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Canada is in the midst of an opioid crisis. Yet, while broad agreement exists that the stigma surrounding opioid use is both significant and consequential, several questions remain before we can have a comprehensive understanding of how it affects persons with opioid use problems:

• What does opioid-related stigma look like?
• Where does it come from?
• How is it expressed?
• How might it interfere with seeking or accessing help?
• How might it affect the quality of care and the availability of services?
• How might it be successfully combated?

Since answering these questions is essential for delivering effective interventions to improve the quality of first response services, the Mental Health Commission of Canada (MHCC) undertook an 18-month research project (funded by Health Canada) under its Opening Minds anti-stigma initiative. The project had three main objectives:

1. Develop a better understanding of the role of stigma in opioid (and other substance) use problems to assist governments (and others) with service delivery and policy decisions.
2. Identify learning needs among first responders (e.g., emergency department staff, fire and police services, paramedics, and outreach workers or other front-line service staff) regarding stigmatization to help create appropriate and effective interventions.
3. Establish a measure for evaluating anti-stigma initiatives that are directed toward first responders on the front lines of Canada’s opioid crisis.

Key Findings

Heather Stuart, PhD, from Queen’s University completed the scoping review in March 2018. In January 2019, she published an invited article based on its findings in Healthcare Management Forum, called “Managing the Stigma of Opioid Use.” The full article is included in Appendix A.

Key Recommendations

Based on the findings in this report, we recommend the following strategies:

1. Develop comprehensive stigma reduction and intervention strategies for front-line providers. These strategies could address stigma as a major barrier to help-seeking and quality of care and the high level of mistrust people with lived experience have toward the health system. To do so, organizations could:

• use this research and the framework developed through the key informant study to guide their plans, designs, and interventions
• draw on lessons learned and evidence-based knowledge for combating mental illness-related stigma in health care (including implementation models/guidelines and key ingredients), while giving people with lived experience a central role in creating interventions
• focus on improving attitudes and behaviours among first responders and cultivating greater compassion satisfaction, understanding, and trust
• include a robust evaluation and monitoring framework in interventions to ensure they are meeting their objectives.

2. Evaluate the effectiveness and efficacy of the promising approaches and strategies in this project. Successful approaches and interventions can then be replicated, shared, and promoted countrywide.

3. Address the ethical dilemmas experienced by some first responders and front-line providers regarding high-recidivism clients and the emergency relief measures (e.g., Narcan) that may increase risk behaviours in some circumstances. It would be important to address these in greater depth, ideally as a separate study.

4. Increase the use of non-stigmatizing language and establish best practice guidelines for opioidrelated terminology and language. Policy makers, professionals, and organizational leaders would be particularly effective in leading this initiative.

5. Prioritize attention to system-level barriers and service and treatment gaps. This strategy includes the need to capture, understand, and systematically address issues related to

• punitive or barrier-creating care practices and policies
• inadequacies related to access and quality of treatment options
• the allocation of resources
• other policy and system level barriers to quality care and support for people with opioid use
  problems.

6. Ensure that efforts toward prevention and prevention policies are stigma-informed. Anti-stigma initiatives are also required for the public. While we recommend research to better understand and address public stigma toward people with opioid and substance use problems, we can use existing knowledge of best practices for reducing mental illness-related stigma, along with relevant findings from this study.