Health Professional Stigma as a Barrier to Contingency Management Implementation in Opioid Treatment Programs

Abstract

Contingency management (CM) has robust evidence of effectiveness as an adjunct to medication for opioid use disorders. However, CM implementation in opioid treatment programs has been limited by a myriad of well-documented barriers. One relatively unexplored barrier that may hinder CM implementation is health professional stigma toward patients with opioid use disorders. Qualitative interviews were conducted with 43 health professionals (21 leaders, 22 front-line counselors) from 11 different opioid treatment programs across Rhode Island to explore their familiarity with CM and to elucidate barriers and facilitators to CM implementation. Interviews were transcribed and coded by 3 independent raters using a reflexive team approach. Transcripts were analyzed for both a priori and emergent themes. Health professional stigma was identified as an emergent major theme with 4 distinct subthemes: (a) distrust of patients (44%, N = 19); (b) infantilizing views about patients (19%, N = 8); (c) belief that patients do not deserve prizes (19%, N = 8); and (d) recognition of patient self-stigma and community-based stigma (23%, N = 10). In addition, we identified multiple instances of health professional use of potentially stigmatizing language toward patients with opioid use disorders via terms such as drug abuser, addict, and clean or dirty urine screens (70%, N = 30). Stigma themes were identified in 86% of the transcripts, highlighting potential targets for multilevel implementation strategies. Findings of this study suggest that multiple types of health professional stigma should be considered and proactively addressed in efforts by psychologists to implement CM and other evidence-based interventions in opioid treatment programs.

Medication for opioid use disorder (MOUD) is the gold standard, evidence-based treatment for patients with opioid use disorder (Connery, 2015), yet MOUD alone is not sufficient to address the overdose crisis. Randomized trials of the most common medications, methadone and buprenorphine, have documented wide variability in retention (i.e., 41% to 74%) and abstinence rates (i.e., 20% to 60%) among patients in the United States over the first six months of treatment (Connery, 2015; Timko, Schultz, Cucciare, Vittorio, & Garrison-Diehn, 2016). Thus, there is an urgent need for the identification and implementation of adjunctive behavioral interventions that can be delivered by psychologists and other health professionals to increase the effectiveness of MOUD.

Contingency management (CM), an intervention in which patients earn motivational incentives for meeting treatment goals (Petry & Stitzer, 2002), is the most effective behavioral intervention when delivered in combination with MOUD. A wealth of literature, including meta analyses, has shown that MOUD plus CM is more effective than both MOUD only (Griffith, Rowan-Szal, Roark, & Simpson, 2000; Prendergast, Podus, Finney, Greenwell, & Roll, 2006) and other behavioral interventions (e.g., Cognitive Behavioral Therapy; Carroll & Weiss, 2019; Rawson et al., 2002). However, CM implementation in opioid treatment programs (OTPs) prescribing methadone is extremely low (McGovern, Fox, Xie, & Drake, 2004). Well-documented barriers to CM implementation include intervention cost, lack of time to implement a novel program, negative attitudes toward the intervention, and poor alignment with health professionals’ typical theoretical orientation (Kirby, Benishek, Dugosh, & Kerwin, 2006; Rash et al., 2012). An understudied potential barrier to CM implementation is health professional stigma toward patients, a phenomenon that may have important implications for the delivery and implementation of CM and other evidence-based interventions in OTP settings (see Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013).

Health Professional Stigma in OUD Treatment

Stigma is broadly defined as a social construct that associates negative attributes to a particular group of people solely based on a set of characteristics (Link & Phelan, 2001). Patients with OUD and especially those who inject drugs have reported experiencing stigma (e.g., judgmental looks, substandard/slow care) in the context of society broadly and medical care in particular, both as a result of their opioid use and their receipt of MOUD (Paquette, Syvertsen, & Pollini, 2018). Health professionals may develop stigmatizing beliefs about individuals with OUD and those who inject drugs through a number of pathways, including personal experiences with drug use and recovery (Nielson, 2016) or burnout within their profession from caring for high caseloads of patients with complex challenges (Shoptaw, Stein, & Rawson, 2000). Health professionals working in community OTPs may be particularly prone to burnout via emotional exhaustion and depersonalization in the workplace (Shoptaw et al., 2000).

Stigmatizing beliefs (e.g., beliefs that patients are manipulative, irresponsible, or violent) have important implications for treatment, as they may lead to reduced empathy and motivation to provide effective treatment (Van Boekel et al., 2013). With regard to CM, health professionals may have negative views about providing incentives to MOUD patients, including beliefs that they are rewarding patients for something they should already be doing or concerns that patients might use incentives to purchase drugs (Rash et al., 2012). These attitudes may increase patients’ perceived discrimination (Brener, Von Hippel, Kippax, & Preacher, 2010) and may serve as a barrier to effective screening, intervention provision, and referrals to appropriate treatment, while also negatively impacting treatment outcomes (van Boekel et al., 2013). Stigmatizing beliefs toward patients may specifically reduce health professionals’ willingness to use CM as an adjunct to MOUD. Additionally, negative beliefs and distrust of patients may reduce CM’s effectiveness and fidelity, as empathy and enthusiasm are core components required to achieve CM competence in line with the treatment manual (Petry & Ledgerwood, 2010; Petry & Stitzer, 2002).

Health professionals may encounter additional barriers to CM delivery in the form of patient self-stigma (influenced by societal/health care stigma) and community stigma. Patient self-stigma is defined as personal feelings of shame, fear, or negative thoughts about oneself due to identifying with a stigmatized group (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008). Self-stigma may emerge from patients’ beliefs that addiction is a moral failing, from loss of freedom resulting from the intense dosing and attendance requirements associated with MOUD, or even from peer recovery programs (e.g., Narcotics Anonymous) that suggest MOUD makes you “not-clean” (Krawczyk, Negron, Nieto, Agus, & Fingerhood, 2018; Paquette et al., 2018). Self-stigma (e.g., viewing oneself as an addict, feeling one’s life is not valuable) has been found to negatively impact patients’ self-esteem, worsen mental health symptoms, and reduce the likelihood of MOUD initiation, compliance, and recovery (Paquette et al., 2018). In addition, health professionals may encounter stigma (e.g., opposition to opening MOUD facilities) from the community at large because of the historic separation of MOUD treatment from the rest of the health care system and beliefs that receiving MOUD is akin to substituting one addictive substance for another (Paquette et al., 2018).

Language as a Stigma Perpetuating Factor

Another way that stigma emerges is through the use of stigmatizing language to describe patients with OUD. The term substance abuse, long used as a diagnostic term, has been demonstrated to increase health professionals’ punitive judgments of patients (Kelly, Dow, & Westerhoff, 2010). The same is true for addict, as use of the term increases perceptions that individuals are dangerous and irresponsible (Goodyear, Haass-Koffler, & Chavanne, 2018). In a similar vein, referring to patients or the results of their urine toxicology testing as dirty or clean moves treatment away from medical terminology and evokes punitive judgments (Kelly, Wakeman, & Saitz, 2015). Use of such stigmatizing terms in a medical record may also transfer stigmatizing beliefs or negative attitudes about patients to other health professionals (Goddu et al., 2018). It is possible that an organizational culture that routinely uses stigmatizing language (even when used without malintent) such as abusers or dirty might be more likely to distrust patients and might be less comfortable with the provision of incentives for meeting treatment goals (Van Boekel et al., 2013).

The Current Study

The current qualitative analysis examined themes of stigma that were identified in interviews with health professionals across a cohort of 11 OTPs. This analysis was embedded within a larger study (Becker et al., 2019) that explored health professionals’ receptiveness to implementing CM. Two specific goals informed the analysis. The first goal was to identify the various types of stigmatizing views that spontaneously emerged in interviews with health professionals at OTPs. A secondary goal was to document and quantify the stigmatizing terms used by health professionals when discussing patients with OUD. The overarching objective of this work was to elucidate types of stigma that may serve as barriers to the implementation of CM and other evidence-based interventions in OTPs.

Method

Recruitment and Participants

This study was funded by a Rhode Island grant (P20GM125507) and, as such, all 13 OTPs in the state were invited to participate. All 13 OTPs provided methadone with modest outpatient counseling services (e.g., most OTPs provided weekly group counseling and monthly individual counseling). The Chief Executive Officer, Director, or President of each OTP was asked to nominate two site leaders and two front-line counselors to participate. The primary inclusion criterion for leaders was being responsible for overseeing front-line staff in a supervisory or managerial capacity for at least six months. Front-line counselors needed to have an active treatment caseload of only MOUD patients. In total, 11 of the 13 OTPs (85%) participated and nominated 22 leaders and 22 treatment counselors. Only one leader (2% of the invited sample) declined. Consistent with the demographics of the Rhode Island OTP workforce, the 43 final participants were predominantly female (72%) and non-Hispanic White (93%). Forty-two percent of the sample had a bachelor’s degree (N = 18), and only 21% had a master’s degree (N = 9). Overall, average tenure of health professionals at their current OTP was 4.8 years (SD = 6.5), with a wide range from 3.5 months to 41 years.

Procedure

Nominated OTP leaders and front-line counselors were informed of the study protocol via a research information letter and, if interested, contacted study staff to schedule an interview. Because of the minimal risk associated with participating, the study was granted waiver of documented consent by the Institutional Review Boards of Brown University and the Miriam Hospital, an affiliate of the Alpert Medical School of Brown University. Leaders and counselors needed to provide verbal informed consent to participate. Participants were assured of their rights to confidentiality and that their participation would not affect their employment as part of informed consent.

Qualitative Interviews

Semistructured participant interviews were conducted over a 2-month period by two trained postdoctoral fellows and two research assistants (see Becker et al., 2019, Additional File 1 for the full interview guide). Interviews were 45–60 min in length and conducted either in-person or by phone. Interviews centered around participants’ familiarity with CM as well as perceived barriers and facilitators to CM implementation at their OTP. Of note, there were no specific questions about stigma in the qualitative interview guide.

Qualitative Data Analysis

Interviews were transcribed verbatim and subsequently cleaned to remove all identifying information. Thematic analysis was conducted by three independent coders (one postdoctoral fellow, two research assistants). A team-based reflexive approach was utilized to evaluate a set of a priori major themes and subthemes using a qualitative coding dictionary. The coding team met weekly to review assignments to a priori codes, to document and obtain consensus about emergent codes, and to revise the coding dictionary accordingly. In line with the reflexive team approach (Hsieh & Shannon, 2005), disagreements in coding were resolved via in-depth discussion and decision-making among the coders until 100% consensus was obtained. During this iterative process, the concept of stigma was identified as a major emergent theme. Following the predetermined protocol for identification of emergent themes, coders reviewed all 43 transcripts using NVivo qualitative coding software (Castleberry, 2014) to identify an exhaustive set of quotes in which participants spontaneously expressed stigmatizing views or used stigmatizing language toward patients.

To confirm that all quotes capturing stigma were identified, queries were run across all transcripts for key words identified in specific quotes. For example, if a specific quote identified stigma related to CM prizes, subsequent queries were run for words such as prize or incentive. Once all quotes were identified, the three coders and the study Principal Investigator met to identify and develop definitions of each emergent subtheme. The two research assistants each coded half of the identified quotes, and 20% were double coded by the postdoctoral fellow. As with the a priori themes, meetings continued until each quote was assigned a consensus code. Any discrepancies in coding were resolved via the study Principal Investigator. Additional queries were run to evaluate the frequency of specific stigmatizing words, including abuse/abuser, addict, and clean/dirty, and to identify exemplar quotes for each theme.

Results

Qualitative analysis revealed stigmatizing language themes in 86% of the evaluated transcripts. Twenty participants (46.5%) used both stigmatizing language and at least one stigmatizing theme, and 13 participants (30.2%) expressed at least two stigmatizing themes during the interview. Four distinct subthemes emerged related to health professional stigma in CM delivery: (a) distrust of OUD patients; (b) infantilizing views toward patients; (c) belief that patients do not deserve incentives; and (d) recognition of patient self-stigma or community stigma toward MOUD. Table 1 presents these four subthemes, their definitions, and illustrative quotes. Table 2 then tabulates health professionals’ use of specific stigmatizing terms when talking about patients or about CM more broadly.

Table 1.

Stigmatizing Views, Definitions, and Illustrative Quotes Identified in Interviews With Health Professionals (N = 43) at Opioid Treatment Programs

Stigmatizing views	Number of transcripts, range of times per transcript	Definition	Illustrative quotes
Distrust of patients/Patients cannot be Trusted	19, 1–3	Health professional suspects that patient will sell prizes for drugs or will try to cheat the system to earn prizes	• “They’re gonna do the wrong thing withit … If we gave them an outfit or a gift card, they could just sell it.” • “Not overgeneralizing, but for a lot ofthem, all they know is that to get something they want, they have to push those boundaries and sometimes manipulate people in certain ways.”
Infantilizing views/Patients are like Children	8, 1–3	Health professional refers to patients as infants or children or uses childlike terms to describe them	• “The way you bribe kids. [Laughter] Ifyou stop screaming, we’ll stop and get an ice cream on the way home.” • “With the demographic of people that wehave, it could probably get … messy with the patients getting upset or angry if something doesn’t go the way that they think it should have gone, expecting a reward.”
Judgment of patients/Patients do not deserve prizes	8, 1–5	Health professional does not believe patients deserve prizes for meeting treatment goals	• “My biggest concern is the idea of giving them [prizes] for showing up for treatment. ‘Cause I see like all the other parts where they’re on state insurance, so they don’t work. Even though a lot of them can work, they don’t work. So I don’t know. The behavior would be just like give them more stuff for doing the bare minimum.”
Recognition of patient and community Stigma	10, 1–3	Health professional recognizes patient self-stigma or stigma from the community at large	• “They need a lot of practice with thewhole incentive thing and … accepting that they are doing a good job and that they’re not scum of the earth like people think that they are.” • “The stigma around methadone—like Isay, to get someone to donate unless they’ve been in treatment is difficult.”

Table 2.

Tabulation of Stigmatizing Terms Used by Health Professionals (N = 43; 21 Leaders and 22 Counselors) at Opioid Treatment Programs

Stigmatizing terms	Number of transcripts N (%)	Number of leader transcripts	Number of counselor transcripts	Times per transcript M (range)
Abuse/Abuser	24 (55.8%)	11	13	1.33 (0–6)
Clean	17 (39.5%)	6	11	1.21 (0–12)
Addicts	4 (9.3%)	1	3	0.21 (0–4)
Dirty	3 (7.0%)	1	2	0.07 (0–1)

Health Professional Distrust Toward Patients

The most common emergent subtheme was health professionals’ distrust of patients related to the receipt of CM incentives. About half of those interviewed (44%, N = 19) expressed negative views about patient trustworthiness with incentives and rewards, with quotes equally represented across leaders and counselors. Many respondents expressed concern specifically around the use of prizes that could easily be converted to cash because of beliefs that patients would use the money to purchase drugs. For instance, one counselor expressed the following concern about gift cards: “If it’s a big amount, like if it’s a $20 gift card, and they’re still in active addiction, they’re gonna sell it for 15, and that’s the truth.” Some health professionals expressed the view that any prizes could be sold for drugs and therefore should be avoided. As an example, one leader said, “Sadly, anything that they could sell, they would sell, so, yeah, that’s hard. You can’t sell a piece of pizza, really. … I suppose you could if somebody was really hungry.” Similarly, another leader said, “I don’t like things that can be turned into cash easily, I mean, because I think that could almost be an enabler.”

Respondents also expressed concerns about patients trying to “game” or “manipulate” the CM protocol to win prizes. As an example, one counselor suggested that patients would “try to falsify what they’re doing” by tampering with their urine screens, while another counselor expressed the view that patients “would maybe try to cheat the system.” One counselor shared the view that patients could not be trusted to earn prizes, by commenting, “not overgeneralizing, but for a lot of them, all they know is that to get something they want, they have to push those boundaries and sometimes manipulate people in certain ways.”

Health Professionals Tendency to Infantilize Patients

Another key subtheme was the tendency of respondents to infantilize patients, by referring to patients as infants or children or describing them in childlike terms. This subtheme was present in 19% (N = 8) of the interviews. Many of the quotes emerged when health professionals were asked about CM prizes. For instance, one counselor noted that, “I mean, kids do great with the rewards system. I think drug addicts would, too. You know?” Another counselor joked that if patients were going to receive positive rewards they should also be punished when they failed to meet treatment goals, “You motivate them positively, but also, do we punish them [laughter] when they’re not doing what they’re supposed to be.”

Other comments reflected the view that patients often acted like children by being argumentative or throwing tantrums when they did not get their way. Several quotes referred to patients as “argumentative,” “rebellious,” or “resistant.” There were also a number of comments suggesting that patients do not know what is best for themselves. As an example, one leader shared the following view: “the more you push, even if it’s beneficial to them … if they make up their mind about something, if you continue to push, even if it’s lightly, they become more and more resistant, and they just want absolutely nothing to do with it.”

Health Professional View That Patients Do Not Deserve Prizes

The third subtheme, which was also present in 19% (N = 8) of interviews, pertained to health professionals’ general negative views toward patients and their beliefs that MOUD patients do not deserve prizes. Such comments generally reflected the underlying belief patients “should” be engaging in treatment and maintaining sobriety and that rewarding patients for “doing what you’re supposed to do” would not be appropriate and would be akin to “another handout where people don’t have to do too much to get it.” Other comments reflected the belief that meeting treatment goals should be “the bare minimum” to stay in treatment and therefore not worthy of special recognition.

Additional quotes in this domain reflected health professionals’ judgments that patients were more committed to self-destructive behavior—for example, “a merry-go-round of self-destructive behavior”—than to their sobriety. For instance, one counselor shared the view that, “some of the people that we deal with though don’t wanna get better. They just wanna be inside chaos all the time ‘cause that’s where they’re comfortable.”

Health Professional Recognition of Self-Stigma and Community Stigma

The final subtheme was health professionals’ recognition of patient self-stigma and community-based stigma. It occurred in 23% (N = 10) of the interviews. Comments about patient self-stigma were found in three transcripts. In one interview, a counselor asserted that patients “are angry with themselves,” whereas in another a counselor commented that patients needed to practice “accepting that … they’re not the scum of the earth like people think that they are.”

Comments about community-based stigma were more common, appearing in nine transcripts. Quotes captured concerns that community members viewed patients and/or MOUD negatively. Three health professionals specifically commented that it would be difficult to get CM prizes donated because people in the community had negative views of MOUD treatment. Meanwhile, six other health professionals commented that community members often did not want MOUD clinics in their neighborhoods for a variety of reasons including, “backwards views,” “stigma attached to methadone,” and the “belief that addiction is a choice.”

Health Professional Use of Stigmatizing Terms

In addition to elucidating stigmatizing views, we identified and quantified stigmatizing language that emerged across the 43 interviews. Stigmatizing language was identified in 70% (N = 30) of the transcripts. The most common stigmatizing terms were abuse or abuser: these terms were present in 24 interviews and used equally by leaders and counselors. Such language was generally used when health professionals described their patients (as substance or drug abusers) or described their role in their opioid treatment program (as providing substance abuse services). Of note, these terms were often used an innocuous way and appeared to reflect the standard use of terms throughout the treatment programs without any negative intent.

The second most frequently endorsed stigmatizing terms were clean or dirty, typically to describe urine screen results (“clean urine”) or a state of abstinence (“staying clean”). Nearly 40% of respondents (N = 17) used the term clean, but only 7% (N = 3) used the term dirty. Clean was more frequently used at the word count level than abuse (see Table 2) and was used more often by counselors than leaders. Finally, the term addict was used in 10% (N = 4) of the transcripts. Respondents using the term addict tended to exhibit many of the other stigmatizing subthemes in their interviews.

Discussion

To our knowledge, this is the first study to examine health professional stigma as a barrier to CM implementation using qualitative interviews with OTP staff. During interviews about their perceptions of CM implementation, leaders and front-line counselors expressed distinct stigmatizing subthemes including distrust of patients, infantilizing views of patients, and the belief that patients do not deserve prizes. Health professionals also acknowledged patient self-stigma and community stigma, and most health professionals used potentially stigmatizing language when describing their patients. Some of the types of stigma identified in the present study were consistent with prior work that has identified negative attitudes toward CM among health professionals; specifically, prior work has documented distrust of patients (e.g., believing CM prizes would be sold for drugs) and concerns about community-based stigma (e.g., “[the] clinic will look bad for giving rewards to substance abusers”; Rash et al., 2012).

The stigmatizing beliefs identified in the current study have the potential to serve as barriers to CM implementation and effectiveness at multiple levels. At the patient-level, it is important to note that many patients already perceive MOUD delivery as stigmatizing because of the nature of the intense surveillance (i.e., daily supervision) and scrutiny (i.e., regular drug testing) required under federal regulations. The strict regulatory guidelines imposed upon OTPs could contribute to staff over-monitoring patients and adopting a more punitive, distrusting approach. Indeed, some patients have likened receipt of MOUD as more akin to probation/parole (i.e., “liquid handcuffs”) than treatment (Allen, Nolan, & Paone, 2019). If patients perceive stigma from health professionals in OTPs, this could reduce their willingness to engage in or experience success in behavioral treatments such as CM. For example, patients may avoid anticipated stigma by delaying treatment, not disclosing opioid use, and seeking alternative treatment services (Biancarelli et al., 2019). They may also prematurely end treatment or limit their engagement because of poor provider enthusiasm in CM delivery (Paquette et al., 2018; Petry & Stitzer, 2002; Van Boekel et al., 2013). Finally, patients’ own self-stigma may impede their willingness to participate in CM or accept prizes, because they might view themselves as not worthy because of internalized shame about their substance use (Luoma et al., 2008).

At the health professional-level, stigma has the potential to negatively affect both willingness to deliver CM as well as the fidelity of treatment delivery, given the high levels of enthusiasm and empathy required in CM sessions (Petry & Ledgerwood, 2010). Finally, at the organizational-level, stigmatization of patients who use opioids and other illicit substances has been linked to structural factors such as punitive communication (e.g., telling colleagues that a patient is manipulating the system, using stigmatizing terms in the health record) and staff shortages (Paterson, Hirsch, & Andres, 2013).

Reflecting the distinct layers of barriers, addressing stigma that impedes care for individuals with OUD is likely to require multifaceted implementation strategies. Needs assessments with organizations may need to systematically assess stigma prior to engaging in CM implementation, evaluate the degree to which stigma emerges as a barrier to CM use, and study its relative role in limiting CM use compared with other well-studied barriers (i.e., provider attitudes; Waltz, Powell, Fernández, Abadie, & Damschroder, 2019). Beyond integrating stigma into needs assessments, Chang, Dubbin, and Shim (2016) noted the importance of health professionals having access to resources and training as well as having adequate time to engage with patients to reduce stigma and better understand patients lived experiences. Many health professionals may have received training in general counseling principles, such as adopting the client’s own words, that may inadvertently lead to the use of stigmatizing terms (e.g., client refers to themselves as “addict” or “drug abuser” so counselor does as well). In the context of CM implementation, highlighting and modeling the importance of using “person-first” language (i.e., an individual with OUD) during CM training and ongoing supervision may be one method to increase health professional awareness and reduce stigma (Kelly et al., 2015). Engaging leaders is also likely to be important to ensure that those in positions of leadership incorporate de-stigmatizing practices within the organization and provide role support to counselors such as mentoring, clinical supervision, and stress management programs (Skinner, Roche, Freeman, & McKinnon, 2009). Such strategies could reduce health professional burnout and improve perceived ability to implement CM (Skinner et al., 2009). Finally, it is important to note that health professionals in this study predominantly had bachelor’s degrees and lacked higher education, which reflects the low reimbursement rates and well-documented challenges recruiting and retaining staff in OTP settings (Hatch-Maillette et al., 2019). Low reimbursement for MOUD is in itself likely a reflection of societal stigma and the chronic undervaluing of the addiction treatment workforce.

Results of the current study extend prior work by our team that found that counselors in OTPs perceived barriers to CM implementation at the patient, health professional, and organizational-levels, with organizational barriers perceived as most common (Becker et al., 2019). Our team has also previously reported that OTP leaders and counselors believed that CM should ideally be delivered by staff with reduced workloads (Becker et al., 2019). Thus, organization-level strategies that target provision of resources, training, and dedicated time for health professionals to learn about patients’ lived experiences are likely to be especially important in reducing stigma and facilitating implementation of CM. A recent systematic review of organization-level stigma reduction strategies recommended that future research test strategies to (a) train staff at all levels, (b) bring patients and health professionals together in novel ways (e.g., having patients participate in training events as speakers), and (c) leverage technology to deliver stigma reduction content to busy health professionals (Nyblade et al., 2019).

Although this study reveals new information about stigma as a potential barrier to CM implementation in OTPs, some limitations should be considered. First, the current study was not designed to assess stigmatizing language and, as such, all responses came up organically in the context of an interview about CM implementation. The frequency and consistency with which stigmatizing views were observed given this limitation is noteworthy. However, it is possible that opportunities to gauge the extent and variety of stigmatizing views were missed as a function of the study design. Second, the reliance upon nominations from organizational leadership to identify health professionals could have introduced selection bias. Our results likely reflect stigmatizing views among the most favored or experienced staff, which could suggest that these results understate the extent of stigmatizing views among all employees at OTPs.

Third, we did not systematically assess key variables such as participants’ personal experience with addiction and recovery or the treatment model at their OTP, which may impact stigmatizing beliefs and should be evaluated in future research. Fourth, we did not assess the perceived harm associated with the stigma themes that emerged from these interviews. Future research should explore whether different stigma themes are more harmful to individuals with OUD to identify key areas for stigma intervention. Finally, the lack of diversity among leaders and counselors limits generalizability. The demographics of health professionals in this study reflects a broader challenge with the OTP workforce, which has been found to be predominantly female and White (Hartzler, Lash, & Roll, 2012).

Increasing the effectiveness of MOUD via the implementation of adjunctive behavioral interventions is essential given the toll of the ongoing opioid crisis in the United States. Findings from this study suggest that multiple types of health professional stigma should be considered and proactively addressed in efforts by psychologists to implement CM and other evidence-based behavioral interventions in OTPs.

What is the significance of this article for the general public?

Millions of individuals in the United States meet criteria for opioid use disorder (OUD); however, very few receive evidence-based treatments such as contingency management (CM) owing to numerous implementation barriers in community settings. This study found that stigmatizing views toward patients, as well as the use of stigmatizing language, were common among staff in opioid treatment programs. Results suggest that stigma toward patients with opioid use disorders might be an important barrier to target when implementing CM in opioid treatment programs.