An Automated Text Messaging Intervention to Reduce Substance Use Self-Stigma (Project RESTART): Protocol for a Feasibility and Acceptability Pilot Study (Preprint)

Abstract

BACKGROUND Stigma is a central barrier to treatment and harm reduction seeking in people who use drugs. Most stigma reduction interventions offer psychotherapy or psychoeducation in group-based clinical settings, failing to reach the majority of people actively using drugs who are not in treatment. Text messaging is an effective and acceptable modality for delivering health information to people who use drugs and may be a suitable conduit for providing information and advice to understand and cope with stigma. OBJECTIVE We aim to determine the feasibility, acceptability, and preliminary effectiveness of a 4-week automated SMS text message intervention to increase stigma resistance and reduce self-stigma in people who use drugs. METHODS We designed a novel automated text message intervention to address the four personal-level constructs of Stigma Resistance: 1) Not believing stigma/catching and challenging stigmatizing thoughts; 2) empowering oneself through learning about substance use and one's own recovery; 3) maintaining one's recovery and proving stigma wrong; and 4) developing a meaningful identity and purpose apart from one's substance use. Theory-based messages were developed and pilot tested in qualitative elicitation interviews with 22 people who use drugs, resulting in a library of 56 messages. In a single-group within-subjects community-based pilot trial, we will enroll 30 participants in RESTART (Resisting Stigma and Reevaluating Your Thoughts). Participants will receive two daily text messages for four weeks. Implementation feasibility will be assessed through recruitment, enrollment, retention, and message delivery statistics. User feasibility and acceptability will be assessed at follow-up using 23 survey items informed by the Theoretical Framework of Acceptability. Primary effectiveness outcomes are changes in self-stigma (Substance Abuse Self-Stigma Scale) and stigma resistance (Stigma Resistance Scale) from baseline to follow-up measured via self-administered survey. Secondary outcomes are changes in hope (Adult Dispositional Hope Scale) and self-esteem (Rosenberg Self-Esteem Scale). Twelve participants will also be selected to complete brief acceptability interviews. RESULTS This pilot study was funded by the National Institute on Drug Abuse in April 2023 and received regulatory approval in January 2024 (University of North Carolina-Chapel Hill IRB #23-2937). Recruitment and enrollment began in March 2024. Follow-up visits are expected to conclude by May 2024. Results will be disseminated in relevant peer-reviewed journals. CONCLUSIONS The study is the first to our knowledge to address substance use stigma via a self-help text messaging program. Results will add to the nascent literature on stigma reduction in people who use drugs. This protocol may interest researchers considering text messaging to address psychosocial needs in hard-to-reach populations. CLINICALTRIAL NCT06281548