Table 1 Co-design group feedback and lessons learned

Patient autonomy regarding disclosure of substance use

I don’t know how many people would open up to their doctor. I opened up to mine. Doctor needs to be responsible and non-judgmental. Maybe they are thinking about opening up and if they see that their doctor is reacting like the doctor in the story they might. (Veteran)

Promoting patient agency and autonomy in their own care

Emphasis on rapport and trust-building between patient and provider

Patient-centered dialogue and nonverbal communication skills can build trust

It’s also important how the doctor presents himself. Eye contact; are you looking at the screen? Are you warm? Are you cold? Are you being a doctor or are you being a person who is someone you can open up to? (Veteran)

Avoiding accusatory or judgmental language around substance use

Illustrating provider eye contact, body language, and active listening skills

Physicians are willing and able to engage in patient-centered conversations, even if they have limited experience with substance use

Providers wanting to ask questions but they didn’t know where to start; we could not get anywhere. What made the difference, if we can just get this first thing, then that gave me the opportunity to engage. (Veteran)

Use of open-ended questions to encourage dialogue

Yeah, I’m open to it; I just didn’t know how to start or what to say. (Physician)

Provider listens to patient before offering thoughts

Patients and providers can learn from each other about substance use and associated risks

The line ‘let’s talk more about that’ always tends to reel me in. Listen to me a little more. The more they listen to me, the more I am giving out information every word I say. (Veteran)

Provider asks permission before providing education

Medical doctors always made me feel in fear that they knew me better than I did. That book smart stuff scares me off. Doctors have to listen and hear, listen and hear- that’s what develops trust. (Veteran)

Provider uses simple language to explain concepts and offers opportunities to ask questions

Use of non-stigmatizing language to describe substance use and PWUD

I see I am going to have to change my terms. Stigma plays a large role in the recovery process. I wasn’t even aware I was using stigmatizing terms; it just became ingrained. (Veteran)

Both patient and provider model use of non-judgmental, non-stigmatizing language

Defining key clinical terms, such as endocarditis

Yeah, I never heard much about bacteria [sic] infections when I was using. And endocarditis? Forget it. (Veteran)

Clinical complexity in vignette simplified to injection-associated abscess

We just assume that we’re speaking the same language and how A can lead to B, but we’re not. (Physician)

Discussion of how inadvertent injection of bacteria can cause both skin infections and more invasive infections

Public health messaging can be dynamic and engaging

For this, maybe don’t throw too many messages. Maybe could throw something very brief in but could turn into too much of a stew of different things. (Veteran)

Streamlining vignette to focus on safer injection techniques

Harm reduction involves multiple complementary strategies, including MOUD, infection screening, safe injection techniques, naloxone, and not using alone

Felt a little long and complicated for your average person, a lot of words. Too much in one booklet… The message is clear, but you might lose people before you get to the important part—here’s how you get help. (Physician)

Other harm reduction strategies featured in centerfold of graphic medicine comic rather than incorporated into vignette

Emphasis on harm reduction, not necessarily abstinence from substance use

Yeah, we remind people that any substance could be tainted with fentanyl… it’s a different game nowadays. That made me want to quit but maybe not everybody. (Veteran)

Provider offers patient MOUD and emphasizes that it is entirely voluntary and his care will not be impacted if he declines

Substance use can affect everyone and thus characters depicted in the graphic medicine comic should represent a diversity of identities

We’re scrolling, and nothing looks like me. Maybe we could make the buddy a little more diversified. (Veteran)

More defined demographic characteristics of graphic medicine comic characters

Representation of multiple races, ethnicities, ages, genders, and branches of the military

Graphic medicine comic format is engaging

I like the comic style but does that make light of the message? Like does it need to be more serious? (Veteran)

Realistic illustrations and changes to graphics and color scheme to de-emphasize comic style

Peer-to-peer education can be an important component of harm reduction and recovery

If you educate the right person, it gets back to the streets and they share the right information…When there is important information they spread it. (Veteran)

Graphic medicine comic ends with a ‘teaching it forward’ moment between two friends

When I do hear support, I tell people my story. It breaks the ice to get rid of barriers. Then I tell them where I am now. (Veteran)