Journal of Substance Abuse Treatment 104 (2019) 28–33

Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

journal homepage: www.elsevier.com/locate/jsat

Brief video intervention to improve attitudes throughout medications for T

opioid use disorder in a correctional setting
⁎
Jeffrey A. Lama, , Hye In Sarah Leeb, Ashley Q. Truongc, Alexandria Macmaduc,d,
Jennifer G. Clarkea,e, Josiah Richa,c,d, Brad Brockmannd
a
Warren Alpert Medical School, Brown University, Providence, RI, United States of America
b
Harvard Department of Psychology, Harvard University, Cambridge, MA, United States of America
c
Center for Prisoner Health and Human Rights, Providence, RI, United States of America
d
Brown University School of Public Health, Brown University, Providence, RI, United States of America
e
Rhode Island Department of Corrections, Cranston, RI, United States of America

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: Medications for opioid use disorder (MOUD) in the criminal justice setting is an effective way to
Patient education address opioid use disorder and prevent associated deaths in the community. The Rhode Island Department of
Methadone maintenance treatment Corrections (RIDOC) is the first statewide correctional system in the United States to offer comprehensive MOUD
Incarceration services to incarcerated individuals.However, due to stigma, eligible individuals may be reluctant to engage with
Stigma
MOUD. This study aims to 1) evaluate the efficacy of an educational video intervention about MOUD and 2)
Opioids
characterize MOUD-related attitudes in a general incarcerated population.
Methods: Participants were recruited from eight elective classes offered to soon-to-be-released incarcerated in-
dividuals at RIDOC. Participants viewed an eight-minute video featuring incarcerated individuals speaking about
their experiences using MOUD, designed to reduce MOUD-related stigma. Participants were administered sur-
veys prior to and after watching the video to assess changes in MOUD knowledge (MOUD-K) and MOUD atti-
tudes (MOUD-A).
Results: This evaluation of the intervention included 80 incarcerated participants (median age = 35, 93% male,
36% non-Hispanic White, and 26% non-Hispanic Black). Forty percent indicated non-medical opioid use within
six months prior to incarceration; 13% had previously used MOUD. Significant improvements in MOUD-K scores
(t(65) = −7.0, p < 0.0001) and MOUD-A scores (t(69) = −5.8, p < 0.0001) were detected after participants
viewed the video. The intervention yielded greater ΔMOUD-A scores among those identifying as non-Hispanic
Black, compared to non-Hispanic Whites (β = 2.6, CI = 0.4, 4.8).
Conclusion: The educational video improved both knowledge and positive attitudes towards MOUD, with
changes in MOUD attitudes being influenced by race. These findings may inform future MOUD educational
programs, thereby helping to reduce opioid use disorder-related morbidity and mortality.

1. Introduction et al., 2018; National Academies of Sciences, 2019; Sharma et al.,

Opioid use disorder (OUD) and opioid-related mortalities are cri-
tical public health challenges in the United States. Criminal justice (CJ)
involved individuals have a greater burden of OUD and are at sub-
stantially increased risk of overdose death following reentry to the
community (Binswanger et al., 2007; Binswanger, Blatchford, Lindsay,
& Stern, 2011; Binswanger, Blatchford, Mueller, & Stern, 2013; Farrell
& Marsden, 2008; Merrall et al., 2010). Growing evidence suggests that
medications for opioid use disorder (MOUD) are an effective, evidence-
based approach to address OUD in correctional populations (Green
2016). Implementing MOUD in correctional populations has extensive
benefits, including reductions in illicit oopioid-use post-incarceration
(Kinlock, Gordon, Schwartz, Fitzgerald, & O'Grady, 2009; Mattick,
Breen, Kimber, & Davoli, 2009), criminal behavior (Deck et al., 2009),
HIV risk behaviors (MacArthur et al., 2012), and overdose risk
(Brinkley-Rubinstein et al., 2018; Degenhardt et al., 2011; Kerr et al.,
2007).
The Rhode Island Department of Corrections (RIDOC) recently be-
came the first statewide correctional system in the US to implement a
comprehensive MOUD program (Clarke, Martin, Gresko, & Rich, 2018;

⁎
Corresponding author.
E-mail address: jeffrey_lam@brown.edu (J.A. Lam).

https://doi.org/10.1016/j.jsat.2019.06.001
Received 12 March 2019; Received in revised form 2 June 2019; Accepted 4 June 2019
0740-5472/ © 2019 Elsevier Inc. All rights reserved.
J.A. Lam, et al.
Green et al., 2018), making the three FDA-approved MOUD options
(methadone, buprenorphine, and naltrexone) available to all clinically
eligible individuals. However, even when structural barriers to MOUD
are removed (i.e., high cost, lack of access, lack of trained providers),
not all eligible individuals elect to initiate MOUD treatment (Booth,
Corsi, & Mikulich, 2003; Booth, Kwiatkowski, Iguchi, Pinto, & John,
1998; Uebelacker, Bailey, Herman, Anderson, & Stein, 2016).
With the removal of many structural barriers to MOUD at RIDOC for
eligible individuals, MOUD stigma may be one of the most important
remaining barriers impeding MOUD uptake and engagement. The
stigmatization of substance use disorders including OUD is particularly
common because individuals with these disorders are often seen to be at
fault for their illness, which overshadows its status as a treatable
medical illness (Corrigan, Kuwabara, & O'Shaughnessy, 2009; Olsen &
Sharfstein, 2014). It is well-documented that stigma is a common cause
for treatment avoidance and treatment dropout in these stigmatized
illnesses (Copeland, 1997; Digiusto & Treloar, 2007; Semple, Grant, &
Patterson, 2005). Specifically, stigma associated with opioid use dis-
order may cause individuals with the condition to avoid the use of
opioid agonists, including methadone and buprenorphine, to assist with
recovery as healthcare providers, recovery organizations, and peers
may see use of these opioid substitutes as a character weakness or lack
of willpower (Olsen & Sharfstein, 2014).
Stigmatized individuals often perceive stigma in their interpersonal
relationships (van Boekel, Brouwers, van Weeghel, & Garretsen, 2016)
and in the general public (van Boekel, Brouwers, van Weeghel, &
Garretsen, 2015). In the correctional setting, MOUD engagement may
be affected by the social stigma from other CJ-involved individuals.
Stigmatized individuals also may internalize these negative beliefs
about themselves, a process known as self-stigma that manifests as an-
ticipated discrimination (Corrigan & Watson, 2002; van Boekel et al.,
2016).
Lack of knowledge and problematic attitudes are two major con-
tributing components to stigma (Thornicroft, 2006). Misperceptions
and lack of knowledge about the efficacy, safety, and perceived con-
sistency with being drug-free influence MOUD utilization and engage-
ment (Gu et al., 2012; Uebelacker et al., 2016). MOUD engagement
levels are influenced by misunderstandings about the treatment, such as
its effect on physical health, withdrawal symptoms, side effects, and
long treatment course (Luty, 2004; Schwartz et al., 2008; Stancliff,
Myers, Steiner, & Drucker, 2002; Zaller, Bazazi, Velazquez, & Rich,
2009). More knowledge about MOUD is associated with more positive
attitudes (Polonsky et al., 2015; Polonsky et al., 2016); however, one
intervention found that even if an individual is knowledgeable about
the benefits of MOUD, this individual may still hold prejudices against
the treatment, especially in the correctional setting where ideological
biases perpetuated by stigma and discrimination among peers and staff
may reinforce negative beliefs about MOUD (Polonsky et al., 2016).
Inaccurate knowledge about MOUD has fostered negative attitudes
about its use. This points to the need for an effective targeted inter-
vention that increases the understanding of MOUD and contributes to
reducing associated stigma, particularly in prison and jail settings. In a
correctional setting, DVDs are an accessible and established medium for
delivery of health education (Green et al., 2015), and there is strong
evidence that video-based interventions can increase knowledge and
decrease stigmatizing attitudes about mental illness and substance use
(Clement et al., 2018; Dalky, 2012; Livingston, Milne, Fang, & Amari,
2012; Yamaguchi et al., 2013). Social stigma may be addressed by
communicating positive stories of individuals with substance use dis-
order (Livingston et al., 2012), and there may be a benefit of featuring
race-matched peers in a video intervention in a correctional setting
(Martin, O'Connell, Inciardi, Surratt, & Maiden, 2008).
We hypothesize that a peer-delivered video intervention will im-
prove both understanding of and positive attitudes about MOUD among
incarcerated individuals. These increases in knowledge and positive
attitudes may lessen stigma and ultimately improve MOUD engagement
29
Journal of Substance Abuse Treatment 104 (2019) 28–33
for eligible individuals. This study aims to 1) evaluate the efficacy of a
brief educational video intervention aimed to increase MOUD knowl-
edge and positive attitudes and 2) characterize MOUD-related attitudes
in a general correctional population.
2. Methods
2.1. Participants
Participants were recruited from all ongoing pre-release classes of-
fered to incarcerated individuals during the month of July 2018 at
RIDOC. Recruitment took place in eight classes at different RIDOC fa-
cilities, including the women's facility and the men's minimum and
medium security facilities. Other facilities, such as maximum security
and intake service center, were not included, as there were no ongoing
pre-release classes at these facilities at the time of the intervention.
Study participants had to be: 1) over the age of 18; 2) incarcerated at
RIDOC; and 3) able to read and speak English in order to give consent.
No identifying information was collected.
2.2. Procedures
All individuals in the pre-release classes were offered the chance to
voluntarily participate in the study. The course instructor of the pre-
release class and a research assistant asked all individuals in the class if
they would like to voluntarily give feedback about a video related to
MOUD. The study population included all individuals in pre-release
classes, all of whom were within six months of their release date.
Potential participants were asked to review a consent form, which de-
scribed study procedures. Participants were not provided any incentives
for participating in the research study. Individuals who chose not to
participate in the survey were given crossword puzzles to work on while
participants completed the surveys. Participants watched an eight-
minute narrative-based video featuring two incarcerated individuals, a
male person-of-color and a white female, speaking about their personal
experiences with OUD and using MOUD. The full video can be viewed
on http://www.prisonerhealth.org/videos-and-fact-sheets/mat-and-
corrections/. The educational video was designed with the goal of in-
creasing knowledge about the MOUD program and reducing MOUD-
related stigma. A research assistant administered handwritten surveys
to participants prior to and following the video screening. These sur-
veys assessed changes in MOUD knowledge (MOUD-K) and MOUD at-
titudes (MOUD-A).
2.3. Ethical considerations
The Miriam Hospital Institutional Review Board and Ethics
Committee and the RIDOC Medical Research Advisory Group approved
the intervention, including the purpose, methods, risks, and benefits of
the study. These were explained to potential participants to inform their
decision to participate. Participants were assured that their participa-
tion would be completely voluntary and that they could stop partici-
pating at any stage if they did not want to continue for any reason.
Neither participation nor non-participation in the research study would
impact release date, privileges, probation, or parole status in any way.
Identifying information, including names, were not collected.
2.4. Measures
Demographic measures included age, gender, self-identified race,
time incarcerated, MOUD use history, and pre-incarceration opioid
exposure. Pre-incarceration opioid exposure was defined as self-re-
ported use of prescription opioids, heroin, or fentanyl non-medically in
the six months prior to incarceration.
The research team created items based on previous studies assessing
MOUD knowledge and attitudes and adapted these scales to the
J.A. Lam, et al. Journal of Substance Abuse Treatment 104 (2019) 28–33

targeted participant population (Matejkowski, Dugosh, Clements, & characteristics) based on the previous literature (Stancliff et al., 2002).
Festinger, 2015; Matusow et al., 2013; Stancliff et al., 2002). Concise We added all variables to the model and used backward elimination to
and simple Likert scale response options were used that allowed par- eliminate variables until the model fit could no longer be improved
ticipants to complete the full survey in < 10 min. All surveys and according to the Bayesian information criterion (BIC) (Posada &
consent forms used commonly used terms and drug names, including Buckley, 2004). Assumptions for linear regression were checked. Sta-
the trade names of some drugs. tistical analyses were conducted using STATA SE 13.0 (StataCorp,
2013).
2.4.1. MOUD-knowledge (MOUD-K)
Knowledge of MOUD and of the MOUD program at RIDOC was 3. Results
assessed by responses to three items. Each was scored on a 5-point
Likert scale ranging from 1 = Strongly Disagree to 5 = Strongly Agree. 3.1. Demographic and opioid use characteristics
The statements assessing for MOUD-K included “I have heard about
MOUD (Methadone, Suboxone, Vivitrol)” and “I can explain MOUD to a From July 16, 2018 to July 24, 2018 eight groups were offered
friend” (refer to Table 2 for full question content). Higher scores on participation in the study; 82 watched the video and 80 agreed to
MOUD-K denoted higher knowledge about and familiarity with the complete the study. The median age for the sample was 35, and 74
MOUD program. Participants with > 25% of the pre-video MOUD-K participants (93%) were male. Twenty-nine participants (36%) self-
items (n = 2) or post-video MOUD-K items (n = 4) items missing were identified as non-Hispanic White; 21 (26%) self-identified as non-
not included in the analysis. Hispanic Black; four (5%) were Asian or other; and 25 individuals
(31%) identified as ethnically Latino or Hispanic. Thirty-two in-
2.4.2. MOUD-attitudes (MOUD-A) dividuals (40%) endorsed non-medical opioid use during the six months
Attitudes towards MOUD were assessed using responses to seven prior to incarceration, including 29 individuals (37%) who reported
items that were developed by adapting previous research surveys to fit using prescription opioids non-medically, four individuals (5%) who
our participant population (Matejkowski et al., 2015; Matusow et al., reported using fentanyl, and five individuals (6%) who reported using
2013; Stancliff et al., 2002). Each item was scored on a 5-point Likert heroin within the six months prior to incarceration. A total of ten in-
scale ranging from 1 = Strongly Disagree to 5 = Strongly Agree; two dividuals (13%) had previously used MOUD, including six (8%) who
items were reverse scored. The statements assessing for MOUD-A in- used methadone, five (6%) who used buprenorphine, and one who used
cluded “Methadone can help an addicted individual” and “MOUD is both methadone and buprenorphine. No participants indicated previous
more effective than treatment without medications” (refer to Table 2 experience using depot-naltrexone. Table 1 summarizes demographic
for full question content). Imputation towards the mean within each and opioid use characteristics.
participant was performed on missing values for each of the seven items
if < 25% of the items were missing for pre-video MOUD-A (n = 4) and 3.2. Inclusion for primary outcomes analysis
post-video MOUD-A (n = 5) (Siddiqui, 2015). Participants with > 25%
of the pre-video (n = 2) MOUD-A items or post-video MOUD-A items Eleven of the 80 participants had either pre- or post- data that was
(n = 4) were not included in the analysis. Scores for the seven items considered invalid as a result of endorsing the same choice for all scale
were then totaled to form a composite score representing MOUD-A. items. An additional four individuals failed to answer > 25% of scale
Higher scores on MOUD-A denoted more positive attitudes towards items from either the MOUD-K or MOUD-A score and were also
MOUD.
For both pre- and post- video MOUD-K and MOUD-A scales, data Table 1
were considered invalid if a participant endorsed the same choice for all Demographic and opioid use characteristics (n = 80).
scale items (n = 11). The construct validity of the scales was examined
Variable Total
using a standardized confirmatory factor analysis, which is a theory-
driven approach to scale validation. Each item was considered accep- n (%)
table if it had a minimum loading factor of p < 0.01 (Babyak, 2010;
Suhr, 2006). Internal consistency was assessed using Cronbach Alpha Agea
18–34 38 (48)
values; a value of > 0.70 is generally considered an acceptable relia- 35+ 41 (52)
bility coefficient for internal consistency of a given scale (Tavakol & Gender
Dennick, 2011). Male 74 (92)
Female 6 (8)
Race
2.5. Statistical analysis plan
Non-Hispanic White 29 (36)
Non-Hispanic Black 21 (26)
Raw data from the paper surveys were coded in Qualtrics. Hispanic/Latino/Other 30 (38)
Descriptive statistics were calculated for all baseline characteristics and Time incarcerated⁎
outcome variables. Age was dichotomized at the median value of 35. ≤1 year 37 (47)
> 1 year 42 (53)
Additionally, a new variable, change in MOUD attitudes (ΔMOUD-A), Pre-incarceration opioid exposure
was created for each individual based on (post MOUD-A) - (pre MOUD- Yes 32 (40)
A) = ΔMOUD-A. Paired t-tests assessed changes in MOUD-K and No 48 (60)
MOUD-A. Bivariate and multiple linear regression models were used to Prior MOUD use
Yes 10 (13)
assess the relationship between 1) pre-video MOUD-A and 2) ΔMOUD-A
No 70 (87)
and sociodemographic variables (age, race, gender, time incarcerated, Valid pre-video survey
substance use characteristics, and prior MOUD use). We first fit bi- Yes 72 (90)
variate models between each of the outcomes and age, race, time in- No 8 (10)
carcerated, pre-incarceration opioid exposure, pre-video MOUD-K, and Valid post-video survey
Yes 75 (94)
pre-video MOUD-A for the ΔMOUD-A outcome. We created final mul- No 5 (6)
tiple linear regression models for 1) pre-video MOUD-A and 2) ΔMOUD-
A with variables found to be significant in the bivariate analyses and Notes. MOUD = medications for opioid use disorder.
a
variables determined a priori (age, race, and substance use One participant opted not to answer this question.

30
J.A. Lam, et al. Journal of Substance Abuse Treatment 104 (2019) 28–33

Table 2
Participant responses to knowledge and attitude surveys.
Variables Pre-survey Post-survey Difference Pre-attitude standardized factor loadings

M (SD) M (SD) M (SD)

MOUD-Knowledge b
8.6 (3.7) 11.4 (2.4) 2.8 (3.3)⁎
1. I have heard about MOUD (Methadone, Suboxone, Vivitrol)a 3.4 (1.4) 4.0 (0.9) 0.7 (1.3)⁎ 0.72
2. I am familiar with the ACI MOUD programa 2.7 (1.4) 3.7 (1.0) 1.1 (1.3)⁎ 0.89
3. I can explain MOUD to a frienda 2.6 (1.3) 3.7 (1.1) 1.1 (1.3)⁎ 0.84
MOUD-Attitudesc 17.8 (4.6) 20.4 (5.0) 2.6 (3.7)⁎
4. Methadone can help an addicted individuala 3.2 (1.0) 3.6 (1.1) 0.5 (0.8)⁎ 0.87
5. Suboxone can help an addicted individuala 3.0 (1.1) 3.6 (1.1) 0.6 (0.9)⁎ 0.98
6. Vivitrol/Naltrexone can help an addicted individual a 3.2 (1.0) 3.6 (1.1) 0.5 (1.0)⁎ 0.80
(7) Methadone/Suboxone are bad for your healtha,d,e 2.3 (1.1) 2.7 (1.1) 0.4 (1.4)⁎ 0.27
8. Methadone/Suboxone reduce the chances of relapse a 2.9 (1.2) 3.4 (1.1) 0.5 (1.3)⁎ 0.73
9. Methadone/Suboxone will extend addictiona,e 2.4 (1.1) 2.8 (1.1) 0.4 (1.3)⁎ 0.35
10. MOUD is more effective than treatment without medicationsa 3.1 (1.0) 3.3 (1.1) 0.2 (1.3) 0.35

Note. MOUD = medications for opioid use disorder; ACI = Adult Correctional Institute.
a
Item rated from 1 = Strongly Agree to 5 = Strongly Disagree.
b
Scale constructed using items 1–3. Higher scores indicate a stronger familiarity MOUD.
c
Scale constructed using items 4–10, imputing items to the average. Item #7 was deleted from the final construct due to low construct validity. Higher scores
indicate more positive attitudes towards MOUD.
d
Scale item removed after testing construct validity.
e
Item was reversed scored.
⁎
p < 0.05 for paired differences between pre- and post-video survey responses.

Table 3 included in the final analysis was race: those who self-identified as Non-
Multiple linear regressions for pre-MOUD attitudes and change in MOUD atti- Hispanic White (six of the 23 excluded or 26%) or Latino/Hispanic/
tudes. Other (nine of 21 or 43% excluded) were more likely to have provided
Dependent variable B (95% CI) SE B data that was excluded, χ2 (2, N = 80) = 8.4, p = 0.03.

Baseline pre-video MOUD attitudes

3.3. Scale validity
Constant 16.3 (12.6, 20.0) 1.8
Age
18–34 Ref. A confirmatory factor analysis demonstrated that each item
35+ 0.1 (−2.4, 2.5) 1.2 achieved a significant minimum loading factor as defined in our
Race methods with the exception of one item in the proposed MOUD-A scale.
Non-Hispanic White Ref.
Non-Hispanic Black −0.3 (−3.0, 2.3) 1.3
Item #7, stating “Methadone/Suboxone are bad for your health,” was
Latino/Hispanic/Other −1.2 (−4.0, 1.7) 1.4 dropped from subsequent analysis because it failed to achieve an ac-
Time incarcerated ceptable level on construct validity with the other items within the
≤1 year Ref. same construct (Table 2). All items in the MOUD-K scale reached an
> 1 year −2.9 (−5.1, −0.6)⁎ 1.1
acceptable level of construct validity (Suhr, 2006).
Pre-incarceration opioid exposure
No Ref. We examined internal consistency using Cronbach alpha. Baseline
Yes −0.5 (−2.8, 1.7) 1.1 MOUD-K was found to have an α = 0.87, and post-video MOUD-K had
Baseline pre-video MOUD knowledge 0.4 (0.1, 0.7)⁎ 0.2 an α = 0.72. For the attitude scales, baseline MOUD-A had an
Change in MOUD attitudes (ΔMOUD-A) α = 0.82, and post-video MOUD-A had an α = 0.84.
Constant 5.4 (0.8, 10.0) 2.3
Age
3.4. Video effect on MOUD-K and MOUD-A
18–34 Ref.
35+ 1.1 (−0.9, 3.1) 1.0
Race Paired t-tests demonstrate significant improvement between MOUD-
Non-Hispanic White Ref. K scores pre-video (M = 8.6, SD = 3.7) and MOUD-K post-video scores
Non-Hispanic Black 2.6 (0.4, 4.8)⁎ 1.1
(M = 11.4, SD = 2.4); t(65) = −7.0, p < 0.0001. MOUD-A scores pre-
Latino/Hispanic/Other 0.7 (−1.6, 3.1) 1.2
Time incarcerated
video (M = 17.8, SD = 4.6) and MOUD-A scores post-video (M = 20.4,
≤1 year Ref. SD = 5.0) also significantly improved; t(69) = −5.8, p < 0.0001.
> 1 year −0.0 (−1.9, 1.9) 1.0 Table 2 summarizes each scale item and participants' responses and
Pre-incarceration opioid exposure MOUD-K and MOUD-A item questions.
No Ref.
A multiple linear regression was calculated to predict pre-video
Yes 1.4 (−0.5, 3.2) 0.9
Baseline pre-video MOUD knowledge −0.2 (−0.5, 0.1) 0.1 MOUD-A based on age, race, incarceration time, risky opioid use be-
Baseline pre-video MOUD attitudes −0.2 (−0.4, 0.0) 0.1 havior, and MOUD-K. Significant associations were found between
higher pre-video MOUD-A scores and (a) higher pre-video MOUD-K
Note. MOUD = medications for opioid use disorder; ACI = Adult. (β = 0.4, CI = 0.1, 0.7) and (b) being incarcerated for less than one
⁎
p < 0.05 for paired differences between pre- and post-video survey re- year (β = 2.9, CI = 0.6, 5.1). Participants' pre-video MOUD-A in-
sponses.
creased by 0.4 points for every one-point increase in pre-video MOUD-K
score. In addition, those incarcerated for less than one year were pre-
removed from the analysis. A chi-square test of independence was
dicted to have pre-video MOUD-A scores 2.9 points above those in-
performed to examine the relationship between exclusion from the
carcerated for more than one year (Table 3).
analysis and demographic and baseline characteristics. The only de-
A multiple linear regression was also calculated to predict ΔMOUD-
mographic characteristic difference between those included and not
A [(post MOUD-A)-(pre MOUD-A)] based on age, race, incarceration

31
J.A. Lam, et al.
time, risky opioid use behavior, pre-video MOUD-K and pre-video
MOUD-A. Statistically significant associations were also found between
greater ΔMOUD-A and identifying as non-Hispanic Black (β = 2.6,
CI = 0.4, 4.8). Those self-identifying as non-Hispanic Black were pre-
dicted to have greater ΔMOUD-A scores by 2.5 more than those self-
identifying as non-Hispanic White (Table 3). We identified three out-
liers (defined by > 2 SD above the mean) and reexamined the results
with these participants removed, but factors significantly associated
with ΔMOUD-A were not impacted.
4. Discussion
This study is among the first to examine MOUD-related knowledge
and attitudes in a general incarcerated population in the United States
(Polonsky et al., 2016). The video intervention was found to improve
participants' self-rated MOUD knowledge and increase positive atti-
tudes towards MOUD. Changes in MOUD attitudes (ΔMOUD-A) were
independently associated with race, with participants identifying as
non-Hispanic Black reporting larger increases in attitude scores post-
intervention compared to non-Hispanic Whites. These results indicate
that a video intervention could contribute to bridging the racial gap
between MOUD perceptions held by the two populations.
The video intervention included the stories of two individuals with
experience using MOUD, one a male person of color and the other a
white female. The results found here are similar to those found in
previous brief peer-delivered DVD educational interventions in a cor-
rectional setting where behavioral health outcomes improved when
compared to education only or standard interventions (Martin et al.,
2008). Further understanding the cultural context of the criminal jus-
tice system and subgroups inside of the criminal justice system is crucial
in providing an effective health education intervention (Zaller et al.,
2009).
The pre-video MOUD-A was independently associated with baseline
time incarcerated. Individuals who were incarcerated for less than one
year had pre-video MOUD-A scores of 2.9 points above those in-
carcerated for more than one year. This may indicate that MOUD
stigma in the correctional environment is greater than MOUD stigma in
the general population, contributing more to negative perceptions of
MOUD with increased duration of incarceration. Another plausible in-
terpretation could be that misperceptions about MOUD may be ampli-
fied by peers and the incarcerated setting during the time incarcerated,
which is a conclusion supported by at least one study (Polonsky et al.,
2016).
These results are consistent with prior research, which suggests that
MOUD perceptions differ by community, ethnicity, and self-identified
race (Zaller et al., 2009). Previous studies have demonstrated that Black
and Latino injection drug users were significantly less likely to utilize
methadone maintenance when compared to Whites (Lundgren,
Amodeo, Ferguson, & Davis, 2001). This study also corroborates pre-
vious research, which finds a relationship between knowledge and at-
titudes; higher pre-video MOUD-K was associated with a higher pre-
video MOUD-A (Polonsky et al., 2015; Polonsky et al., 2016;
Uebelacker et al., 2016).
Data from this study may have limited generalizability. The sample
size was relatively small, as we did not achieve the sample size we
originally anticipated, given the challenge of conducting research in
correctional facilities and recruiting participants (McKenzie, Nunn,
Zaller, Bazazi, & Rich, 2009). As a result of the small sample size, our
analysis lacked statistical power and we were not able to assess dif-
ferences in those with prior MOUD exposure and those without prior
MOUD exposure. Additionally, the proportion of the sample with OUD
is unknown, as we collected data related to opioid use prior to in-
carceration. Lastly, while there are demonstrated improvements in
positive attitudes in our sample, it is unclear whether these changes in
MOUD-related attitudes translate to behavioral changes in engagement
with MOUD. Future studies should examine whether positive attitudes
32
Journal of Substance Abuse Treatment 104 (2019) 28–33
towards MOUD are associated with increased MOUD uptake and ex-
amine the effect of stigma on MOUD treatment engagement in correc-
tional settings.
Our findings suggest that a brief video intervention is a feasible and
replicable approach to improve MOUD-related knowledge and attitudes
in correctional settings. The video used in the present study could be
adapted to other jurisdictions and may even have utility for correctional
officers, prison healthcare staff, and hospital administrators as these
groups may also contribute to social stigma and subsequently reduced
MOUD engagement among clinically eligible individuals. Educational
interventions aiming to increase MOUD knowledge and attitudes are an
important part of combatting the opioid crisis and reducing opioid-re-
lated mortality.
Acknowledgments
We would like to thank the participants of this study, all of whom
kindly contributed their time to provide us with their insights and
opinions. We would also like to thank the countless staff members at the
Rhode Island Department of Corrections who provided their logistical
support and expertise throughout the project.
A special thank you is offered to the students who created the video,
Harmony Schorr and Meredith Morran, as well as the two incarcerated
individuals who agreed to speak to share their experiences in the video.
The video was developed as part of a course offered by Brown
University's School of Public Health and funded by Brown's Swearer
Center as one of the first University courses in Engaged Scholarship.
The research itself was supported by grants from the National
Institute on Drug Abuse (K24DA022112 and R21DA044443). This work
was also supported by the COBRE on Opioids and Overdose funded by
the National Institute of General Medical Sciences of the NIH under
grant number P20GM125507. The content is solely the responsibility of
the authors and does not necessarily represent the official views of the
National Institute of Health.
References
Babyak, M. (2010). Confirmatory factor analysis: An introduction for psychosomatic
medicine researchers. Psychosomatic Medicine, 72(6), 587–597. https://doi.org/10.
1097/PSY.0b013e3181de3f8a.
Binswanger, I. A., Blatchford, P. J., Lindsay, R. G., & Stern, M. F. (2011). Risk factors for
all-cause, overdose and early deaths after release from prison in Washington state.
Drug and Alcohol Dependence, 117(1), 1–6. https://doi.org/10.1016/j.drugalcdep.
2010.11.029.
Binswanger, I. A., Blatchford, P. J., Mueller, S. R., & Stern, M. F. (2013). Mortality after
prison release: Opioid overdose and other causes of death, risk factors, and time
trends from 1999 to 2009. Annals of Internal Medicine, 159(9), 592–600. https://doi.
org/10.7326/0003-4819-159-9-201311050-00005.
Binswanger, I. A., Stern, M. F., Deyo, R. A., Heagerty, P. J., Cheadle, A., Elmore, J. G., &
Koepsell, T. D. (2007). Release from prison—A high risk of death for former inmates.
New England Journal of Medicine, 356(2), 157–165. https://doi.org/10.1056/
NEJMsa064115.
van Boekel, L., Brouwers, E., van Weeghel, J., & Garretsen, H. (2015). Comparing stig-
matising attitudes towards people with substance use disorders between the general
public, GPs, mental health and addiction specialists and clients. International Journal
of Social Psychiatry, 61(6), 539–549. https://doi.org/10.1177/0020764014562051.
van Boekel, L., Brouwers, E., van Weeghel, J., & Garretsen, H. (2016). Experienced and
anticipated discrimination reported by individuals in treatment for substance use
disorders within the Netherlands. Health & Social Care in the Community, 24(5),
e23–e33. https://doi.org/10.1111/hsc.12279.
Booth, R. E., Corsi, K. F., & Mikulich, S. K. (2003). Improving entry to methadone
maintenance among out-of-treatment injection drug users. Journal of Substance Abuse
Treatment, 24(4), 305–311. https://doi.org/10.1016/s0740-5472(03)00038-2.
Booth, R. E., Kwiatkowski, C., Iguchi, M. Y., Pinto, F., & John, D. (1998). Facilitating
treatment entry among out-of-treatment injection drug users. Public Health Reports,
113(Suppl. 1), 116.
Brinkley-Rubinstein, L., McKenzie, M., Macmadu, A., Larney, S., Zaller, N., Dauria, E., &
Rich, J. (2018). Erratum to: A randomized, open label trial of methadone continua-
tion versus forced withdrawal in a combined US prison and jail: Findings at 12
months post-release [Drug and Alcohol Dependence 184 (2018) 57-63]. Drug and
Alcohol Dependence, 186, 9. https://doi.org/10.1016/j.drugalcdep.2018.02.005.
Clarke, J. G., Martin, R. A., Gresko, S. A., & Rich, J. D. (2018). The first comprehensive
program for opioid use disorder in a US statewide correctional system. American
Journal of Public Health, 108(10), 1323–1325. https://doi.org/10.2105/AJPH.2018.
J.A. Lam, et al.
304666.
Clement, S., van Nieuwenhuizen, A., Kassam, A., Flach, C., Lazarus, A., De Castro, M., ...
Thornicroft, G. (2018). Filmed v. live social contact interventions to reduce stigma:
Randomised controlled trial. British Journal of Psychiatry, 201(01), 57–64. https://
doi.org/10.1192/bjp.bp.111.093120.
Copeland, J. (1997). A qualitative study of barriers to formal treatment among women
who self-managed change in addictive behaviours. Journal of Substance Abuse
Treatment, 14(2), 183–190. https://doi.org/10.1016/S0740-5472(96)00108-0.
Corrigan, P. W., Kuwabara, S. A., & O'Shaughnessy, J. (2009). The public stigma of mental
illness and drug addiction: Findings from a stratified random sample. Journal of Social
Work, 9(2), 139–147. https://doi.org/10.1177/1468017308101818.
Corrigan, P. W., & Watson, A. C. (2002). The paradox of self-stigma and mental illness.
Clinical Psychology: Science and Practice, 9(1), 35–53. https://doi.org/10.1093/clipsy.
9.1.35.
Dalky, H. F. (2012). Mental illness stigma reduction interventions: Review of intervention
trials. Western Journal of Nursing Research, 34(4), 520–547. https://doi.org/10.1177/
0193945911400638.
Deck, D., Wiitala, W., McFarland, B., Campbell, K., Mullooly, J., Krupski, A., & McCarty,
D. (2009). Medicaid coverage, methadone maintenance, and felony arrests:
Outcomes of opiate treatment in two states. Journal of Addictive Diseases, 28(2),
89–102. https://doi.org/10.1080/10550880902772373.
Degenhardt, L., Bucello, C., Mathers, B., Briegleb, C., Ali, H., Hickman, M., & McLaren, J.
(2011). Mortality among regular or dependent users of heroin and other opioids: A
systematic review and meta-analysis of cohort studies. Addiction, 106(1), 32–51.
https://doi.org/10.1111/j.1360-0443.2010.03140.x.
Digiusto, E., & Treloar, C. (2007). Equity of access to treatment, and barriers to treatment
for illicit drug use in Australia. Addiction, 102(6), 958–969. https://doi.org/10.1111/
j.1360-0443.2007.01842.x.
Farrell, M., & Marsden, J. (2008). Acute risk of drug-related death among newly released
prisoners in England and Wales. Addiction, 103(2), 251–255. https://doi.org/10.
1111/j.1360-0443.2007.02081.x.
Green, T. C., Bowman, S. E., Ray, M., McKenzie, M., Lord, S. E., & Rich, J. D. (2015).
Development of an incarceration-specific overdose prevention video: Staying alive on
the outside. Health Education Journal, 74(5), 627–637. https://doi.org/10.1177/
0017896914550321.
Green, T. C., Clarke, J., Brinkley-Rubinstein, L., Marshall, B. D., Alexander-Scott, N., Boss,
R., & Rich, J. D. (2018). Postincarceration fatal overdoses after implementing med-
ications for addiction treatment in a statewide correctional system. JAMA Psychiatry,
75(4), 405–407. https://doi.org/10.1001/jamapsychiatry.2017.4614.
Gu, J., Xu, H., Lau, J. T., Hao, Y., Zhong, Y., Fan, L., & Ling, W. (2012). Misconceptions
predict dropout and poor adherence prospectively among newly admitted first-time
methadone maintenance treatment clients in Guangzhou, China. Addiction, 107(9),
1641–1649. https://doi.org/10.1111/j.1360-0443.2012.03859.x.
Kerr, T., Fairbairn, N., Tyndall, M., Marsh, D., Li, K., Montaner, J., & Wood, E. (2007).
Predictors of non-fatal overdose among a cohort of polysubstance-using injection
drug users. Drug and Alcohol Dependence, 87(1), 39–45. https://doi.org/10.1016/j.
drugalcdep.2006.07.009.
Kinlock, T. W., Gordon, M. S., Schwartz, R. P., Fitzgerald, T. T., & O'Grady, K. E. (2009). A
randomized clinical trial of methadone maintenance for prisoners: Results at 12
months post release. Journal of Substance Abuse Treatment, 37(3), 277–285. https://
doi.org/10.1016/j.jsat.2009.03.002.
Livingston, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of inter-
ventions for reducing stigma related to substance use disorders: A systematic review.
Addiction, 107(1), 39–50. https://doi.org/10.1111/j.1360-0443.2011.03601.x.
Lundgren, L. M., Amodeo, M., Ferguson, F., & Davis, K. (2001). Racial and ethnic dif-
ferences in drug treatment entry of injection drug users in Massachusetts. Journal of
Substance Abuse Treatment, 21(3), 145–153. https://doi.org/10.1016/S0740-
5472(01)00197-0.
Luty, J. (2004). Treatment preferences of opiate-dependent patients. Psychiatric Bulletin,
28(2), 47–50. https://doi.org/10.1192/pb.28.2.47.
MacArthur, G. J., Minozzi, S., Martin, N., Vickerman, P., Deren, S., Bruneau, J., &
Hickman, M. (2012). Opiate substitution treatment and HIV transmission in people
who inject drugs: Systematic review and meta-analysis. British Medical Journal, 345,
e5945. https://doi.org/10.1136/bmj.e5945.
Martin, S. S., O'Connell, D. J., Inciardi, J. A., Surratt, H. L., & Maiden, K. M. (2008).
Integrating an HIV/HCV brief intervention in prisoner reentry: Results of a multisite
prospective study. Journal of Psychoactive Drugs, 40(4), 427–436. https://doi.org/10.
1080/02791072.2008.10400649.
Matejkowski, J., Dugosh, K. L., Clements, N. T., & Festinger, D. S. (2015). Pilot testing of
an online training for criminal justice professionals on medication-assisted treatment.
Journal of Addictions & Offender Counseling, 36(1), 13–27. https://doi.org/10.1002/j.
33
Journal of Substance Abuse Treatment 104 (2019) 28–33
2161-1874.2015.00032.x.
Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance
therapy versus no opioid replacement therapy for opioid dependence. Cochrane
Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD002209.pub2.
Matusow, H., Dickman, S. L., Rich, J. D., Fong, C., Dumont, D. M., Hardin, C., &
Rosenblum, A. (2013). Medication assisted treatment in US drug courts: Results from
a nationwide survey of availability, barriers and attitudes. Journal of Substance Abuse
Treatment, 44(5), 473–480. https://doi.org/10.1016/j.jsat.2012.10.004.
McKenzie, M., Nunn, A., Zaller, N. D., Bazazi, A. R., & Rich, J. D. (2009). Overcoming
obstacles to implementing methadone maintenance therapy for prisoners:
Implications for policy and practice. Journal of Opioid Management, 5(4), 219.
Merrall, E. L., Kariminia, A., Binswanger, I. A., Hobbs, M. S., Farrell, M., Marsden, J., ...
Bird, S. M. (2010). Meta-analysis of drug-related deaths soon after release from
prison. Addiction, 105(9), 1545–1554. https://doi.org/10.1111/j.1360-0443.2010.
02990.x.
National Academies of Sciences, Engineering, and Medicine (2019). Medications for opioid
use disorder save lives. Washington, DC: The National Academies Presshttps://doi.org/
10.17226/25310.
Olsen, Y., & Sharfstein, J. M. (2014). Confronting the stigma of opioid use disorder—And
its treatment. JAMA, 311(14), 1393–1394. https://doi.org/10.1001/jama.2014.
2147.
Polonsky, M., Azbel, L., Wickersham, J., Marcus, R., Doltu, S., Grishaev, E., & Altice, F.
(2016). Accessing methadone within Moldovan prisons: Prejudice and myths am-
plified by peers. International Journal of Drug Policy, 29, 91–95. https://doi.org/10.
1016/j.drugpo.2015.12.016.
Polonsky, M., Azbel, L., Wickersham, J. A., Taxman, F. S., Grishaev, E., Dvoryak, S., &
Altice, F. L. (2015). Challenges to implementing opioid substitution therapy in
Ukrainian prisons: Personnel attitudes toward addiction, treatment, and people with
HIV/AIDS. Drug and Alcohol Dependence, 148, 47–55. https://doi.org/10.1016/j.
drugalcdep.2014.12.008.
Posada, D., & Buckley, T. R. (2004). Model selection and model averaging in phyloge-
netics: Advantages of Akaike information criterion and Bayesian approaches over
likelihood ratio tests. Systematic Biology, 53(5), 793–808. https://doi.org/10.1080/
10635150490522304.
Schwartz, R. P., Kelly, S. M., O'Grady, K. E., Mitchell, S. G., Peterson, J. A., Reisinger, H.
S., ... Brown, B. S. (2008). Attitudes toward buprenorphine and methadone among
opioid-dependent individuals. American Journal of Addictions, 17(5), 396–401.
https://doi.org/10.1080/10550490802268835.
Semple, S. J., Grant, I., & Patterson, T. L. (2005). Utilization of drug treatment programs
by methamphetamine users: The role of social stigma. American Journal on Addictions,
14(4), 367–380. https://doi.org/10.1080/10550490591006924.
Sharma, A., O'Grady, K. E., Kelly, S. M., Gryczynski, J., Mitchell, S. G., & Schwartz, R. P.
(2016). Pharmacotherapy for opioid dependence in jails and prisons: Research review
update and future directions. Substance Abuse and Rehabilitation, 7, 27. https://doi.
org/10.2147/SAR.S81602.
Siddiqui, O. I. (2015). Methods for computing missing item response in psychometric
scale construction. American Journal of Biostatistics, 5(1), 1. https://doi.org/10.3844/
amjbsp.2015.1.6.
Stancliff, S., Myers, J., Steiner, S., & Drucker, E. (2002). Beliefs about methadone in an
inner-city methadone clinic. Journal of Urban Health, 79(4), 571–578. https://doi.
org/10.1093/jurban/79.4.571.
StataCorp (2013). Stata statistical software: Release 13. College Station, TX: StataCorp LP.
Suhr, D. D. (2006). Exploratory or confirmatory factor analysis? .
Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. International
Journal of Medical Education, 2, 53–55. https://doi.org/10.5116/ijme.4dfb.8dfd.
Thornicroft, G. (2006). Shunned: Discrimination against people with mental illness. Vol. 399.
Oxford University Press Oxford.
Uebelacker, L. A., Bailey, G., Herman, D., Anderson, B., & Stein, M. (2016). Patients'
beliefs about medications are associated with stated preference for methadone, bu-
prenorphine, naltrexone, or no medication-assisted therapy following inpatient
opioid detoxification. Journal of Substance Abuse Treatment, 66, 48–53. https://doi.
org/10.1016/j.jsat.2016.02.009.
Yamaguchi, S., Wu, S. I., Biswas, M., Yate, M., Aoki, Y., Barley, E. A., & Thornicroft, G.
(2013). Effects of short-term interventions to reduce mental health-related stigma in
university or college students: A systematic review. The Journal of Nervous and Mental
Disease, 201(6), 490–503. https://doi.org/10.1097/NMD.0b013e31829480df.
Zaller, N., Bazazi, A., Velazquez, L., & Rich, J. (2009). Attitudes toward methadone
among out-of-treatment minority injection drug users: Implications for health dis-
parities. International Journal of Environmental Research and Public Health, 6(2),
787–797. https://doi.org/10.3390/ijerph6020787.