Clinical implications

Daily supervised dispensing of methadone to individuals with opioid dependence has been recommended in Britain since the early 1990s, when more people died from methadone overdose (much of which was diverted from prescriptions onto the black market) than from heroin. ^{Reference Best and Campbell10,11} Provision of methadone from accessible community pharmacies is essential given the effectiveness of this treatment. ^{Reference Ward, Hall and Mattick8} The majority of pharmacies in England provide this service - dispensing of methadone is available from those pharmacies who are part of national chains and also from the majority of independent pharmacies. Hence in many areas, particularly urban areas, there is readily accessible provision of methadone treatment to those addicted to opioids. Consequently, the main objective of the study was to provide validation of the AMIQ anti-stigma questionnaire by showing behavioural consequences.

In sociological terms, discrimination is the tendency to treat people who have identical relevant characteristics differently. Although the term discrimination has implications of misconduct, this is not automatically the case. For example, several pharmacies may be closely located and there would not be sufficient demand for two neighbouring pharmacies to provide methadone. Similarly, there is often some training and special facilities required for pharmacies to provide supervised consumption facilities. However, it also remains possible that the managers of some pharmacies are discriminating against individuals with opioid dependence because of prejudice or adverse experiences. Attempts to reduce prejudice and stigma are currently being introduced and these are likely to be just as applicable to pharmacy staff as other healthcare professionals.

Methods to reduce the stigma of mental illness

Methods to reduce stigma are extensively discussed in other reports. ^{Reference Luty, Fakuda, Umoh and Gallagher14} Promoting direct interpersonal contact with people who have mental illness may be an effective strategy, but the amount of contact required remains unknown. ^{Reference Luty, Rao, Arokiadass, Easow and Sarkhel15-Reference Wolff, Pathare, Craig and Leff18} Indeed, this study may indicate that exposure to individuals with opioid dependence may reduce the perceived stigma. For example, the staff in pharmacies where methadone is prescribed presumably have frequent contact with opioid-dependent illness. It is therefore possible that this familiarity reduces the stigmatised attitudes of these pharmacy staff. This contrasts with the interpretation that pharmacy staff who have a negative view of heroin addicts may be choosing not to dispense methadone. Although the difference was modest, it was highly statistically significant. This is highly comparable with other research in which a brief face-to-face intervention (motivational interviewing) was carried out with the aim to reduce the stigma of alcoholism perceived by members of the general public (effect size 0.43). ^{Reference Corrigan and Penn19} By comparison, Wolff et al ^{Reference Penn, Guynan, Daily, Spaulding, Garbin and Sullivan16} reported a labour-intensive controlled study of the effect of a public education campaign on community attitudes towards people with mental illness which involved contact with people with mental illness in the experimental sample. It produced effect sizes of 1.23 for fear and exclusion, 1.22 for social control and 0.66 for goodwill. Presenting people with substance use problems in a positive manner (by emphasising abstinence in treatment) produced an effect size of 1.5.

There are many other initiatives that have been tried to reduce the stigma of mental illness, especially the Time to Change campaign (www.time-to-change.org.uk). ^{Reference Pinfold, Toulmin, Thornicroft, Huxley, Farmer and Graham20} Unfortunately, there have been reports that national anti-stigma campaigns are not particularly effective. ^{Reference Mehta, Kassam, Leese, Butler and Thornicroft6,Reference Luty, Umoh and Nuamah21-Reference Mayville and Penn24}

Instruments for measuring stigma

There remains no agreed gold standard interview against which to validate a stigma questionnaire. No stigma instrument has been validated against behavioural discrimination. For example, the Opinions About Mental Illness questionnaire is a self-completion instrument widely used to measure stigmatised attitudes towards mental illness. ^{Reference Paykel, Hart and Priest25} However, it measures attitudes towards the causes and treatment of mental illness rather than attitudes towards people with mental illness. Ritsher et al ^{Reference Luty, Umoh, Sessay and Sarkhel26} have validated a 29-item self-completion instrument (the Internalized Stigma of Mental Illness scale) that can be used to determine the degree of stigma experienced by people with mental illness. However, it was not designed to determine the attitude of members of the general population towards people with mental illness. The Community Attitudes Towards Mental Illness scale is useful when assessing attitudes towards various aspects of mental illness although, once again, this instrument is interviewer-rated. ^{Reference Knox, Smith and Hereby27} Crisp et al ^{Reference Crisp, Gelder, Goddard and Meltzer5} used a Likert scale in a large UK survey for the Changing Minds campaign. However, this used interview questionnaires that are too costly and cumbersome for routine use in other projects, especially where self-completion questionnaires are necessary.

Other instruments have been employed to measure stigmatised attitudes within the general population, although few have been fully validated. Pinfold et al ^{Reference Wolff, Pathare, Craig and Leff18} used a questionnaire with Likert response in 472 secondary school children. Unfortunately, the questionnaire referred only to ‘people with mental illness.’ This is similar to Corrigan's attributions questionnaire. ^{Reference Corrigan, Markowitz, Watson, Rowan and Kubiak2} These instruments cannot be used to compare attitudes towards those with mental illness with attitudes towards other groups such as those without mental illness or those addicted to opioids (who by many people are not seen as having a mental illness).

The AMIQ was used in this report as it was the most appropriate available instrument for this postal survey. The AMIQ was developed as a short self-report questionnaire to assess stigmatised attitudes towards people with mental illness. It has good psychometric properties and was validated in a sample of over 1000 UK adults. ^{12,Reference Cunningham, Sobell and Chow13}

Strengths and limitations

The response rate was reasonably good (over 66%) and probably involves a representative sample of independent pharmacy managers at 20 different sites across England. The study presented a hypothetical person with opioid dependence. This is less accurate than real experience. The views expressed may be influenced by social desirability bias. Consequently, the project assessed actual behaviour (whether the pharmacy chose to dispense methadone to opioid addicts or not) rather than relying simply on surrogate measures.

The results from other similar studies show a negative view of people with active substance use disorder and suggest that participants had little reservation about indicating their disapproval of these disorders. ^{Reference Cunningham, Sobell and Chow13,Reference Luty, Fakuda, Umoh and Gallagher14} This is confirmed in other reports. ^{Reference Crisp, Gelder, Goddard and Meltzer5} This would indicate that social disability bias had only a modest effect. Furthermore, social desirability bias would affect managers at both dispensing and non-dispensing pharmacies.

Overall, the report shows clearly that rating scales such as the AMIQ can usefully and meaningfully be applied in the context of substance dependence and the relationship between clients and treatment providers.