Journal of Drug Abuse Open Access

Keywords

Discrimination; Without primary school; Methadone treatment

Introduction

Drug addiction related stigma exists worldwide. Stigma is the process of the marginalisation of a group or class of people by others in a more powerful possition by labeling them as different and perceiving them in terms of stereotypes. This results in the loss of social status and discrimination and affects many areas in the lives of those who are stigmatized. Social stigma is severe social disapproval of personal characteristics or beleiefs that are against cultural norms. Mental health experts suggest that it refers to the negative effects of a label placed on any group including those who have been diagnosed as having mental health problems [1,2]. Stigma often leads to discrimination and less favourable treatment of the individual. Research on Slovenian public opinion shows that Slovenia has a significantly lower tolerance to groups who acquired their differential behaviours through their own acts. The lowest level of tolerance is shown towards alcoholics, PWUD (people who use drugs) and male homosexuals [3-5].

Treatment utilisation may be impeded if afflicted individuals believe that they will be stigmatized by others once their affected status is known. The experience of stigma ranges from perceptions that the stigmatizing characteristics sets one apart from the others to feelings of rejection and isolation. The scientific evidence and strong message from service and their advocates indicate that stigma blights the lives of many PWUD, making marriage, childcare, work and a normal social life more difficult. The perception of mental illness stigmatization is associated with a number of adverse consequences, including psychological (lower self esteem, decreased self efficacy and increased distress) and behavioural (diminished pursuite of goals such as housing and employment, non-adherence to treatment recommendations and poor treatment retention) [6-8].

Addiction disorders may be among the most highly stigmatized psychiatric disorders. As a result, people with drug addiction who perceive high levels of alcohol stigma may avoid entering treatment because it confirms their being a part of a stigmatized group [9].

Key research questions were construed to identify and study factors that lead to the stigmatization of PWUD who do not seek much needed help and to examine the relationship between stigma and previous treatments.

Methods

Definition of target group

Data was collected from the beginning of January to the middle of September 2007 in a crosssectional survey, which is part of a wider international project Correlation. The selected target group consisted of PWUD who had previous experience with assistance from programs concerning health care and social security as well as in seeking assistance from non-governmental high threshold and/or low threshold organizations. These are PWUD who used drugs for at least one year. Throughout the research, there were approximately 100 informative contacts with PWUD of various drugs. Among these, 59 PWUD filled in aquestionnaire.

Questionnaire

For data collection we used a questionnaire: A survey on experiences (satisfaction) of PWUD with the assistance programs

The survey constitutes 131 questions, mostly of the closed-ended type. Each individual section had at least one additional openended question [10,11]. This article represents only a fraction of the overall research. We have selected the following specific sections:

1. Social demographical characteristics;

2. History of assistance/medical treatment/treatment and purchase/exchange of needles;

3. Assumed reasons why PWUD do not seek help which they could use

4. Stigma discrimination including only those PWUD whose feelings and perceptions we have described.

Methods of data collection and sampling

For sampling we applied a non-probability approach, including the elements of the »snowball« method. Known PWUD and certain coincidences served as a starting point in developing contacts with the target population. Some of them were prepared to bring us to actual meeting points (streets, pubs, parks, homes…). This approach may also be subject to the problem of bias because the research assistants personally knew the majority of the PWUD. Using the snowball-approach allowed for the risk of bias to be lowered. The data was collected with the help of a questionnaire in the form of an interview held at three locations (Ig, Celje, Ljubljana). The sample is very heterogenous. We collected the data from three different sources – prisons, high threshold and low threshold non-governmental organisations (NGO's).

Data analysis

We calculated a descriptive statistic (frequency, percent). We used the T test to calculate differences between variables (variables that are markers of the previous experience of treatment and those PWUD who feel more discriminated against and those who feel the most discriminated against). In the statistical test, a p-value of 0.05 or less was considered significant. The SPSS statistical package for Windows Version 21.0 (SPSS Inc., Chicago, IL, USA) was used for the analysis.

Results

53 PWUD were prepared to answer the questionnaire. The response rate was 89% (53/59). 6PWUD did not satisfy the criteria for research participation as they did not fulfil the criteria of being problematic PWUD. The fact that we collected the data from three different sources – prisons, high threshold and low threshold NGO's, represents a specific stratification of the whole sample and reduced errors in drawing to conclusions on the whole population. However, this does not completely eliminate limitations due to the relatively small and non-representative sample. The questionnaire: A survey on experiences (satisfaction) of PWUD with assistance programs was developed by the Slovenian working group for promoting social inclusion and health, together with partners from Hungary (coordinators of the international research Correlation) and PWUD in Ljubljana. In accordance with commonly held views we added questions, which expressed characterics related to the Slovenian environment.

Socio-demographic characteristics for three data sources – low threshold (»street«) population, high threshold population and PWUD in prisons – were summarised in (Table 1). We counted 83%, 74% and 14% males and 17 %, 25% and 86% females from three data sources. Mean age were 28, 22 and 27, respectively. The socio-demographic characteristics of the subjects interviewed show a very high unemployment rate. Only 25% of people in the high threshold sample were employed whereas noone was in regular employment in the low threshold sample. It is understandable that during interviewing all female PWUD in prison were without regular employment. For a more complete interpretation, data on the percentage of people in education at the time of interviewing is missing. According to further research, it is interesting that the highest percentage of people without a completed primary school education were female prisoners. A high percentage (100%) of problematic PWUD from the high threshold sample lived with parents as compared to the low threshold sample of PWUD that were homeless. Almost half of the people interviewed (42%) in the low threshold sample did not have basic health insurance, one quarter were without basic and additional health insurance which was an important factor influencing their motivation for seeking assistance or prevented them from exploring their right to treatment (Table 1).

Socio-demographic information	Low threshold (%)	High threshold (%)	Prison (%)
Males	83	75	14
Females	17	25	86
Below 20 years old	6	6	0
Mean age	28	22	27
Not completed primary school	0	0	5
Completed secondary school	58	63	57
Regular employment	0	25	0
Living with parents	13	100	0
Living with partner	22	25	0
Living on the street	26	0	0
In prison	22	20	100
Basic health insurance	58	100	33
Basic and additional  health insurance	25	100	67

Table 1: Socio-demographic information of PWUD according to 3 sources of data collection.

When we talked with drug users why they come for treatment only after two, three or more years of being addicted to drug we confirmed known findings that they seek help only when they are mature to receive treatment. Due to pleasure for taking drugs, addiction, personaly change and other reasons, they have poor motivation for treatment. They come for a treatment only when due to consequences for drug taking they find themselfs in a death and distress. They seek help only due to social presuress and severe medical complications. They put off visiting experts who would require abstinence and active personal growth. Much earlier, they seek assistance from low threshold programmes on lessening damage that satisfies their needs for taking psychoactive substances and that are more tolerant to different life style. There are a number of other reasons why drug users do not seek assistance they need. The majority of PWUD feel that discrimination is the main reason for not seeking help (80% of those who consider the statment as more or the most important). They are discouraged by the long waiting time (70%). Among imporatnt reasons, they have listed expensive assistance (68%) and unsatisfactory experience (PWUD are not understood, 67%) and lack of understanding of their needs (service is too judgmental 63%, limited time to talk about problem 59%). Other reasons why PWUD do not seek the treatment they need is depicted in Table 2.

Why do some drug users not seek help?	% of those who consider the statement as  more or the most important
PWUD  are discriminated against	80
Waiting time too long	70
Service too costly	68
PWUD  are not understood	67
Service is too judgmental	63
Limited time to talk about problem	59
Too much focus on abstaining	58
Lack of necessary documents	58
Bad former experience	56
Not welcoming or friendly	54
Restrictive hours of service	50
Problems of physical accessibility of the program facilities	47
Confidentiality is broken	47
Travel problems	43
They do not know how to get to treatment	38
Staff lacks the skills	36
Atmosphere of service too chaotic	32
Other reasons	20

Table 2: Reasons why PWUD do not seek the treatment they need.

We calculated the links between the previous experiences of drug treatment and the disctrimination stigma indicator. Those who had already received some medical support such as methadone treatment, psychotherapy, detoxification, feel discriminated against, but among the listed variables we found with methadone treatment only, statistically significant connections (p=0.029). Those who have already received social benefits and had low and high treshold experience feel more discriminated against (social benefits 70%, needle excgange 85%, councelling 82%, therapetic community 60%, education 63% and employment support 75%), but among the listed variables we did not find statistically significant connections. All statistical data are presented in Table 3.

Treatment history	%  PWUD  who feel more or the most discriminated against	p	Mean differences	95%  CI
Needle exchange	85	0.101	-0.49	-1.074 - 0.102
Methadone treatment	72	0.029	0.58	0.060 - 1.107
Counseling	82	0.932	-0.02	-0.581 - 0.533
Friend's help	82	0.492	-0.19	-0.738 – 0.360
Parent's help	76	0.932	0.02	-0.533 - 0.581
Day center	88	0.174	-0.41	-1.006 -0.190
Help in jail	80	0.750	0.10	-0.551 - 0.755
Psychotherapy	61	0.095	0.59	0.114 – 1.298
Social benefits	70	0.603	0.17	-0.551 - 0.857
Detoxification	73	0.927	0.03	-0,619 - 0.677
Therapeutic community	60	0.080	0.63	-0,086 - 1.352
Outreach	89	0.422	-0.29	-1.105 - 0.516
Education	63	0.598	0.24	-0.771 -1.259
Employment support	75	0.636	0.22	-1.006 - 1.450

Table 3: Previous experience of treatment and percentage of PWUD who feel more and the most discriminated against.

Discussion

According to our results, the majority of PWUD feel that discrimination is the main reason for not seeking help. Research results in Budapest indicate that methadone maintenance programes for PWUD are the hardest to join, while getting into day care was judged easy, although the latter was the least known among PWUD. Among the number of barriers to drug treatment, there was one that attracted more information than the rest: methadone maintaince treatment [12]. A study conducted in Amsterdam showed that when it comes to substutution treatment, nine people (40.9%) who were on methadone treatment all said they were quite satisfied with the service. One respondent did not receive the help he asked for, because he did not have a residence permit. Twelve respondents (54.5%) did not want methadone, mainly because they did not want to have another addiction or they did not want to depend on drug care institutions [13]. A study in Bulgaria listed the most often quoted barriers obstructing the search for drug dependence treatment: treatment does not help; treatment is expensive; personnel are unfriendly; there is no treatment available where I live; lack of motivation for treatment; lack of information on where and how to find treatment; previous bad experience with other types of treatment; required documents missing; long list of people waiting for treatment to join; too remote and embarrassed to be registered [14].

In our study we asked PWUD of illicit drugs about their feelings of injustice, which originate from the actual stigmatisation and discrimination. Our results showed that PWUD feel discriminated against by medical and social sevices [15,16]. It is very interesting that methadone treatment showed a significant tendency towards PWUD feelings of being discriminated against. This suggests the need for debate on the relative risks of stigma and discrimination in this context. The majority of subjects agreed that the attitude of profession has somewhat improved in last years but the attitude in society has not. General labeling, rejection and social exclusion of people who use illegal drugs increases personal suffering and contributed to their deficient ability to enforce their rights and interests. There are another barriers to accessibility and attainanability of health care and social security. Due to fears of discrimination and the consequences brought on by it, PWUD often do not seek assistance even though they need it. To the question as to why expert asistance for addiction and poor physical health is not sought, a participant replied: ''I don't want them to find out I am an addict because I would lose my job.'' In focus groups we talked about 'people with drug phobia' and 'drug phobia: ''As soon as it comes out that you are an addict or former addict, you are stigmatized forever.'' Drug PWUD can be expelled from school or work even if they do not violate any school rules or rules at work. It is sufficient to be stamped as a drug addict. With the label 'drug addict' it is practically imossible to get a job. People who do seek help for addiction are fired. A drug addict met her boss by chance when she went to get methadone at the clinic: "Methadone treatment was used against me and I was fired from my job.'' There are a lot of similar testimonies with regard to unequal treatment in connection with drug use: ''A dentist did not want to give me an injection when extracting a tooth when I told her I am on methadone treatment.'' Another reported: ''I was punished because I was loitering in front of Metelkova (in front of medical service) due to methadone…loitering of junkies is prohibited'' [15,10-11]. The attitude of PWUD towards methadone treatment is still highly charged due to lack of knowledge and understanding of the substitution treatment methods. PWUD are afraid that methadone would increase their addiction or even cause death [16]. A similar study in the United States measured discrimination related to drug use. In adjusted models, discrimination was associated with poorer mental and poorer physical health. Angry responses to discrimination and stigma were associated with poorer mental health [17]. American authors estimate that the cost of heroin addiction in the USA was USD 21.9 billion. Of these costs, productivity losses acounted for USD 11.5 billion (53%), criminal activities USD 5.2 billion (24%), medical care USD 5 billion (23%), and social welfare USD 0.1 bilion (0.5%) (11). Statistical data in Slovenia in 2013 show an estimate around 9,600,691.75 EUR for resolving problems in the field of illegal drugs [18]. Does the risk associated with the use of drugs exclusively concern the individual?

Contemporary professionals believe that the use of drugs is associated with a number of reasons, and it is not only the problem of individual failure. The reasons for taking up drug use involve much broader issues: social, cultural, economic and political [19-21]. Drug addiction has been growing from a complex interaction between individuals, drugs and the environment. The first administration of the drug is largely voluntary. The individual has more or less consciously decided to try the drug. As drug use becomes more frequent routine decision making in life generally becomes more difficult. When it comes to addiction, interference by drugs takes over and influences most decision making. The user allegedly loses the former 'freedom' of decision and therefore becomes a less responsible personality.

Key risk factors, which play a role in dependence and therefore reduce liability, are the user him/herself, the family, peers, social and cultural factors and the type of psychoactive substances used. For example, various risk factors regarding drug use include: family, a disturbed childhood, disorganized care and education, depression and other mental disorders, emotional instability, low self-esteem, lack of ambition, excessive dependence on people and institutions, easy availability of drugs, social exclusion, poverty. The protective factors however, include for example: a healthy stable family, a positive parental role model, appropriate education and training programs, healthy attitudes and habits of the school and social workers [22-24].

Problematic PWUD are the population group that suffer from myriad health problems but have limited access to health care. PWUD who experience more discrimination may be more likely to drop out of treatment or those in treatment may experience less discrimination because of their efforts to rehabilitate. The results of our study suggest that we should avoid surely the potential negative effects of stigma and discrimination on PWUD treatment seeking. The constructive responses to stigma and discrimination should be associated with the promotion of better health while unconstructive responses will be associated with poorer health [25,26].

The results partially supported our hypotheses, showing that the given stigma and the perceived discrimination were associated in combination with poorer treatment seeking. There are several limitations to consider in the interpretation of the findings. The stigma, discrimination information and treatment seeking behaviours were self reported. There is the possibility that problematic PWUD, because of their poor mental health and perhaps with regard to stigma and past experience of discrimination, might have provided us with unreliable answers. The respondents might exaggerate or their responses might be considerably influenced by drugs, embarrassment or forgetfulness. With the available data it was not possible to conduct an analysis and study the associations between perceived discrimination and the mental poor health condition of PWUD. We were unable to examine whether the levels of stigma and discrimination and their associatons with treatment seeking varied according to their mental health status [27-29].

Conclusion

This is one of the first studies in Slovenia to have examined the association of both stigma and discrimination with the treatment seeking of problematic PWUD. Research has shown that it will be necessary to provide the realization of protecting human rights and for the integration of PWUD through an active concern for their health, but this is still a long way away. Based on the results of this research, our observations bring us to the conclusion that PWUD are among the most discriminated against population groups. From the research results it can be deduced in the many recommendations for policymakers and practitioners of health and social assistance, how to improve drug treatment programs: the involvement of PWUD in society, and the local community, involvement in various activities to reduce stigma and social exclusion and improve respect for human rights, improvement of confidentiality, respect the involvement of PWUD in the decisions that affect their health and treatment, better understanding of the needs of PWUD by providers of aid and policies [30,31].

Conflict of Interest

The authors declare that no conflicts of interest exist.

Funding

The study was financed by the National Institute of Public Health.

Ethical Approval

The research is a part of an international project Correlation.

References

1. Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E (2008) Reducing stigma and discrimination: candidate interventions. Int J Ment Health Syst 2: 3.
2. Hayward P, Bright J (1997) Stigma and mental illness: a review and critique. J Mental Health 6: 345.
3. Rus VO (2006) (ne)strpnosti pri Slovencih (država, ki se odpira v svet). Delo 13.
4. Nolimal D (2008) Socialna vkljuenost in zdravje: posebej ogroene skupine in pomen terenskega dela v zdravstvu. ISIS 2: 56-60.
5. Drev A, Sever M, Kamin T (2006) Prepovedane droge v slovenskih mnonih medijih. Zdrav Var 45: 126-139.
6. Room R (2005) Stigma, social inequality and alcohol and drug use. Drug Alcohol Rev 24: 143-55.
7. Nolimal D (1995) Razvoj epidemiološe dejavnosti v okviru bacionalnega programa prepre?evanja škodljivih posledic uživanja drog v Sloveniji. Zdrav Var 34: 233-237.
8. Keyes KM, Hatzenbuehler ML, McLaughlin KA, Link B, Olfson M, et al. (2010) Stigma and treatment for alcohol disorders in the United States. Am J Epidemiol; 172: 1364-1372.
9. Ahern J, Stuber J, Galea S (2007) Stigma, discrimination and the health of illicit PWUD. Drug and Alcochol Dependance 88: 188-196.
10. Nolimal D, Leskovšek E, Pokrajac T (2008) Ovire v dostopnosti in dosegljivosti programov pomo?i – vidiki uporabnikov prepovedanih drog v Sloveniji. Ljubljana: Ministrstvo za  zdravje.
11. Nolimal D, Leskovšek E, Pokrajac T (2008) Obstacles in availability and accessibility of assistance programs: Perspectives of PWUD in Slovenia. In: Voets A, Bröring G, editors. Access to health and social services for substance PWUD. Amsterdam: Foundation Regenboog AMOC: 75-119.
12. Rácz J, Márványkövi F, Melles K (2008) Barriers to treatment and needle exchange among problem PWUD in Budapest. In: Voets A, Bröring G. editors. Access to health and social services for substance PWUD. Amsterdam: Foundation Regenboog AMOC 19-35.
13. Voets A, Schmitt J, Ensdoff J (2008) Barriers to service For Moroccan PWUD in Amsterdam. In: Voets A, Bröring G. editors. Access to health and social services for substance PWUD Amsterdam: Foundation Regenboog AMOC 37-52.
14. Rusev A (2008) Treatment of drug dependencies in Bulgaria: Survey on the treatment demand and barriers to access among problem PWUD in Bulgaria. In: Voets A, Bröring G. editors. Access to health and social services for substance PWUD. Amsterdam: Foundation Regenboog AMOC 53-73.
15. Nolimal D (2000) Tehnike souporabljanja pribora za vbrizgavanje, družbeni okvir in prepre?evanje okužb s krvjo pri uporabnikih drog. Zdrav Var 39: 56-62.
16. Room R (2005) Stigma, social inequality and alcohol and drug use. Drug Alcohol Rev 24: 143-155.
17. Young M, Stuber J, Ahern J, Galea S (2005) Interpersonal discrimination and the health of PWUD. Am J Drug Alcohol Abuse 2005 31: 371-91.
18. Wasserman D (2004) Addiction and disability: moral and policy issues. Subst Use Misuse 39: 461-488.
19. NIJZ (2014) Nacionalno poro?ilo 2014 o stanju na podro?ju prepovedanih drog v Republiki Sloveniji. Ljubljana. Available January 10, 2016 from: https://www.nijz.si/.
20. Wodak AD, Lynch PA, Crofts N (2004) Is lawful discrimination against illicit PWUD  acceptable? Med J 180: 405-407.
21. Cohen J, Ezer T, McAdams P (2016) Health and Human Rights. A Resource Guide for the Open Society Institute and Soros Foundations Network. Open Society Institute and Equitas- International Centre for Human Rights Education 2007. https://www.soros.org in www.equitas.org.
22. Zadel A (1995) Svetovanje staršem kot prevencija recidiva pri bolnikih, odvisnih od ilegalnih psihoaktivnih snovi. Zdrav Var 34: 278-282.
23. Gyarmathy VA, Latkin CA (2008) Individual and social factors associated with participation in treatment programs for PWUD. Subst Ise Misuse 43: 1865-1881.
24. Ruefli T, Rogers SJ (2004) How do PWUD define their progress in harm reduction programs? Qualitative research to develop user-generated outcomes. Harm Reduct J 1: 8.
25. Chan KY, Yang Y, Zhang KL, Reidpath DD (2007) Disentangling the stigma of HIV/AIDS from the stigmas of drug use, comercial sex and commercial blood donation – a factorial survey of medical students in China. BMC Public Health 7: 280.
26. Kipke MD, Weiss G, Ramirez M, Dorey F, Ritt-Olson A, et al. (2007) Club drug use among young men who have sex with men. Subst Use Misuse 42: 1723-1747.
27. Thirthalli J, Benegal V (2006) Psychosis among substance PWUD. Curr Opin Psychiatry 19: 239-245.
28. Nolimal D (1999) Evidenca obravnave uporabnikov drog in eti?na vprašanja. Zdrav Var 38: 354-349.
29. Wu Y, Yan S, Bao Y, Lian Z, Qu Z, et al. (2016) Cross-sectional study of the severity of self-reported depressive symptoms in heroin users who participate in a methadone maintenance treatment program. Shanghai Arch Psihiatry 28: 35-41.
30. Krek M, Krek JM, Nolimal D (1994) Politika zmanjševanja škode zaradi uživanja drog meduživalci ilegalnih drog. Zdrav Var 1994 33: 263-267.
31. Dombrowski K, Crawford D, Khan B, Tyler K (2016) Current Rural Drug Use in the US Midwest. J Drug Abuse 2: 22.