Perceptions of Substance Use Disorder and Associated Sanctions: A Factorial Vignette Experiment

AuthorBenjamin T. Kuettel
Published date01 June 2023
Date01 June 2023
Subject MatterArticles
Perceptions of Substance
Use Disorder and Associated
Sanctions: A Factorial
Vignette Experiment
Benjamin T. Kuettel
This study examines whether characteristics of people who use drugs (PWUD) inf‌luence public per-
ceptions of substance use disorder (SUD) and punitiveness. Using a full-factorial vignette experi-
ment, a nationwide sample (N =448), and a series of regression models, I estimate the causal
effect of characteristics of PWUD on substance use evaluations and punitiveness. Results reveal
that drug type and prior criminal drug record affected both SUD and punitive judgements, implying
a prosocial punitiveness, where punishments are intended to rehabilitate. Demographics of PWUD
(e.g., race, sex, etc.) mattered little. However, racial resentment moderated the relationship
between SUD and punitiveness, suggesting aggressive punitiveness. These f‌indings imply that SUD
evaluations and punitiveness are linked in the public mind, suggesting that citizens may see punish-
ments as a way to address SUD by helping PWUD recover. This is not true for racially resentful
respondents, who appear to want to punish PWUD for punishments sake.
factorial vignette experiment, perceptions, punishment, stigma, substance use disorder
The United States continues to grapple with drug-related overdose mortalities. According to the
Centers for Disease Control and Prevention (CDC), there were approximately 70,630 drug overdose
deaths in 2019, with about 49,860 of those deaths involving opioids such as heroin, fentanyl, and
prescription opioids (Mattson et al., 2021). In 2019, opioids were responsible for 70.6% of all
drug overdose deaths in the United States (Mattson et al., 2021). Age-adjusted rates of drug overdose
deaths in 2019 were 21.6 per 100,000 compared to just 6.1 per 100,000 in 1999 (Hedegaard et al.,
2020; Mattson et al., 2021). Drug-related mortalities increased by 4.3% from 2018 to 2019 (Mattson
et al., 2021), and preliminary evidence suggests that overdose deaths have continued to increase
School of Criminal Justice, University at Albany, State University of New York, Albany, NY, USA
Corresponding Author:
Benjamin T. Kuettel, School of Criminal Justice, University at Albany, State University of New York, 135 Western Avenue,
Albany, NY 12222, USA.
Criminal Justice Review
2023, Vol. 48(2) 203-231
© 2022 Georgia State University
Article reuse guidelines:
DOI: 10.1177/07340168221105002
throughout 2020 partially due to the COVID-19 pandemic (Haley & Saitz, 2020; Slavova et al.,
2020). This swift rise in opioid-related drug overdose deaths across the United States beginning in
the late 1990s and continuing since has been called the opioid crisis, with the increase in
drug-related mortalities being referred to by academics as deaths of despair(Case & Deaton, 2020).
As policymakers, emergency service personnel, and the general populace continue to seek ways
of alleviating this drug overdose crisis, one key factor concerns who is perceived to have a substance
use disorder (SUD). What we think about addiction very much depends on who is addicted
(Courtwright, 1982, p. 4). The broader academic literature on public opinion, including attitudes
on spending for drug treatment, f‌inds that support for public health and harm reduction strategies
to combat drug overdose mortalities are contingent on positive attitudes and perceptions (Barry
et al., 2014; Kennedy-Hendricks et al., 2017; Kulesza et al., 2015; Matheson et al., 2014). Public
perceptions of SUD are often driven by drug scares and intertwined with historical drug stereotypes
(Earnshaw et al., 2013; Murakawa, 2011; Reinarman, 1994; Reinarman & Levine, 2004), including
implicit acts of stigmatization that serve to discourage drug use but instead act as barriers for those
seeking drug treatment (Ahern et al., 2007; Livingston et al., 2012). Moreover, stereotypes associated
with drug use may not ref‌lect real demographic changes in drug use or rates of drug overdose deaths
among different groups within the United States (Courtwright, 1982; Kolodny et al., 2015).
When ref‌lecting on the opioid crisis, some scholars argue that opioid overdose victims have been
disproportionately portrayed as working-class rural Whites, to which the response has been a sym-
pathetic public health approach (Beckett & Brydolf-Horwitz, 2020; Hansen & Netherland, 2016;
Netherland & Hansen, 2017). This response is in stark contrast to punitive war on drugs policies rem-
iniscent of prior drug epidemics that unfairly punished racial/ethnic minority individuals and com-
munities (Beckett & Brydolf-Horwitz, 2020; James & Jordan, 2018). Research has begun
exploring public perceptions and subsequent stereotypes concerning who is believed to have an
opioid use disorder in context of the opioid crisis. Sobotka & Stewart (2020) f‌ind the likelihood
of being identif‌ied as a person who has an opioid use disorder is greater when the individual is por-
trayed as White or unemployed. Although stereotypes concerning who uses opioids during the opioid
crisis has been studied, questions remain concerning whether historical drug stereotypes are relevant
or have changed alongside stereotypes of opioid use, what factors inf‌luence the likelihood of labeling
someone as having a SUD, and what factors drive punitive public responses regarding people who
use drugs (PWUD), including opioids.
The present study attempts to clarify contemporary public perceptions of SUD, as well as identify
what factors inf‌luence punitiveness concerning PWUD. To accomplish this, I use a factorial vignette
experimental design to see how respondents perceive SUD based on descriptions of PWUD. This
approach can reveal how manipulating characteristics of PWUD inf‌luence respondent judgements
of SUD, while also measuring support for punitive sanctions against PWUD. Findings from this
study can reveal interaction effects, or whether being labeled as having a SUD or receiving
greater punitive judgements by respondents is contingent on specif‌ic characteristics of PWUD
(e.g., race, sex, criminal record, etc.). These f‌indings can provide a better understanding of public
perceptions of SUD during the opioid crisis which can improve access to drug treatment, support
for harm reduction policies, and treatment of individuals with SUD in the criminal justice system.
Race, Drug Stereotypes, and Drug Enforcement in the United States
There is a long history of problems related to drugs and subsequent legislation attempting to combat
problematic drug use in the United States (Beckett & Brydolf-Horwitz, 2020; Lock et al., 2002;
Meier, 1992; Reinarman, 1994; Reinarman & Levine, 2004). These legislative decisions are
rooted in public perceptions that historically ref‌lected popular prejudices against a variety of
social and racial/ethnic minority groups (Alexander, 2010; Chambers, 2011; Nielsen, 2010). From
204 Criminal Justice Review 48(2)

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