People, Places and Stigma Management: A Qualitative Study Exploring the Overdose Risk Environment in Rural Kentucky Public
Fadanelli, Monica (Spring 2019)
Published
Abstract
Background: The opioid epidemic has become a significant public health crisis, as opioid-related mortality rates have increased over the last two decades. Kentucky, a predominately rural state, has been dramatically affected by the epidemic. Rural environments differ from urban environments in multiple ways, including differences in infrastructure, attitudes, norms, social networks and characteristics of the places where drug-related behaviors and potential harms take place. Therefore, in order to improve understanding of opioid use in rural contexts, the “Risk Environment Framework” by Tim Rhodes was used to investigate the places where people use opioids and how features of those places affect vulnerability to an overdose occurring or an overdose becoming fatal. Additionally, Erving Goffman’s ideas related to stigma management were incorporated into the discussion to further understanding of the phenomena.
Methods: Young adult opioid users, between 18 and 35 years old, were recruited using multiple strategies, including through recruitment by stakeholders, cookouts, flyers, walkabouts, and peer recruitment (Respondent-Driven Sampling [RDS]). Nineteen 1-on-1 semi-structured interviews were performed with the target population in order to develop an emic understanding of people who use opioids (PWUO) and the contexts in which they use drugs. The current investigation used a subset of the data collected, focusing on domains related to overdose and the overdose risk environment. Data were analyzed using grounded theory methods outlined by Strauss & Corbin (1998).
Results: The most salient settings that emerged, as places where people use opioids were homes, public bathrooms, cars or vehicles, outdoor spaces and places of drug dealing. Among the 19 participants, nine had either overdosed themselves (N=3) or knew someone who had overdosed. Strategies discussed by participants that decreased vulnerability to overdose included using small amounts of opioids, avoiding polysubstance use, and not rushing the injection process. Vulnerability to dying from an overdose was related to receiving delayed medical attention, which occurred when a PWUO was not identified as overdosing or when they were identified, but medical attention was delayed or denied. Lack of identification occurred most often in examples where PWUO were using alone or were hidden behind a barrier that prevented others from recognizing that they were overdosing.
Conclusions: Stigmatization of drug use, particularly injection drug use, frequently arose across all participants. In order to mitigate feelings of shame and stigma, PWUO engaged in concealment strategies to manage their different selves or social roles. While these strategies decreased stigma and managed identity, they were at odds with safe injection practices meant to protect PWUO from an overdose.
Table of Contents
ABSTRACT.................................................................................................................................. 4
CHAPTER 1.................................................................................................................................. 9
1. INTRODUCTION AND RATIONALE.......................................................................... 9
2. FORMAL STATEMENT OF PROBLEM..................................................................... 10
3. THEORETICAL FRAMEWORK................................................................................... 10
4. PURPOSE STATEMENT............................................................................................... 12
5. RESEARCH QUESTION................................................................................................. 12
6. SIGNIFICANCE STATEMENT..................................................................................... 12
CHAPTER 2: LITERATURE REVIEW...................................................................................... 14
1. RISE OF THE OPIOID EPIDEMIC................................................................................ 14
2. DEFINITION OF IMPORTANT TERMS..................................................................... 15
3. BASIC PHARMACOLOGY OF OPIOIDS.................................................................... 18
4. OPIOID OVERDOSE....................................................................................................... 19
5. NALOXONE.................................................................................................................... 20
6. INDIVIDUAL-LEVEL DETERMINANTS OF OD....................................................... 21
7. ENVIRONMENTAL DETERMINANTS OF OD......................................................... 24
8. OVERDOSE TRENDS..................................................................................................... 25
9. OVERDOSE IN KENTUCKY......................................................................................... 27
10. CONTRIBUTIONS TO HIGH OD DEATHS IN KY.................................................... 27
11. THEORETICAL FRAMERWORK................................................................................ 30
12. LEVELS OF THE RISK ENVIRONMENT.................................................................... 32
13. TYPES OF ENVIRONMENTS....................................................................................... 33
14. INTERSECTION OF RISK ENVIRONMENT AND OD............................................. 36
15. IMPACTS OF INCREASED OPIOID PRESCRIBING................................................. 37
16. RISK ENVIRONMENT IN THE RURAL CONTEXT................................................. 39
17. SUMMARY OF CURRENT PROBLEM....................................................................... 42
18. JUSTIFICATION OF PROJECT AND LITERATURE GAP....................................... 43
CHAPTER 3: METHODOLOGY............................................................................................... 44
1. INTRODUCTION........................................................................................................... 44
2. POPULATION AND SAMPLE...................................................................................... 44
3. RESEARCH DESIGN...................................................................................................... 45
4. MEASURES..................................................................................................................... 47
5. DATA ANALYSIS METHODOLOGY.......................................................................... 48
6. ERVING GOFFMAN AND MANAGEMENT OF STIGMA..................................... 51
7. ETHICS AND CONFIDENTIALITY............................................................................. 52
CHAPTER 4: RESULTS.............................................................................................................. 54
1. INTRODUCTION........................................................................................................... 54
2. KEY FINDINGS............................................................................................................... 55
3. DEMOGRAPHICS.......................................................................................................... 55
4. EXPERIENCES WITH OVERDOSE............................................................................... 56
5. STRATEGIES, VULNERABILITY TO OD................................................................... 58
6. STRATEGIES, VULNERABILITY TO DYING FROM OD........................................ 60
7. PHYSICAL RISK ENVIRONMENT.............................................................................. 62
8. SETTINGS AND FEATURES OF SETTINGS.............................................................. 63
CHAPTER 5: DISCUSSION........................................................................................................ 82
1. INTRODUCTION........................................................................................................... 82
2. DISCUSSION OF KEY RESULTS.................................................................................. 82
3. OTHER FINDINGS......................................................................................................... 92
4. STRENGTHS................................................................................................................... 94
5. LIMITATIONS................................................................................................................ 97
6. IMPLICATIONS AND RECOMMENDATIONS................................................... 100
7. CONCLUSION........................................................................................................... 103
REFRENCES.......................................................................................................................... 104
APPENDICIES....................................................................................................................... 106
A. INTERVIEW GUIDE................................................................................................. 106
B. CODEBOOK.............................................................................................................. 115
About this Master's Thesis
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Primary PDF
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People, Places and Stigma Management: A Qualitative Study Exploring the Overdose Risk Environment in Rural Kentucky () | 2019-04-25 01:03:59 -0400 |
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Supplemental Files
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Appendix B (Appendix B with codebook) | 2019-04-25 01:04:02 -0400 |
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