Knowledge, experiences, and perceptions of medications for opioid use disorder among Black Kentuckians

Abstract

Background

Opioid overdoses have continued to increase at higher rates among Black Americans compared to people from other racial groups. Despite demonstrated effectiveness of MOUD in reducing risk of opioid overdose, Black Americans face decreased access to and uptake of MOUD. The current study aimed to examine the knowledge, perceptions, and experiences with MOUD among a sample of Black adults who use prescription opioids nonmedically in order to inform tailored efforts to improve MOUD uptake.

Methods

Data were derived from a larger study assessing cultural and structural influences on drug use and drug treatment among people who use prescription opioids nonmedically. Semi-structured qualitative interviews were conducted with 34 Black men and women across four generational cohorts: born 1955–1969; 1970–1979; 1980–1994; and 1995–2001. Participant responses were analyzed using thematic analysis.

Results

Nearly half of participants (44.1%) reported no knowledge or experience with MOUD. Among participants who had any knowledge about MOUD, four major themes regarding their perceptions emerged: MOUD Helps with Recovery; Not Needed for Level of Drug Use; Side Effects and Withdrawal; Equivalence with Illicit Drug Use. The majority reported negative perceptions of MOUD (52.6%), and the youngest cohort (born 1995–2001) had a higher proportion of negative perceptions (80%) relative to other age cohorts (born 1980–1994: 50%; 1970–1979: 75%; 1955–1969: 16.6%).

Discussion

Findings indicate a significant knowledge gap and clear points of intervention for improving MOUD uptake. Interventions to improve communication of health information in ways that are culturally relevant and tailored by age group can be used in conjunction with efforts to improve MOUD access among Black individuals who use opioids nonmedically.

KEY MESSAGES

• Half of our sample of Black Americans who use opioids nonmedically had no knowledge of medications for opioid use disorder (MOUD).

• For those who knew about MOUD, most reported negative perceptions, including concerns about side effects of using MOUD and believing MOUD is equivalent to illicit drug use.

• The youngest age group endorsed the highest rates of negative perceptions relative to older age cohorts, indicating a need for intervention approaches tailored by age group.

Keywords:

• Medications for opioid use disorder
• Black Americans
• nonmedical prescription opioid use

1. Introduction

Opioid overdose deaths are increasing at a faster rate among Black Americans than they are among other racial groups; however, Black Americans are less likely to receive treatment for opioid use compared to White Americans [1]. This disparity is evident in Kentucky, where the rate of opioid overdose deaths increased 121.5% among Black residents between 2016 and 2020 compared to a rate increase of 39.7% among White residents in the same time period [2]. Pervasive racial disparities in the treatment of opioid use disorder (OUD) sustain these racial differences in opioid-related mortality [3]. Specifically, in response to the opioid epidemic, initial national and state efforts to increase treatment access and improve research on effective drug treatments and interventions primarily targeted White, middle-class, suburban, and rural populations [4]. The lack of immediate attention to the devastating impact of the opioid crisis on the Black community can be attributed to the long-standing history of stigmatization and racial bias in which substance use is disproportionately criminalized among Black individuals [1, 5]. However, evidence shows that with access to high-quality treatment using medications for opioid use disorder (MOUD), Black Americans experience improved quality of life and reduced substance use and risk behaviors [3, 6]. Further research is needed to determine potential barriers and facilitators to MOUD use among Black Americans who use opioids nonmedically. Thus, the current study aims to address this need through examining Black individuals’ knowledge, experiences, and perceptions of MOUD.

The opioid epidemic has led to a renewed interest in MOUD due to evidence that it reduces the likelihood of overdose and enhances treatment retention for people with opioid use disorder (OUD) [7]. Further, compared to non-pharmacological therapies for OUD, MOUD has been primarily associated with reduced substance use recurrence [8]. However, despite positive treatment outcomes associated with MOUD, Black Americans are less likely to be prescribed MOUD [9, 10]. Hollander et al. [11] assert that racial disparities in access and utilization of MOUD treatment may stem from racial differences in interactions with health, human services, and criminal justice systems [12, 13]. Another important consideration is public perception and knowledge of MOUD treatment.

Public stigma towards MOUD creates significant barriers to treatment and help-seeking [14]. For example, a study examining patients’ and providers’ attitudes toward MOUD showed healthcare providers often questioned the effectiveness of MOUD, believed patients with MOUD were more likely to be difficult to treat, and were thus less inclined to prescribe MOUD [15]. In the same study, individuals with OUD reported negative treatment experiences stemming from healthcare providers’ stigmatizing beliefs, ultimately resulting in discontinuation of services and adopting negative perceptions towards MOUD themselves [15]. Further, when comparing attitudes towards MOUD among people prescribed MOUD and those who were not, participants with less knowledge expressed skepticism regarding its effectiveness [16]. Beachler et al. [17] suggest a need for empirically based interventions to reduce stigma and discrimination toward individuals who use MOUD. Accordingly, exploring MOUD knowledge and perceptions among Black Americans that misuse opioids, a population disproportionately impacted by the opioid crisis, is an important first step in developing effective tailored interventions.

Importantly, perceptions toward MOUD vary across ages. For example, Adams et al. [18] conducted a study examining the attitudes of young adults (19–29 years old) towards OUD treatment and endorsement of social stigma, discrimination, and policy attitudes about OUD. Findings indicated that with each one-year increase in age, stigma towards OUD also increased. Research examining how perceptions of MOUD may vary by age among Black adults that use opioids nonmedically is critical, given within-group differences in opioid mortality rates. Specifically, the most recent data from the CDC shows opioid overdose mortality rates are highest among Black Americans aged 45–64, but Black individuals aged 15–24 experienced the largest relative increase in overdose rates from 2019 to 2020 [19]. Notably, among middle aged adults, Black men saw the most significant increase in opioid mortality rates relative to White and Hispanic men and women, increasing 36% from 1999 to 2018 [20]. Therefore, older Black adults who use opioids nonmedically are a vulnerable population to target for interventions aiming to enhance MOUD uptake. However, despite these age and race related disparities, Black individuals aged 50–64 are still more likely to utilize MOUD compared to younger Black adults aged 18–29 [11], indicating a need to examine age differences in MOUD perceptions across adulthood.

1.1. Theoretical framework

This study is guided by the Theory of Subcultural Evolution and Illicit Drug Use, which posits that drug use occurs within a cultural context in which social processes facilitate the evolution of drug related subcultures [21]. These drug subcultures are interconnected values, symbols, norms, and behaviors associated with illicit drug use in social settings [21]. The theory also posits that drug subcultures evolve differently across time periods. As the popularity and perceptions of use of a certain drug evolves, it leads to increases in use in a given population, followed by stagnation and decline. Due to the temporal nature of the evolution of drug subcultures, there tends to also be generational shifts in patterns of drug use, called drug generations. Drug generations are people born within a specific time frame that are most impacted by a given drug era. This concept indicates that patterns of drug use will vary by age cohort, and thus it is important to attend to the unique ways drug use patterns emerge across groups. Based on this theory, it is likely that drug subcultures that have evolved among Black individuals who misuse opioids may influence their perceptions of MOUD, and that these perceptions may vary across age cohorts. Further investigation of these perceptions is pertinent to addressing disparities in access and uptake of MOUD among Black Americans.

1.2. The current study

Extant research indicates that knowledge and perceptions of MOUD directly influence successful treatment outcomes among people who misuse opioids. However, few studies have explored the perceptions and knowledge Black Americans who use opioids nonmedically possess towards MOUD, even though opioid mortality is increasing at a faster rate among Black Americans compared to other racial groups [1]. Examining within group differences in MOUD knowledge and perceptions can help identify needs for tailored interventions among targeted subgroups. Thus, the current study sought to examine knowledge and perceptions of MOUD and to explore age differences in these perceptions among Black adults who use opioids nonmedically.

2. Methods

2.1. Study design

The current study is a secondary data analysis of a larger mixed methods study examining cultural and structural factors related to nonmedical prescription opioid use and treatment experiences among Black Americans in one southern state. The study received approval from the University of Kentucky’s Institutional Review Board (reference # 55957). All study procedures adhere to the Declaration of Helenski. Participant recruitment occurred in the two largest urban areas in the state: Louisville and Lexington. Participants were recruited through social media (e.g. Facebook, Instagram, Twitter), neighborhood canvasing, and distributing flyers in zip codes with between 40 and 95% Black residents during the years 2020–2021. Eligible participants met the following criteria: (1) self-identify as Black, (2) 18 years of age or older, (3) English speaking, (4) have used any prescription opioid in a way that was not prescribed (e.g. more than prescribed, obtained from a nonmedical source without a prescription) at least once in the last six months, and (5) willing to be audio-recorded. Treatment participation was not an eligibility criterion; thus, some participants had engaged in treatment or were in recovery at the time of their enrollment, while others had not. Of the 39 participants enrolled in the parent study, n = 23 were recruited in Lexington and n = 16 were recruited in Louisville. All participants provided written informed consent prior to participating in the study.

After obtaining informed consent, participants completed a brief demographic survey and the Mini-Mental State Examination [22], which was used to ensure participants were oriented to time and place and were able to participate in the study. Participants then completed an audio-recorded semi-structured interview lasting between 55 and 120 min. Interviews were conducted by race-matched study team members, which is identified as an important and preferred strategy among Black adults in treatment [23] that we expanded to the research context. Interviewers were research assistants earning doctoral degrees, one professor, and one postdoctoral fellow. All interviewers were female. Thus, while interviewers were race-matched, they were not all gender-matched. Face-to-face interviews were conducted at a community center in one metropolitan area and in a private suite on a university campus in the second metropolitan area. All interviews were conducted in a private and confidential setting with only the interviewer and the participant present, providing a space free of judgment and stigmatization so the participants could feel open to discussing vulnerable topics such as substance use. Participants answered several questions related to their nonmedical opioid use and treatment experiences (e.g. What prescription drugs are you using in a way NOT prescribed? Where do you usually get prescription drugs that are NOT prescribed to you? Have you ever heard of medications used to treat opioid use disorder, such as methadone or buprenorphine?). Participants received $40 for completing the interview. They were also offered opioid overdose education materials and free Narcan®, an emergency treatment for opioid overdose reversal [24]. Participants could accept or decline any of these items with no penalty or change in status with their involvement in the study.

2.2. Participants

The parent study used for the current project was also guided by the Theory of Subcultural Evolution of Illicit Drug Use, which informed participant sampling methods. Purposive sampling was used to recruit participants across four generational cohorts: (1) born 1955–1969, (2) born 1970–1979, (3) born 1980–1994, and (4) born 1995–2001. Each cohort was recruited to be equally stratified by gender (i.e. 5 males and 5 females per age cohort). However, during enrollment, the Black women sub-cohort born 1995–2001 was not filled (n = 3) and the Black women sub-cohort born 1980–1994 was oversampled (n = 6). The remaining cohorts (men born 1955–1969; women born 1955–1969; men born 1970–1979; women born 1970–1979; men born 1980–1994; and men born 1995–2001) had 5 participants each. Thus, the total sample of the parent study included 39 Black individuals. Among these, 5 participants did not answer the interview question about MOUD knowledge and were thus excluded from the current analysis. This resulted in a final sample of 34 (17 men, 17 women) for the current study.

2.3. Data analysis

Prior to analysis, interviews were de-identified and transcribed using a professional transcription service. Next, transcripts were uploaded to Dedoose, a qualitative analysis program [25]. Data were analyzed using a six-phase thematic analysis [26]. First, the first and second author familiarized themselves with the transcripts. Following data familiarization, the first and second author identified segments of each transcript where participants were asked, ‘Have you ever heard of medications used to treat opioid use disorder, such as methadone or buprenorphine?’ The authors also used a search tool in Dedoose to identify words appearing throughout the manuscript that may have indicated other times participants talked about MOUD (e.g. medications; methadone; suboxone; buprenorphine, vivitrol). The authors then re-read each transcript to identify any additional segments missed by the search tool that were related to medications for opioid use disorder. Following the identification of relevant data segments, the authors analyzed excerpts for latent and semantic components during initial coding. Then codes were organized into larger themes, which were named and clearly defined. The first and second author met regularly to compare codes and themes to ensure consistency and thoroughness of data analysis.

3. Results

Participants reported nonmedical use of several prescription opioids. The most commonly misused opioids were Percocet (n = 23, 67.6%) and Lortab/Hydrocodone (n = 16, 47%). Some participants reported recent use of more than one type of prescription opioid, though not necessarily at the same time (e.g. Percocet and Oxycodone). Among the 34 participants in the sample, 44.1% (n = 15) reported no knowledge or experience with MOUD. Approximately 23.5% (n = 9) reported knowledge of MOUD but no personal experience using them, and 29.4% (n = 10) reported having personal experience using MOUD. Among participants who did have some knowledge or experience with MOUD, four major themes emerged about their perceptions: (1) MOUD helps with recovery; (2) MOUD are not needed for my level of drug use; (3) Concerns about side effects and withdrawal; (4) Equivalence to illicit drug use.

3.1. MOUD helps with recovery

Participants perceived MOUD as a strategy for managing cravings and withdrawal and aiding in accountability for recovery efforts. For some participants, using MOUD provided structure in routine. Participant 039 (1995–2001, F) said, ‘I go to…have them hand me my addiction medicine and then I’m doing urinary things with them every two weeks so I can stay accountable’. For this participant, having a routine that involved returning to the methadone clinic regularly and getting drug tested kept her on track for her recovery goals. Other participants perceived it to be helpful for others even if they had not used MOUD themselves. Participant 008 (1955–1969, M) said, ‘Believe me, the methadone and all those, I believe that they’ll help people, but I just took another route’. While this participant preferred to rely on spiritual guidance and social support, he observed how others in his life were impacted by MOUD but noted discrepancies in who had access. ‘They work, but I’m just saying, I don’t personally know enough about that, because that wasn’t really popular in my population…Methadone was a big thing, and … Remember that very strong shot and stuff like that, that was mostly – They were giving them to – I’m not saying we couldn’t get it, but most of the Caucasian population, they were educating properly. They the ones who do it’. This participant recognized that despite the effectiveness of MOUD, it was not equally available across communities which inhibited his knowledge about them.

3.2. Not needed for level of drug use

The second theme embodied perceptions that MOUD were not necessary given a participant’s drug use patterns. These participants did not perceive their nonmedical prescription opioid use to have created problems in their day-to-day functioning. As a result, many had little interest in discussing MOUD at all. For example, participant 016 said, ‘I’m not really interested in that talk because it don’t really apply to me’ (1970–1979, M). Participant 016 described interacting with people outside of a methadone clinic who were attempting to sell him suboxone despite his objections. Another participant echoed this sentiment when asked whether he had ever spoken to a doctor about MOUD, to which he answered no. He simply stated, ‘Because I’ve never needed them’ (Participant 035, 1955–1969, M). When asked whether he had used MOUD, one participant responded, ‘It’s got to be hard drugs’ (020, 1955–1969, M). This participant did not believe that his use of prescription opioids necessitated MOUD to the same extent as ‘harder’ drugs like heroin. Unlike participants who perceived MOUD as a helpful resource even if they had not utilized MOUD, these participants misused prescription opioids on occasion.

3.3. Side effects and withdrawal

More commonly, participants had negative perceptions about MOUD and its effects. The third theme was Concerns about Side Effects and Withdrawal, in which participants perceived being on MOUD was a negative experience given the physical consequences of the medications. For some, this was specific to withdrawal symptoms incurred when wanting to stop MOUD. ‘I did methadone one time but to get off it, I don’t like the way it made me feel. And I said, “Why would somebody want to feel like that if they’re trying to get off of drugs?” And I said, “Nah, I don’t like it”’ (Participant 019, 1955–1969, M). This participant’s concerns about withdrawal led him to avoid engaging in MOUD use again. Concerns about withdrawal were also faced by participants who had challenges with appropriate dosage. For example, participant 026 (1995–2001, F) said, “…they can have you on a higher dose, and then they can lower you and that [crosstalk] makes me feel like shit. They’ll support your habit, but then they’ll cut you off so [inaudible], so what are you going to do?” Importantly these withdrawal concerns were regarding stopping use of MOUD, not stopping nonmedical use of opioids at the beginning of treatment.

For other participants, there were concerns about side effects separate from withdrawal. When describing his experience using suboxone in jail, one participant said: ‘They’re just using that stuff. They can have other stuff, it would suffice. But the way it made me feel, it’s horrible. It makes you feel like you’re sick as fuck. Makes your stomach hurt and then you don’t want to eat’ (029, 1995–2001, M). Despite observing his peers willingly use MOUD, the side effects he experienced were extremely aversive and deterred him from wanting to use them. Similarly, participant 022 said, ‘Yeah, I did take one methadone pill one time, and it did make me so sick it was crazy. [Interviewer: Sick how?] Throwing up, dizzy. That’s about it. I’ll never do that again’ (1970–1979, F). In the case of this participant, it only took one bout with side effects of methadone to discourage continued use. Some participants also expressed concerns with the long-term health impacts of MOUD. For example, when describing regret about having been on suboxone while in residential treatment, one participant said, ‘It damages the liver. It damages the liver’ (005, 1980–1994, F). For her, the potential for organ damage from taking MOUD outweighed the possibility of therapeutic benefit. Overall, side effects and withdrawal symptoms were perceived as negative consequences of MOUD and were major deterrents for use.

3.4. Equivalence with illicit drug use

Related to concerns about withdrawals among participants was a perception that MOUD were a substitute for illicit drug use. Several participants endorsed ideas that MOUD was just as bad as being on illicit opioids. ‘I never understood methadone clinics. You see them on TV, be people right out front nodding off. And I’m like, “yo, it looks like they’re giving out heroin in the clinic.” What’s the… I don’t get it’ (017, 1970–1979, M). Seeing how an opioid agonist produced similar effects to heroin convinced this participant that MOUD garnered no additional benefit to people’s treatment efforts.

Similar to Participant 017, some participants were concerned that taking MOUD to treat substance use disorders is essentially swapping one addiction for another. For example, Participant 005 said, ‘I just don’t want to be addicted to anything else. Period’ (1980–1994, F). Participant 030 phrased this in a more explicit way: ‘I don’t substitute one for another…Suboxone is just as bad as being on dope’ (1970–1979, F). Consistent with the previous theme, viewing MOUD as equivalent to illicit opioids was a deterrent for engaging in this form of treatment. Participants preferred not to have to depend on medications to function, as it felt like they had not made any progress toward recovering from addiction.

3.5. Age cohort endorsement of themes

To assess generational trends in endorsement of perceptions about MOUD, the above themes were categorized as either positive (MOUD helps with recovery), negative (Concerns about side effects and withdrawal; Equivalence with illicit drug use) or neutral (Not needed for level of drug use). Proportions of participants in each age cohort who endorsed each category of MOUD perceptions were calculated. All age cohorts had only one participant endorse positive perceptions, with the exception of the 1970–1979 cohort which had zero participants endorse positive perceptions. The 1955–1969 cohort had the highest proportion of participants who endorsed the neutral category (n = 4, 66.6%) whereas the other cohorts reported only one (1970–1979; 1980–1994) or zero (1995–2001) participants with a neutral perception towards MOUD. Overall, most participants endorsed negative perceptions toward MOUD (52.6%). The youngest age cohort, born 1995–2001 had the highest proportion of participants with negative perceptions (n = 4, 80%), relative to cohorts born 1980–1994 (n = 2, 50%), 1970–1979 (n = 3, 75%), and 1955–1969 (n = 1, 16.6%).

4. Discussion

The purpose of the current study was to explore knowledge and perceptions about MOUD among a sample of Black adults who misuse prescription opioids. Among the 34 participants, approximately half reported they did not know what medications for opioid use disorder were. Among those with knowledge, perceptions towards MOUD fell under four major categories: helpful for recovery, unnecessary for their pattern of drug use, opioid substitution, and concerns about withdrawals.

Our finding that nearly half of our sample of people who use opioids nonmedically did not have any knowledge about MOUD is one of the most striking results from this study. The lack of knowledge among our participants may reflect poorer availability of treatment resources that provide MOUD in communities with high proportion of Black residents, as has been demonstrated in the literature [27, 28]. Importantly, even among individuals with some knowledge about MOUD, many do not perceive it to be readily available in their community [29]. This is consistent with our findings, as some participants perceived MOUD to be something that White individuals had more experience with. This represents a significant public health need, as MOUD are a highly effective way to decrease overdose risk. It is possible these disparities in both knowledge and access may be contributing to the rise in overdose rates, indicating a need for equitable provision of MOUD education in Black communities.

Disparities in MOUD access also likely contributed to the prevalence of negative attitudes toward MOUD among our sample. We found that Black adults who misuse prescription opioids frequently viewed MOUD as equivalent to staying on illicit drugs. This finding is consistent with a recent study examining attitudes towards methadone among Black Americans residing in Florida, which showed that participants commonly viewed methadone the same as being on heroin [30]. These perceptions toward methadone may extend to or influence perceptions of other MOUD, as current findings indicated similar beliefs when discussing suboxone.

The tendency to view MOUD as equivalent to opioid misuse is accompanied by concerns that one would receive disapproval from others in abstinence-based recovery if they were on MOUD [31]. In our sample, both individuals who were pursuing recovery and those who were not viewed MOUD as unhelpful, either because it meant they were not truly abstinent or because it didn’t confer any additional benefit and thus nullified any rationale for stopping illicit opioid use. This belief would likely deter individuals in treatment from seeking MOUD, as they may see it as a hindrance rather than a facilitator for their recovery. In addition to structural barriers that inhibit access to MOUD, these attitudes may contribute to the lower MOUD retention rates among Black adults [32, 33].

Several studies support the belief that MOUD are equivalent to illicit opioid use is common across various populations including community members [34], correctional officers [35], and medical providers [36, 37]. Stigma about MOUD among medical providers likely influences community perceptions about MOUD and impacts the quality of care they provide to people who use drugs. For many in Black communities, this is compounded by both racial bias and stigma against people who use drugs [38], thereby exacerbating disparities in access and knowledge about MOUD. Thus, intervening with medical providers to ensure equitable provision of information about MOUD could potentially improve knowledge rates in the community and shift stigma about MOUD and opioid substitution.

Another major concern among participants that could benefit from provider level intervention is concerns about side effects and withdrawal. Participants in this sample voiced that the symptoms experienced when stopping MOUD were too intense and counterproductive for someone wanting to stop drug use. The sentiment that withdrawal from MOUD is just as bad or worse than withdrawal from illicit opioid use has been echoed in the literature as well [39]. It is possible that barriers to care may contribute to these symptoms. For example, inadequate implementation of MOUD in criminal justice settings leads to experiences of withdrawal, which deterred individuals from use [40]. Further, programs that primarily serve Black patients are more likely to provide inadequate methadone doses than methadone programs in predominately White communities [41]. Future research should examine the extent to which quality of medical supervision is associated with side effects and withdrawal symptoms among Black individuals using MOUD.

Relatedly, perceptions about MOUD among Black individuals are largely driven by methadone [42], a full agonist opioid medication that needs to be obtained from a methadone clinic daily [43]. Other MOUD that do not require daily trips to a clinic, such as buprenorphine, are less available in areas with greater proportions of Black residents [28, 44, 45]. However, transportation and housing issues may make traveling to methadone clinics daily less feasible [29], which would place one at greater risk for unintended withdrawal if unable to procure their daily dosage. In addition to ensuring adequate dosing, it is imperative to ensure that Black patients are being equitably prescribed and informed about all MOUD options and prescribed with consideration for any barriers to treatment access that may impact their adherence. It may be helpful to investigate the extent to which policy changes can be used to increase the availability of a breadth of MOUD options in addition to methadone in predominately Black areas.

Medicaid expansion is a policy intervention that helped improve access to MOUD by increasing the availability of substance use treatment for individuals with low income who did not qualify for Medicare [46]. Evidence suggests that as of 2017, the resultant increases in access to MOUD contributed to a 10% decrease in the rate of overdose from synthetic opioids in expansion states compared to those who did not adopt Medicaid expansion [47]. Despite this systemic change, disparities in the rate of opioid overdose increases have persisted among Black individuals [19] and findings from the current study suggest knowledge about MOUD may still remain low. Future research should examine the extent to which Medicaid expansion in Kentucky impacted both access to and perceptions of MOUD among Black individuals, and whether it differentially altered the availability of methadone versus other MOUD options in Black communities.

Participants who exemplified the theme that MOUD were not needed for their level of drug use often demonstrated an underlying sense of superiority for not being on MOUD or were adamant not to discuss anything about it. There are two possible and non-mutually exclusive reasons for this resistance. First, these participants may have used opioids casually or occasionally and thus would not have needed to be on MOUD. Alternatively, while this theme was categorized as ‘neutral’ because participants generally did not explicitly voice disdain for MOUD, it is possible that this theme may have been undergirded by negative perceptions about MOUD. Specifically, participants who reported MOUD was not needed for their level of drug use might not have wanted to be associated with people who are on these medications due to stigma about opioid use. Further examination is needed to determine whether these participants are more likely to have lower rates of use, whether these perceptions shift over time if patterns of use also change, or if this attitude serves as a barrier for MOUD even if their opioid misuse escalates.

4.1. Implications for intervention

Several studies have demonstrated effective ways to intervene with health service professionals and medical providers to address perceptions both within the medical institution and within communities. Robles et al. [48] implemented an education intervention among medical residents which improved knowledge about opioid use disorders and increased willingness to prescribe MOUD. Another educational intervention among graduate students involved a train-the-trainer program that taught about various topics related to opioid use, including use of MOUD and a detailed review of medications [49]. Students were also trained on how to disseminate information in community settings, resulting in both improved attitudes about MOUD among the students and increased knowledge among community members [49]. Interventions to build knowledge and address bias are also effective amongst providers in various medical settings, including emergency departments [50] and primary care [51]. Further work should be done to see how these interventions can be tailored for providers who work with Black communities. For example, programs could integrate racial bias training and education on how to address structural barriers experienced by Black Americans who use drugs that are likely to impact their access to and knowledge about MOUD.

Our finding that over half of participants had negative perceptions of MOUD also suggests a need for culturally tailored interventions to improve MOUD uptake among Black individuals. Importantly, Black patients with substance use disorders are nearly twice as likely to have negative attitudes towards MOUD compared to White patients [42], suggesting there are unique cultural experiences among Black patients that exacerbate the tendency to view MOUD negatively. For instance, many medical myths and hesitance to use medications among Black Americans stem from a mistrust of medical systems [52], which is grounded in the historical legacy of mistreatment of Black communities by healthcare institutions. A culturally tailored intervention aiming to shift perceptions of MOUD among Black Americans should integrate cultural considerations such as medical mistrust.

Findings from the current study also suggests a need for age-tailored efforts to improve knowledge about MOUD among Black Americans. Participants aged 18–29 had higher proportions of negative attitudes towards MOUD relative to some other age groups, consistent with previous findings [42]. The age differences may explain previous evidence demonstrating that younger Black adults are less likely to use MOUD compared to older adults who misuse opioids [53]. Further, the 1955–1969 age cohort had the largest proportion of individuals reporting that MOUD was not needed for their level of drug use, with a relatively low proportion of explicitly negative perceptions. While formal analyses on age differences were not feasible in this study given the small sample size, these trends do suggest there is notable variation in MOUD perceptions across different age groups. Future research should examine the processes that undergird age cohort differences in MOUD perceptions and determine whether there are age differences in the effectiveness of interventions aiming to improve uptake of MOUD. Further, while few participants had positive attitudes about MOUD in this study, exploration of the experiences that lead to positive attitudes toward MOUD can inform strengths-based intervention approaches.

4.2. Limitations and conclusion

This study has some limitations to note. First, participants were not formally assessed for OUD and we did not assess frequency of use, only whether participants had used a prescription opioid nonmedically in the past six months. Thus, we are unable to determine whether results may have differed for individuals based on severity of use. Relatedly, we were unable to assess rates at which people’s experiences with MOUD were from medical sources or had been diverted, which may have impacted their perceptions regarding effectiveness and side effects. Another limitation includes that while participants were interviewed by a race-matched interviewer, they were not gender-matched and were not matched to interviewers with a similar drug use history, which may have impacted level of trust and willingness to share sensitive information. Given the importance of provider characteristics (e.g. drug use history, race- and gender-matching) reported among Black adults who use substances [23], it would be important to conduct qualitative studies with race-, gender-, and experience-matched interviewers to see if results are replicated.

While our findings were consistent with previous literature, we cannot guarantee the sentiments reported among our participants are generalizable to Black Americans across subcultural groups and in other regions of the US. Our examination of prescription opioid use in one southern state was intentional given rising rates of opioid related mortality in that state. However, it is possible that Black communities in other areas that have been differentially impacted by the opioid crisis may demonstrate different attitudes. Further, given how knowledge rates appear to be largely determined by structural barriers [27], the current findings may not be applicable to Black communities with higher socioeconomic resources. Despite these limitations, this study makes an important contribution to the literature on attitudes toward MOUD and highlights critical points of intervention both at the provider level and among communities impacted by disparities in use of MOUD.

Authors contributions

PBW and DSW conceptualized the study. PBW and BMR, analyzed the data and PBW, BMR, and JJ drafted the manuscript. DSW conceptualized the parent study and PBW, BMR, and JJ all collected data for the parent study. All authors approved the final version of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on reasonable request from the corresponding author, BMR. The data are not publicly available due to containing information that could compromise the privacy of research participants. Further, data collection for the parent study is still in process as of February 2024, and will be available upon reasonable request at the conclusion of data collection in 2025.

Additional information

Funding

This work was supported by the National Institute on Drug Abuse under Grant R01-DA049333; PI: Stevens-Watkins. The content is solely the responsibility of the authors and does not necessarily reflect the views of the National Institutes of Health.