Including the multiply excluded: a mixed methods study exploring intragroup stigma towards people who use synthetic cannabinoid receptor agonists

Abstract

People who use drugs are a highly stigmatized population. This study explored within-group stigma associated with the use of synthetic cannabinoid receptor agonists (SCRA) in a sample who accessed a support service in a large city in England. We used semi-structured interviews and a questionnaire that included two measures of stigma adapted for this population. Complete data were obtained from 42 participants (69.0% male, mean age 38.5 years). Increased contact with people who use SCRA (PWUS) was associated with reduced levels of stigma, and while qualitative data mirrored some stigmatizing views found in the wider population, mitigating factors such as the attribution of social and environmental influences on the use of SCRA were identified. While intersectional stigma was identified, for example between SCRA use, homelessness, or street activities such as begging, there was also evidence of mutual support within the service. Participants helped peers who were under the influence of SCRA, suggesting the role of safe environments in reducing harm for PWUS and for those who experience intersectional stigma. Aligned with intergroup contact and attribution theories, findings supported attempts to reduce SCRA-related stigma using peer educators, and the framing of substance use disorders from a viewpoint of social inequalities.

Keywords:

• Substance use
• stigma
• multiple exclusion
• inclusion health
• synthetic cannabinoid receptor agonists

Introduction

Stigma towards people who use drugs (PWUD) has a negative impact on factors such as help-seeking (Meltzer et al., 2013; Witte et al., 2019), expectations of health care (Farrugia et al., 2020), treatment adherence (Brener et al., 2010), and risk of overdose (Latkin et al., 2019), which further increase the risk of mortality and morbidity associated with substance use (Degenhardt et al., 2013; Link & Phelan, 2006). People who experience marginalization associated with issues such as substance use, homelessness, poverty, mental ill-health, social isolation, or welfare dependence are sometimes referred to as being multiply excluded (Andersen & Kessing, 2019; Dwyer et al., 2015), with high levels of public stigma directed towards them. Intersectionality is rooted in Black feminist scholarship (Crenshaw, 1991; King, 1988), but usefully highlights how multiple stigmatized social identities may interact, and intersectional stigma leads to a further negative impact on health and social outcomes (Turan et al., 2019).

Although PWUD is stigmatized compared to the general population, levels of stigma may vary depending upon the drugs used, social norms and acceptability of use behaviors, and potential for harm (Brown, 2015; Williams & Parker, 2001). Increased levels of public stigma have been associated with the use of synthetic cannabinoid receptor agonists (SCRA): synthetic compounds that have been associated with a range of adverse effects (Cohen & Weinstein, 2018). First emerging in the mid-2000s, SCRA were initially popular as intoxicants in their own right; as alternatives to controlled drugs such as cannabis; and as substances that would allow circumvention of forensic testing regimes (Sumnall et al., 2013). However, more recently, use has become concentrated within groups such as rough sleepers, prisoners, and vulnerable young people (Blackman & Bradley, 2017; Gray et al., 2021). Corresponding with changes in the primary user population, people who use SCRA have become highly stigmatized, with the emergence of pejorative terms such as ‘Spice Zombies’, which is reinforced by some media reporting (Atkinson & Sumnall, 2020a; Swalve & DeFoster, 2016). Within excluded populations, substance use can exacerbate existing intersectional stigma associated with poverty and homelessness (Alexandrescu, 2020). For example, within the setting of homeless shelters, there is evidence to suggest discrimination from volunteers towards service users who use substances (Cloke et al., 2007), in keeping with studies finding increased levels of stigmatizing views towards PWUD among health professionals more generally (van Boekel et al., 2013c).

Intragroup stigmatization

People’s social identities and group memberships help them navigate social worlds (Abrams et al., 2021), and when faced with intergroup threats, such as stigma and discrimination from others, they may seek to strengthen intragroup identity and relations (Greenaway & Cruwys, 2019). Perceived intragroup threats have the potential to undermine this process, and intragroup marginalization may result through social sanctions or stigma that members of groups impose on those who diverge from group norms (Castillo et al., 2007). For example, stigmatizing views towards people who use heroin have been identified in people who use ecstasy (McElrath & McEvoy, 2001), and within groups of people who injected drugs, hierarchies emerged, with stigmatization towards those who were distinct from perceived group norms, in particular people who were experiencing homelessness (Simmonds & Coomber, 2009). Additional factors such as the legal status of drugs, and the socio-economic status of people using them also affect intragroup stigmatization. For example, Cooper (2013) found that participants who were dependent on over-the-counter opioids considered themselves socially and economically distinct from those who used controlled substances. Stigma within groups that use particular substances is also evident; participants who used heroin in the study conducted by Furst and Evans (2015) made distinctions between ‘addicts’ who ‘worked’ and ‘took care’ of their families, and ‘junkies’ who didn’t adhere to social norms such as working or attending to personal hygiene. This intragroup stigmatization mirrors stigmatizing beliefs held towards PWUD by the wider public, including stigma around welfare dependency and discourses around the ‘productive citizen’ (Alexandrescu, 2020; Atkinson & Sumnall, 2020a).

The impact of attribution and contact on stigmatizing beliefs

Attribution theory states that the beliefs that people have about the cause and controllability of a condition or signifying characteristic lead to inferences about personal responsibility, which in turn lead to judgements that result in emotional responses (Corrigan et al., 2003). The extent to which a person’s actions are perceived to be in their control determines responses towards them; people who are judged to be responsible for their condition or circumstances, for example, through the use of substances, evoke less pity and more anger, as they are perceived to have control over the causes (Livingston et al., 2012; Weiner, 1980). Attribution theory has been used in previous substance use research that has found that perceptions of personal responsibility for substance use problems are associated with negative attitudes towards PWUD (Schomerus et al., 2011; van Boekel et al., 2013b). In one study undertaken with healthcare professionals, including general practitioners and substance use specialists, attributional beliefs predicted lower ratings of the regard in which they held working with patients with substance use disorders, and whether they thought this group was worthy of medical resources (van Boekel et al., 2013a). In another experimental study that sought to manipulate perceptions of personal responsibility for substance use, the presentation of a history of adverse childhood experiences (ACEs) was associated with less stigmatizing attitudes towards PWUD (Sumnall et al., 2021).

Related to attribution theory, contact theory suggests that contact between groups and by extension, members of those groups, can reduce stigma and discrimination (Pettigrew, 1998). In Allport’s original formulation of the theory (1954), four key optimizing conditions were necessary: equal group status within the situation; common goals; cooperation; and the support of authorities, laws, or social custom. However, a meta-analysis of studies using the theory suggested that whilst adherence to these conditions generally enhanced the positive effects of contact, they were interrelated, and it was the act and process of contact itself that reduced prejudice, possibly through reduction of anxiety about future interactions with stigmatized groups (Pettigrew & Tropp, 2006). The nature and quality of contact are important, and poor quality contact can exacerbate underlying bias. For example, misunderstanding of intent in exchanges between White and Chinese Canadians resulted in a reduced interest in intergroup interactions (Vorauer & Sakamoto, 2006), and negative contact with immigrants in areas with high levels of migration was associated with increased prejudice towards them (Meleady et al., 2017). Within the substance use field, research on the role of intergroup contact in addressing stigma towards PWUD has primarily focused on specialist treatment and general healthcare professionals and has found that contact with PWUD led to increased compassion and humanization (Dumenco et al., 2019).

Stigma towards people who use SCRA

People who use SCRA experience stigma specifically related to their use of these drugs, which are perceived to be ‘lower class’ drugs in the UK, and because use is popularly associated with characteristics such as being homeless, or being in supported accommodation (Addison et al., 2018). Whilst there has been researched conducted into the stigma associated with co-occurring substance use and homelessness (Lee & Petersen, 2009), studies examining intragroup attitudes within multiply excluded populations are scarce. There is also a lack of research on intersectional stigma and the use of SCRA. This is an important public health topic not only because of direct associations between SCRA and harm (Cohen & Weinstein, 2018), but because use is associated with populations who already experience high levels of health and social harm, and stigma negatively impacts on treatment (Magwood et al., 2020). This study aimed to respond to some of these research gaps. We explored the stigma towards PWUS within a multiply excluded population, how this was characterized, and whether this was associated with factors such as personal demographics or substance use. We drew upon attribution and contact theories to explore whether proximity to PWUS affected stigmatizing views towards them and whether the nature and quality of contact mitigated stigmatizing beliefs. The setting of this study was a service where people who experience multiple exclusion converged for both food and social support and thus presented an opportunity to investigate these processes between members of an already stigmatized population, with both intra- and intergroup dimensions.

Methods

Study design and setting

A convergent, parallel mixed methods design, comprising a short semi-structured interview and questionnaire was used (Mason, 2006). The study setting was a service in a large city in the North East of England that provides food, clothing and welfare support to the multiply excluded community, including those who are sleeping rough, sofa-surfing, in temporary or emergency accommodation. Due to the busy service setting for the research, and some of the participants’ complex presenting issues, contact time with participants was limited, and so materials were designed to be completed in less than 15 minutes. Contact theory was used to shape and develop research questions, interview schedule and thematic analysis. Attribution theory, which posits that thoughts and feelings are determinants of attribution (Weiner, 2010, p. 561) was used within qualitative analysis; giving depth to integrated findings and providing a framework in analysis and interpretation of findings. Interviews began with semi-structured questions that captured participants’ views on attributions of SCRA use and associated problems and the nature and quality of contact with PWUS. Quantitative data was then collected through the use of an interviewer-completed questionnaire, which was delivered orally and visually to allow for participants’ literacy levels. There was then a further open-ended discussion with participants around the interpretation of the questions, and the answers they had given, which was recorded and formed part of the qualitative data. The mixed-methods approach allowed for the collection of qualitative data for descriptions of thoughts, beliefs and emotions, and quantitative data on demographics and contact with, and desired distance from PWUS. It also allowed for variation in participants’ communication styles; for example, participants who were more comfortable in conversation could spend more time responding to the discussion. Data were integrated into the analysis stage of the research.

Study sample

Forty-two people aged above 18 years were recruited using convenience sampling. Posters were displayed in the building and the researcher and staff gatekeepers were available at various times and days, along with handing out flyers to clients, to invite people to take part in the study, and to answer any questions. Eligibility criteria comprised attendance at the service, ability to give informed consent, and understanding of the term ‘Spice’. Interviews lasted approximately 10–20 minutes, were completed in a single session by the lead author (MA), and were held in a private room in the service’s main building.

Materials

Qualitative interviews

The interviews were designed to facilitate a relaxed, open-ended discussion that would elicit knowledge of SCRA, and allow for a wider conversation about participants’ feelings and opinions about the drug class and the people who used them. Interviewees were first asked six open-ended questions in which the slang term Spice was used in place of SCRA as this was the term used by clients, media and the general public (see interview schedule, Supplementary Material S1). Initial questions (e.g. ‘When did you first hear about Spice?’) were designed to be emotionally neutral, aiming to ease participants into a conversation, while subsequent questions asked for more personal views (for example ‘What do you think about people who use Spice?’). Follow-up questions were used to elicit further information or to clarify meaning, for example exploring the responses of participants who felt differently about people who used Spice on a more or less frequent basis. Additional interview data was collected following quantitative data collection, either if participants wished to keep talking about their experiences, or to expand upon comments that contained dissonant or inconsistent elements. For example, if a participant responded ‘yes’ to the question ‘I have a friend who uses Spice’ and ‘Definitely not OK’ when asked how they would feel about having someone who used SCRA regularly as a best friend, the interviewer asked the participant to expand on their responses. In this manner, qualitative discussions were used to capture and explore some of the complexity associated with intersectional stigma (Turan et al., 2019).

Quantitative measures

Participants completed a single questionnaire after the interview that took approximately 5 minutes to complete. Demographic questions included age, gender, substance use, and housing status. Measures included the Social Distance Scale (SDS), adapted for this work to refer to people who use SCRA (SDS-PWUS). The SDS is a psychological attitude scale that was initially designed to assess the desired social distance between ethnic groups (Bogardus, 1960; Wark & Galliher, 2007). Social distance is a proxy measure of behavioral discrimination used in research on outgroup stereotypes that reflects a participant’s self-report on their willingness to engage in social activities: individuals who perpetuate stigma are more likely to socially distance themselves from outgroup members (Corrigan et al., 2001). The scale was adapted by S. A. Brown (2011) for substance use but was further adapted for this study and population. Culturally insensitive or irrelevant terms, for example, those relating to homeownership or work colleagues were replaced, and response options and format were amended to improve comprehension (Rosenkranz et al., 2019). Participants were asked to rate how they would feel taking part in ten social activities with someone who uses SCRA regularly (more than once a week) on a 5-point Likert scale scored from 1 to 5. Rather than the presentation of questions and Likert responses, the questionnaire was delivered in the form of a printed grid onto which participants placed their laminated responses (see Supplementary Material S2). Whereas the versions of the SDS used by Link et al. (1987) and S. A. Brown (2011) used a 4-point Likert scale, a Not sure/neutral option was added for those participants for whom the questions might have caused emotional discomfort. A total score was calculated (range 10-50) with higher scores indicating a greater preference for social distance. Internal consistency was calculated, Cronbach’s α = 0.73, indicating acceptable reliability.

Participants were then asked to complete an amended version of the Exposure to Drug Users Index (EDUI) developed by Palamar et al. (2011) to assess the level of perceived exposure to PWUD, with higher scores indicating increased levels of perceived exposure. The EDUI has been previously utilized in samples of people who reported exposure to five drugs (cannabis, powder cocaine, ecstasy, opioids, amphetamine). For the purposes of this study, the EDUI was amended to measure proximity to people who use SCRA (and referred to as ESUI). In addition, references to working with or been in class with were replaced for the purposes of cultural comprehension (see Supplementary Material S3). The original EDUI demonstrated acceptable reliability, ranging from α = 0.77 to α = 0.82 depending on the drug assessed. However, in this study, α = 0.64, suggesting possible problems with questionable reliability (see Supplementary Material S4 for details of scales used in this study). Most items appeared to be worthy of retention, resulting in a decrease in the alpha if deleted; the one exception to this was item 5 (“I have a family member who uses Spice”), removal of which would have increased the alpha to α = 0.658; but due to the relatively small increase, this was not undertaken.

Analysis

Quantitative data were summarized using SPSS v26 (IBM Corp, 2019). SDS-PWUS and ESUI scores were analyzed using Spearman’s correlation coefficient. Alpha was set at p < 0.05. Audio-recorded interviews were transcribed verbatim, with any identifiable data anonymized or removed. Transcriptions were thematically coded in NVivo v12 (QSR International Pty Ltd, 2020) by the lead author, and then reviewed and discussed with co-authors.

The process of coding took place in a heuristic, iterative manner that used both inductive and deductive approaches, rather than being driven solely by either theory or data. Initially, inductive coding analyzed content thematically (Braun & Clarke, 2012), with coded data grouped into themes that were revisited until data saturation was reached. This data then informed questions related to attribution theory, leading to deductive analysis (Creswell & Creswell, 2018). This deductive approach examined reasons that participants attributed to the use of SCRA, and their emotional responses to SCRA and PWUS. Initial analysis of the data revealed that participants tended to hold polarized views towards SCRA and PWUS, with many participants holding clearly-stated negative or positive views towards SCRA and the people using them. To aid interpretation and discussion of findings, each interview was therefore allocated an overall sentiment towards both SCRA (negative, neutral/mixed, positive) and PWUS (negative, neutral/mixed, compassion). Data across the qualitative and quantitative components were triangulated by transferring scale scores and responses to demographic questions to NVivo, where counts of responses to deductive coding and overall sentiment were cross-tabulated with quantitative data (Teddlie & Tashakkori, 2011).

Ethics

Ethical approval was granted by Liverpool John Moores University Research Ethics Committee (19/PHI/050).

Results

Study sample

Participants’ ages ranged from 19 to 64 years (mean 38.5 ± 12.8) with 29 (69%) male, 12 (28.6%) female and 1 (2.4%) trans/non-binary. Substance use and housing status data are presented in Table 1. Around one half (52.4%) of participants reported a lifetime use of SCRA, and 90% reported use of any other controlled drug. One third (33.0%) of participants in this study were currently sleeping rough or in unstable accommodation.

Table 1. Baseline characteristics of sample demographic data.

Characteristic (n = 42)	n	%
Alcohol use
None/never used	1	2.4
Past use < once a week	7	16.7
Past use > once a week	15	35.7
Current use < once a week	12	28.6
Current use > once a week	7	16.7
Other drug use
None/never used	4	9.5
Past use < once a week	7	16.7
Past use > once a week	6	14.3
Current use < once a week	4	9.5
Current use > once a week	21	50
SCRA use
None/never used	20	47.6
Past use < once a week	7	16.7
Past use > once a week	12	28.6
Current use < once a week	1	2.4
Current use > once a week	2	4.8
Housing status
Rough sleeper	6	14.3
Sofa surfing/NFA	1	2.4
Hostel/supported	7	16.7
Rental tenancy	28	66.7

Social distance and contact with people who use SCRA

There was a significant negative correlation between total scores on the SDS-PWUS and ESUI (r_s = −0.483, n = 42, p = 0.001), suggesting that fewer personal contacts with PWUS were associated with a desire for greater social distance.

Examining individual items of the ESUI, there were statistically significant negative correlations between People in the area I live use Spice (r_s = −0.475, n = 42, p = 0.001) and I have a friend who uses Spice (r_s = −0.332, n = 42, p = 0.032). Within questions in the SDS-PWUS, people with greater exposure to PWUS were less likely to express a preference for social distance in the following scenarios: Sharing a meal (r_s = −0.463, n = 42, p = 0.002); Sharing a room (r_s = −0.496, n = 42, p = 0.001); Sharing a flat (r_s = −0.361, n = 42, p = 0.019); Have as a best friend (r_s = −0.384, n = 42, p = 0.012). There were no statistically significant correlations between SDS-PWUS score and demographic, substance use, and housing variables.

Qualitative themes

Qualitative themes are presented in this section which illustrates some of the explanations given for stigmatizing views towards PWUS within this sample.

Attribution: It’s (not) their fault

Drug use, more so than physical or psychiatric conditions, was viewed by many to be a matter of personal controllability and choice (Corrigan et al., 2006), with much of the current public discourse around drug use in the media framed around blame or personal choice (Atkinson & Sumnall, 2020a). These attitudes were reflected in responses; echoing the concept of individuals’ ‘bad character’ found in studies exploring attribution theory (Martin et al., 2000). Some participants attributed use of SCRA to innate personality or moral failings, for example: ‘Anyone who uses it, in my opinion, they’re fools…’ (P3, male, 54, never used SCRA), with PWUS being described as ‘very morally wrong’ by one participant (P16, female, 19, past use of SCRA). Seven responses highlighted the role of personal choice in use of SCRA, with only one of this noting that choice was often influenced by social setting. The language of morality (e.g. good/bad, right/wrong) was also used by a number of participants who held mixed views towards PWUS, distinguishing the individual from the drug by defining them as ‘good’ people whose behavior was being changed or controlled by SCRA. In this way, PWUS were not blamed for their actions or viewed negatively when intoxicated: ‘I’ve got friends that take Spice but they’re good, bad… it depends on the person at the time…’ (P14, female, 51, never used SCRA). SCRA therefore could be seen to be acting as a more acceptable proxy for the views of people towards PWUS; it was more acceptable for participants to blame substances, rather than being seen to be critical of people using them. This shifting of responsibility away from the individual towards the ‘addictive’ nature of SCRA was seen to be as a mitigating factor in stigma towards PWUS, with 11 participants attributing reasons for use away from the person to the drug itself: ‘It’s just addictive, it changes them’ (P36, female, 52, never used SCRA). Aligned with attribution theory, awareness of social and environmental influence was also noted as a mitigating factor in stigma. As shown in extract 1 from a young male who currently used SCRA, use was attributed to coping with external social or environmental influences such as managing the stress of adverse life experiences in childhood or adulthood, such as homelessness, mental ill-health or poverty. Drawing on his experiences he raises the rhetorical question as to whether other people who may go through ‘hard times’ in addition to living in ‘freezing cold’ conditions, would initiate use:

Extract 1

Because people do go through hard times and end up… on the streets. And they might think to theirself ‘I would never ever smoke that’, but then… you are freezing cold, sitting down [local train station]… You probably would have a couple off [a couple of inhalations], wouldn’t you…?

(P30, male, 24, current use of SCRA).

Downward comparisons: not as bad as them

Labelling and ‘othering’ language is used to discredit stigmatized groups (Link & Phelan, 2001; Walter et al., 2017) and was used by participants to express negative attitudes towards PWUS, thereby distinguishing the speakers from those using the substances. Twenty participants used labels to describe PWUS including ‘spiceheads’ and ‘zombies’: this latter term, in particular, has been used to portray PWUS as both threatening and disgusting (Alexandrescu, 2020). Differentiation was drawn between groups depending upon the substances used, and user characteristics: people who use (controlled) drugs; those who use drugs as opposed to alcohol; those who used ‘natural’ versus synthetic drugs (i.e. cannabis vs SCRA); young people; homeless people; and people who were involved in street activities such as begging. Ten participants compared SCRA to heroin and crack cocaine (Class A drugs in the UK, strictest control), with four believing SCRA to be more harmful than them. SCRA was described ‘like a Class A… you would do anything to get it’ (P29, male, 28, past use of SCRA), echoing similar findings in which SCRA was referred to as ‘green heroin (Gray et al., 2021). A hierarchy of stigma identified PWUS on a par (or more stigmatized) than people who used heroin or crack cocaine, with synthetic drugs more stigmatized than natural ones. Negative effects of intergroup contact such as conflict (Pettigrew, 2008) were also identified: some homeless participants who did not use SCRA expressing negative views towards PWUS due to conflict over optimal spots for street begging:

Extract 2

If someone else is there rattling [in withdrawal from SCRA] because they know that is a good spot they will go over and move them and set about them [physically assault].

(P30, male, 24, current use of SCRA).

Criminality: as perpetrator and victim

While the links between crime and drug use are a common theme both in government policy and media reporting (Atkinson & Sumnall, 2020b), PWUS in this study was framed both in relation to criminality and victimhood. Criminal behavior associated with PWUS was mentioned by 17 participants, with 16 of these identifying PWUS as perpetrators, and six as both perpetrators and victims. Supporting findings that the links between drug use, crime and stigma are complex (Hammersley & Reid, 2002), there was a duality in the attribution of criminal behavior to PWUS, such as shown in Extract 3, in which a male who was sofa surfing mentioned the increased likelihood of PWUS being both perpetrators and victims:

Extract 3

They're [PWUS] a lot more violent and aggressive thinking… There was a guy smoked Spice… and fell asleep and when he woke up, his mate had been away with his phone. So, it's got people robbing off their own best friends.

(P9, male, 33, past use of SCRA).

Of the 16 participants attributing criminal behavior to PWUS, nine stated that they would steal from their friends, and seven that they would assault others. Of the six participants who identified that use of SCRA made people more susceptible to being victims of crime, all felt that PWUS were vulnerable to being assaulted, either while under the influence of SCRA or by other PWUS. Views associating PWUS as perpetrators of the crime were more prevalent in those who expressed overall negative sentiment towards PWUS. These were found in six of the 12 participants who expressed negative sentiment mentioning crime, compared to one of the nine participants who held overall compassionate views.

Intersectional stigma: AxB = C

While the interview schedule did not include specific questions about intersectional stigma, a number of stigmatized identities other than those collected in the demographic questionnaire were self-identified by participants during interviews, including the history of institutionalized care; children were taken into care; drug use while pregnant; ‘street culture’ activities; receiving benefits; experience of domestic violence; and Class A drug use. Substance use was valued differently in its intersection with some of these other characteristics, and 25 participants made references to people being ‘homeless’ or ‘the streets’ in interviews, while 13 mentioned these when discussing groups of people whom they believed used SCRA. As shown in Extract 4, a currently homeless participant who had not used SCRA identified intersectional stigma associated with unstable accommodation (Weng & Clark, 2018) and SCRA use:

Extract 4

The people that are smoking Spice are sitting outside of shops begging for money when they’ve actually got hostels to go into. But the people that are actually homeless and sitting there, it’s making us look like we’re doing the wrong thing as well… they [the public] look at us like we’re scum.

(P28, male, 28, never used SCRA)

Nature and quality of contact

Individuals aim towards consistency within their attitudes and opinions, and inconsistencies can lead to a psychological discomfort labelled cognitive dissonance (Festinger, 1957; Paluck et al., 2021), which was observed in a number of interviews. For example, one participant (P33, male, 52, never used SCRA) who initially expressed strongly negative views towards PWUS: ‘They’re just mugs… stupid… dragging other people down… the family have to pick the pieces up…’ later stated that one of his friends used SCRA. When asked to clarify this he replied ‘Yes, but it’s different knowing someone. If I knew someone and he started taking Spice, then that would be his decision… I would still be his friend.’ This mitigation of stigmatizing views by the nature and quality of the contact was aligned with intergroup contact theory, and further supported by statements that the service itself was seen to create a sense of community: ‘I’ve had a good few people from this place… it's like a family in here’ (P39, male, 27, never used SCRA). The influence of the community was mentioned by nine participants, both in terms of impacting their own use of SCRA, or beliefs held towards PWUS. Three of these said that attending the service would reduce the use of SCRA, either because of a personal desire, or pressure from peers not to have thought to have taken them, while six mentioned that people who accessed the service would offer support to their peers who used SCRA.

Visible and concealable stigma

Goffman (1963) proposed that stigma experiences of discredited (visible) and discreditable (concealable) stigma diverge, and different outcomes have been identified for these two groups (Chaudoir et al., 2013). Comments from PWUS highlighted that their use of SCRA could be both visible (in the case of street use) or concealable (for example when used in private residences, or in backstreets). Those who were engaged in the visible use of SCRA shared their experience of stigma: ‘people judge you differently…They don’t want to talk to you, they think you’re a fucking rat basically’ (P13, male, 49, current use of SCRA), while for a concealed user, being open about her SCRA use for the purpose of this study was a factor in taking part (see Extract 5). This process of self-disclosure, or ‘coming out’, may therefore have been away both of claiming identity as someone who uses SCRA and reducing both internalized and external stigma (Corrigan et al., 2016; Stefan, 2003).

Extract 5

That’s why I say straightaway, as soon as I’ve seen Spice on the table, I stood up and I went, I’m a spicehead, straightaway because no-one can admit it.

(P31, female, 27, current use of SCRA).

Integration of findings

When analyzing participant responses in this study the issue of attribution came to the fore as a factor in stigmatizing views, and deductive analysis explored factors that participants attributed to the use of SCRA. To examine this further, a cluster or cognitive map was initially created to capture terms and themes which were then merged into the final, integrative stage of data analysis. Data from the SDS-PWUS and ESUI were compared and cross-tabulated with counts of the qualitative and deductive overall sentiment and factors attributed to use of SCRA expressed by participants. Care was taken when extrapolating conclusions from these integrated analyses, as a single overall sentiment was condensed from each interview, which may lead to subjective over-simplification. In addition, counts of instances within themes cannot be assumed to act as a proxy indicator of importance, however, they can be ‘a useful supplement when considering some aspects of discourse’ (Bazeley, 2007, p. 201).

Counts of overall sentiment however showed marked differences in responses towards SCRA and PWUS. Whilst the majority (n = 35) of participants expressed an overall negative view of SCRA, there was a more varied pattern in responses towards PWUS: 12 indicated overall negative views, 21 neutral or mixed views, and nine expressed positive/compassionate views. When results from the ESUI were cross-tabulated with counts of qualitative overall sentiment towards PWUS, no counts of overall compassion towards PWUS were identified in people scoring 1 or 2 on the ESUI, and overall compassion was found in people with an ESUI score of 3–6. This is consistent with the framework of contact theory, and findings that suggest that familiarity is expected to increase understanding and decrease stigmatization (Pettigrew et al., 2011).

Drug use history

During interviews, it was noted that some participants who had regularly used SCRA in the past (more than once per week) held strong negative sentiments towards PWUS. Although there was no statistically significant correlation between SDS-PWUS scores and SCRA use, when numerical counts from the deductive overall sentiment category were cross-tabulated with SCRA use, 50% of the total negative views towards PWUS were expressed by people who had regularly used SCRA. This may suggest a desire of former users to distance themselves from the stigma associated with those that continue to use SCRA, for example: ‘Like I say, you don't get it on the streets of [location], where I'm from… It's mainly a homeless thing.’ (P18, male, 34, past use of SCRA). Further exploration revealed similar results when counts of overall sentiment were cross-tabulated with other drug use. No participants with a previous history of regular drug use were classified as positive/compassionate, while those with less frequent, or no use of drugs showed approximately evenly-balanced levels of compassionate and negative views towards PWUS.

Attribution: cause and controllability

Attribution theory suggests that people who are judged to be responsible for their condition evoke more negative emotions than those who are perceived to have a lack of control over the cause. This was supported by this study’s findings. Two themes emerged in the deductive analysis of qualitative interviews that were linked to causing or controllability of use of SCRA: hedonism (personal responsibility) and use as a coping strategy (lack of control over the cause). Counts of overall sentiment (compassion/negative) were cross-tabulated with factors attributed to use of SCRA (hedonism/coping strategy): 19 attributed the use of SCRA to hedonism, 21 attributed the use of SCRA as a coping strategy. Of the 19 participants that attributed use to hedonism, six held overall compassionate views and 13 held negative views; of the 21 participants that attributed use as a coping strategy, 15 held overall compassionate views and six negative views.

Discussion

This study investigated intragroup stigma towards people who use SCRA, and whether this was related to interpersonal contact. We found a significant negative correlation between participants’ exposure to people who use SCRA and their desire for social distance from them, suggesting that increased exposure to PWUS was associated with reduced levels of stigma. This was further supported by qualitative analysis of interview data. Findings were consistent with existing studies and contract theory, in which familiarity was associated with improved attitudes towards PWUD (Livingston et al., 2012; Tostes et al., 2020).

Contact

Intergroup friendship, increased knowledge of SCRA, and enhanced empathy with PWUS was identified in the current study, and positive peer relationships and the culture within the service itself may have contributed to this. Pettigrew et al. (2007, p. 413) noted that affective mediators such as empathy appear to be more important than cognitive ones (such as knowledge), and that ‘cross-group contact, and especially friendship, enables one to empathize with and take the perspective of the outgroup’. In this study, participants shared physical space and ate together in the service, and those who identified that they had shared a meal or a room with PWUS demonstrated less desire for social distance from them. Supportive social networks have been identified within excluded populations (Cloke et al., 2010; Neale & Brown, 2016), and clients made references to the service’s importance in their life in providing support and a family environment. In this manner, the service provided elements of a demarginalized environment (Lee & Petersen, 2009), which in contrast to more public settings, describes a treatment setting that is non-judgmental and where the open conversation is encouraged. Even within these demarginalized settings, negative views were expressed and there was evidence in this study of public stigma. However, in spite of this, for those who experience intersectional stigma or multiple exclusion, a sense of in-group belonging can improve self-image despite the public stigma and can be effective in reducing the impact of stigma (Cook et al., 2014; Treichler & Lucksted 2018). There was also evidence of peers supporting each other to reduce the risk of harm either from SCRA or from accidents whilst intoxicated, and this peer-peer harm reduction within a demarginalized environment may add additional support for findings identifying the positive impact of these types of treatment settings (Belackova et al., 2019).

However, as suggested by intergroup contact theory, contact alone is not always enough to reduce stigma, and the nature and quality of contact must be taken into consideration. The quality of contact within this group was not always positive, with evidence of stigmatizing views, such as participants attributing PWUS with being responsible for aggressive and criminal behavior. Theories of negative bias suggest that unpleasant experiences with a member of a group are likely to be more influential than positive ones (Kanouse, 1984; Unkelbach et al., 2020) and that negative attributes are then applied to other members of stigmatized outgroups (Paolini & McIntyre, 2019). However, in accordance with attribution theory, PWUS in this study were also identified both as victims of crime, and ‘good’ people despite their use, regardless at times of whether they were known personally to participants, suggesting that positive contact can counter harmful effects of previous negative intergroup contact (Pettigrew & Tropp, 2011). Thus, despite sharing negative first-hand experiences of PWUS, feelings of overall compassion towards them were also expressed, along with an awareness of social or environmental factors influencing substance use.

A secondary aim of the study was to explore whether participant characteristics, including personal drug use experience affected stigmatizing attitudes. Although the study’s findings were broadly concordant with both contact and attribution theories, there was dissonance in the responses towards current PWUS by those who had formerly used SCRA more than once per week. Contradictory views were identified in people who had themselves used SCRA frequently in the past, many of whom defined themselves as having been previously ‘addicted’, yet who expressed negative views towards PWUS. This has also been found in other studies that suggested that people who have formerly used drugs may distance themselves from PWUD in order to distinguish themselves from a stigmatized identity (Furst et al., 1999; Simmonds & Coomber, 2009). In 12-step programs, for example, there may be a negation of past drug-using identities and judgement passed on others who relapse in order to consolidate a transformed identity of being ‘in recovery’ (Anderson & Ripullo, 1996). These findings are also of relevance in the education and training field, where interactions with peer educators or ‘experts by experience’ have been found to be broadly successful in reducing stigma within the fields of nursing (Happell et al., 2014), mental health (Fellinger & Amering, 2015), and blood-borne viruses (Batchelder et al., 2017). Studies exploring the effectiveness of stigma-reducing interventions that included education or direct contact with PWUD usually involve peer educators working with professionals rather than fellow members of marginalized groups (Livingston et al., 2012), and the findings of this study relating to intergroup contact theory would support the use of PWUS as peer educators in professional settings. However, a recent study by Geregová and Frišaufová (2020) suggested that caution is required, as peer educators may inadvertently create divisions between ‘good’ and ‘bad’ clients, for example, those that are in recovery, and those that are not.

Attribution

Qualitative and integrated data analysis revealed associations between attribution of reasons for use of SCRA and stigmatizing views towards PWUS. The divergent sentiment was expressed by participants towards SCRA and PWUS: notably higher levels of negative overall sentiment were directed towards the drugs than the people who used them. Whilst PWUD is often blamed for their disorder (Nieweglowski et al., 2018) this can also be attributed to external factors (Mendoza et al., 2019). Corrigan and Watson (2004) have suggested that while well-intentioned, this may lead to benevolence stigma and the belief that PWUD is ‘controlled’ by a ‘bad’ drug, thus reducing personhood and agency. The increased use in policy and discourse of the term ‘vulnerable’ to describe people most at risk from the harms of drugs may lead to a reduced focus on the impact of social inequalities and policy, and prioritization of individual factors including personal weakness (K. Brown & Wincup, 2020; Cole, 2016; Ferrarese, 2016, p. 151). These authors suggest that redefining vulnerability in terms of social divisions and material inequalities could also help to reduce stigma.

Study findings were broadly aligned with attribution theory. Participants who expressed overall compassion towards PWUS were more likely to attribute SCRA use to managing the stress of adverse life experiences than other reasons, while those who expressed overall negative sentiment towards PWUS were more likely to attribute use to hedonism. However, whilst informed by relevant theory, the study was not a direct assessment of attribution. Some participants attributed the use of SCRA to multiple factors, the themes and categories attributed often overlapped, and clarification was not sought in instances where there were multiple ways of interpreting a statement. Further studies would therefore be required to collect data specifically relating to attribution theory within this population, perhaps building on expanded attribution models such as that developed by Corrigan et al. (2003) which included controllability of cause as a predictor of social distance.

Social context

There is emerging evidence of the impact of intersectional stigma on mental and physical health outcomes, and within these studies, social context has been shown to impact both levels of stigma and health-related behaviors (Turan et al., 2019). The importance of socially safe spaces for those experiencing intersectional stigma has been identified (Parker et al., 2017); one recent study found that current healthcare settings were experienced as being inherently unsafe for a population who were both homeless and injecting drugs and that the creation of safe treatment settings offers ‘transformative potential to reduce serious health harms’ (Harris, 2020, p. 8). With stigma comes separation or rejection from the ‘norm’, and therefore efforts to improve health outcomes and behaviors of those experiencing intersectional stigma should include strategies to include them in treatment, rather than an expectation that they should conform to existing treatment provision.

Supporting existing research on the impact of awareness of the history of childhood adversity on stigmatizing attitudes towards PWUD (Sumnall et al., 2021), findings from this study suggest that an awareness of external or societal factors in substance use disorders was associated with fewer stigmatizing views. This is aligned with calls for public health efforts to treat substance use as a health behavior (Palamar, 2013), and to develop campaigns and interventions which highlight the role of the social determinants of health in substance use disorders, or acknowledge the links between trauma and substance use (Quinn et al., 2016).

Study strengths and limitations

This study’s use of mixed methods design supports one of the more common justifications of this approach: that it can lead to the increased richness of both data and understanding of the topic (Fetters et al., 2013; Greene et al., 1989). Merging data allowed for greater depth of comprehension of the nature and quality of the contact with PWUS identified in quantitative measures. Patterns emerged in qualitative data identifying both how friendships and the setting of the study could mitigate stigmatizing views, and merging data types revealed associations between attribution of reasons for use of SCRA, and stigmatizing views towards PWUS. This gave a deeper understanding of some of the processes (attribution) behind the outcome (the impact of contact on stigmatizing views), and merging these theoretical frameworks also highlighted how the theories intertwined.

We acknowledge a number of weaknesses in our study. Reliability and validity could have been reduced by the use of the adapted (and therefore non-validated) measurement tools (Althubaiti, 2016). Cronbach’s alpha for the ESUI in the current study was questionable, and despite piloting and adaptation for cultural relevance and sensitivity, there was still room for a lack of understanding. For example, some participants required clarification around the statement ‘I have eaten with people who use Spice’; confused about whether this meant ‘eating at the same table as’ or ‘eating from the same plate as’. In addition, attitude and social distance surveys ask participants what they would do in hypothetical situations, with the assumption being drawn that their responses are congruent with their actual behavior (Thornicroft et al., 2007).

Although around one-half of participants had used SCRA in the past, we only recruited two regular (> weekly) users of SCRA. While some of the high use frequency group had been banned from the service’s main building, those who attended and declined to take part in the study cited reasons such as a desire for payment and suspicions about researcher motives, which have been identified in other studies with marginalized populations (Matthews & Velleman, 1997; Slomka et al., 2007).

Study implications

While the correlational findings presented here do not reveal a causal direction in the relationships between variables, the association between increased contact with PWUS with lower levels of stigmatization give assurance of the relevance of intergroup contact theory within this population, also adding support, with the caveats noted earlier, for approaches that make use of interactions with peer educators or ‘experts by experience’.

The study findings would suggest that attribution plays a significant role in stigmatizing beliefs within this multiply excluded population, and would encourage further studies using this theoretical perspective, with a focus on the impact of perceived controllability and choice on stigmatizing views. They would also support interventions that highlight the impact that social inequalities play in substance use disorders, rather than highlighting individual moral failings or ‘vulnerability’.

Findings are also consistent with research that identifies significant gaps in our understanding of intersectional stigma, how this impacts on people’s experience of, and access to health services, and support attempts to close these gaps. Alternate study designs such as ethnographic studies or those with financial incentives might be considered, and while the use of a researcher-practitioner was an effective recruitment method, a separate researcher not known to participants to conduct interviews could both add reliability to the study’s findings and also complement the validity of the mixed methods approach. The continued development, piloting and testing of research tools for those experiencing intersectional stigma using culturally-sensitive and appropriate language is also recommended, including innovative approaches to quantitative data collection tools.

In addition, the degree and nuance of intragroup marginalization found in this study might encourage awareness of the diversity of beliefs and backgrounds within a cohort that might generally be viewed as a homogenous group. The study’s findings would also suggest a greater consideration of treatment settings; for example, either the implementation of demarginalized treatment environments such as drop-in centers or for treatment providers to consider delivering outreach services into settings already defined as safe by those experiencing intersectional stigma.

Conclusion

PWUS are at risk of marginality, abjection and shaming (Alexandrescu, 2020), and are subject to stigmatization not only from the public but also from treatment services, with research highlighting the importance of the development of improved service responses to meet their needs (Gray et al., 2021). Intra-group stigma directed towards PWUS could lead to a heightened sense of isolation, with its associated negative impact on health and treatment outcomes. However, despite this intragroup marginalization, there was evidence to suggest that belonging to a supportive service community could mitigate the effects of stigma or contribute to this process. This supports the implementation of more inclusive, culturally safe treatment models in reducing the stigma associated with SCRA, or consideration of service activities that are designed to address intragroup stigma within client groups.

Disclosure statement

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