(7) Stigma and Treatment Engagement in Addiction Medicine: Pilot Findings Across Stigma Domains

Background & Introduction: Stigma toward people who use drugs (PWUD) remains a persistent barrier to healthcare access, disclosure of substance use, and sustained engagement with harm reduction services. Prior literature identifies anticipated, enacted, and internalized stigma as distinct mechanisms through which stigma shapes care-seeking behaviors and health outcomes among PWUD. Most empirical studies have examined these processes within traditional medical settings, where experiences of judgment and discrimination are frequently reported. In contrast, limited research has assessed stigma within Syringe Service Programs (SSPs), despite their expanding role in overdose prevention and engagement of individuals at high risk. As of now, SSPs are designed to function as low-threshold and nonjudgmental environments, yet it remains unclear whether stigma is reduced across domains from the client perspective. Existing stigma measurement tools have been developed for clinical contexts and limited information is known on whether these tools can be mirrored in capturing stigma dynamics in harm reduction settings. The objective of this pilot study was therein to assess and compare anticipated, enacted, and internalized stigma as experienced by SSP clients. By characterizing stigma patterns within an SSP setting, this study aims to inform service quality improvement and support the integration of harm reduction principles within addiction medicine practice.

Methods: We conducted a cross-sectional pilot among clients accessing services at a storefront Syringe Service Program (SSP) in New Haven, Connecticut. Participants were recruited through convenience sampling during routine SSP visits and were eligible if they were adults who had utilized SSP services. Approximately 70 surveys were initially collected. Following data cleaning, including removal of practice entries and incomplete or response outliers, 52 valid surveys were retained. Data was collected using a structured questionnaire that included an adapted version of the Medical Provider Stigma Experienced by People Who Use Drugs (MPS-PWUD) scale. The instrument contained Likert-type items with five response options ranging from strongly disagree to strongly agree and assessed experiences related to fear of judgment, perceived quality of care, and trust in staff. Items were adapted to capture stigma experienced across three domains: (1) Anticipated, (2) Enacted, and (3) Internalized stigma. Responses were reverse-coded as needed and aggregated to generate composite domain scores. Internal consistency reliability was assessed using Cronbach’s alpha. Descriptive statistics summarized participant characteristics. Normality testing indicated non-normal distributions. Nonparametric analyses were therefore conducted. Differences across stigma domains were assessed using the Kruskal-Wallis H test. Item-level analyses were performed to further characterize stigma patterns and inform future refinement.

Results: The study included 52 participants with a mean age of 45.3 years (range 29-72). The sample was predominantly male (73%) and majority White (65.4%), with substantial socioeconomic vulnerability, as 50% of participants reported literal homelessness. Participants also reported a mean of 1.6 overdose events in the past 12 months, indicating high clinical vulnerability within the sample. Most participants reported prior use of SSP services (90%), including access to sterile syringes, while 65% accessed medical services such as screenings and case management. Overall satisfaction with SSP services was high, with 73% of participants reporting being highly satisfied, suggesting strong acceptability despite demographic concentration and structural risk factors. Mean stigma scores were calculated on a five-point Likert scale, with higher values indicating greater perceived stigma. Enacted stigma was lowest (mean = 1.6), reflecting infrequent experiences of overt discrimination by staff. Internalized stigma was moderate (mean = 1.9), indicating some self-directed stigma. Anticipated stigma was highest (mean = 2.2), suggesting greater expectations of future judgment or discrimination. Nonparametric comparison using the Kruskal-Wallis H test demonstrated significant differences across stigma domains (χ² = 21.678, p < .001), with anticipated stigma exhibiting the highest mean rank. Internal consistency was modest across domains (Cronbach’s alpha: enacted = 0.663; internalized = 0.455; anticipated = 0.511). Given these findings, item-level analyses were conducted. Internalized stigma differed significantly by housing status (p = .033), with higher levels observed among participants who declined to report housing. This subgroup reported reduced willingness to discuss drug use (mean = 3.0) and greater concern that disclosure would negatively affect their care ( mean = 3.6), indicating heightened vulnerability. Enacted stigma remained low across all housing groups, with no significant differences. Anticipated stigma scores were consistent across housing categories, suggesting shared expectations of discrimination outside SSP settings regardless of housing stability. Gender differences were observed in anticipated stigma, particularly around disclosure.

Conclusion & Discussion: This pilot study demonstrates clear differentiation across stigma domains among Syringe Service Program (SSP) clients. Enacted stigma was consistently low, suggesting that SSP staff largely succeed in providing respectful and nonjudgmental care. In contrast, anticipated stigma was most prominent, indicating persistent expectations of judgment and discrimination beyond the SSP setting. Internalized stigma was moderate and varied by housing status, with higher levels observed among participants who declined to report housing, highlighting the intersection of stigma with structural vulnerability. Together, these findings support the conclusion that SSPs function as protective environments that mitigate overt discrimination while remaining embedded within broader systems characterized by stigma. These results suggest that effective stigma reduction in addiction medicine requires attention to both interpersonal care quality and clients’ expectations outside SSP settings. Interventions to address anticipated stigma may therefore extend beyond staff training to include structured communication that supports disclosure, warm handoffs, and navigation to medical services. Findings also underscore the need to refine stigma measurement tools to better capture experiences specific to harm reduction settings. Study limitations include a small sample size, a single-site design, and modest internal consistency. Despite this, the findings provide actionable evidence to inform service quality improvement.

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