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

Background: Women with a history of opioid use disorder (OUD) and criminal legal involvement face rising overdose rates and barriers to engagement in medications for opioid use disorder (MOUD) treatment. Intensified by gender and criminal legal status, experiences of stigma can negatively influence MOUD treatment outcomes among women. While the effectiveness of MOUD in treating OUD is well-documented, there is a gap in understanding how MOUD-related stigma impacts engagement in MOUD treatment, particularly among criminal-legal involved women. To address this gap, we applied the FINIS model (Framework Integrating Normative Influences on Stigma) to explore how MOUD-related stigma manifests for criminal legal-involved women at the micro (intrapersonal), meso (interpersonal/institutional), and macro (structural/policy) levels. Methods: From May to July 2022, semi-structured qualitative interviews (N = 42) were conducted in Pennsylvania. Participants included women with a lifetime history of MOUD use and criminal legal system involvement (N = 20), criminal legal professionals (N = 10), and SUD treatment professionals (N = 12) who work with women who use opioids. The interviews explored participants’ lived or working experience with substance use, MOUD treatment, criminal legal involvement, and gender-specific issues around such. Data were analyzed utilizing thematic analysis. Results: Utilizing the FINIS model, our thematic analysis identified influences to MOUD uptake across the three levels of stigma: (1) micro-level (internalized beliefs), (2) meso-level (stigma encountered across settings) and (3) macro-level (structural and institutional barriers). A recurring theme across levels was the existence of a MOUD hierarchy—specifically, stigma surrounding methadone as a treatment for OUD. Conclusion: This study’s findings show how MOUD-related stigma operates simultaneously at the three levels, undermining treatment and recovery for criminal-legal involved women. Interpretation of these results through the FINIS model further highlights that stigma is not only experienced internally but also reinforced through peer dynamics, provider attitudes, and policies within criminal legal settings. Ultimately, reducing stigma across all levels will require systemic reforms, targeted education programs for providers, and recovery models that validate diverse treatment pathways.