resistance” OR “perceived stigma” OR “stigma-related coping” OR …), interventions (e.g., “intervention” OR “trial” OR “pilot” OR “program” OR …), and substance use (e.g., “substance use” OR “substance misuse” OR “drug use” OR “people who use drugs” OR “addiction” OR …). Proximity operators were used when allowable to capture longer phrases (e.g., “perceived W/4 stigma” would capture “perceived opioid-related stigma”). A full list of search terms is available in Appendix A. In addition to our initial database searches, for studies eventually included in full-text screening, we reference harvested and conducted forward citation searches in Google Scholar on June 4, 2023. Finally, we manually searched program databases of federal public health agencies, including the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention. The full search strategy was developed in consultation with a behavioral and social science university librarian.

2.3. Study Selection

Citations from the search results were uploaded into Zotero reference management software. A total of 1,968 studies were initially identified, which decreased to 1,195 after de-duplication. These citations were imported into Covidence for screening and data extraction by the first and second authors (AS and DC). The authors reviewed the inclusion and exclusion criteria together before screening began. Each study’s title and abstract were then independently screened as potentially relevant by both authors (inter-rater agreement 94%, Cohen’s κ = 0.50). Discrepancies were reviewed and discussed by the authors and resolved by consensus. Both authors subsequently reviewed the full text of each article independently; discrepancies were once again discussed and resolved by consensus (inter-rater agreement 88%, Cohen’s κ = 0.72).

2.4. Data Extraction

A modified extraction tool was created based on the Covidence Extraction 2.0 template. The first author completed data extraction on all 15 included studies; the second author checked the data extracted against the articles’ full text for accuracy. The following information was extracted: title, publication year, lead author contact details, country in which the study was conducted, other setting details (e.g., city, facility type), study aims and/or research questions, study design, population description, participant inclusion/exclusion criteria recruitment methods, number of participants (in total and in each group), baseline demographics (age, sex, drug(s) of choice), intervention description (content, duration, and data collection timing), intervention dates, target stigma construct, stigma scale/measure used, other primary outcomes, and main findings (impact on stigma and effect sizes where available).

2.5. Data Synthesis

A review of included studies revealed considerable heterogeneity regarding intervention length and design, outcome measures, participant characteristics, geographical and clinical setting, and study design. Consequently, we deemed meta-analysis inappropriate for this review. Data were reviewed, summarized, synthesized, and interpreted using narrative synthesis (Popay et al., 2006). We first categorized intervention approaches (i.e., psychotherapeutic, psychoeducational, multi-modal) and then synthesized design features and evidence of effectiveness within each category. Risk of bias was assessed using the Downs and Black (1998) checklist for methodological quality in randomized controlled trials and quasi-experimental studies. One item was modified (question 27 – 1 if a power calculation is provided, 0 if one is not provided). Studies were assigned a score from 0–28 and assessed a quality level based on cut-points reported elsewhere in the literature (Hooper et al., 2008): excellent (26–28), good (20–25), fair (15–19), poor (≤15). The first and second authors (AS and DC) reviewed articles independently and then resolved discrepancies by consensus.

3. Results

Our search yielded 1,195 studies after deduplication (Figure 1). 60 articles were assessed for eligibility in an independent full-text screen by the first and second authors. Reasons for exclusion were wrong study design (n=18, e.g., only qualitative evaluation reported), outcomes (n=11, e.g., HIV stigma), population (n=8, e.g., occasional drinkers), no published results (n=7, e.g., study protocols), and not including an intervention (n=2). In total, 15 studies were included in this review: 13 peer-reviewed journal articles and two doctoral dissertations. Study characteristics are presented in Table 1.

Figure 1.

Study Selection PRISMA Flow Chart

Table 1.

Characteristics and Findings from 15 Substance Use Self-Stigma Interventions

Author(s)	Study design	Setting	Population	Inclusion/exclusion criteria	Sample characteristicsa	Intervention description	Stigma outcome(s)	Measure(s)	Other primary outcomes	Main findings
Ali et al. (2017)	Comparison group with post-test only	Alexandria, Egypt	Inpatients in substance abuse treatment unit of psychiatric hospital	18 years or older, detoxified, able to read/write, no psychiatric disorders or suicidal ideations	N=165 (I: 87, C: 78) Mean age: 32.3 Male: 96% Substance(s) used: 'Chemical preparations' (80%), heroin (77%), cannabis (73%), alcohol (40%)	Expressive disclosure writing: 2 60-minute psychoeducation sessions and 5 consecutive days of 15-minute EDW sessions (comparator: TAU)	Self-stigma	Self-Stigma in Alcohol Dependence (64 items, modified by substituting 'alcohol dependence' with 'drug use', α=NR)	Depression and anxiety	No significant difference in self-stigma reduction between groups. Between-group difference in applying stigma to self subscale (Cohen's d = −0.6) became nonsignificant after adjusting for baseline covariates
Barré et al. (2023)	Comparison group with pre- and post-test	Southern France	Inpatient and outpatient service recipients for alcohol use disorder (AUD) from state-run addiction support centers	18 years or older, fluent in French, current or history of AUD, no cocaine or opiate dependence, not pregnant, not a dependent adult, no severe cognitive impairment or psychiatric disorders	N=92 (I: 34, C: 58) Median age: 50.4 Male: 68.5% Substance(s) used: Alcohol (100%)	Therapeutic patient education: 5 modules over 10 weeks. Each module includes 2–4 group workshops (120 minutes each). Topics include psychoeducation about addiction, coping skill-building, and learning to express feelings (comparator: TAU)	Anticipated and internalized stigma	Substance Use Stigma Mechanisms Scale (α=NR), Anticipated and Internalized Subscales (6 items each)	Alcohol-related harms	Reduction in internalized stigma at 6-month follow-up significantly greater in treatment group (adjusted regression coefficient: 15.9, p<0.05, 95%CI: 1.9, 29.8). No significant between-group difference in anticipated stigma
Belinn-Cerullo (2018)	Comparison group with pre- and post-test	Philadelphia, Pennsylvania, US	Patients in intensive outpatient program	NR	N=100 (I: 43, C 57) Age range: 21–30 (28.6%), 31–40 (35.7%), 41–50 (9.5%), 51–60 (23.8%), 61–70 (2.4%) Male: 67% Substance(s) used: NR	5-session course of neuroscience education including educational and practical (e.g., cognitive behavioral therapy, mindfulness, music therapy) components (comparator: psychoeducation, e.g., CBT, relapse prevention, coping skills, and mindfulness)	Stigma-related rejection	Stigma-Related Rejection Scale-Substance Abuse Version (9 items, α=0.79 from scale development, α=0.632 at time 1 and α=0.557 at time 2)	Relapse (self-report and toxicology screen)	Main effect for group (p=0.834), time (p=0.233), and group*time (p=0.215) were all nonsignificant
Emamghaisi & Atashpour (2020)	Randomized controlled trial	Isfahan, Iran	Meth users in residential treatment	20–45 years old, at least one year of methamphetamine use, no chronic conditions affecting mood/emotions, not participating in Narcotics Anonymous or related programs, elementary school education	N=38 (I: 18, C: 20) Age range: 20–30 (63%), 31–45 (37%) Male: 100% Substance(s) used: Methamphetamines (100%)	Acceptance and Commitment Therapy: 8 group sessions held twice weekly for 90 minutes each (comparator: TAU)	Internalized shame	Internalized Shame Scale (30 items, α=0.79)	Self-criticism	Significant reduction in shame at post-test (η2p=0.41, p=0.001) and one-month follow-up (η2p=0.24, p=0.005) compared with control group
Go et al. (2015)	Four-arm factorial randomized controlled trial	Thai Nguyen, Vietnam	People who inject drugs	All participants: 18 years or older, male, injected drugs in past 6 months. Index participants: HIV positive, had sex in past 6 months, planned to live in Thai Nguyen for next 2 years. Network participants: HIV negative	N=455 (Individual I: 95, Community I: 139, Both I: 132, C: 89) Mean age: 35.2 Male: 100% Substance(s) used: NR	Individual intervention: 2 individual counseling sessions (coping with stigma, social support, partner testing, disclosure) and 2 small group sessions (HIV knowledge and skill-building), Community intervention: 2-part video presentation and 6 HIV education sessions to community (comparator: standard-of-care - HIV testing and counseling at pre/post)	IDU-related stigma	Novel IDU-related stigma scale created for study (7 items, α=NR)	HIV risk behaviors (injecting equipment sharing, unprotected sex)	IDU stigma decreased by an average of 0.6 units (20% s.d.) between baseline and 24 months (uncalibrated p=0.002, calibrated p=0.063). No significant difference in IDU stigma across arms at 24-month follow-up
Gul & Aqeel (2020)	Randomized controlled trial	Pakistan	Inpatients in residential treatment program	18–35 years old, DSM-V diagnosis of SUD (except caffeine) of mild to moderate severity in early to sustained remission, in treatment for at least 2 months, no cognitive impairment that would obstruct participation	N=65 (I: 35, C: 300) Age: NR Male: 100% Substance(s) used: NR	Acceptance and Commitment Therapy: Up to 3 group sessions of 2 hours each (comparator: TAU)	Shame; enacted, anticipated, internalized stigma	Other as Shamer Scale (8 items, α=0.81); Substance Use Stigma Mechanisms Scale (18 items, α=0.60)	NR	Significant reductions in stigma (η2p=0.389, p=0.000) and shame (η2p=0.247, p=0.000) from pre to post and follow-up; significant between-group differences in stigma (η2p=0.153, p=0.000) and shame (η2p=0.166, p=0.000); significant group*time interactions for stigma (η2p=0.199, p=0.000) and shame (η2p=0.219, p=0.000)
Hernandez & Mendoza (2011)	One-group with pre- and post-test	Central California, US	Women in residential substance use treatment facilities	Enrolled in substance use treatment during the intervention, able to read and write English	N=19 Mean age: 36 Male: 0% Substance(s) used: Multiple substances (74%), methamphetamine (58%)	Connections: 12-week, 12-session group-based psychoeducational shame resilience curriculum	Internalized shame and perceived stigma	Internalized Shame Scale (24 items, α=0.95), Perceived Stigma of Addiction Scale (8 items, α=0.73)	Shame, guilt, blame self-talk	Significant reduction in internalized shame (z=−2.703, p=0.007). No significant change in perceived stigma (z=−1.242, p=0.214).
Luoma et al. (2012)	Randomized controlled trial	Reno, Nevada, US	Inpatients in residential treatment program	Diagnosis of substance abuse or dependence, not pending discharge, no cognitive impairment that would obstruct participation	N=134 (I: 68, C: 66) Mean age: 34 Male: 69% Substance(s) used: Alcohol (46%), methamphetamines (37%), marijuana (24%), cocaine (14%)	Acceptance and Commitment Therapy: 3 group sessions of 2 hours each (comparator: TAU)	Internalized shame	Internalized Shame Scale (24 items, α=0.97)	Treatment utilization, drug and alcohol use	Shame reduction in intervention group was small at post-test (Cohen's d=0.26, p=0.045) and moderate at 4-month follow-up (Cohen's d=0.66, p=0.000). Interaction of condition and time was significant (Cohen's d=0.38, p=0.03). Main effect of condition was non-significant (p=0.83).
Luoma et al. (2023)	Randomized controlled trial	St. Petersburg, Russia	People who inject drugs living with HIV	18 years or older, HIV positive by self-report, past 30-day injecting drug use, fluent in Russian, no cognitive impairments or acute severe psychiatric illness	N=100 (I: 67, C: 33) Mean age: 38.1 Male: 51% Substance(s) used: Street methadone (99%), prescription drugs (41%), cannabis (26%), amphetamines/ methamphetamines (21%)	Acceptance and Commitment Therapy adapted for intersectional HIV and substance use stigma: 3 weekly 2-hour group sessions (comparator: TAU – continued access to services at host harm reduction program)	Self-stigma	Substance Abuse Self-Stigma Scale (abbreviated from 40 to 12 items, α=NR)	Internalized HIV stigma, initiation of HIV care, engagement in substance use care, frequency of injection drug use	No significant difference in self-stigma change between intervention and control groups from baseline to 1-month (adjusted mean difference [AMD]=−2.18, p=0.11, 95%CI: −4.87, 0.52) or 6-month follow-up (AMD=1.40, p=0.31, 95%CI: −1.30, 4.00)
Maskay et al. (2018)	One group with pre- and post- test	6 sites in California, Connecticut, North Carolina, Oregon, and Texas, US	People living with HIV diagnosed with mental health or substance use disorders and experiencing homelessness	18 years or older, HIV positive, currently experiencing or at-risk for homelessness, previous or current SUD or mental illness	N=548 Mean age: 42.3 Male: 76% Substance(s) used: Cocaine (51%), alcohol (41%), amphetamines (33%), opiates (24%)	Patient-centered medical home framework: 1) navigators/care coordinators providing client-centered care, 2) expedited access and linkage to comprehensive HIV care, 3) behavioral health and primary HIV medical care, 4) partnerships with housing providers to enable access to stable housing (comparator: N/A)	Perceived external SUD stigma	Question adapted from Behavioral Risk Factor Surveillance System (respondents asked if they felt they were treated 1) better than, 2) same as, or 3) worse than people who are ‘clean and sober’)	Perceived external stigma related to HIV, homelessness, and mental health	Significant decrease in composite perceived substance use/mental health/homelessness stigma at 6-month vs. baseline (b=−0.24, 95%CI: −0.41, −0.08) and 12-month vs. baseline (b=−0.35, 95%CI: −0.52, −0.18)
Mateu-Gelabert et al. (2014)	One group with pre- and post- test	New York City, New York, US	People who inject drugs	18 years or older, injecting drugs for at least a year, visible track marks (to confirm injecting status)	N=68 Mean age: 32 Male: 66% Substance(s) used: NR	Staying Safe: 5 small group sessions of 2 hours each focused on safe injecting practices and upstream threats to safe injection, including stigma. (comparator: N/A)	Stigma management	Keeping It Together Scale (10 items, α=0.82)	Drug use, perceived control over drug use, injection risk behavior	Moderate increase in stigma management strategies (stochastic dominance effect size=0.69, p=0.002)
Mehel Tutuk & Budak (2023)	Randomized controlled trial	Istanbul, Turkey	Inpatients in alcohol and substance use treatment unit of private hospital	18 years or older, DSM-5 diagnosis of SUD, no other psychiatric diagnosis, no difficulties with communication, no previous experience with mindfulness programs	N=116 (I: 58, C: 58) Age range: 18–28 (46%), 29–39 (43%), 40 or older (11%) Male: 89% Substance(s) used: NR	Mindfulness-based psychoeducation: eight 40-minute group sessions, including mindfulness training, meditation exercises, and psychoeducation on SUD (comparator: TAU)	Internalized stigma	Internalized Stigma of Mental Illness Scale-Turkish (29 items, α=0.94)	Substance abuse proclivity	Significant between-group difference in internalized stigma at post (t=1.677, p<.05). Significant within-group change in internalized stigma from pre to post in intervention group (t=1.976, p<.05)
Silverman (2019)	Cluster randomized controlled trial	Midwestern US	Inpatients in hospital detoxification unit	Inpatient with SUD, able to read English	N=118 (I: 58, C: 60) Mean age: 37.1 Male: 54% Substance(s) used: Heroin (50%), alcohol (44%), prescription (8%), methamphetamine (<1%)	Therapeutic songwriting: single group session lasting 45 minutes, focused on co-writing a blues song challenging shame and guilt of substance use (comparator: TAU)	State shame	State Shame and Guilt Scale (15 items, α=0.89, 0.82, 0.87 for shame, guilt, pride subscales)	NR	No significant difference in shame between groups, small improvement in pride subscale compared with control (η2p=0.053, p=0.012)
Silverman (2020)	Cluster randomized controlled trial	Midwestern US	Inpatients in hospital detoxification unit	Inpatient with SUD, able to read English	N=132 (I: 70, C: 62) Mean age: 35.0 Male: 67% Substance(s) used: Heroin (44%), alcohol (42%), prescription (12%), crack cocaine (<1%)	Therapeutic songwriting: single group session lasting 45 minutes, focused on co-writing a blues song challenging stigma of substance use (comparator: TAU)	Perceived stigma	Perceived Stigma of Addiction Scale (8 items, α=0.73)	Perceived social support	No significant differences between groups in perceived stigma (p=0.763)
Verona (2020)	Randomized controlled trial	Western Pennsylvania, US	Inpatients in residential treatment facility	18 years or older, SUD diagnosis, ASAM 4 level of care	N=130 (I: 65, C: 65) Mean age: 49 Male: 51% Substance(s) used: Alcohol (55%), opiates (24%), cocaine/crack (15%), benzodiazepines (5%)	Self-forgiveness model: 6 individual counseling sessions over 1–2 weeks applying the six-step self-forgiveness model using psychoeducation and exercises completed between sessions (comparator: TAU)	Self-stigma	Substance Abuse Self-Stigma Scale (40 items, α=0.94)	Self-forgiveness	Reduction in self-stigma and all subscales significantly larger in intervention group (R2=0.30, p<.001)

NR: Not reported; N/A: Not applicable; TAU: Treatment as usual

^aOnly four most prevalent substances reported to conserve space

3.1. Study Designs and Methodological Quality

Among included interventions, nine were evaluated using randomized controlled trials (RCTs, 60%), including two cluster RCTs and one multi-arm factorial RCT. The remaining studies were quasi-experimental: Three used a non-randomized comparison group, and three used a single-group pre-post design. Overall study quality was moderate, with all 15 studies rated as fair (n=9) or good (n=6) on the Downs and Black [DB] checklist (Table 2; mean score: 18.7, range: 16–23). Studies were particularly prone to selection bias, as none reported random selection of participants from the sampling frame (DB #12), while lack of blinding to condition among participants and staff was noted in all but one study (DB #14, #15, #24), impacting internal validity.

Table 2.

Study Quality Appraisal Using the Downs & Black Checklist

Author(s)	Reporting (0–11)	External validity (0–3)	Internal validity - bias (0–7)	Internal validity - confounding (0–6)	Power (0–1)	Total score	Quality
Ali et al. (2017)	8	2	4	2	0	16	Fair
Barré et al. (2023)	8	1	5	1	1	16	Fair
Belinn-Cerullo (2018)	9	2	4	2	0	17	Fair
Emamghaisi & Atashpour (2020)	8	1	5	4	0	18	Fair
Go et al. (2015)	10	1	4	5	1	21	Good
Gul & Aqeel (2020)	8	1	7	5	0	21	Good
Hernandez & Mendoza (2011)	8	1	5	3	0	17	Fair
Luoma et al. (2012)	11	1	5	5	0	22	Good
Luoma et al. (2023)	11	0	5	5	1	22	Good
Maskay et al. (2018)	7	1	4	4	0	16	Fair
Mateu-Gelabert et al. (2014)	7	1	4	4	0	16	Fair
Mehel Tutuk & Budak (2023)	6	1	5	3	1	16	Fair
Silverman (2019)	10	2	5	5	1	23	Good
Silverman (2020)	9	2	5	5	1	22	Good
Verona (2020)	8	2	3	3	1	17	Fair

Quality ratings: Excellent (26–28), Good (20–25), Fair (15–19), Poor (≤15)

Most studies were conducted in the United States (60%, n=9), with the remainder carried out in the Middle East (n=3), South Asia (n=2), and Europe (n=2). All studies used a form of convenience sampling: 11 (73%) recruited from substance use treatment clinics, one from public health departments and healthcare delivery systems, and three from community settings using snowball sampling. The majority of studies recruited participants from a single site (67%, n=10). Among multi-site studies, two recruited from geographically diverse settings (i.e., multiple states or provincial subdistricts), while three studies invited participants from multiple clinics in the same geographical region or clinical network.

3.2. Study Samples

The 15 interventions included a total of 2,280 participants (median sample size = 116, range: 19–548). Two multi-site studies accounted for nearly half of the total sample size (n=1,003) (Go et al., 2015; Maskay et al., 2018). 14 study samples were predominantly male (range: 51–100%), with three including only males. One study recruited only women (Hernandez & Mendoza, 2011). Studies varied markedly with regard to participants’ drug use characteristics. About half did not restrict inclusion to users of particular substances (n=8); these eight studies included participants who used alcohol, while heroin/opioids, methamphetamine, and cocaine were also commonly reported. One study focused specifically on people who use methamphetamines (Emamghaisi & Atashpour, 2020), while another study was offered to people with alcohol use disorder (Barré et al., 2023). The remaining five studies did not report drug(s) of choice, although two of these were restricted to people who inject drugs. Participation was limited to adults in all interventions.

3.3. Study Measures

Studies varied markedly in stigma measures. Almost all studies used a previously validated self-report scale (n=14). However, scale validity is unclear in several studies: One study adapted its scale from an existing measure of alcohol self-stigma to capture substance use self-stigma more broadly (Ali et al., 2017), while another study incorporated only a single item from the original scale (Maskay et al., 2018). A third study used an abbreviated 12-item version of a 40-item scale, retaining three items with the highest factor loadings in each subscale (Luoma et al., 2023). Authors in the remaining study developed a 7-item scale de novo and did not provide information about validation (Go et al., 2015). There was substantial heterogeneity in measurement across interventions: Among the 11 scales used, only one (Internalized Shame Scale) was used in more than two studies (Emamghaisi & Atashpour, 2020; Hernandez & Mendoza, 2011; Luoma et al., 2012). Nearly all measures were attitudinal (e.g., stigma-related beliefs), although one was behavioral, capturing participants’ efforts to avoid or minimize stigma (e.g., hiding track marks) (Mateu-Gelabert et al., 2014). Stigma constructs captured in the measures included self-stigma, internalized stigma, anticipated stigma, enacted stigma, perceived stigma, stigma-related rejection, IDU-related stigma, stigma management, internalized shame, state shame, and external shame.

3.4. Stigma Reduction Approaches

3.4.1. Psychotherapeutic Approaches

Eight out of 15 studies used a psychotherapeutic approach to self-stigma reduction, providing individual or group psychotherapy sessions with trained counselors with the goal of modifying stigma-related attitudes and beliefs. Acceptance and Commitment Therapy (ACT) was utilized in four studies (Emamghaisi & Atashpour, 2020; Gul & Aqeel, 2020; Luoma et al., 2012, 2023). ACT is a therapeutic approach designed to improve patients’ psychological flexibility, or the ability to be in contact with unpleasant emotions, and emphasizes a commitment to actions that align with one’s chosen values rather than avoiding experiences that are perceived to cause distress (Hayes et al., 2006). ACT emphasizes cognitive defusion, or altering how one relates to one’s thoughts rather than treating them as distorted cognitions that need to be changed (Levin, Haeger, et al., 2018)

Luoma and colleagues (2012) delivered ACT in therapist-facilitated group sessions. Exercises focused on how shame and self-stigmatizing thoughts served as barriers to recovery, how these feelings can be defused and accepted rather than suppressed or avoided, and how mindfulness and acceptance can cultivate achievement of identified life values and goals. Gul and Aqeel (2020) also delivered ACT in a group setting using a culturally and linguistically adapted manual based on the approach of Eifert and Forsyth (2005). Therapists, psychologists, and an addiction counselor co-led sessions. The intervention included five modules (willingness, values, committed action, workability, defusion) and targeted both stigma and shame. Emamghaisi and Atashpour (2020) facilitated eight sessions of ACT for people who use methamphetamine based on the approach of Bond and colleagues (2011). Content was largely similar to the other ACT interventions. Finally, Luoma and colleagues (2023) delivered ACT to address intersectional HIV and substance use stigma in people who inject drugs. The approach was adapted from the first author’s previously evaluated ACT intervention for substance use stigma (Luoma et al., 2007, 2008) with input from community members and practitioners and was designed to improve stigma coping skills and subsequent utilization of HIV and substance use care. Trained psychologists delivered sessions, which included didactic content, activities, and homework assignments.

Verona (2020) aimed to reduce self-stigma by encouraging self-forgiveness in participants. Like ACT, the intervention was theoretically grounded in psychological flexibility. The intervention included six individual counseling sessions and homework exercises and was adapted from a self-forgiveness model and accompanying self-directed workbook originally developed by Griffin and colleagues (2017). The model includes six steps focused on identifying events that evoke regret, repairing relationships affected by the event, cultivating self-forgiveness and self-acceptance, and moving forward with a commitment to living by previously held values.

The remaining three psychotherapeutic interventions all employed a creative or expressive approach to stigma reduction (Ali et al., 2017; Silverman, 2019, 2020). Two cluster RCTs, both conducted by Silverman (2019, 2020), explored whether a therapeutic group songwriting session could reduce feelings of shame and perceived stigma, respectively. Facilitated by a music therapist, both interventions invited individuals on a hospital detoxification unit to co-write a song as a way of venting and restructuring their thoughts around these constructs. Ali and colleagues (2017) implemented an expressive disclosure writing (EDW) intervention for inpatients in a government psychiatric hospital in Egypt. Over two 60-minute sessions, participants received brief instruction in cognitive behavioral therapy (e.g., identifying and naming negative emotions). They then engaged in 15-minute EDW activities over five days, writing about a traumatic experience from their past. The authors theorized that through re-encountering negative experiences and restructuring their narrative around the events, participants could develop new, more positive self-evaluations and enhance their perceived control over stigmatizing situations.

3.4.2. Psychoeducational Approaches

Five of 15 studies employed a psychoeducational approach, providing participants with knowledge and skills pertaining to substance use and stigma (Barré et al., 2023; Belinn-Cerullo, 2017; Hernandez & Mendoza, 2011; Mateu-Gelabert et al., 2014; Mehel Tutuk & Budak, 2023). Belinn-Cerullo (2017) conducted a 5-session group-based neuroscience education intervention. The author contended that knowledge of the disease model of addiction would allow participants to revise their view of addiction as a medical issue rather than as a moral failure, ultimately reducing perceptions of stigma-related rejection. Participants learned about the biomedical basis of substance use dependence and were then presented with tools and resources (e.g., mindfulness, art therapy) they could use to manage distress in recovery.

The Staying Safe Intervention aimed to reduce injecting risk by promoting skills to address the upstream determinants of unsafe use, including stigma (Mateu-Gelabert et al., 2014). The five-session group-based intervention was grounded in Social Action Theory, emphasizing routinized systems of interlinked actions that drive sustainable behavior change. Participants learned about stigma as a determinant of unsafe injection and skills and strategies they could use to manage stigma (e.g., caring for injection wounds, distancing from other people who inject drugs [PWID]). These skills were modeled by peers then practiced by participants. In the last session, participants identified concrete steps they intended to take to manage stigma in the future.

Hernandez and Mendoza (2011) developed a novel 12-week, group-based psychoeducational curriculum to promote shame resilience among women in residential treatment. Participants developed critical awareness of their shame triggers, learned how to manage these emotions, practiced empathy and self-compassion, identified personal strengths, and spoke out about their experiences. This empowerment-based intervention was tailored to address the unique cultural expectations of women who use drugs (e.g., mothers, caregivers). Sessions included didactic videos, group discussions, homework, and review of weekly readings.

Barré and colleagues administered a therapeutic patient education (TPE) intervention to reduce stigma and alcohol-related harms in outpatients with alcohol use disorder by emphasizing agency and control over drinking rather than abstinence. Comprised of five modules with two to four small-group sessions each, the intervention aims to educate participants on alcohol use triggers, developing personalized controlled-drinking strategies, identifying problematic thoughts and emotions, cultivating self-observation skills, and expressing feelings with important others. The program was co-designed and co-facilitated by peer educators.

The eight-session mindfulness-based psychoeducation curriculum used by Mehel Tutuk & Budak (2023) emphasized improving emotional regulation and learning to notice, accept, and cope with distressing feelings. The intervention included practice in several forms of meditation and weekly instruction on cultivating judgment-free awareness of difficult emotions (S.P. Mehel Tutuk, personal communication, June 14, 2023).

3.4.3. Multi-Modal Approaches

Two interventions used multiple complementary strategies to reduce self-stigma (Go et al., 2015; Maskay et al., 2018). Though both included psychotherapeutic/psychoeducational components, they were also notable for addressing social-structural determinants of stigma as well. Go and colleagues’ (2015) four-arm factorial multi-site RCT evaluated individual, community, and combined individual-community interventions against the standard of care in PWID living with HIV/AIDS (PLWHA). The individual intervention included two counseling sessions on coping with stigma and two group sessions focused on knowledge, skill-building, and social support. In the community condition, a 2-part video presentation and 6 education sessions were presented to community members to challenge myths surrounding PLWHA and PWID. Finally, Maskay and colleagues (2018) hypothesized that providing multiple client-centered medical care and support services would reduce participants’ perceptions and fear of external stigma). Activities included care coordination and navigation, behavioral health services, and primary medical care. Notably, none of the activities were designed to reduce stigma directly per se, instead focusing on building trust, addressing unmet needs, and reducing barriers to care.

3.5. Outcomes and Effectiveness

Overall, six studies showed significant favorable effects in all reported stigma-related outcomes, including four RCTs (Emamghaisi & Atashpour, 2020; Gul & Aqeel, 2020; Mehel Tutuk & Budak, 2023; Verona, 2020) and two quasi-experiments (Maskay et al., 2018; Mateu-Gelabert et al., 2014). Five studies showed significant improvements in some, but not all, outcomes (three RCTs, two quasi-experiments). Of these, three studies demonstrated improvements in at least one scale or subscale but not others (Barré et al., 2023; Hernandez & Mendoza, 2011; Silverman, 2019), while two demonstrated significant main effect of time and/or group-by-time interaction effects but non-significant main effects of condition (Go et al., 2015; Luoma et al., 2012). Finally, two RCTs (Luoma et al., 2023; Silverman, 2020) and two quasi-experiments (Ali et al., 2017; Belinn-Cerullo, 2017) showed no favorable results in any of the stigma measures. Evidence was especially weak for perceived and anticipated stigma, with only Maskay et al.’s (2018) single-item measure capturing significant changes among five studies measuring these constructs (Barré et al., 2023; Belinn-Cerullo, 2017; Hernandez & Mendoza, 2011; Silverman, 2020)

Evidence for effectiveness of psychotherapeutic approaches was mixed. Three of four ACT interventions demonstrated significant moderate improvements in shame and/or stigma; in each study, effects were attenuated but remained significant at long-term follow-up (1–4 months) (Emamghaisi & Atashpour, 2020; Gul & Aqeel, 2020; Luoma et al., 2012, 2023). Verona’s (2020) self-forgiveness intervention, which included elements of ACT, also had strong effect sizes for the full scale and all subscales. However, therapeutic interventions emphasizing creative modalities like writing and songwriting were generally ineffective, with none reporting significant main effects (Ali et al., 2017; Silverman, 2019, 2020). Notably, these interventions were short (e.g., single session or multiple brief sessions) as compared with the ACT and self-forgiveness models. Among psychoeducational approaches, the Staying Safe Intervention demonstrated significant moderate improvements in stigma management strategies (Mateu-Gelabert et al., 2014), as did the mindfulness-based and shame resilience interventions on internalized stigma and shame, respectively (Hernandez & Mendoza, 2011; Mehel Tutuk & Budak, 2023). Barré et al.’s (2023) controlled-drinking program notably recorded reductions in internalized stigma at 6-month follow-up. Meanwhile, Belinn-Cerullo’s (2018) neuroeducation intervention had no significant impact on self-stigma (the authors note that internal reliability of the scale in the sample was quite low: time 1 α=0.63, time 2 α=0.56). Both multi-modal interventions demonstrated reductions in self-stigma (Go et al., 2015; Maskay et al., 2018), although in the Go et al. study, these reductions became marginally non-significant (p=0.06) after calibrating for differences in mortality rates between intervention arms and across data collection time points.

4. Discussion

Our review identified 15 published studies that evaluated interventions to reduce self-stigma in people who use drugs, marking a notable increase in such studies since Livingston et al.’s (2012) review of SUD stigma interventions a decade prior. That 10 of these studies were published after 2018 points to a growing interest in self-stigma as a target for improving psychosocial health in PWUD. Our review noted several psychotherapeutic, psychoeducational, and multi-modal approaches used in a variety of settings and populations. The heterogeneity of study designs, populations, and outcome measures precluded us from synthesizing effect sizes in a meta-analysis. Nonetheless, 11 studies demonstrated some evidence of effectiveness, a promising indication that self-stigma could be a complementary piece of the SUD stigma reduction toolkit.

4.1. Implications and Limitations of Included Studies

4.1.1. Intervention Approaches

We categorized interventions into three main approaches: psychotherapeutic, psychoeducational, and multi-modal. Psychotherapeutic approaches were the most common strategy, appearing in eight of 15 interventions. Psychotherapy relies on communication with a trained therapist to uncover adaptive explanations for recurring personal problems and develop healthier thoughts, emotions, and behaviors (Wampold, 2007). Acceptance and Commitment Therapy (ACT) was evaluated in four studies (Emamghaisi & Atashpour, 2020; Gul & Aqeel, 2020; Luoma et al., 2012, 2023), while Verona (2020) also incorporated elements of ACT into their self-forgiveness intervention. Participants in four of five studies experienced significant reductions in self-stigma. The exception was Luoma’s (2023) ACT intervention in Russia, where the authors note substance use stigma is particularly pervasive and stigmatizing attitudes are resistant to change (S. E. Burke et al., 2015; Vetrova et al., 2021, 2022). Notably, ACT was effective at doses as low as 3–6 hours (Gul & Aqeel, 2020). ACT is premised on improving clients’ psychological flexibility, or their ability to stay in contact with the present moment, accepting and moving through difficult memories and emotions as they arise rather than attempting to change them (i.e., cognitive defusion) (Hayes et al., 2006; Ruiz, 2012). In contrast, the three arts-based studies used elements of cognitive-behavioral therapy (CBT) (Ali et al., 2017; Silverman, 2019, 2020), which is premised on identifying and changing distorted patterns of thinking (i.e., cognitive restructuring) (Deacon et al., 2011). For instance, Silverman (2020) used music therapy to encourage clients to identify shame as a cognitive distortion and shift such feelings to pride instead. None of the three interventions was effective, although each was relatively brief (<2 hours), limiting inferences about CBT as a self-stigma reduction practice more generally. Nonetheless, that four of five studies incorporating ACT demonstrated effectiveness lends promise to this approach for PWUD. Substance use stigma is pervasive in US society (Crapanzano et al., 2014), and it may prove more useful for PWUD to accept and move through inevitable encounters with stigmatizing thoughts and feelings rather than attempt to challenge these cognitions in the face of constant social reinforcement. Such an approach is in line with a push for more consciousness-raising and empowerment in the mental illness self-stigma literature (Mittal et al., 2012).

None of the 15 studies included an SUD disclosure component, although one study incorporated HIV disclosure counseling (Go et al., 2015) and another facilitated private self-disclosure through expressive writing (Ali et al., 2017). Disclosure is a common component of many HIV/AIDS and mental illness self-stigma interventions (Ma et al., 2019; Rüsch & Kösters, 2021; Talluri & Corrigan, 2022). Disclosure can engender a sense of empowerment and ease the burden of keeping one’s stigmatized condition a secret (Bos et al., 2009; Corrigan & Rao, 2012). After disclosure, trusted others may further serve as sources of social support as one copes with one’s condition (Chaudoir et al., 2011). Written expressive disclosure (WED) was ineffective in reducing self-stigma in Ali et al. (2017). Participants in the intervention were not expected to share their writing with others. Although private disclosure can help individuals access difficult feelings and integrate them into their self-narrative, shared disclosure generally leads to greater improvements in mental and physical health (Radcliffe et al., 2010). Honest, Open, Proud (HOP) is one evidence-based program from the mental illness literature that reduces self-stigma and stigma stress in the short-to-medium term (Rüsch & Kösters, 2021). HOP has been suggested as a stigma reduction strategy for PWUD, although we found no published trials in our review (Talluri & Corrigan, 2022). Importantly, HOP offers guidance on making selective disclosure-related decisions, acknowledging that deciding when and with whom to share one’s condition is a balancing act between maximizing social support and minimizing enacted stigma (Bos et al., 2009; Rüsch & Kösters, 2021). For instance, disclosing substance use to an employer may lead to workplace discrimination, whereas the risks may be different when disclosing to a friend or family member (Corrigan et al., 2017). The Staying Safe intervention, which promoted strategies like hiding track marks to avoid stigma from the public, illustrates how concealing one’s PWUD identity may prove helpful in contexts where disclosure is unlikely to be beneficial (Mateu-Gelabert et al., 2014).

4.1.2. Populations and Settings

There was high homogeneity across studies in participant gender, as all populations but one were majority male (Hernandez & Mendoza, 2011), and three studies included only males. Illicit drug use prevalence is higher globally in men than women, although this gap is narrowing (McHugh et al., 2018). Women and men likely experience stigma differently, and women who use drugs are more likely to indicate perceived stigma as a barrier to seeking treatment (Agterberg et al., 2020). Different stigma reduction approaches may be appropriate for men and women who use drugs. For instance, disclosure may have more positive health benefits for women than men (Geary et al., 2014). More research is needed to differentiate intervention efficacy across gender identities and to explore gender preferences for intervention content.

Likewise, 11 of the 15 interventions recruited PWUD from substance use treatment in in-patient or intensive outpatient settings. Treatment facilities are feasible and practical venues for engaging PWUD in intervention research. Patients are often receptive to participating, as they are already engaged in ongoing behavioral programming, and the length of stay – typically several weeks – improves the likelihood of retention (Smyth et al., 2005). However, 94% of people with SUD are not engaged in treatment in a given year, indicating a notable gap in reach to those in active use (Substance Abuse and Mental Health Services Administration, 2022). Self-stigma is a barrier to treatment-seeking, so those who may be best served by self-stigma reduction initiatives may not have equitable access (Benz et al., 2021; Hammarlund et al., 2018; von Hippel et al., 2018). Further, the multi-session, group-based interventions that demonstrated effectiveness in this review may not be appropriate for PWUD in community settings: Barriers like time, transportation, and lack of trust preclude engagement among many prospective participants, and recruitment and retention remain challenges in community-based studies (Bonevski et al., 2014; Hetrick et al., 2021; Mills et al., 2020). Harm reduction programs, which often have high legitimacy and trust among PWUD, may be appropriate recruitment venues (Treloar et al., 2016), though like treatment settings, may not generalize to PWUD not formally engaged in services. Among included studies, only two recruited participants from harm reduction programs (Luoma et al., 2023; Mateu-Gelabert et al., 2014). Snowball sampling from index participants, used by Mateu-Gelabert et al. (2014) and Go et al. (2015), is one potential tactic for recruiting PWUD not formally engaged in substance use-related services. More advanced snowball sampling approaches that can simulate random selection and improve generalizability (e.g., respondent-driven sampling) are also available to use in this population (Abdul-Quader et al., 2006).

4.1.3. Intervention Delivery

All studies in our review involved face-to-face contact with providers, and 13 of 15 studies included a group component. Being in a group can help participants feel less alone and more connected to others facing similar stigma-related feelings and experiences (Drapalski et al., 2021). Group work can also promote empowerment and foster peer support, which researchers have noted are important components of the stigma reduction agenda moving forward (Corrigan & Nieweglowski, 2018; Kundert & Corrigan, 2022; Ma et al., 2019). Nonetheless, group-based interventions may not be appropriate for all PWUD. Participating in a group requires disclosing one’s identity, and many PWUD may avoid situations where disclosure poses a risk for judgement or discrimination (Newbold et al., 2013; Papamihali et al., 2020; Pearce et al., 2020). Interventions requiring minimal interpersonal contact may complement the group-based interventions identified in this study. Self-help interventions can be effective, health-enhancing alternatives for those afraid of encountering stigma from service providers or peers (Levin, Krafft, et al., 2018). Mills et al. (2020) identified eight self-help intervention studies addressing mental health self-stigma. These interventions delivered psychoeducational or psychotherapeutic content through interactive web-based modules or printed workbooks, demonstrating some preliminary evidence of effectiveness. One recent pilot study used automated text messages to target mental health self-stigma (King et al., 2022), an approach that may translate for PWUD, who have deemed text messaging an acceptable way to participate in research and to receive health education (Kmiec & Suffoletto, 2019; Schwebel & Larimer, 2020; Sugie, 2018).

None of the 15 studies were peer-facilitated. Peer-led interventions have demonstrated reductions in self-stigma and improvements in empowerment and self-efficacy in the mental health literature (E. Burke et al., 2019; Sun et al., 2022). Experts argue that peers can help challenge the imposed roles and stereotypes of the stigmatized identity, convey empathy rather than pity, and promote a sense of belonging and community among those with similar life experiences (L. D. Brown, 2009; Vayshenker et al., 2016). Peer-led interventions may encourage positive self-appraisal and identity transformation, as participants reevaluate themselves as worthy and capable (L. D. Brown, 2009). Emerging evidence in the substance use literature suggests that peer supporters can promote positive social identity and assist in overcoming stigma-related barriers to treatment (Anvari et al., 2022; Brener et al., 2021). Still, some peer-facilitated efforts, including 12-step recovery programs, may exacerbate self-stigma by promoting negative self-appraisals and prohibiting evidence-based practices like medications for opioid use disorder (Andraka-Christou et al., 2022; McGovern et al., 2022). Future research should investigate the role of peers in delivering self-stigma interventions while being mindful of the different recovery philosophies that peers may bring to this work.

4.1.4. Study Design

Inconsistency in the design and evaluation of included studies limits our ability to make comparative assessments of effectiveness. Importantly, only one self-stigma measure (Internalized Shame Scale) was used in more than two studies. It is well known that self-stigma lacks conceptual clarity in the literature, and various overlapping constructs – especially internalized stigma, but also others like perceived and felt stigma – are used interchangeably, though they may be conceptually distinct (Link & Phelan, 2001; Livingston & Boyd, 2010; Semegni et al., 2021; Stangl et al., 2019). For instance, six studies measured perceived or anticipated stigma, with only one intervention demonstrating improvements in these constructs (Maskay et al., 2018). This may be a case of Type III error: the selection of inadequate measures, rather than the intervention itself, could have influenced the nonsignificant findings (Green & Tones, 1999). That is, interventions may be less likely to change PWUD beliefs about the existence of public stigma (e.g.., perceived or anticipated stigma) than their dispositions to internalize, react to, or cope with this stigma (e.g., internalized stigma, shame, stigma management).

Measurement presents a particular challenge to substance use self-stigma, as many instruments have been adapted from the mental health literature without insight from PWUD (Semegni et al., 2021). Luoma et al.’s (2013) Substance Abuse Self-Stigma Scale (SASSS) is the only self-stigma total-scale identified in this review developed for and validated with PWUD. Among included studies, only Verona (2020) used the full SASSS, where it demonstrated high internal consistency reliability (α=0.94), while Luoma et al. (2023) used an abbreviated version of the scale. The SASSS casts a broader nomological net than other self-stigma measures, capturing both its attitudinal and experiential components across four subscales, and could be considered a measurement standard moving forward. Either way, interventionists should strongly consider reviewing the literature and selecting measures that have been used in similar interventions, settings, and populations. This will ensure that like studies can be compared and the nascent evidence base for effectiveness can be grown.

4.2. Limitations of the Review

This systematic review should be interpreted in light of a few methodological limitations. We employed a comprehensive search strategy due to the limited literature base and thus encountered heterogeneity in the included studies regarding study designs, populations, settings, and measures. Our search thus provides an exhaustive synopsis of intervention approaches at the expense of some comparability across studies. We included only studies published since Livingston et al.’s (2012) review, and we cannot discount the possibility that the authors’ search strategy failed to capture relevant self-stigma interventions published before 2011 that are by extension missing in our review. We also excluded studies published in languages other than English, indicating our review may have missed studies published in other languages.

The delineation between psychotherapeutic and psychoeducational interventions – a distinction drawn in previous systematic reviews (Ma et al., 2019) – may be somewhat artificial. Psychoeducation often includes behavioral counseling or skill-building in cognitive-behavioral techniques, while group psychotherapy sessions may incorporate didactic lessons, homework assignments, and other educational components (Cummings & Cummings, 2008). These categories are nonetheless helpful in differentiating between approaches that favor imparting knowledge and skills and those that actively address thoughts and beliefs through therapeutic means.

Finally, the studies in this review may not be fully representative of the diversity of approaches currently being developed, implemented, and evaluated. We screened and rejected multiple intervention studies that were evaluated using qualitative data or included an intervention protocol that had not yet been evaluated (see, for example, Moore et al., 2023 and Nguyen & Bellhouse, 2022). Given the accelerating frequency of self-stigma reduction trials in the past decade, we advise that this systematic review should be replicated in the next three to five years.

5. Conclusions

We identified 15 interventions targeting self-stigma in PWUD, filling an important gap in the literature. Two recent systematic reviews documented only public stigma interventions (Bielenberg et al., 2021; Tostes et al., 2020); our review highlights that, in line with other conditions like HIV/AIDS and mental illness, efforts are also underway to provide PWUD resources to reduce, resist, or cope with the stigma of substance use. The evidence in this review, though promising, is not robust or consistent enough to warrant recommending a specific approach, nor to draw inferences about effectiveness along demographic lines. Our review nonetheless offers several clear directions for future research. Researchers evaluating self-stigma interventions should strive for consistent measurement, employing self-stigma instruments validated for PWUD rather than those adapted from other conditions or those measuring constructs that are imperfect proxies, like perceived stigma. The psychological processes underlying self-stigma reduction warrant further study, particularly in therapeutic settings. Cognitive restructuring, which underlies CBT, and cognitive defusion, a hallmark of ACT, are dissimilar processes for addressing self-stigmatizing thoughts. Previous studies have compared the effectiveness of these techniques to reduce self-criticism and other self-referential cognitions (Deacon et al., 2011; Levin, Haeger, et al., 2018); however, to our knowledge, their comparative effectiveness has not been explored in substance use self-stigma. Researchers may also look toward the HIV/AIDS and mental health literatures for stigma reduction approaches that may be appropriate for PWUD (Ma et al., 2019; Mittal et al., 2012; Yanos et al., 2015). We highlight disclosure as one promising method missing from the substance use literature; other evidence-based approaches, like narrative enhancement and cognitive therapy (NECT), could be adapted from mental health contexts (Hansson et al., 2017; Yanos et al., 2011). Self-help options, especially mHealth interventions, may also be helpful to serve PWUD reluctant to engage in group work (Mills et al., 2020). Finally, we note that most interventions are available only in clinical settings, though the vast majority of PWUD are not formally engaged in treatment. From both an equity and population health perspective, current research is failing to serve those most in need of stigma reduction resources. Researchers should strongly consider community-based settings for future intervention studies.

Appendix A: Systematic Review Protocol

Title: Interventions to Reduce Self-Stigma in People Who Use Drugs: A Systematic Review

Brief background:

Stigma is recognized as a key barrier to treatment and harm reduction seeking and retention among people who use drugs (PWUD). Much research has been dedicated to developing and evaluating substance use stigma reduction strategies. To date, the majority of evaluated interventions have targeted those who perpetrate stigma – e.g., the general public or specific stakeholder groups like treatment providers and law enforcement officials. However, less is known about strategies that address PWUDs’ perceptions, experiences of, responses to, and internalization of substance use stigma. In this systematic review, we aim to identify the effectiveness of self-stigma reduction interventions targeting PWUD.

Research questions:

1. What is the effectiveness of self-stigma reduction interventions among people who use drugs?

2. What are the characteristics (i.e., design features, approaches) of self-stigma reduction interventions among people who use drugs?

3. How does effectiveness vary by context (e.g., treatment facility vs. syringe exchange program) and population (e.g., people in recovery vs. people in active use)?

Study dates:

January 1, 2011 – present (since literature search of Livingston et al. 2012, the most recent substance use stigma intervention systematic review that included self-stigma interventions)

Databases:

PubMed, PsycInfo (EBSCO), CINAHL (EBSCO), Social Work Abstracts (EBSCO), Sociological Abstracts (ProQuest), Dissertations & Theses (ProQuest), SCOPUS, and government databases (e.g., SAMHSA, CDC, NIDA).

Inclusion criteria:

Interventions must include self-stigma or a dimension of self-stigma (e.g., stigma resistance) related to substance use as a primary or secondary outcome. Intervention recipients must be people who use drugs, including those with substance use disorders and those in treatment for substance use disorders. Randomized controlled trials, quasi-experiments, and pre-post designs are included. Study must be published in English.

Exclusion criteria:

Studies targeting public stigma, studies with a pre-experimental design, studies targeting stigma relating to another condition or identity among people who use drugs (e.g., HIV-related stigma), observational studies.

Search strategy:

PubMed (TIAB – title and abstract):

(“self-stigma” or “self stigma” or “internalized stigma” or “stigma resistance” or “perceived stigma” or “experienced stigma” or “experiences of stigma” or “anticipated stigma” or “perceptions of stigma” or “internalized discrimination” or “internalized prejudice” or “internalized stereotypes” or “internalization” or “internalized stigma” or “fear of stigma” or “perceived devaluation” or “shame” or “coping with stigma” or “stigma-related coping” or “fear of discrimination” or “anticipated discrimination” or “felt stigma” or “imagined stigma” or “Substance Use Stigma Mechanism Scale” or “Internalized Stigma of Mental Illness Scale” or “Perceived Stigma of Addiction Scale” or “King’s Stigma Scale” or “King Stigma Scale” or “Substance Abuse Self-Stigma Scale” or “Stigma-Related Rejection Scale” or “Active Coping with Stigma Scale”)

AND (“intervention” or “trial” or “pilot” or “program” or “experiment” or “experimental” or “feasibility study” or “therapy” or “training” or “treatment” or “educational” or “effectiveness” or “efficacy” or “workshop” or “support group”)

AND (“alcohol use” or “alcoholism” or “alcohol misuse” or “alcohol abuse” or “opioid” or “opiate” or “methamphetamine” or “substance use” or “substance misuse” or “substance abuse” or “drug use” or “drug misuse” or “drug abuse” or “substance dependence” or “drug dependence” or “addiction” or “SUD” or “OUD” or “MAT” or “medication assisted treatment” or “medication assisted therapy” or “MOUD” or “methadone” or “suboxone” or “use disorder” or “who use drugs” or “who inject drugs”)

NOT (“schizophrenia” OR “psychosis” OR “epilepsy” OR “autism”)

SCOPUS (TITLE-ABS-KEY – title, abstract, keywords):

((perceive* OR anticipat* OR internaliz* OR interanlis* OR self OR coping OR resilience OR resistance OR felt OR imagined) W/4 stigma*) or (“Substance Use Stigma Mechanism Scale” or “Internalized Stigma of Mental Illness Scale” or “Perceived Stigma of Addiction Scale” or “King’s Stigma Scale” or “King Stigma Scale” or “Substance Abuse Self-Stigma Scale” or “Stigma-Related Rejection Scale” or “Active Coping with Stigma Scale”)

AND (“intervention” or “trial” or “pilot” or “program” or “experiment” or “experimental” or “feasibility study” or “therapy” or “training” or “treatment” or “educational” or “effectiveness” or “efficacy” or “workshop” or “support group”)

AND (“alcohol use” or “alcoholism” or “alcohol misuse” or “alcohol abuse” or “opioid” or “opiate” or “methamphetamine” or “substance use” or “substance misuse” or “substance abuse” or “drug use” or “drug misuse” or “drug abuse” or “substance dependence” or “drug dependence” or “addiction” or “SUD” or “OUD” or “MAT” or “medication assisted treatment” or “medication assisted therapy” or “MOUD” or “methadone” or “suboxone” or “use disorder” or “who use drugs” or “who inject drugs”)

AND NOT (“schizophrenia” OR “psychosis” OR “epilepsy” OR “autism”)

ProQuest (NOFT – no full text)

((perceive* OR anticipat* OR internaliz* OR interanlis* OR self OR coping OR resilience OR resistance OR felt OR imagined) NEAR/4 stigma[*7]) or (“Substance Use Stigma Mechanism Scale” or “Internalized Stigma of Mental Illness Scale” or “Perceived Stigma of Addiction Scale” or “King’s Stigma Scale” or “King Stigma Scale” or “Substance Abuse Self-Stigma Scale” or “Stigma-Related Rejection Scale” or “Active Coping with Stigma Scale”)

AND (“intervention” or “trial” or “pilot” or “program” or “experiment” or “experimental” or “feasibility study” or “therapy” or “training” or “treatment” or “educational” or “effectiveness” or “efficacy” or “workshop” or “support group”)

AND (“alcohol use” or “alcoholism” or “alcohol misuse” or “alcohol abuse” or “opioid” or “opiate” or “methamphetamine” or “substance use” or “substance misuse” or “substance abuse” or “drug use” or “drug misuse” or “drug abuse” or “substance dependence” or “drug dependence” or “addiction” or “SUD” or “OUD” or “MAT” or “medication assisted treatment” or “medication assisted therapy” or “MOUD” or “methadone” or “suboxone” or “use disorder” or “who use drugs” or “who inject drugs”)

NOT (“schizophrenia” OR “psychosis” OR “epilepsy” OR “autism”)

EBSCO (AB – abstract):

((perceive* OR anticipat* OR internaliz* OR interanlis* OR self OR coping OR resilience OR resistance OR felt OR imagined) N4 stigma*) or (“Substance Use Stigma Mechanism Scale” or “Internalized Stigma of Mental Illness Scale” or “Perceived Stigma of Addiction Scale” or “King’s Stigma Scale” or “King Stigma Scale” or “Substance Abuse Self-Stigma Scale” or “Stigma-Related Rejection Scale” or “Active Coping with Stigma Scale”)

AND (“intervention” or “trial” or “pilot” or “program” or “experiment” or “experimental” or “feasibility study” or “therapy” or “training” or “treatment” or “educational” or “effectiveness” or “efficacy” or “workshop” or “support group”)

AND (“alcohol use” or “alcoholism” or “alcohol misuse” or “alcohol abuse” or “opioid” or “opiate” or “methamphetamine” or “substance use” or “substance misuse” or “substance abuse” or “drug use” or “drug misuse” or “drug abuse” or “substance dependence” or “drug dependence” or “addiction” or “SUD” or “OUD” or “MAT” or “medication assisted treatment” or “medication assisted therapy” or “MOUD” or “methadone” or “suboxone” or “use disorder” or “who use drugs” or “who inject drugs”)

NOT (“schizophrenia” OR “psychosis” OR “epilepsy” OR “autism”)

Additional planned search strategies:

Articles passing title/abstract screen will be reference harvested and forward citation searched in Google Scholar.