Pilot testing a multi-level stigma intervention to improve substance use care with providers in mental health settings: A cluster-randomized trial

J Subst Use Addict Treat. 2026 May 19:210026. doi: 10.1016/j.josat.2026.210026. Online ahead of print.

ABSTRACT

INTRODUCTION: Stigma toward substance use disorders (SUD) lowers care quality, but little is known about such stigma in mental health (MH) settings. Past research suggests training reduces stigma among healthcare professionals. Additional approaches addressing upstream drivers of stigma are largely unknown, despite evidence that organizational context contributes to SUD stigma. This study aimed to develop and test a multi-level intervention addressing both professional and organizational SUD stigma.

METHODS: This study used mixed methods to evaluate an intervention composed of professional training and organizational policy change at two outpatient MH sites. The policy change was identified via systematic policy review and qualitative interviews with site staff. The Controlled Substances Agreement (CSA) was selected as the modifiable policy, which encouraged clinicians to provide documents listing patient behavioral expectations for CS prescriptions and repercussions for violations. The CSA policy was altered to include a conversation tool and CSA text eliminated stigmatizing language and promoted shared decision-making. A cluster-randomized trial assessed the multi-level intervention with an experimental arm (policy+training) and a control arm (only training). Prescribing MH providers were the primary sampling unit/clusters and patient electronic health records were secondary. Surveys and qualitative interviews assessed primary intervention feasibility outcomes and secondary attitude outcomes. Mixed-effect modified Poisson regressions evaluated changes in primary efficacy outcomes of diagnosing SUD, prescribing SUD pharmacotherapy, and retention in MH care among patients with SUDs.

RESULTS: Ten prescribing providers (n = 5 per arm) participated in surveys and n = 20 MH staff participated in interviews. Qualitative and quantitative data demonstrated intervention feasibility. Pilot efficacy data suggested only the control arm increased diagnosing SUD from pre- to post-intervention periods (aPR = 1.94, 95% CI: 1.05-3.61). Neither arm significantly changed prescribing SUD pharmacotherapy, retention, or stigmatizing attitudes. Triangulation with qualitative data revealed that MH professionals agreed SUD stigma may occur at their site but justified avoiding SUD patients and SUD treatment provision as a legitimate limit to their scope of practice.

CONCLUSION: The intervention was feasible, but future SUD stigma research may explore organizational policies that expand MH clinicians’ scope of practice perceptions, such as through integrated care programs, consultations with specialized SUD clinicians, or referral support.

PMID:42162741 | DOI:10.1016/j.josat.2026.210026