Reducing Stigma Among Individuals With Addiction and Staff in the Criminal Justice System: A Pilot Feasibility Trial

Stigma is one of the most pervasive barriers to addiction care in the U.S. criminal justice (CJ) system. Stigmatizing attitudes about addiction, its intersecting conditions (i.e., criminal involvement), and its treatment (i.e., medications for opioid use disorder [MOUD]) are widespread throughout court, corrections, probation, and treatment sectors. These attitudes impact treatment decisions as well as how staff interact with clients. CJ-involved individuals with addiction are aware of this stigma, perceiving negative stereotypes, expecting to be judged, and often feeling ashamed and worthless as a result (i.e., self-stigma). Self-stigma is a robust predictor of treatment avoidance, non-compliance, and dropout in many stigmatized groups, including people with addiction and CJ involvement, making this a critical treatment barrier. Despite the negative consequences of stigma in the CJ system, there are virtually no stigma reduction interventions in this context. Given that the CJ system provides a substantial portion of addiction treatment, and untreated addiction increases risk for relapse, re-arrest, overdose, and other negative outcomes, it is essential to address stigma-related barriers to addiction care.

We drew from existing evidence-based interventions to develop a multi-level stigma intervention, Combatting Stigma to Aid Re-entry and Recovery (CSTARR), that simultaneously targets CJ staff attitudes as well as CJ-involved individuals' ability to cope with stigma in separate client and staff interventions. The staff intervention involves a half-day Stigma Awareness Training, and the client intervention involves a three-session Acceptance and Commitment Therapy for self-stigma group that was adapted to address criminal involvement in addition to addiction stigma. We will deliver both interventions virtually in 6 (primarily rural) Tennessee counties that contain infrastructure called the Tennessee Recovery Oriented Compliance Strategy (TN-ROCS). TN-ROCS coordinates multiple CJ sectors (i.e., courts, corrections, probation, treatment) to divert and treat people with addiction, thus presenting a unique unified system to intervene with stigma at both client and staff levels. Also, select TN-ROCS counties are integrating MOUD services, providing an opportunity to reduce stigma that may ultimately impact MOUD engagement. This project aims to 1) examine the feasibility, acceptability, and implementation considerations of integrating CSTARR in the TN-ROCS program, and 2) determine whether CSTARR impacts individual, staff, and program-level outcomes.

We aim to recruit 25 stakeholders, 80 clients, and 75 staff over the course of this 18-month project to participate in our intervention and evaluation efforts. Staff and clients will be asked to complete online surveys before and after the intervention, as well as 1- and 3-month follow ups, for which they will receive gift-cards. The overall goal of this project is to examine the feasibility and utility of stigma reduction efforts in the criminal justice system to determine whether they can help facilitate engagement with evidence-based addiction care and improve client and staff outcomes.