Opioid use disorder (OUD) is one of the main causes of death in the U.S. Nearly 50,000 people died by opioid-involved overdoses in 2019. Among people who use opioids, there is an inordinate amount of OUD rate among low-income populations (i.e., Medicaid beneficiaries). Currently, there are findings showing the association of social determinants of health (SDoH) as risk factors for OUD. However, factors like stigma, political determinants of health are not well researched. This study was conducted to provide a broader understanding of how the lower income population in the southern U.S. gets impacted by community level stigma, in relation to being in a conservative political environment.
For the quantitative portion of this study, several large data sets from various sources were obtained. First, as our dependent variable, we obtained Alabama Medicaid administrative claims database from all 67 counties. For our independent variables, the count of medical practitioners trained and qualified to administer buprenorphine products as part of Medication Assisted Treatment was retrieved from the Drug Enforcement Agency. We also obtained data from the 2015-2019 American Community Survey of the United States Census Bureau to quantify the number of residents living in poverty, number of residents not completing high school, number of residents access to high-speed internet, as well as their marital status, index of racial residential segregation, and the rural-urban code for each county. Lastly, we extracted political environment variable from the Massachusetts Institute of Technology’s Election Lab.
Regarding the qualitative piece of the study, focus groups were held in all 67 counties of Alabama with community stakeholders, excluding healthcare providers. Quotes related to stigma were extracted to examine whether community level stigma was present in a particular county.
Our quantitative findings showed the county-level substance use stigma was positively associated with OUD rate among Medicaid beneficiaries. When examining the SDoH, households with internet and racial residential segregation had significant associations. Our qualitative findings also indicated a positive association between county level substance use stigma and OUD rates among Medicaid beneficiaries. Three themes of denying substance use in the local community, refusing to discuss substance use, and hiding substance use from others emerged from qualitative analysis.
Conclusions and Implications:
Despite the significant amount of literature related to SDoH and substance use disorder, OUD rate is on a sharp incline. Our findings revealed the association between community level substance use stigma and political determinants of health have significant impact to the rate of OUD among Medicaid beneficiaries in Alabama. There is a need to further expand our methodological findings to various states in the south for geographical generalizability.