|AWARD PAPER: DR ANIL MALHOTRA AWARD PAPER
|Year : 2018 | Volume
| Issue : 1 | Page : 30-36
Disability among patients with opioid use disorders and its relationship with stigma toward substance use
Saurabh Kumar, Swarndeep Singh, Siddharth Sarkar, Yatan Pal Singh Balhara
Department of Psychiatry, National Drug Dependence and Treatment Centre, All Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||29-Mar-2018|
Dr. Saurabh Kumar
Department of Psychiatry, National Drug Dependence and Treatment Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background: From a medical model perspective of substance use disorders (SUDs), opioid use disorders are associated with some degree of disability. This study aimed to assess the disability among patients with opioid use disorders (OUDs) and its relationship with internalized stigma. Methodology: This cross-sectional study assessed patients with SUDs at a tertiary care center. Disability among patients with OUDs was assessed using Indian Disability Evaluation and Assessment Scale (IDEAS) while stigma was measured using Internalized Stigma of Mental Illness Scale (ISMIS). Results: Among 168 patients with OUD, the disability was greatest in the domain of work followed by interpersonal activities. About 48.2% and 3.0% of the participants had moderate and severe disability according to IDEAS. Disability (IDEAS) scores had a robust correlation with the stigma (ISMIS) scores (r = 0.453, P < 0.01). Multiple regression analysis found that internalized stigma (ISMIS score) was an independent predictor of disability among patients with OUDs (β =0.42, P < 0.01). Conclusions: From a medical perspective, OUDs are associated with considerable disability which has significant correlation with internalized stigma. Designing interventions which can target internalized stigma among patients with OUD may help in reducing the disability associated with it.
Keywords: Disability, Indian Disability Evaluation and Assessment Scale, internalized stigma, opioid use disorders
|How to cite this article:|
Kumar S, Singh S, Sarkar S, Singh Balhara YP. Disability among patients with opioid use disorders and its relationship with stigma toward substance use. Indian J Soc Psychiatry 2018;34:30-6
|How to cite this URL:|
Kumar S, Singh S, Sarkar S, Singh Balhara YP. Disability among patients with opioid use disorders and its relationship with stigma toward substance use. Indian J Soc Psychiatry [serial online] 2018 [cited 2019 May 24];34:30-6. Available from: http://www.indjsp.org/text.asp?2018/34/1/30/228786
| Introduction|| |
Opioid use disorder (OUD) is a chronic condition leading to significant social and health burden. The findings of the Global Burden of Disease Study 2010 draw attention to the growing burden of opioid dependence worldwide. Globally, about 15.5 million people are affected with opioid dependence. The emergence of high-potency, synthetic opioid preparations such as heroin has resulted in a considerable rise in opioid use in India, especially in the northern and north-eastern parts of the country, where it has taken epidemic proportions. A national survey report from India estimates that there are about two million opioid users in India, among whom half a million are opioid dependent. This suggests that the problem related to OUD is quite severe and acute in India.
Substance use disorders (SUD) are known to be a highly disabling condition disrupting most of the domains of social functioning. Disability is a complex phenomenon, encompassing impairments, activity limitations, and participation restriction. It results from the interaction of between people with impairments and attitudinal and environmental barriers that hinder their full and effective participation in society on an equal basis with others. The available literature suggests that disability in SUD is associated with poor psychological and physical health, interpersonal and family conflicts, lack of education, duration and severity of substance use, and degree of stigma and discrimination experienced in the society. Stigma is one of the challenges that is associated with a condition that carries social disapproval. Stigma can be defined as an attribute that is deeply discrediting and reduces the bearer from a whole and usual person to a tainted and discounted one. Three broad levels of stigma described in the context of persons with mental illness are, namely, public, structural, and internalized stigma. Internalized stigma or self-stigma is defined as the stigma which is internalized by an individual and is applied to him or herself or to other people with similar conditions. It develops in stages where initially, the person with SUD becomes aware of the public views about their condition (awareness) which is followed by agreeing with the negative stereotypes (agreement). Subsequently, the person concurs that the stereotype applies to them (application) resulting in decreased self-esteem and self-efficacy. Internalized stigma results in decreased self-esteem and self-efficacy and is associated with various negative outcomes in individuals with SUD, such as poor physical and mental health, delayed treatment seeking, and poor quality of life.,
To best of our knowledge, there has been no study in Indian settings gauging the disability associated with OUD. There remains a need to understand the various facets of disability among individuals with OUD in this setting. Researchers have postulated that the stigma associated with substance use may result in higher levels of disability, but there has been no systematic study which has been undertaken to understand the relationship between stigma and disability in OUD. Hence, we aimed to assess disability among individuals suffering from OUD and seeking treatment at a de-addiction center in India and attempted to assess the relationship of internalized stigma with disability.
| Methodology|| |
Study settings and participants
This is an exploratory study with cross-sectional observational design conducted at a public-funded tertiary care center in India. The center is located in the National Capital Region of Delhi and caters to patients mainly from North India. The center provides both inpatient and outpatient care treatment facility.
The inclusion criteria for study participants were aged between 18 and 65 years, a clinical diagnosis of OUD was made by a trained psychiatrist according to the Diagnostic and Statistical Manual-5 criteria and using the substance for at least 1 year. Patients with comorbid SUD other than nicotine, presence of moderate-to-severe withdrawals at the time of assessment, or refusal to give informed written consent formed the exclusion criteria. Patients were included from both the inpatient and the outpatient services of the center.
Patients attending the outpatient or the inpatient treatment services were explained about the nature of study, and those who agreed to participate and gave informed written consent were assessed for inclusion based on the eligibility criteria for the study. The study participants were recruited by purposive sampling over a period of 12 months. They were assessed for demographic and clinical data using a structured questionnaire. Indian Disability Evaluation and Assessment Scale (IDEAS) was used to assess the disability and Internalized Stigma of Mental Illness scale (ISMIS) for measuring internalized stigma. The data collection was carried out by trained psychiatrists in a single sitting. The study was approved by the Institute Ethics Committee.
IDEAS is scale developed by the Rehabilitation Committee of Indian Psychiatric Society for quantifying and certifying disability in mental disorders and has been gazetted by the Ministry of Human Resources and Empowerment, Government of India, as the recommended instrument to measure psychiatric disability. The scale was field tested at nine centers across India involving 1078 patients and found to have good internal consistency, face, content, and criterion validities. It assesses disability in four domains: (1) Self-care: Includes taking care of body hygiene, grooming health including bathing, toileting, dressing, eating, and taking care of one's health, (2) Interpersonal activities (social relationship): Includes initiating and maintaining interactions with others in contextual and socially appropriate manner, (3) Communication and understanding: Includes communication and conversation with others by producing and comprehending spoken or written or nonverbal messages, and (4) Work: Three areas covered are employment/household work/schoolwork-related functioning. Each of the above four items is rated on a 5-point Likert scale, and total disability score is obtained by adding scores from all the four items. Final global disability score (IDEAS-GS) is calculated by adding total disability score and weightage score for the duration of illness.
ISMIS is an instrument to assess internalized stigma from the perspective of stigmatized individuals. It can be self-rated or interviewer based. It comprises of 29 items, which are rated on a 4-point Likert scale (strongly disagree 1, disagree 2, agree 3, and strongly agree 4), which are divided into five components (alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance). Higher ISMIS scores indicate greater degree of internalized stigma. The total ISMIS score ranges from 29 to 116. Internal consistency coefficients (alpha) range from 0.84 to 0.96, and test–retest reliability coefficients range from 0.61 to 0.90. The scale has been translated into various languages included including Hindi and has been utilized in varied cultural contexts. An adaptation of the scale has been made for patients with SUDs which has shown high degree of internal consistency.
Statistical analysis was carried out using SPSS version 23.0 (Armonk, NY, IBM Corp). Descriptive statistics were used to tabulate sample characteristics and scores on different scales applied in the study. Means and standard deviations were used to describe continuous variables, whereas frequencies and percentages were used for categorical variables. Pearson's correlation, independent t-test, and one-way analysis of variance were used to examine associations between measures of disability, stigma, and other demographic and clinical variables. Multiple linear regression analysis was carried out to find independent predictors of disability. The level of statistical significance was set at P < 0.05 for all the tests. Missing value imputation was not conducted.
| Results|| |
A total of 168 patients with OUD were included in the present study. The demographic and clinical characteristics of the participants are described in [Table 1].
|Table 1: Demographic and clinical characteristics of the study participants (n=168)|
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The disability scores (individual domains and IDEAS-GS) are described in [Table 2] and are depicted in [Figure 1]. The greatest degree of disability was found with respect to the work domain, followed by the interpersonal activity domain. Based on IDEAS-GS, about 48.2% and 3.0% of the participants had moderate (IDEAS-GS = 8–13) and severe (IDEAS-GS = 14–19) level of disability, respectively. Further, about 48.8% of the participants had mild disability (IDEAS-GS <8). The mean score of internalized (ISMIS total score) stigma was 3.13 ± 0.27.
|Figure 1: Representation of the Indian Disability Evaluation and Assessment Scale items and responses|
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Pearson's correlation analysis was conducted to assess the relationship between the disability (IDEAS-GS), age of participants, duration of substance use, and internalized stigma. Duration of substance use (r = 0.168, P = 0.04) and ISMIS score (r = 0.453, P < 0.01) were significantly correlated with disability summary scores while age did not have a significant relationship. Further, the relationship of IDEAS with other demographic and clinical variables is described in [Table 3]. Injecting drug use, history of incarceration in prison or caught by police, and involvement in high-risk behavior or drug peddling were found to have significantly higher disability scores.
|Table 3: Comparison of mean Indian Disability Evaluation and Assessment Scale global disCability score across variables with two groups|
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Multiple linear regression analysis was carried out to find the independent predictors of disability. IDEAS-GS was entered as the dependent variable, and all variables found to be significantly associated with disability in the outcome of Pearson's correlation and independent t-test were entered as independent variables. To check for multicollinearity, the tolerance statistic and variance inflation factor were examined, which did not reveal multicollinearity. The model [Table 4] was statistically significant and explained 27.1% of the variance in disability among the study population. It was seen that higher internalized stigma (β = 0.42, P < 0.01) was the most relevant independent predictor of greater disability.
|Table 4: Multiple linear regression equation for predictors of disability (n=168)|
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| Discussion|| |
Our study reveals that the entire study participant experienced disability to some extent with more than half of the sample having moderate-to-severe level of disability. The findings suggest that as per medical conceptualization of OUD, disability is substantial among such patients, and this disability is often unrecognized. Although no study had previously reported disability among Indian patients with OUD, a couple of studies have reported disability among alcohol use disorders (AUD) using IDEAS. These previous studies reported that about 13.33% and 16.7% of the participants had moderate level of disability,, compared to little over 50% of the participants having moderate and severe disability in the present study. The higher percentage of disability in our study population could be due to use of illicit substances. This is supported by our findings that study participants with injecting drug use, history of incarceration in prison or caught by police, and involvement in high-risk behavior or drug peddling were found to have significantly higher disability scores.
The most common domains of IDEAS which showed impairment was work related followed by difficulties in interpersonal relationships and the least affected domain was self-care. The findings are in concordance with earlier study assessing disability among patients with AUD, which revealed greatest impairment in the domains of participation in the society, household, and work-related activities. The WHO survey on global assessment of disability in various disorders indicated that those with AUD have a significantly worse outcome in participation and work-related domains when compared with other disorders and the least impairment in self-care and mobility domains. The present work suggests that opioid is similar to alcohol in producing primarily work-related impairments. People suffering from SUD are generally more likely to be unemployed compared to the general population even if there mean educational levels were same. The lower level of employment can be disorder related where a person using the substance loses the control over its use, which may lead to frequent absenteeism during the periods of intoxication and withdrawal. The individual suffering from the disorder usually gives up important life activities or events to procure the substance of use and continue its use which could, in turn, hamper their ability to sustain any job. The other prevalent work barriers include marginalization to areas where few career and employment opportunities are present, low levels of interpersonal skills, low level of soft skills such as computer knowledge, and frequent housing or legal problems. In this context, getting involved in meaningful employment is an important positive outcome indicator in the context of substance use treatment and recovery. Employment helps patients with SUD by providing them legal source of income and adds important structures and reinforcement. Studies have shown that there is positive association between employment and long-term heroin abstinence, lower rates of substance use relapse, enrolment in more comprehensive treatment programs, and improved duration of treatment. Hence, vocational rehabilitation should be an important treatment goal in the management of patients with OUD, which, in turn, can help in reducing the associated disability.
The low scores in interpersonal domain among patients with OUD are not surprising since substance users are frequently subjected to rejections by others leading to coping approaches such as withdrawal and isolation, further harming their overall well-being. In a study conducted in therapeutic community settings for SUD, it was found that more than two-thirds of the participants were single and 42% of them spent their time alone. Further, similar high rates of social isolation have been found in large population-based studies. Hence, developing a good social support is a predictor for retention of patients in treatment and helps in reduction of substance use. Qualitative studies have shown that patients with SUD experience a loss of valued identities during onset of their illness which they regain during the course of recovery. Thus, one of the key focuses while treating patients with SUD should be reinforcing the individual's place in the community as a productive worker, family member, and community member.
Opioid substitution treatment has been shown to have multiple health-related benefits in patients with OUD. The benefits include reducing illicit opiate use, HIV risk behaviors, death from overdose and criminal activity, and financial and other stresses on drug users and their families, thus reducing the overall burden associated with substance use.,, Despite a large body of evidence supporting opioid substitution treatment in reducing the overall burden due to OUD, a minority of injecting drug users currently receive oral substitution therapy, especially in low-income countries. The members of Addictive Disorder Specialty Section of Indian Psychiatric Society have recently suggested several steps to increase the reach of oral substitution therapy for patients with OUD. These include enhancing the capacities of health professionals and legal and policy reforms and to bring oral substitution therapy into the mainstream of addiction treatment. A concerted effort is required by multiple stakeholders to advocate for the reforms which could make oral substitution therapy available, affordable, and accessible to the large number of patients with OUD in India.
This study revealed that higher internalized stigma among the participants was the most relevant predictor of greater disability. The members of the society who does not misuse substance tend to stereotype individuals suffering from SUD in extremely pejorative and negative categories, as a result of which the person comes to see him or herself as part of the conceptual group resulting in internalization of stigma. Researchers have proposed a “why-try?” model of internalized stigma which suggests that internalized stigma in people with mental illness results in reduced self-esteem and self-efficacy which prevents them from pursuing life goals. Accepting others' prejudiced beliefs about themselves results in patients suffering from SUD to believe that they are less worthy of respect and inclusion in society, leading to social isolation. This may make them less motivated for social interaction and work-related pursuits, leading to greater disability in these domains. A recent study assessing internalized stigma and social functioning among patients with SUD reported higher levels of internalized stigma to be associated with poorer social functioning. This suggests that rehabilitation of substance users should include interventions to reduce internalized stigma, which can help in reducing the disability associated with this condition. Several studies have found that internalized stigma acts as an important barrier in treatment seeking resulting in further disability. A population-based survey used different instruments to measure anticipated stigma and self-stigma and reported that self-stigma was more of an obstacle to help seeking. Similarly, a study examining the role of self-stigma in seeking psychological help found that anticipated risk, tendency to conceal personal information, and negative belief about anticipated benefits were related to decreased treatment seeking. The internalization of stigma associated with mental illness results in hopelessness about possibility of recovering and other negative self-evaluations leading to low engagement in rehabilitation treatment and other services. This, in turn, results in a tendency to use avoidant coping strategies to deal with symptoms and stressors.
There are several limitations to consider while interpreting findings of the present study. The sample was from a single center, comprising of predominantly males, and a convenience sample of treatment seekers. Hence, generalization if any should be done with caution. The severity and frequency of substance use were not assessed in the study although both these variables have been shown to affect stigma and disability. The study is cross-sectional in nature which does not allow us to explore the effect of treatment on disability, which requires a longitudinal follow-up study. Social desirability bias might have affected the patient responses. Furthermore, control group of another condition or general population was not used in the present study.
Despite the limitations, our study has several important clinical implications. Patients with OUD suffer from high degree of disability, especially in work-related and interpersonal domains. Various interventions such as vocational rehabilitation and harm-reduction strategies can help in reducing this burden. In our study, we found that internalized stigma is an important predictor of disability associated with OUD. Internalized stigma is a measurable construct where specific interventions may be attempted. The interventions which can alter the stigmatizing beliefs and attitudes of the individuals suffering from the disorder and attempt to enhance coping skills through improvements in self-esteem, empowerment, and help-seeking behavior can be effective in reducing the internalized stigma. Acceptance and commitment therapy appears to be one of the useful interventions in this regard. This strategy is based on reducing internalized stigma by accepting the existence of stigmatizing stereotypes without challenging them and then focusing on overt actions that will help the patient in moving in the valued directions. Targeting internalized stigma in patients with OUD can possibly contribute toward reducing the disability associated with it.
I would like to thank Dr. Shreeya, Dr. Vaibhav, Dr. Vinay, Dr. Arpit, and Dr. Akriti who provided a great support in screening and collection of data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]