Stigma hurts, when stigmatizing language is used against those with substance use disorders. In a study by the Recovery Research Institute,1 314 survey respondents were asked to answer questions about two individuals who were using substances. The only difference in the way that the individuals were described was how they were labelled. The first individual was described as a “substance abuser” and the second individual was described as “a person with a substance use disorder.” The person described as a “substance abuser” was perceived by the study respondents to be:
- less likely to benefit from treatment,
- more likely to benefit from punishment,
- more likely to be socially threatening,
- more likely to be blamed for their substance use, and
- more likely to be able to control their substance use without help.
This study highlights the power of language to influence the perception of people who use substances or have a substance use disorder. This perception has consequences for relationships, interactions with authorities and systems (e.g., health care, child welfare, criminal justice, law enforcement), and policy development. If the language we use confers blame on or belittlement of the individual for substance use or a substance use disorder, we are less likely to have empathy for them or want to assist them in accessing harm reduction services, treatment, other social services, and community supports.
One of the consequences of stigma is social isolation. In her blog on the National Institute on Drug Abuse (NIDA) website, Nora Volkow,2 Director of NIDA, discusses how stigma and societal judgment discourage people from participating in social contact. You can imagine that every interaction in which an individual experiences judgment or disapproval discourages future interaction. Dr. Volkow describes how stigmatizing interactions work like an electric shock or punishment and individuals learn to avoid contacts that cause them pain.
In a recent article in the journal Nature, Venniro3 demonstrated how social interaction serves as a deterrent to substance use in rats. Venniro’s research builds on research done in the 1970s by Bruce Alexander4. He challenged some of the studies done at the time showing the power of opioids to take over the brains of rats in experimental conditions. Alexander questioned the results of the previous studies because the rats in these studies were isolated and kept in small cages away from stimulation and other rats. Knowing that rats are social animals, he created what came to be known as the rat park experiments. He showed that these social animals opted for socialization and had less opioid use compared with the rats in previous studies who existed in isolation.
Perpetuating Shame and the Internalized Negative View of the Self
The sum of these stigmatizing interactions can lead individuals to internalize the views of others and feel shame about themselves and their substance use. This causes a self-perpetuated loop of increased substance use as the person avoids social interaction and self-medicates the feelings associated with that isolation. This can lead to additional internalized stigma and can result in more use of substances, supporting a cycle of use, stigma, and shame. Historically, there was a lot of focus on “tough love” or allowing a person to “hit bottom” and a belief that individuals needed to face the consequences of their substance use. This thinking justified the use of stigmatizing and disparaging language.
Many people trained to work with people with substance use disorders will learn not to believe what someone who uses substances says about their use or their motivation. This learning occurs in formal classrooms, workshops, and through others working in the field. It also occurs in popular media as people who use drugs are depicted as dishonest. They may have learned that people with substance use disorders lie to protect their use and cannot be trusted. Seeing a person as distrustful, in denial, and as an unreliable reporter about their own life and circumstances can affect the relationship and make it difficult to form trust. These unjustified beliefs can result in internalized stigma for the person who uses substances.
Ways to Help: Use Person-First Language
Language about substance use, substance use disorder, and people who use substances has changed over time as we understand more about the causes of and effective interventions and treatments for substance use disorders. What doesn’t change is that a person’s health condition does not define them. A person is not a cancer, a person has a type of cancer. A person is not an “addict” or “substance abuser”, a person has a substance use disorder. Regardless of how language evolves to discuss substance use disorder, the person-first language should remain. Substance use disorder is just one of many aspects of an individual’s life; they may also be a sister, father, aunt, cousin, son, carpenter, student, nurse, mechanic, painter, and teacher. The impact of this small change in language signifies that they are a person-first and conveys dignity and respect for the individual which, in turn, changes how they are seen and how they see themselves.
Avoid Placing Blame
People who have substance use disorders often are blamed for continued use. They frequently have heard things like, “I don’t understand why you don’t just stop.” It is difficult to understand why a loved one or an employee or a patient just doesn’t stop using. To an outside observer, it seems like a person who is using substances makes other conscious decisions and they can conclude that continued use is a choice as well. With respect to substance use disorder, the diagnostic criteria include the inability to stop using despite negative consequences in multiple spheres of their lives. It isn’t that an individual doesn’t want to stop, but rather that the brain undergoes physiological and anatomical changes with chronic use that reinforce the use itself.
Agency, or the ability to have control over one’s behaviors, is a complex concept in all chronic health conditions. All chronic health conditions are a complex combination of genetic, social, environmental, and individual behavioral factors. For health conditions where stigma is low, such as high blood pressure, there is less blame directed towards the individual for having the condition with more emphasis on support for choosing behaviors (following a heart healthy diet, regular exercise) that can improve the condition and less blame for choosing behaviors (unhealthy eating, lack of exercise) that may exacerbate them.
Stigma associated with people who use substances can be contradictory. People can be seen as either passively controlled by an external force, the substance, or as fully in control of their behavior. Both viewpoints are stigmatizing and inaccurate. They fail to take the whole person into account. A more accurate, holistic view of the person includes the biological impact of the substance that drives continued substance use and acknowledges their ability to make decisions that can impact their use of substances.
Providing support for choices that reduce substance use can encourage the person to continue choosing healthier alternatives. For example, Community Reinforcement5 is an evidence-based model that helps family members support positive behaviors that have been shown to be effective at reducing substance use. It is a way to help without stigmatizing the person who is using.
Acceptance and Inclusion
If judgment and shaming increase social isolation, acceptance of the person and inclusion in social activity encourage connectivity. It has been said that connection is the opposite of addiction3, and Venniro’s research supports that statement. People, like the rats in Venniro’s study, seek out social connections, acceptance, and inclusion. Acceptance can lead to a self-perpetuating cycle that involves less substance use and more opportunity for inclusion. Believing a person can solve problems in their life and report accurately about their experiences can support trust in the relationship and support a positive internalized view of self.
Patricia Lincourt, LCSW, is Associate Commissioner Addiction Treatment and Recovery, and Kelly S. Ramsey, MD, MPH, MA, FACP, DFASAM, is Chief of Medical Services, at the NYS Office of Addiction Services and Supports (OASAS).
- Addressing the Stigma that Surrounds Addiction | National Institute on Drug Abuse (NIDA) (nih.gov)
- Venniro, M., Zhang, M., Caprioli, D. et al. Volitional social interaction prevents drug addiction in rat models. Nat Neurosci 21, 1520–1529 (2018). https://doi.org/10.1038/s41593-018-0246-6
- Addiction: The View from Rat Park (2010) (brucekalexander.com)
- Smith, J. E., Milford, J. L., & Meyers, R. J. (2004). CRA and CRAFT: Behavioral approaches to treating substance-abusing individuals. The Behavior Analyst Today, 5(4), 391–403. https://doi.org/10.1037/h0100044