Stigma as a fundamental hindrance to the United States opioid overdose crisis response

The current United States opioid overdose crisis is a complex, multifaceted, public health emergency that urgently requires the implementation of evidence-based primary, secondary, and tertiary preventive interventions. We develop a typology of the stigma related to opioid use, showing how multiple dimensions of stigma continue to fundamentally hinder the response to the crisis. • Public stigma is driven by stereotypes about people with opioid use disorders, such as their perceived dangerousness or perceived moral failings, which translate into negative attitudes toward people with opioid use disorders. • Enacted stigma describes the behavioral manifestations of public stigma, including discrimination and social distancing. Public and enacted stigma, in turn, lead to delivery of suboptimal care and undermine access to treatment and harm reduction services. • Public stigma and enacted stigma can become structural stigma when they become encoded in cultural norms, laws, and institutional policies. Collectively, these forms of stigma run at cross purposes to-and reduce public support for-public health-oriented policies to address the opioid overdose crisis. • When people with opioid use disorders internalize or anticipate the public stigma attached to their illness, maladaptive behaviors (e.g., disengagement from care) leading to poorer health outcomes may occur. • Each of these dimensions of stigma (structural, public, enacted, internalized, and anticipated) serve to reinforce each other, resulting in poorer health outcomes even as the epidemiology of opioid overdose mortality continues to change. • These dimensions of stigma must be overcome to facilitate the requisite policy and programmatic changes needed to effectively address the opioid overdose crisis.