Date of Award

January 2023

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)

Department

Yale University School of Nursing

First Advisor

Tish M. Knobf

Abstract

Insomnia occurs in as many as 75% of people with Opioid Use Disorder (OUD). The prevalence of insomnia is attributable to concurrent factors such as mental health disorders, chronic pain, and medication use; however the contribution of social factors is not well understood. Persistent social factors and concerns within this population include stigma and discrimination. People who use prescribed medication for OUD (MOUD) report stigma and discrimination related to OUD, MOUD, and possibly other characteristics (e.g., race, gender, socioeconomic status, and incarceration history). However, the relationship between OUD-related stigma and discrimination with insomnia and between intersectional experiences, perceptions of stigma, and discrimination among patients on MOUD are not well understood. This dissertation research is nested within the NIH HEAL funded mechanistic study (CLOUDS STUDY: Collaboration Linking Opioid Use Disorder and Sleep) whose primary goal is understanding the contributions of sleep deficiency to relapse and retention in MOUD. The purpose of this dissertation is to examine the association between OUD-related stigma, and intersectional discrimination with insomnia among individuals on MOUD. Using a convergent mixed methods design, we addressed the following aims: Aim 1: Examine the associations between OUD-related stigma and intersectional discrimination with insomnia among individuals on MOUD [quantitative]. Hypothesis: OUD-related stigma and intersectional discrimination are positively correlated with insomnia severity among individuals on MOUD. Aim 2: Describe (1) how individuals perceive issues of stigma, discrimination, and sleep; (2) the intersectional phenomena of stigma and discrimination; (3) how experiences and perceptions associate with sleep [qualitative]. Aim 3: Gain a comprehensive understanding of the relationship between stigma and discrimination with insomnia among individuals on MOUD through integration of quantitative and qualitative data from Aims 1 and 2 [mixed methods].Informed by the Health Stigma and Discrimination Framework, manuscript #1 was a systematic review of original research describing associations between dimensions of stigma and sleep deficiency. There was consistent evidence that stigma, whether internalized, perceived, or anticipated, is associated with self-reported characteristics of sleep deficiency. This review highlighted important gaps in the literature which included, but were not limited to, the lack of exploration of this association among highly stigmatized populations, including those on MOUD. In manuscript #2, I report qualitative findings from 25 diverse participants on MOUD who described how they experienced intersectional stigma and discrimination and identified supports and resources that could be used to better understand and cope with the cumulative experiences of multiple forms of disadvantage. Five themes with supporting subthemes highlighted several identities that intersected with OUD. The intersection of multiple marginalized identities, which often led to discriminatory experiences, internalization of negative feelings, anticipated stigma, and shifts in self-perception. Participants also commented on recommendations for care to address the cumulative intersecting experiences of OUD. In manuscript #3, I explored (1) the relationships among OUD-related stigma, intersectional discrimination and insomnia among participants on MOUD, (2) how individuals perceived stigma, discrimination, and sleep. and (3) how individuals believed their experiences with discrimination and stigma were linked to sleep. The integration of quantitative and qualitative data led to a more comprehensive understanding of the relationship between stigma, discrimination, and sleep and the intersectional phenomena of stigma and discrimination experienced by this population. Analysis revealed moderate correlations between intersectional discrimination, physical symptoms and psychological distress with insomnia severity. Participants’ descriptions of their sleep illustrated how they connected discriminatory and stigmatizing experiences to sleep. Overall, the findings of this dissertation underscore that OUD-related stigma is a complex and nuanced concept. Study findings add to the growing body of literature linking intersectional discrimination, physical symptoms, and psychological distress with insomnia in people on MOUD. These findings may help to inform future intervention development aimed at advancing anti-discrimination efforts to improve sleep outcomes among those with OUD.

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This is an Open Access Thesis.

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