|Year : 2020 | Volume
| Issue : 3 | Page : 208-213
A cross-sectional study to assess disability and internalized stigma among treatment-seeking individuals with opioid use disorders
Shabir Ahmad Dar, Zaid Ahmad Wani, Naziya Fayaz Baba, Junaid Nabi, Aaliya Khanam
Department of Psychiatry and Clinical Psychology, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||02-Nov-2019|
|Date of Decision||06-Feb-2020|
|Date of Acceptance||02-Apr-2020|
|Date of Web Publication||28-Sep-2020|
Shabir Ahmad Dar
Department of Psychiatry Government Medical College, Srinagar - 190 003, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: India being located between the Golden Crescent and the Golden Triangle is vulnerable to being both a destination and transit route for opioids, leading to significant clinical and public health burden. This study aimed to assess the disability and internalized stigma among opioid use disorder (OUD) patients. Materials and Methods: This was a cross-sectional, observational, descriptive study conducted in the drug de-addiction center of a tertiary care medical college and hospital in North India in patients with OUDs. Disability among patients with OUDs was measured using the Indian Disability Evaluation and Assessment scale (IDEAS), while stigma was measured using the Internalized Stigma of Mental Illness scale. Results: Among 100 patients with OUD, maximum impairment noted was in interpersonal relationships followed by the work domain. However, the least affected was the self-care domain. The mean total score of internalized stigma was 4.31 ± 0.39. There was a statistically significant correlation between demographic variables with injection drug use and high-risk behavior (r = 0.92, P < 0.01, and 0.883, P < 0.01, respectively). Conclusions: Disability assessment using IDEAS among patients with OUD shows a significant impairment across various domains. The highest degree of disability was found in the interpersonal relationships followed by the work domain. Targeting internalized stigma in patients with OUD can contribute toward reducing the disability associated with it.
Keywords: Indian Disability Evaluation and Assessment scale, internalized stigma, opioid use disorders
|How to cite this article:|
Dar SA, Wani ZA, Baba NF, Nabi J, Khanam A. A cross-sectional study to assess disability and internalized stigma among treatment-seeking individuals with opioid use disorders. Indian J Soc Psychiatry 2020;36:208-13
|How to cite this URL:|
Dar SA, Wani ZA, Baba NF, Nabi J, Khanam A. A cross-sectional study to assess disability and internalized stigma among treatment-seeking individuals with opioid use disorders. Indian J Soc Psychiatry [serial online] 2020 [cited 2023 Feb 6];36:208-13. Available from: https://www.indjsp.org/text.asp?2020/36/3/208/296253
| Introduction|| |
Opioid use disorder (OUD), a chronic condition characterized by problematic pattern of opioid use, causes significant impairment or distress. It has been seen that opioid-dependent users continue to use opioids despite the significant social and health problems. Opioid-dependent users are at high risk of being arrested, imprisoned for drug or property crimes, and exposure to blood-borne viruses and fatal opioid overdose.,
Even after the successful completion of drug treatment of a given episode, many opioid users relapse to heroin use. The advent of high-potency, synthetic opioid preparations such as heroin has resulted in a significant rise in opioid use in the northern and northeastern parts of India, and has taken a significant chunk.
OUDs are among the most common illicit drug-related conditions, bringing patients to health-care providers. The use of opioids through injection is a matter of grave concern. In India, nearly all injection drug users (IDUs) are opioid-dependent, and the prevalence of HIV in this group is >9%. This suggests that the problem related to OUD is quite severe and problematic in India.
Substance use disorders (SUDs) are highly disabling conditions which cause disruption in most of the domains of social functioning. Disability is an emerging concept which results from the complex interaction between persons with impairments and attitudinal and environmental barriers that make their full and effective participation difficult in the society in comparison to others. Disability is a complex phenomenon, encompassing impairments, activity limitations, and restriction.
It has been seen that SUD are associated with poor interpersonal relationships, familial conflicts, physical and psychological disturbances, and lack of education. SUD are associated with a substantial degree of stigma and discrimination in society.
Stigma is frequently defined as an attribute that is deeply discrediting and that it reduces the bearer from a whole and usual person to a tainted, discounted one. Stigma remains the main obstacle to a better life for millions of people suffering from mental disorders. Stigma can affect whether people with mental illness seek and adhere to treatment and influence their self-esteem and social adjustment. Stigma creates a barrier preventing help seeking because people avoid the label of mental illness. Self-stigma is the hatred which people with mental illness show against themselves. Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination, the behavioral reaction.
Self-stigma or 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 (QoL).,
The literature on disability among individuals with OUD is quite limited. Further, there is a paucity of literature on QoL among individuals with OUD in Kashmir. Hence, it is imperative to assess the disability associated with OUD systematically. Moreover, the QoL of substance users is known to be severely impaired and opioid users are no different. The current study was aimed at the assessment of disability and internalized stigma among individuals with OUDs.
| Materials and Methods|| |
This was a cross-sectional, noninterventional, observational, descriptive study conducted at the drug de-addiction center, department of psychiatry of a tertiary care medical college and hospital in North India, which has the facility of round-the-clock de-addiction services. After obtaining written informed consent from the patients in the case of adults and from guardians in the case of minors, 100 consecutive OUD patients visiting the inpatient and outpatient department services and recruited through purposive sampling technique were taken. The study was conducted over 2 months from March to April 2019.
The patients included in the study were aged between 16 and 54 years with a clinical diagnosis of OUD made by two qualified psychiatrists as per the Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria. Patients with SUD other than nicotine, moderate-to-severe withdrawal symptoms at the time of assessment, with comorbid chronic physical illnesses, and those who refused to give informed written consent were excluded from the study.
A semi-structured proforma was prepared to record age, gender, education, occupation, marital status, family type, locality, total duration of substance use (in years), injection drug use, high-risk behavior, ever caught by the police, legal case pending, a history of incarceration, and involvement in drug peddling.
The Indian Disability Evaluation and Assessment Scale (IDEAS), the official tool to assess and certify disability due to mental illness, was developed by the Rehabilitation Committee of Indian Psychiatric Society and has been gazette by the Ministry of Human Resources and Empowerment, Government of India.
The IDEAS has been used by many authors for the evaluation of patterns and prevalence in the past for various psychiatric disabilities in hospital- and community-based studies.,
The IDEAS measures disability under four domains which include self-care, interpersonal activities, communication and understanding, and work. Each item in the domain is scored on a Likert scale with a range of 0–4 (no to profound disability). The total duration of mental illness is included to calculate the global disability score. The total disability score is obtained by summing up the ratings on the four domains. The global disability score is determined by adding the total disability score with the duration of illness score. Global disability score of >7 signifies a disability of >40%.
The Internalized Stigma of Mental Illness scale was used for measuring internalized stigma. It is a 29-item self-rated or interviewer-based instrument with a Likert-type scoring (strongly disagree, disagree, agree, and strongly agree). Each item is rated from 1 to 4. The 29 items are divided into five domains, namely, alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance. Higher score on each domain denotes higher stigma. The scale has been previously standardized in India and translated into various languages including Hindi on a variety of patients with mental illnesses and was found to have good internal consistency and test–retest reliability.
All the ethical guidelines were adhered to. The study was approved by the ethics committee of the institute. Written informed consent was taken from all the patients. The Indian Council of Medical Research Ethical Guidelines for Biomedical Research on Human Participants were adhered to.
Statistical analysis was done using SPSS version 23.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics using mean, standard deviation, frequency, and percentage were used to describe the sample characteristics and scores on different scales. Pearson's correlation and independent t-test were used to examine associations between demographic and clinical variables. The level of statistical significance was set at P < 0.05.
| Results|| |
A total of 103 individuals with OUD were approached, and 100 were finally included. Among those who were excluded, two individuals were having moderate-to-severe withdrawal symptoms at the time of assessment and one had comorbid SUD other than nicotine and refused to participate. The sociodemographic and clinical characteristics of the study participants are summarized in [Table 1]. The study participants comprised almost exclusively of males, and the majority of them were unemployed and stayed at an urban residence with a mean age of 27.34 ± 5.38 years.
The individual domain disability scores and IDEAS global disability scores are summarized in [Table 2]. The greatest degree of disability was found in the interpersonal relationships followed by the work domain. The mean total score of internalized stigma was 4.31 ± 0.39.
Pearson's correlation analysis was done to assess the relationship between demographic and clinical variables, as shown in [Table 3].
The variables associated with heroin dependence revealed that peer pressure was the most common reason for starting the use of heroin (83%). Most patients perceived heroin use as being continued as a result of force of habit or due to the enjoyment derived from it (63%). The most common reason for seeking treatment was family/marital complications (51%). This was followed by self-motivation, financial complications, and health-related consequences [Table 4].
| Discussion|| |
OUD are chronic conditions with significant social and health problems that it causes, such as being arrested and imprisoned for drug or property crimes, exposure to blood-borne viruses and infectious diseases, and fatal and nonfatal opioid overdose. Research in high-income countries has shown that dependent heroin users, who seek treatment or come to attention through the legal system, may continue to use heroin for decades.,
In our study, the mean age of the participants was 27.34 ± 5.38 years, with majority of them in the young age group of 25–34 years, which is in concordance to the study from the same center. Drug abuse affects the young age groups, as they are the most vulnerable group; their most productive years of life are wasted. A community-based study conducted by Margoob and Dutta on drug abuse in Kashmir had found most of the abusers to be aged below <42 years of age. Different studies conducted by Nigam et al. and Kalra and Bansal have reported the mean age of substance abuse as 28.7 ± 7.2 and 25.46 ± 7.613 years, respectively, in their participants and their results match our study results.,
Majority of the patients were unemployed, which is supported by the fact that people suffering from SUD are generally more likely to be unemployed compared to the general population even if their mean educational levels were same and the reasons seem to be the frequent work absenteeism, inability to sustain any job, low levels of interpersonal skills, and frequent housing and legal problems.
Employment helps patients with SUD by providing them a legal source of income and adds important structures and reinforcement. Studies have shown that there is a positive association between employment and long-term heroin abstinence, lower rates of substance use relapse, enrollment 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.
Almost half of the opioid users taken were current injecting drug users. The highest rate of injection use seen in the younger age range of 18–25 years and most IDUs were single. The Initiation of injection drug use was later than that of chasing at around 25 years, and the mean duration of injection drug use was 2.3 ± 1.14 years, suggesting that most were recent injectors. Heroin was mostly mixed with tap water for injection. A minority (8%) reported sharing syringes and needles. The significant risk factors for Injection drug users (IDU) were being unmarried and high high-risk behavior.
The most common domains of disability which were affected include interpersonal relationships followed by work-related domain and the least affected domain was self-care. This supports the bio-psychosocial nature of OUD, which negatively affects multiple aspects of an individual's life such as physical and mental health, education, family functioning, employment, and housing. The maximum impairment was for the domain of social relationships, which assesses an individual's satisfaction with personal relationships, social support, and sexual activity, emphasizing the social nature of the OUDs. These findings are similar to those reported in a previous study assessing the QoL among patients with OUD in India.
The findings are in concordance with an earlier study assessing disability among patients with Alcohol use disorder (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 have the least impairment in self-care and mobility domains.
The low scores in the interpersonal domain among patients with OUD are not surprising because 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 the 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, a family member, and a community member.
The present study showed higher internalized stigma among the respondents, which may be the most relevant predictor of disability. It has been seen that higher level of perceived stigma is associated with a greater degree of internalized shame and self-concealing behavior. This might lead to reduced self-esteem and self-efficacy and, in turn, negatively affect the various domains of QoL. Furthermore, studies among patients with SUD have suggested that those with higher perceived stigma were more likely to have delayed utilization of treatment services for their substance use-related problems.
Thus, a higher level of perceived stigma among patients with OUD might act as an important barrier in the utilization of services such as opioid substitution treatment. Opioid substitution treatment is associated with multiple health-related benefits and has been shown to improve all domains of QoL in patients with OUD.
Accepting prejudgmental beliefs about themselves leads patients suffering from SUD to believe that they are less worthy of respect and inclusion in the 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.
The findings of this study should be viewed with some limitations which include its cross-sectional nature, being a single-center study, absence of control group, and presence of social desirability bias. Patients with OUDs usually have comorbid psychiatric illness predisposing to poor functioning, which should be considered among the limitations of the study.
| Conclusions|| |
Disability assessment using IDEAS among patients with OUD shows a significant impairment across various domains. The highest degree of disability was found in the interpersonal relationships followed by the work domain. Targeting internalized stigma in patients with OUD can contribute toward reducing the disability associated with it.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Arch Gen Psychiatry 2001;58:503-8.
Hser YI. Predicting long-term stable recovery from heroin addiction: Findings from a 33-year follow-up study. J Addict Dis 2007;26:51-60.
Gerstein DR, Lewin LS. Treating drug problems. N Engl J Med 1990;323:844-8.
Ambekar A, Murthy P, Basu D, Rao GP, Mohan A. Challenges in the scale-up of opioid substitution treatment in India. Indian J Psychiatry 2017;59:6-9.
] [Full text]
Ambekar A. Association of Drug Use Pattern with Vulnerability and Service Uptake among IDUs. New Delhi: United Nations Office on Drugs and Crime (UNODC) Regional Office for South Asia, and National AIDS Control Organisation; 2012.
Daley DC. Family and social aspects of substance use disorders and treatment. J Food Drug Anal 2013;21:S73-S76.
Balhara YP, Singh S, Modak T, Sarkar S. A crosssectional study to assess disability and its correlates among treatment seeking individuals with alcohol use disorders. Indian J Psychol Med 2017; 39:405.
Goffman E. The Presentation of Self in Everyday Life. New York: The Overlook Press, 1959.
Sartorius N. Iatrogenic stigma of mental illness. BMJ 2002;324:1470-1.
Trude S, Stoddard JJ. Referral gridlock: Primary care physicians and mental health services. J Gen Intern Med 2003;18:442-9.
Crocker J. Major B. Steele C. Social stigma. In: Gilbert D, Fiske ST, Lindzey G, editors. The Handbook of Social Psychology. 4th
ed. Vol. 2. New York: McGraw-Hill; 1998. p. 504-53.
Lysaker PH, Roe D, Yanos PT. Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders. Schizophr Bull 2007;33:192-9.le with schizophrenia spectrum disorders. Schizophr Bull 2007;33:1929.
Ritsher JB, Phelan JC. Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Res 2004;129:257-65.
Thara R. IDEAS (Indian Disability Evaluation and Assessment Scale)-a Scale for Measuring and Quantifying Disability in Mental Disorders. India: The Indian Psychiatric Society; 2002.
Chaudhury PK, Deka K, Chetia D. Disability associated with mental disorders. Indian J Psychiatry 2006;48:95-101.
] [Full text]
Kumar SG, Das A, Bhandary PV, Soans SJ, Harsha Kumar HN, Kotian MS. Prevalence and pattern of mental disability using Indian disability evaluation assessment scale in a rural community of Karnataka. Indian J Psychiatry 2008;50:21-3.
] [Full text]
The Rehabilitation Committee of the Indian Psychiatric Society. IDEAS (Indian Disability Evaluation and Assessment Scale) – A Scale for Measuring and Quantifying Disability in Mental Disorders. Gurgaon, India: Indian Psychiatric Society; 2002.
Singh A, Grover S, Mattoo SK. Validation of Hindi version of internalized stigma of mental illness scale. Indian J Soc Psychiatry 2016;32:10414.
Farhat S, Hussain SS, Rather YH, Hussain SK. Sociodemographic profile and pattern of opioid abuse among patients presenting to a de-addiction centre in tertiary care Hospital of Kashmir. J Basic Clin Pharm 2015;6:94-7.
Margoob MA, Dutta KS. Drug abuse in Kashmir-Experience from a psychiatric diseases hospital. Indian J Psychiatry 1993;35:163-5.
] [Full text]
Nigam AK, Ray R, Tripathi BM. Buprenorphine in opiate withdrawal: A comparison with clonidine. J Subst Abuse Treat 1993;10:391-4.
Kalra I, Bansal PD. Socio-demographic profile and pattern of drug abuse among patients presenting to a Deaddiction Centre in rural area of Punjab. Psychiatry J 2012;15:327-31.
Sigurdsson SO, Ring BM, O'Reilly K, Silverman K. Barriers to employment among unemployed drug users: Age predicts severity. Am J Drug Alcohol Abuse 2012;38:580-7.
Castellani B, Wedgeworth R, Wootton E, Rugle L. A bidirectional theory of addiction: Examining coping and the factors related to substance relapse. Addict Behav 1997;22:139-44.
Lundgren LM, Schilling RF, Ferguson F, Davis K, Amodeo M. Examining drug treatment program entry of injection drug users: Human capital and institutional disaffiliation. Eval Program Plann 2003;26:123-32.
Reif S, Horgan CM, Ritter GA, Tompkins CP. The impact of employment counseling on substance user treatment participation and outcomes. Subst Use Misuse 2004;39:2391-424.
Giri OP, Srivastava M, Shankar R. Quality of life and health of opioid-dependent subjects in India. J Neurosci Rural Pract 2014;5:363-8.
] [Full text]
Üstün TB, Chatterji S, Villanueva M, Bendib L, Çelik C, Sadana R, et al
. WHO multicountry survey study on health and responsiveness 20002001. In: Health Systems Performance Assessment: Debates, Methods and Empiricism. Geneva: World Health Organisation; 2003. p. 76196.
Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997;38:177-90.
Dingle GA. Report of an Independent Evaluation of the Logan House Therapeutic Community. Report One June; 2012.
Chou KL, Liang K, Sareen J. The association between social isolation and DSM-IV mood, anxiety, and substance use disorders: wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2011;72:1468-76.
Dobkin PL, De CM, Paraherakis A, Gill K. The role of functional social support in treatment retention and outcomes among outpatient adult substance abusers. Addiction 2002;97:347-56.
Dingle GA, Cruwys T, Frings D. Social Identities as Pathways into and out of Addiction. Front Psychol 2015;6:1795.
Luoma JB, Twohig MP, Waltz T, Hayes SC, Roget N, Padilla M, et al
. An investigation of stigma in individuals receiving treatment for substance abuse. Addict Behav 2007;32:1331-46.
Oliveira SE, Carvalho H, Esteves F. Internalized stigma and quality of life domains among people with mental illness: the mediating role of self-esteem. J Ment Health 2016;25:55-61.
Keyes KM, Hatzenbuehler ML, McLaughlin KA, Link B, Olfson M, Grant BF, et al
. Stigma and treatment for alcohol disorders in the United States. Am J Epidemiol 2010;172:1364-72.
Feelemyer JP, Jarlais DCD, Arasteh K, Phillips BW, Hagan H. Changes in quality of life (WHOQOL-BREF) and addiction severity index (ASI) among participants in opioid substitution treatment (OST) in low and middle income countries: An international systematic review. Drug Alcohol Depend 2014;134:251-8.
Can G, Tanrıverdi D. Social functioning and internalized stigma in individuals diagnosed with substance use disorder. Arch Psychiatr Nurs 2015;29:441-6.
[Table 1], [Table 2], [Table 3], [Table 4]