“My Addiction Doesn’t Define Me”—Experiences of Stigma among Mothers with Opioid Use Disorder

Round 1

Reviewer 1 Report

Abstract:

-Page 1, Line 10: Please include “.” after women.

-Page 1, Line 12:  The focus of this manuscript is opioid use disorder, but there are several references of substance use disorder, where opioid use disorder might be more appropriate.

-Page 1, Line 13:  Suggest changing quantitative methods to qualitative methods.

-Page 1, Line 16:  Suggest including “4)” before Conclusion.

Introduction:  Overall, the introduction provides an overview of the stigma associated with substance use disorder.  However, the introduction could be focused more on opioid use disorder, including the defining medications for opioid use disorder (MOUD) and their use in the treatment of OUD.  A distinction should also be made between SUD and OUD, as these seem to be used interchangeably within the manuscript.  Additionally, ending with more information as to why understanding the stigma surrounding this disease and its impact on maternal health is important to research.    

-Page 2, Lines 44:  Please provide a space in “1999with”.

-Page 2, Lines 44-52: Suggest providing the distinction between SUD and OUD, as these seem to be used interchangeably. 

-Page 2, Line 58:  Suggest replacing “and” with “while”.

Materials and Methods:

-Page 2, Line 69: The eligibility criteria is SUD but the focus and purpose of the study is on OUD.  Was the eligibility criteria SUD or OUD?  Please make this distinction.  If this focuses on SUD, then please update the title.

-Page 2, Line 90: Suggest providing a reference for first-level semantic coding to aid readers in understanding the coding technique used.  Is this similar to inductive or deductive coding?  If specific codes were used, suggest listing those here.  Also, was data saturation reached?

Results:  Overall, the results section contains powerful statements, with themes and subthemes represented in an effective way. 

-Page 3, Lines 97-103:  Suggest including (n=x) after each %. 

-Page 4, Line 112: Please correct spelling to “internal”

-Page 4, Line 113: Please correct spelling to “forgiveness”

-Page 5, Line 124: Suggest discussing MOUD prior to presenting this in the results section.  This will prime the readers to more readily engage with the material.

-Page 6, Lines 152: Suggest clarifying if the women had SUD vs. OUD to maintain focus on the purpose of the study.

-Page 8, Line 264: It may be appropriate to include some information on the overarching theme, recovery and healing from stigma, to lead the readers into the subtheme of Advocacy.

Discussion: This section could be expanded more by including discussion on internal stigma, external stigma, and recovery and healing findings that coincide with current literature and how this information is expanded upon based on the findings of the study.  A limitations section should also be included pertaining to participants’ bias and positionality, and how these may impact generalizability of the study results.     

Conclusion:  The conclusion discusses substance use disorder rather than opioid use disorder.  Additionally, the conclusion can be further elaborated on with providing next steps for research or perhaps integration of findings to inform interventions in reducing stigma pertaining to mothers with OUD.

Figures:

Figure 1: While this was a good visual representation, it was difficult to identify the major themes and subthemes.  Repositioning these points may make the major themes easier to identify. Suggest restructuring the figure to better identify stigma as the focus with external, internal, and recovery stigma as major themes, and the subthemes branching from them. 

Author Response

Point 1: (Abstract): Page 1, Line 10: Please include “.” after women.

Author's Response: Completed

Point 2: Page 1, Line 12: The focus of this manuscript is opioid use disorder, but there are several references of substance use disorder, where opioid use disorder might be more appropriate.

Author's Response: Authors reviewed the manuscript and made changed SUD to OUD where it was more appropriate. Authors added more in the introduction section discussing OUD and explaining its prevalence compared to all SUD.

Point 3: (a) Page 1, Line 13:  Suggest changing quantitative methods to qualitative methods. (b)Page 1, Line 16:  Suggest including “4)” before Conclusion.

Author’s Response: Corrections completed.

Point 4: Introduction: Overall, the introduction provides an overview of the stigma associated with substance use disorder.  However, the introduction could be focused more on opioid use disorder, including the defining medications for opioid use disorder (MOUD) and their use in the treatment of OUD.  A distinction should also be made between SUD and OUD, as these seem to be used interchangeably within the manuscript.  Additionally, ending with more information as to why understanding the stigma surrounding this disease and its impact on maternal health is important to research.    

Author’s Response:  Authors added more information in the introduction section on OUD and explaining its prevalence compared to all SUD.

Point 5: (a) Page 2, Lines 44:  Please provide a space in “1999with”. (b) Page 2, Lines 44-52: Suggest providing the distinction between SUD and OUD, as these seem to be used interchangeably. 

Author's Response:  Page 2 lines 44 actually on line 46 – corrected.  Also added distinction between SUD and OUD and updated references.

Point 6:  Page 2, Line 58: (a) Suggest replacing “and” with “while”. (b) (Materials and Methods): Page 2, Line 69: The eligibility criteria is SUD but the focus and purpose of the study is on OUD.  Was the eligibility criteria SUD or OUD?  Please make this distinction.  If this focuses on SUD, then please update the title.

Author’s Response: Authors changed “and” to “with.” (b) Authors changed SUD diagnosis to OUD. All participants in this study are treated for OUD.

Point 7: (a) Page 2, Line 90: Suggest providing a reference for first-level semantic coding to aid readers in understanding the coding technique used.  Is this similar to inductive or deductive coding?  If specific codes were used, suggest listing those here.  Also, was data saturation reached? (b) (Results):  Overall, the results section contains powerful statements, with themes and subthemes represented in an effective way. 

Author's Response:  Authors added more information about analysis and data saturation, including updating citations, in data analysis section.

Point 8: (a) Page 3, Lines 97-103:  Suggest including (n=x) after each %. (b) Page 4, Line 112: Please correct spelling to “internal” (c) Page 4, Line 113: Please correct spelling to “forgiveness”

Author's Response:  Edited and fixed spelling and grammar errors.

Point 9: Page 5, Line 124: Suggest discussing MOUD prior to presenting this in the results section.  This will prime the readers to more readily engage with the material.

Author's Response:  See page 1 lines 78-81. Added discussion for MOUD. Added reference, fixed all citations.

Point 10:  Page 6, Lines 152: Suggest clarifying if the women had SUD vs. OUD to maintain focus on the purpose of the study.

Author's Response:  See line 110-111 “This study used qualitative methods and descriptive thematic analysis to explore the experiences of stigma among mothers with opioid use disorder.”

Point 11:  Page 8, Line 264: It may be appropriate to include some information on the overarching theme, recovery and healing from stigma, to lead the readers into the subtheme of Advocacy.

Author's Response: Authors wrote more about advocacy in the discussion section. Because deductive coding was used, this was an unexpected finding in the results and therefore not explained more until discussion section.

Point 12:  Discussion: This section could be expanded more by including discussion on internal stigma, external stigma, and recovery and healing findings that coincide with current literature and how this information is expanded upon based on the findings of the study.  

Author's Response:  Authors added more information on internal and external stigma, as well as gender in the discussion section, first paragraph.

Point 13:  Limitations section should also be included pertaining to participants’ bias and positionality, and how these may impact generalizability of the study results.     

Author's Response:  Limitations section added: see lines 457 - 467

Point 14:  (Conclusion):  The conclusion discusses substance use disorder rather than opioid use disorder.  Additionally, the conclusion can be further elaborated on with providing next steps for research or perhaps integration of findings to inform interventions in reducing stigma pertaining to mothers with OUD.

Author's Response: Authors added to the conclusion to future research. Substance use disorder was changed to opioid use disorder.

Point 15: (Figure 1): While this was a good visual representation, it was difficult to identify the major themes and subthemes.  Repositioning these points may make the major themes easier to identify. Suggest restructuring the figure to better identify stigma as the focus with external, internal, and recovery stigma as major themes, and the subthemes branching from them. 

Author's Response: Figure 1 has been amended.

Reviewer 2 Report

This was a qualitative study to explore the experiences and perceptions of stigma among mothers with OUD. 

INTRODUCTION:
1. The first sentence states that SUD is not an individual problem. I'm not sure that is a typo, but if not, that statement is not appropriate or accurate. SUD impacts both individuals and society. 

2. Page 2, line 54 is confusing: "Although mothers with SUD are more likely to enter treatment for child custody reasons, they are less likely to initiate treatment..." What is the difference between entering treatment and initiating treatment? and who are they being compared with in this statement? Is it men? non-mothers? 

3. In general, there have been prior studies exploring stigmatizing experiences among this population. The introduction would be stronger if there would be more description of what new information this study adds. 

METHODS:

1.  This section could include more information regarding the recruitment process, including how participants were contacted, and who was conducting recruitment. 

2. How was the sample size determined. 

RESULTS:

1. I would have preferred for Table 1 to show aggregate sample characteristics rather than individuals. As shown, it's difficult to interpret particularly bc some of the variables don't have standard responses (i.e. child age). 

2. The remainder of the qualitative results are presented in a clear and accessible way. I think a short table summarizing themes and representative quotes could be useful. 

Author Response

Point 1: The first sentence states that SUD is not an individual problem. I’m sure that is a typo, but if not, that statement is not appropriate or accurate. SUD impacts both individuals and society.

Author’s Response: This is not a typo. Substance use disorder is not an individual problem but a complex condition that negatively impacts individuals on the micro, mezzo, and macro levels, in addition to having economic and societal implications. This sentence is meant to convey that message.

Point 2: Page 2, Line 54 is confusing: “Although mothers with SUD are more likely to enter treatment for

child custody reasons, they are less likely to initiate treatment . . . “ what is the difference between entering treatment and initiating treatment? And who are they being compared with in this statement? Is it men? Non-mothers?

Author’s Response: This sentence has been clarified to explain that mothers are less likely to initiate treatment on their own, but more likely to enter treatment as a condition of maintaining custody of their children due to CPS involvement, when compared to their male counterparts.

Point 3: In general, there have been prior studies exploring stigmatizing experiences among this population. The introduction would be stronger if there would be more description of what new information this study adds.

Author’s Response: While there have been other studies examining stigma of mothers with OUD, there is still a dearth of research on the topic, and our study adds to the body of literature. The authors provide more detailed information about what this study adds in the discussion section.

 Point 4: (Methods): This section could include more information regarding the recruitment process, including how participants were contacted, and who was conducting the recruitment.

Author’s Response: A sentence was added to provide more detail of the recruitment process.

Point 5: (Methods): How was the sample size determined?

Author’s Response: More information regarding sample size and saturation was added to the Methods section.

Point 6: (Results): I would have preferred for Table 1 to show aggregate sample characteristics rather than individuals. As shown, it’s difficult to interpret particularly because some of the variables don’t have standard responses.

Author’s Response: We included individual characteristics, along with an ID that readers can refer to when reading the results, as it helps provide a picture of the mother who is speaking. We did describe aggregates in the results section.

Point 7: (Results): The remainder of the qualitative results are presented in a clear and accessible way. I think a short table summarizing themes and quotes could be useful.

Author’s Response: We revised Figure 1, the visual of themes and subthemes so that it is easier to follow.

Reviewer 3 Report

The article is interesting and considers an important problem. However, it needs significant development that will bring some insights that are sorely lacking.

The introduction should emphasise the sociological and psychosocial aspects inherent in the relationship between drug addiction and gender, and present an overview of the studies that have addressed this issue. What is missing is a reflection on the socio-cultural reasons that may explain the phenomenon under analysis. Moreover, there is a total lack of reflection on the concept of gender identity and the different social categories involved in the drug addiction circuit. For women, the history of feminist self-consciousness has marked a point of no return with regard to the efforts of autonomisation with respect to any expression of addiction. Women victims of violence and abuse have had the opportunity to be supported by anti-violence services: what are the stories of those who do not access these services and ultimately become further victims of drugs. There is a lack of literature on this issue and the problem is not presented at all, i.e. the pathway that produces this outcome is not considered.

There is a lack of definition of research objectives and discussion of their achievement.

The conclusion lacks a clear definition of the limits of the research and the possibilities of development.

A clear definition of the clinical and psychosocial application implications of these results is missing.

Author Response

Point 1: The introduction should emphasize the sociological and psychosocial aspects inherent in the relationship between drug addiction and gender and present an overview of the studies that have addressed this issue. What is missing is a reflection on the socio-cultural reasons that may explain the phenomenon under analysis.

Author's Response: More on the role gender plays in the cycle of addiction was added to the introduction section. The authors are not conducting an analysis on the socio-cultural reasons for gender differences in stigma, however more information on socio-cultural reasons have been added. See lines 72-84.

Point 2: Moreover, there is a total lack of reflection on the concept of gender identity and the different social categories involved in the drug addiction circuit. For women, the history of feminist self-consciousness has marked a point of no return with regard to the efforts of autonomisation with respect to any expression of addiction. Women victims of violence and abuse have had the opportunity to be supported by anti-violence services: what are the stories of those who do not access these services and ultimately become further victims of drugs. There is a lack of literature on this issue and the problem is not presented at all, i.e. the pathway that produces this outcome is not considered.

Author's Response:  The authors feel this is out of the scope of this manuscript. We were conducting deductive research exploring stigma from the perspective of the person (women) while in use or during treatment experiencing it. We touched on victimization and perceived feminine roles briefly in lines 67-70, however, fully addressing victimization and feminist bias/self-consciousness or the role victimization plays in pathways to addiction was  not within the scope of this paper.

Point 3: There is a lack of definition of research objectives and discussion of their achievement.

Author's Response: This was a deductive exploration of experiences of stigma, therefore the research objective was to explore stigma from the point of view of the person experiencing stigma. The researchers were careful to not contaminate the data collection with their knowledge or assumptions on the subject.

Point 4: The conclusion lacks a clear definition of the limits of the research and the possibilities of development. A clear definition of these results' clinical and psychosocial application implications is missing.

Author's Response: Limitations was added. More was added on the application and future direction of research.