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

Background: Stigma toward people who use drugs (PWUD) remains a pervasive barrier to disclosure of substance use and sustained engagement with harm reduction services. While extensive research has documented stigmatizing behaviors within traditional medical settings, less is known about how stigma manifests within Syringe Service Programs (SSPs), which are intentionally designed to be low-threshold and nonjudgmental. Understanding how stigma operates is critical to improving service acceptability, client engagement, and care continuity.

Methods: The study was a cross-sectional pilot among clients accessing services at a storefront 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. 52 valid surveys were retained for analysis. Data was completed using an adapted version of the validated 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 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 and stigma scores. 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 final analytic sample 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. Most participants reported prior use of SSP services (90%), including access to sterile syringes, naloxone, and safer use supplies, while 65% had accessed medical services such as screenings and case management. Across the various stigma domains, enacted stigma was the lowest, internalized stigma was moderate, and anticipated stigma was highest. 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 and 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). Internalized stigma differed significantly by housing status (p = .033), with higher levels observed among participants who declined to report housing. Gender-based patterns were observed in anticipated stigma, particularly related to concerns about disclosure. Conclusions: This pilot study identified clear differences across stigma domains among Syringe Service Program (SSP) clients. Findings suggest SSPs function as protective environments that reduce overt discrimination but cannot fully mitigate broader systemic stigma. Implications include the need for stigma-informed communication, strengthened care linkages, and refined measurement tools tailored to harm reduction settings. Despite limitations, results offer actionable insights for service improvement and future research.

Key Words: Harm Reduction; Public Health; Syringe Service Programs; Stigma; Disclosure; Community Health; Screening & Assessment; Prevention; Service Quality Improvement

Soha Khoso is a Master of Public Health candidate at Yale University specializing in Social and Behavioral Sciences with a focus on Implementation Science. She completed her undergraduate training at Cornell University, where she studied the intersection of medicine, ethics, and health policy. Her research focuses on addiction medicine, particularly stigma mechanisms, access to care, and harm reduction service delivery. She has contributed to NIH-funded research initiatives examining telehealth and emerging AI and Machine Learning approaches to advancing healthcare. In addition to her research, she is actively engaged in public health education and mentorship initiatives supporting students and early-career scholars.