Table 1.

Summary of characteristics of included qualitative publications

Study	Country	Participants	Relevant constructsa	Design	Analysis approach	Outcome(s)	Relevant results
Frank (2011)15	United States	N=16 heroin addicts Sex: 56% male	Perceived social stigma Self-stigma	Cross-sectional In MMT or 12-step treatment	Critical discourse analysis, with QSR’s NVivo 8 software	MMT participation	Current heroin users not seeking MMT cited stigma against programs that do not promote abstinence only as a reason not to seek MMT treatment and reported feeling socially superior to those in MMT. Those who were currently in MMT also reported this stigma and felt that this made it more difficult to continue to participate in the program.
Hill and Leeming (2014)16	England	N=6 people with AUD Age range: 40–75 years Sex: 50% female	Perceived social stigma Self-stigma (shame and blame)	Cross-sectional In AA treatment at least 5 years	Interpretative phenomenological analysis	Abstinence from alcohol	Participants felt unfairly judged and blamed by others for their alcoholism and had internalized images of an alcoholic as a poorly educated, unhygienic person in poverty. They felt others would judge them as lacking in willpower and morals even after years of abstinence. Despite this negative view of the “alcoholic,” all felt accepting this label was crucial to recovery. In order to accept this label, individuals had to see it as an indication of self-awareness rather than social deviance.
Brooks (1996)17	United States	N=11 individuals with SUD Age range: 25–70 years Sex: 100% female Race/ethnicity: 55% Anglo	Perceived health care provider stigma Self-stigma (shame and self-doubt)	Cross-sectional Post-treatment	Grounded theory approach with open and axial coding	Treatment completion	Successful recovery was a result of connecting with both treatment and the self. Perceived health care provider stigma interfered with connection to treatment, whereas self-stigma (ie, shame and self-doubt) interfered with connection to the self. In this way, both perceived and self-stigma interfered with recovery.
Grønnestad and Sagvaag (2016)18	Norway	N=25 people in the illicit drug scene Age: mean = 40 years Sex: 72% male	Perceived social stigmatization of identity Self-stigma	Ethnographic over 3 years History of treatment attempts	Thematic structured analysis	Continued opioid maintenance therapy	Participants reported strong social stigma that led to social exclusion once their addict status was known. This social exclusion included decreased expectations from others that were internalized, resulting in self-stigmatization and a desire to stay in the drug culture, where they felt accepted. Those in treatment perceived their involvement in the program as satisfying to others (ie, treatment providers), but not personally satisfying as they continued to feel marginalized by family and social structures.
Sanders et al (2013)19	United States	N=19 patients in MMT Age range: 29–60 years Sex: 53% Race/ethnicity: 47% White Hispanic, 26% White non-Hispanic, 11% Black Hispanic, and 11% Black non-Hispanic	Perceived social stigma (extrinsic factors) Self-stigma (intrinsic factors)	Cross-sectional In MMT treatment	Thematic analysis, using Nvivo 9 software	Ideal methadone dose	Both social and self-stigma caused patients to feel that their “ideal dose” was lower than the current dose, regardless of objective metrics. They felt that accidentally getting high off of methadone was “disgusting” and that there was a danger of methadone becoming a new drug habit to replace the old. Some had arbitrary yet firm ideas that some dosages were simply too high and hard to wean off of. They also felt that individuals on these “high” doses were “crazy, greedy, or abusive.”
Radcliffe and Stevens (2008)20	England	N=53 people with SUD Age: range 19–50 years Sex: 74% male Race/ethnicity: 75% White, 8% Black	Shame	Cross-sectional Dropped out of drug treatment	Adaptive coding	Engagement in treatment services	First treatment encounters triggered self-stigma in users who had not previously considered themselves “junkies.” Being seen accessing treatment, segregated in pharmacies, and supervised during use were seen as humiliating and stigmatizing. Participants sought to avoid these circumstances as a result of this stigma. Thus, both social and self-stigma led to treatment dropout.
McCallum et al (2016)21	Australia	N=34 people with AUD Age: mean = 44.25 years (SD = 10.92) Sex: 65% male Race/ethnicity: 97% Caucasian	Perceived health care provider stigma Self-stigma (shame and guilt)	Cross-sectional In treatment	Framework analysis	Desire to continue treatment	Participants who felt that staff were judgmental felt more shame and guilt for their addiction, whereas participants who felt that staff were understanding of them said that this good relationship with staff helped motivate them to continue to abstain from alcohol.
Pauly et al (2016)22	Canada	N=7 people with AUD Age range: 25–61 years Sex: 57% male Race/ethnicity: 100% indigenous	Perceived health care provider stigma	Longitudinal In “managed alcohol” treatment program	Coded inductively and a constant comparative analysis approach was used	Desire to remain in the program	The program gave participants a sense of safety, community, and a reported increased quality of life compared to life in jail, streets, shelters, or hospitals. The positive attitudes of staff contributed to the decision to remain in the program. They saw the housing provided in the program as “home.”
Tang (2015)23	China	N=13 current MMT clients and 18 dropouts Age range: 29–51 years Sex: 84% male	Perceived social stigma Self-stigma	Cross-sectional In MMT treatment or dropped out of MMT	Analyzed using ATLAS.ti v5.0 software in Chinese	Reasons to quit MMT	Self-stigma was reported as a fear of becoming addicted to the methadone and opposition to using MMT long-term, whereas social stigma was discussed in the form of societal discrimination. Stigma was not experienced from MMT staff, but registering to use MMT was associated with structural discrimination from police. Although all these forms of stigma were mentioned, no dropout cited stigma as a reason to leave MMT treatment. All dropouts had several reasons to quit.

Note:

^aConstruct labels in italics were not used verbatim by the authors, but were inferred from the content of the discussion.

Abbreviations: AA, alcoholics anonymous; AUD, alcohol use disorder; DUD, drug use disorder; MMT, methadone maintenance therapy; SUD, substance use disorder.