Title: The Role of Micro-, Meso-, and Macro-Level Stigma on the Uptake of Medications for
Opioid Use Disorder (MOUD) Among Women in the Criminal Legal System
Version: 4 Date: 27 Mar 2025
Reviewer's report:
Review of “The Role of Perceived, Enacted, and Internalized Stigma on the Uptake of
Medications for Opioid Use Disorder (MOUD) Among Women in the Criminal Legal System”
This article examines an important topic, stigma against MOUD in various contexts.
However, I have several concerns.
First, there is already a substantial literature demonstrating stigma in relations MOUD and I’m
not sure if this article, as it currently written, is adding anything new. I also felt that many of the
claims made by the authors were overstated, and not really supported by the data - the authors
seemed to be exaggerating or stretching what their quotes actually said. There was also very
little discussion of how stigma is enacted or experienced differently for women.
I was also confused by the use of the FINIS model and also the enacted, perceived, internalized
model. Although the authors mention using FINIS in the Theory section, they do not use its
framework (micro, meso, macro) in the analysis. I would recommend choosing one (probably
the FINIS model) and use it throughout, while dropping the other.
I also thought the analysis was fairly light and a little superficial, and I think part of that has
to do with the organizational structure based on enacted, perceived, and internalized stigma. I
would recommend looking for themes in your data that can add new insights to the literature,
or add depth to current knowledge.
Lastly, the writing could use some editing and tightening up.
Here are my specific comments.
Abstract
• The first sentence in Background is a fragment rather than a complete sentence. Additionally,
the authors seem to be describing the study aims rather than the background information. Also,
I’m not sure that the authors are using “triangulates” correctly – it’s different than “comparing”
which seems to be what the authors mean.
Intro
Section 1.2
• Goffman sentence is not cited.
• The claim that “women with OUD are more likely to discontinue MOUD treatment than men”
needs to be discussed in more detail rather than just stated.
• This paper would be improved if the authors described the three types of stigma (enacted
stigma, perceived stigma, and internalized stigma) as a framework for understanding stigma
rather than an objective reality.
o The discussion of the literature on stigma should be expanded and improved.
Section 1.3
• Drop the word “particularly” from the second sentence.
Methods
Section 3.1
• Can you clarify the inclusion criteria – specifically, did participants have to be on MOUD and
legal-justice-involved at the same time, or do they just need to have experience with both? Also,
I’m guessing that people using MMT and bupe were included – can you report on approximately
how many there were in each group?
Results
Section 4.2.1
• In the first quote: As much as I hate vivitrol, I don’t think you can make this claim based on this
quote alone. There are people who genuinely believe in the therapeutic value of vivitrol and I’m
not sure how you separate that from a decision based on stigma without more evidence. Plus, the
quote does not suggest that the patient was against using vivitrol or that it was forced on them.
• I don’t think you should describe participants as “affected” (presumably by stigma) - it’s too
presumptuous.
• I don’t think you can make either of these claims (interviews suggested that some substance
use treatment centers may enforce a hierarchy on patients as to which MOUDs are most
acceptable, and some SUD treatment professionals may express discriminatory attitudes toward
those who are taking specific types of maintenance medications.) based on the two quotes
you presented (even though both are true). The quote relating doctors discriminating against
certain medications does not specify SUD professionals but seems to be more about general
care practitioners.
Section 4.2.2
• The lack of provision of MOUD in jails and prisons is a complicated issue that is not solely the
result of stigma (although there is that). The evidence presented here–that access to MOUD is
limited in carceral settings–is not speaking clearly enough to the claims of stigma as the reason.
Quotes from jail/prison administrators talking negatively about MOUD would be better here.
• The article “The Trouble with Morality: The Effects of 12-step discourse on addicts decision
making” (Frank, 2011) may be helpful in bridging the gap between stigma and negative
outcomes.
Section 4.4.1
• I think the quote that begins “I don't think methadone is very helpful…” is the strongest quote
in terms of presenting evidence of stigma against MOUD.
• The one after that is good too. And the one from the provider – this section is definitely stronger
than the previous ones for demonstrating stigma. However, I would avoid phrases like “deeply
internalized”.
Discussion/Conclusions
• This section did not really engage with the data beyond re-iterating the findings in the Results.
But I think that using a different theoretical and analytical approach will help sort that out.