Abstract

Background

Rural communities are disproportionately affected by substance use disorder (SUD) and public stigma impedes access to and utilization of treatment and support services.

Methods

This study compares data from a 2020 study conducted in rural Ohio (N鈥�=鈥�173) with results from a recent study conducted in South Dakota (N鈥�=鈥�41) on publicly-held stigmatizing views of SUD. South Dakota participants were recruited at several public events across the state via convenience sampling between August 2022-February 2023 to complete a survey. Data from responses to 19 stigma-related questions were merged with the associated data from the 2020 Ohio study and a comparative analysis was performed using Fisher鈥檚 exact and Chi square tests.

Results

The data shows that respondents in South Dakota, when compared to respondents in Ohio, are more likely to believe addiction is an illness (SD鈥�=鈥�86.5%, OH鈥�=鈥�48.5%, p鈥�<鈥�0.001). The belief in SUD as an illness aligns with reduced stigmatizing beliefs, as indicated by respondents in SD showing lower stigmatizing ideologies and higher support for naloxone and harm reduction services, when compared to Ohio respondents. In both studies, the belief that SUD is an illness was associated with a reduction in other stigmatizing beliefs.

Conclusions

These results can be used to inform more focused anti-stigma efforts. As more people adopt fewer stigmatizing views on SUD in rural areas, more people with SUD may be supported to seek treatment and recovery services.

Background

Opioid use disorder, psychostimulant use disorder, and related substance use disorders (SUDs), remain a public health crisis in the United States (US). A dramatic increase of overdose deaths was seen in the US from 2020 to 2021 (an increase of 28.5% from the previous year) with overdose fatalities topping 100,000 for the first time [1]. Individuals experiencing SUD have increased rates of morbidity and mortality from a variety of causes, including HIV, hepatitis, overdose, psychological and neurological effects, infections, and sepsis [2,3,4,5,6]. The economic and social costs of this epidemic are myriad, including an estimated cost to insurers of over $72听billion per year, lost productivity, criminal justice systems costs, and the rippling impact on families and children [2,3,4,5,6,7].

South Dakota is particularly susceptible to the impacts of SUD. Of South Dakota鈥檚 66 counties, 63 are rural, and the state has the fourth highest population of American Indian/Alaskan Native (AI/AN) residents [8,9,10,11]. Although substance use impacts all socioeconomic groups, early prevention efforts have focused on urban populations, leaving rural communities with scarce resources [10]. As a result, the National Survey on Drug Use and Health (NSDUH) estimated that in 2019 illicit drug use among those 12 years and older in South Dakota was at 2.5% [11, 12]. Among the AI/AN population of 12 years or older, the rate was 25.9% [12,13,14]. Furthermore, substance use is estimated to be severely under-reported due to multiple factors, including stigma-influenced social desirability bias [13, 14].

Stigma is the dehumanization of an individual based on their social identity or participation in a negative or undesirable social category, such as substance use [15]. Five types of stigma and their relation to SUD have been characterized, including public, enacted, anticipated, internalized, and structural [16]. Public stigma, the focus of this study, is the dehumanization of individuals by the projection of stereotypes and prejudice through discriminatory acts based on perceived differences in social identity from society or participation in undesirable social categories, such as substance use [15, 17, 18]. Consequently, public stigma impedes access and utilization of treatment and support services for SUDs, including medication-assisted treatment (MAT), naloxone, and harm reduction services [19]. The stigmatizing public perception that SUD is the result of moral failing or willing choice impedes public support of evidence-based interventions, including treatment, support services, and implementation of public health-based policies [20, 21]. When individuals internalize or anticipate the public stigma towards their SUD, maladaptive behaviors occur, including use recurrence, avoidance and social exclusion, and reclusion from necessary employment and health services, leading to poorer health outcomes [16, 19, 22,23,24,25,26,27]. Additionally, higher public stigma is associated with greater public support for punitive policies, with lower support for public health-oriented policies, such as MAT [28]. Delivery of stigma relies on social norms established by communities or the public, who establish what is considered ordinary or acceptable in a community. Studies consistently show that the public holds highly stigmatizing attitudes towards SUDs, perpetuating these negative outcomes [18, 23, 24, 29].

Despite this perception, recent literature refutes the notion that SUD is a choice but supports the view of SUD as a chronic relapsing disease of the brain [30]. The underlying biological mechanism of SUD and its involvement in voluntary behavioral control leads to the understanding of SUD as a chronic relapsing brain disease [30, 31]. In a nationwide randomized study, annotating SUD as chronic relapsing brain disorder was found to be optimal to reduce public stigmatizing blame [32]. This brain disease model of SUD is less stigmatizing because it identifies and supports an understanding of how substances biologically alter dynamic neurological networks, bringing hope for medical interventions [21]. With the increased recognition and support of SUD as a brain disease, an increased understanding and support for less stigmatizing punitive approaches, and more public health-oriented efforts nationwide have followed [23, 24].

In a novel study published in 2021, Lanzillotta-Rangeley et al. (2021) aimed to conceptualize public knowledge and attitudes towards SUD. To accomplish this, a survey was developed and distributed to residents of a rural Ohio county of 45,000 people (n鈥�=鈥�173) in 2019 [24]. Of those surveyed, 48.5% followed the disease model of SUD, agreeing with the statement that 鈥淎ddiction is a real illness like diabetes and heart disease.鈥� Significant findings of the study showed that respondents who believed that SUD was a disease were more likely to support evidence-based treatment practices, show less stigma towards individuals with a SUD, and support harm reduction services, indicating the association between belief of the brain disease model and a reduction in stigmatizing ideologies [12, 24].

As a result of research on the brain disease model of SUD, recent nationwide efforts have been made to educate the nation on the medicalization of SUD with the goal of reducing public stigma towards SUD. These include initiatives conducted by the Addiction Policy Forum (the Stop the Stigma Campaign), the Substance Abuse and Mental Health Services Administration (the Power of Perceptions and Understanding initiative), and the National Institute of Drug Abuse with the National Institute of Health (updating public educational resources) [33,34,35]. These nationwide initiatives are important efforts to change the landscape around SUD stigma in the US, including in rural states like South Dakota.

In South Dakota, there exists a need to respond to the public health impact related to SUD by assessing stigma and attitudes and utilizing findings to complete work to reduce stigma. In response, we began a study to assess SUD stigma in South Dakota, modeled after the novel study conducted in Ohio by Lanzilotta-Rangely et al. The novelty of the Ohio study and the demographic similarities between the two locations allow for an interstudy comparison for the identification of patterns and differences in stigmatizing beliefs between the two locations. Demographic similarities include percent of the population with health insurance coverage (88.6% and 89.7%, respectively), percent of population below the federal poverty line (12.3% and 13.9%, respectively), breakdown of population age and classification as rural and medically underserved [36, 37]. Additionally, the political climate in South Dakota and the Ohio county are very conservative, with a majority of voters voting republican in the 2020 presidential election (61.8% and 79.7%, respectively) [38, 39].

Past research on the relation between stigma and SUD is limited, indicating the novelty of this work [20]. The aim of this study was to learn from community members on stigma and SUD across the state of South Dakota. The findings of our study will inform the creation and implementation of a culturally centered anti-stigma campaign in five rural target counties South Dakota. Prospectively, delivery of anti-stigma materials to the public will reduce psychosocial barriers, promoting individuals with SUD access to treatment services and promote recovery.

Methods

The study aimed to assess differences in public stigma towards SUD in rural South Dakota and Ohio, using an instrument devised by Lanzillotta-Rangeley et al. [24]. To this end, we conducted a comparative analysis using data gathered by Lanzillotta-Rangeley et al. and by our team in Ohio and South Dakota, respectively [24].

One key survey item measured the belief of SUD as a medical disease (see Fig.听1), using the statement 鈥淎ddiction is an illness like diabetes and heart disease鈥�. This survey item was slightly modified from the original version as the word 鈥渞eal鈥� was removed. In accordance with the original study, this survey item, along with the survey items measuring disease and evidence-based treatment knowledge, were developed from the brain disease model of SUD [24]. Acknowledging the medicalization of SUD, in which it is believed to be a disease requiring medical treatment, measures the support of the brain disease model of SUD [31]. Thus, consistent with original study, respondents who indicated that they agree with the statement that SUD is an illness were interpreted to believe in the brain disease model of SUD.

The Ohio survey was fielded in a rural, medically underserved county. Our survey targeted Brookings, Brown, Codington, Hughes, and Roberts Counties, rural communities designated as mental health shortage areas [40]. Thus, these counties have limited access to SUD treatment, counseling, and recovery. Public stigma negatively affects access to SUD services and is observed throughout South Dakota. Thus, survey responses from individuals outside of the five target counties were included in the study.

Fig. 1

Q1. Addiction is an illness like diabetes and heart disease

Data collection and analysis

Both the Ohio data and South Dakota data were gathered using convenience sampling. In Ohio broader methods of distribution were used, resulting in a larger sample. Additionally, participants were recruited from a single rural, medically underserved county of approximately 45,000 residents, based on county specific concerns. We recruited respondents at county (Brown County) and state fairs (Hughes County). Most attendees were representative of the population of rural South Dakota. We also used snowball sampling by encouraging participation to share the survey with peers. We chose the sampling methodology and recruitment locations strategically; we could recruit from a larger sample of potential participants than normal, given South Dakota鈥檚 dispersed, isolated rural population. Furthermore, with limited broadband access in rural areas of the state, social media was not a practical recruitment tool. Our survey was administered online using QuestionPro via QR code or link. Respondents could take the survey on tablets at each location, or on their own devices later. Respondents were entered in a drawing for a gift card. The Ohio survey was open through 2019; The South Dakota survey link was active from August 2022 to February 2023.

Stigma data were gathered using a 25-item instrument developed by Lanzillotta-Rangeley et al. for their Ohio study [24]. The content validity of the original instrument was evaluated by a team of experts; changes were made in keeping with recommendations. The instrument was adapted to assess knowledge and attitudes of rural South Dakotans towards individuals with SUD, and evidence-based practices related to SUD for broader research purposes. However, for this study, we used the same measures as Ohio, to ensure comparability, albeit with some slight modifications for clarity, to improve lay understanding of the questions (see Table听1). Five questions from the original survey were omitted from the South Dakota survey: three questions related to infectious disease due to our refined focus on stigmatizing beliefs toward SUD, and two questions related to public availability of Naloxone, to shorten the survey length. Questions were grouped into six subcategories: disease related general knowledge, evidence-based treatment knowledge, public stigma, criminalization, naloxone-related questions, and harm reduction services. The final questions contained within the adapted 19-question/item survey are provided in Table听1. Our adapted instrument for South Dakota yielded a Cronbach鈥檚 Alpha reliability score of 0.72.

The respective data sets were merged to facilitate comparative analysis. The data were coded 0 for South Dakota and 1 for Ohio. Stigma measures were coded as follows: 0 for disagree and 1 for agree except for attitudes towards harm reduction, which were coded as 0 for does not support and 1 for supports a particular item. Missing data and invalid responses were dropped from the analyses. While the South Dakota version of the survey included measures for demographic and SES controls, the Ohio version did not. Thus, they are not reported/analyzed here.

We analyzed the data using cross-tabulations and statistical testing to assess significant differences in public stigma towards SUD between Ohio and South Dakota respondents. Since the variables were nominal, we employed Chi square testing, except for 2鈥壝椻��2 tables with observed cell counts of less than 5. In those cases, Fischer鈥檚 exact test was used. Survey questions 1 (Figs.听1), 3, 6, 8鈥�11, 13鈥�19 (Table听1) were analyzed using a Chi square test, while questions 2, 4, 5, 7, 12 (Table听1) were analyzed using a Fisher鈥檚 exact test. Significance was tested at the p鈥�=鈥�0.05 level. All statistical analyses were conducted using SPSS v29.0.

Ethics approval

This work was reviewed and approved by the South Dakota State University鈥檚 Institutional Review Board (IRB) in August 2022. Informed consent was obtained from all participants; letters of consent were read by all participants and subsequently signed. Following data collection, any personal identifying features collected were separated from the analyzed data and destroyed to protect personal anonymity and privacy. An IRB amendment was submitted and approved in February 2023 requesting access to the Ohio study鈥檚 de-identified data set for study comparison and additional analysis.

Results

Forty-one responses were collected from community members in South Dakota. Responses from the South Dakota survey were compared to similar survey items in the Ohio study. Of the 19 statements compared between the two locations, there was a statistically significant difference (p鈥�<鈥�0.05) in nine items between South Dakota and Ohio respondents (Table听1).

Results indicated those residing in South Dakota were significantly more likely to agree that addiction is an illness like diabetes and heart disease (86.5%), compared to those from Ohio (48.5%; p鈥�<鈥�0.001) [24].

Table 1 Results of cross-tabulation of key indicators, Ohio (2019) and South Dakota (2022)

Disease and evidence-based treatment related general knowledge

There were four survey items related to SUD disease and evidence-based treatment knowledge. There was a significant difference on one survey item related to evidence-based treatment knowledge between respondents residing in South Dakota and those in Ohio (see Table听1).

Results indicated those residing in South Dakota were significantly more likely to disagree that abstinence-based therapy is the only successful form of treatment for SUDs (88.2%), compared to those from Ohio (65.7%; p鈥�=鈥�0.006) [24]. Additionally, respondents from South Dakota were more likely (statistically insignificant) to disagree with the statement that individuals who are addicted to drugs can stop using if they really want to (52.8%) and the statement that individuals who receive rehabilitation or treatment will just use substances or overdose again (87.5%), compared to those from Ohio (38.4%; 75.7%, respectively) [24]. Both South Dakota and Ohio respondents agreed that any person is vulnerable to become addicted to pain medications (95.1% and 90.1%, respectively). Overall, respondents from South Dakota had a higher rate of non-stigmatizing responses across all four of the questions in this category, compared to Ohio.

Public stigma

Community stigma-related perceptions were measured through seven survey items. There was a significant difference on four of the public stigma questions between respondents in South Dakota and those in Ohio (see Table听1). Negative perceptions towards people with SUD due to stigma occurred in both groups, however, those residing in South Dakota generally responded more positively to the survey items.

Results indicated that survey respondents from South Dakota were significantly more willing to reside in the same neighborhood as an individual with a known SUD (80.6% vs. 47.0%; p鈥�<鈥�0.001); more likely to disagree individuals with a SUD are likely to be dangerous (78.6% vs. 54.1%; p鈥�=鈥�0.015); and more likely to believe an individual with a SUD should have the same right to a job as anyone else (78.8% vs. 38.8%; p鈥�<鈥�0.001), compared to those from Ohio [24]. Additionally, respondents from South Dakota highly indicated that individuals cannot be easily spotted based on generalized characteristics (77.8%), they would not be embarrassed to tell others that someone close to them has a SUD (62.2%), and that it is important for individuals with a SUD to be a part of a supportive community (97.6%). However, South Dakota respondents were significantly less likely to disagree with the stigmatizing belief that SUDs only affect individuals with low incomes (89.7%) compared to Ohio respondents (98.8%; p鈥�=鈥�0.011) and less likely to disagree that they would be embarrassed to tell people that someone close to them has a SUD, without significance [24]. Overall, respondents from South Dakota had a higher rate of non-stigmatizing responses across five of the seven questions in this category, compared to Ohio respondents.

Naloxone use

There were three survey items regarding community beliefs towards naloxone accessibility, with a significant difference in all three of the items between the two survey groups (see Table听1). Generally, those residing in South Dakota were more supportive of community naloxone interventions, with a lack of support existing in roughly one third of this group. Those from South Dakota were significantly more likely to agree that naloxone should be administered to every individual experiencing an overdose, every time (69%), agree that they would be willing to administer naloxone as a bystander in an overdose situation (77.4%), and disagree that a limit should be set for how many times an individual can receive naloxone for an overdose (69%), compared to those from Ohio (46.5%, p鈥�=鈥�0.025; 58.0% p鈥�=鈥�0.041; 42.2%, p鈥�=鈥�0.007, respectively) [24]. Overall, respondents from South Dakota had a higher rate of non-stigmatizing responses across all three of the questions in this category, compared to Ohio.

Harm reduction services

Community perceptions regarding support for harm reduction services were measured by four survey items, with a significant difference in one of the items between the two survey groups (see Table听1). Medication to treat SUD had significantly higher support from respondents in South Dakota (85.4%) compared to those in Ohio (54.3%; p鈥�<鈥�0.0001) [24]. Although not significant, South Dakota respondents indicated a higher support for HIV and Hepatitis C testing services, condom distribution services, and syringe exchange services compared to Ohio respondents. A majority of respondents from both locations indicated support for HIV and Hepatitis C testing and condom distribution services.

Discussion

The initial design of this study was to conduct a general comparative analysis between South Dakota and Ohio respondents across all five categories to determine best strategies to reduce SUD-related stigma for the South Dakota population. However, the study team did not anticipate that respondents from South Dakota would be significantly more likely to believe that SUD is an illness compared to Ohio respondents. Given this difference, the variation in responses to all other survey items may be characterized not only as a difference between South Dakota and Ohio respondents, but also as a difference between those who are more likely to believe addiction is a medical illness compared to those who do not. Comparing this preliminary finding to the other results of our comparative analysis between the South Dakota (2022) and Ohio (2019) groups thereby supported the finding that a higher belief that addiction is an illness was aligned with being more supportive of evidence-based practices, being more likely to support harm reduction services, and being less likely to stigmatize individuals with SUD [23, 24].

Specifically, past research shows that a higher belief that SUD is a medical illness generates increased awareness and support for evidence-based treatment, such as MAT [23, 24, 30]. The survey item 鈥渁bstinence-based therapy is the only successful form of treatment for substance use disorders鈥� measured the stigma towards medical treatment of SUD by disregarding the necessity of medical treatment and contradicting the brain disease model. Our findings support the association between the belief of SUD as an illness and support for evidence-based treatment. South Dakota respondents, which were more likely to believe SUD is an illness, were significantly more likely to disagree that abstinence-based therapy is the only successful method for SUD treatment, compared to Ohio respondents. Public stigmatizing perceptions towards the medical treatment of SUD views MAT as trading one substance for another, such that individuals who use medications for treatment are not successfully recovering [41]. Methods to address stigma towards medications for treatment, including the promotion of SUD as a medical illness and emerging service models show promising results in reducing barriers to accessing treatment services, including public stigma, for individuals with SUD [23, 42].

Additionally, the published literature demonstrates that the belief that SUD is a medical illness reduces public stigma towards SUD, which aligns with the findings of this comparative analysis. South Dakota participants responded more positively compared to Ohio participants to all but two survey items assessing public stigma, with a positive significance between three survey items [23, 24]. Most notably was the strong belief that it is important for individuals with a SUD to be a part of a supportive community, thus work needs to be done to develop a supportive community for those with SUD. The Substance Abuse and Mental Health Services Administration (SAMHSA) promotes Recovery-Oriented Systems of Care (ROSC), which is an organization model to developing a supportive network of community-based services for those experiencing SUD. Building on the strengths and resilience of individuals, families, and communities, ROSC coordinates multiple systems, services, and supports through four guiding principles with person-centered approach [43, 44]. Adapted from ROSC, the recovery ready ecosystems model (RREM) and recovery ready community framework is proposed to identify systems that improves support within the community, including harm reduction, educational recovery programs, and other traditional support structures [45]. Grounded in the ROSC and RREM models, programs developed to reduce public stigma through the implementation of community education and social inclusion have been successful in building supportive communities [46,47,48].

Furthermore, belief that SUD is a medical illness is also associated with increased support for naloxone services, including administration and public access [23, 24]. The association between the belief in SUD as a medical illness and support for naloxone services was supported by our findings, in which South Dakota respondents were significantly more likely to indicate a destigmatized response towards all naloxone survey items compared to Ohio respondents. Public perceptions of naloxone are rooted in stigmatizing misconceptions, including that its availability enables opiate use, that only those with a substance use disorder are at risk for an overdose and may require naloxone, and general misconceptions regarding the education and safety of its use [49,50,51]. Stigma towards SUD is a significant driver of naloxone stigma and is considered a major barrier for naloxone distribution, and therefore, overdose-death prevention efforts [52, 53]. Based on evidence from a recent meta-analysis, bystander naloxone education programs have been successful in improving knowledge regarding the safety of naloxone administration, thus increasing its use and consequently improving the odds of overdose recovery [54].

Finally, harm reduction services in the form of medical and community-based interventions have been shown to promote safety and reduce risks related to SUD, such as infections, overdose, and death [55]. In accordance with the brain disease model of SUD, acknowledgement that SUD is an illness has been shown to facilitate destigmatization against harm reduction services, namely, HIV and Hepatitis C testing, syringe exchange, and MAT [23, 24]. Our findings support that a higher belief that addiction is a medical illness is associated with an increased support for the harm reduction service of MAT. Despite the awareness of SUD as a medical illness and the strong evidence-base demonstrating the safety and efficacy of harm reduction services, implementation of some of these services are still met with high political and public resistance [56]. Our findings align with the resistance towards harm reduction services in literature, which view harm reduction services, namely syringe exchange services, as enabling the use of substances [55, 57]. The persistent resistance towards harm reduction services indicates the potential involvement of more complex factors when it comes to public support for these services.

In considering potential reasons for the difference in responses between the South Dakota and Ohio groups, the project team considered place factors, namely demographics of the populations that the survey was made available to, prior to the study in order to justify a comparative analysis. In this regard, the South Dakota and Ohio populations surveyed were similar in regard to ruralness, available medical services, percent of population with health insurance, percent of population below the federal poverty line, age of population, and political leanings of the population [18,19,20,21].

Despite only a three-year difference between the two studies, time may be a more likely factor. As a social construct, stigma is not static, but rather it changes over time as public values, attitudes, and beliefs change [58]. With the nationwide campaigns and other work from SAMHSA, the Addiction Policy Forum, and the National Institute of Drug Abuse starting in late 2018, 2020, and 2020, respectively, much work was completed to increase awareness of the disease model in the three years that occurred between the two studies [28, 29, 31]. Therefore, the differences in the results observed between the Ohio and South Dakota respondents may be a result of the influence of these nationwide efforts, among others, to reduce stigma towards SUD. The findings of this study, then, may also indicate that the work to educate the public on the brain disease model of SUD to reduce stigmatizing perceptions is making an impact. Thus, the positive trends in public stigma observed in this preliminary study provides support for the continuation of efforts to educate the public on the brain disease model of SUD.

Conclusions

Overall, the trends displayed by the preliminary data collected in the South Dakota survey reflect the knowledge that exists in the published literature: the brain disease model of SUD is less stigmatizing, recognizing the need for appropriate treatment and recovery services. In accordance with the brain disease model, efforts to increase health professional and public knowledge that SUD is a medical illness are needed to further increase evidence-based practice support, as well as efforts to improve awareness of the availability of these services to improve accessibility among individuals with a SUD. Further, public education of the brain disease model may also help to generate naloxone awareness regarding its safety and lifesaving capabilities.

Furthermore, the preliminary results of this analysis indicate an increase in the number of people who follow the brain disease model, which may indicate that places like South Dakota are ready for the availability of evidence-based practices, namely harm reduction services, to increase. However, accessibility to services like MAT in rural communities of South Dakota remains limited, creating a barrier to those seeking these services [59]. Therefore, further efforts need to be conducted to educate the community and key stakeholders on the brain disease model of SUD and the benefits of harm reduction services, as well as to increase the availability of these services in the state. By continuing to educate South Dakotans on the brain disease model, we can decrease misconceptions and increase the support and adoption of these impactful services to improve accessibility and utilization. Results of this preliminary study suggest that increasing the public belief that SUD is a medical illness can be used to reduce social exclusion, characteristic stereotypes, and imposition of penalties and retributions towards individuals with SUD, reducing public stigma can create a more supportive community for individuals with SUD, which can in turn help them receive the care that they need. Therefore, by first educating rural populations like South Dakotans on the brain disease model of SUD, they will not only support the evidence-based and harm reduction services that are needed, but they may become be the driving force for change.

Given the encouraging but preliminary nature of these findings, the next steps for the START-SD and START-SD-PSS projects to address public stigma towards SUD in South Dakota are clear. Building on this work, follow-up surveys will be broadly distributed and analyzed to confirm the findings of this preliminary study. Additionally, these preliminary results will help the development of focus group materials for the qualitative measure of public stigma towards SUD in South Dakota. Prospectively, the identification of public stigma will help focus and develop an anti-stigma campaign to be implemented in the five rural target counties. Preliminary results suggest that anti-stigma interventions should be focused on educating and informing the public according to the brain disease model which acknowledges that SUD is an illness, thus reducing other stigmatizing perceptions related to SUD. Furthermore, as more South Dakotans view SUD as a disease, more people with SUDs will be supported to seek treatment and recovery services.

Limitations

Several limitations should be considered when interpreting these findings. Forty-one survey responses were collected from South Dakota. The small sample size may diminish the study outcome鈥檚 reliability by introducing a higher variability. Sampling error may have been introduced during survey distribution. South Dakota respondents were limited to recruitment through convenience sampling at two statewide public events. Volunteer bias may be present, in which those willing to participate had a generally more positive response to the survey items and are not representative of the South Dakota population as a whole. Additionally, some adaptations were made to the original survey, thus introducing inconsistencies between the survey instruments between comparison groups. Variation in respondent interpretation of how survey questions are presented always brings into question the validity of the results. As in the original study, we assume the valid measurement of the brain disease model using one survey question, thus failing to acknowledge the potential for additional interpretation, such as the socio-ecological model of disease. For future survey distribution, qualitative methods to measure public responses to different presentations of this question can be done to determine for valid measurement. Further, bivariate modification was present due to the alteration of both location and time for comparison, both factors that influence stigma perceptions. Therefore, we cannot attribute statistically significant differences to either factor. However, we have gained evidence to suggest that further educating the public that SUD is a medical illness will further reduce stigmatizing ideologies going forward in time. With the understanding of these limitations, appropriate adaptations should be conducted during future efforts of stigma assessment and comparison. However, having collected this data prior to the development of a statewide anti-stigma campaign, we have the ability to conduct program evaluations of success in the future.