Does It Really Matter How We Talk About Addiction?

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The old adage, “Sticks and stones may break my bones, but words can never hurt me,” implies words cannot convey harm. Today, however, more and more research on stigma is showing that words truly can hurt people, and in ways that the users of those words may not anticipate. This seems to be especially true when those words serve to reinforce misconceptions and misrepresentations of already heavily stigmatized medical conditions.

Language is a standardized set of sounds (talking) and symbols (writing) that not only reflects, but also influences, our attitudes, viewpoints, and approaches, to various problems including addiction. Our language also evolves over time for example, in the mental health and addiction fields we no longer use the term “lunatic asylum” or refer to people with an alcohol use disorder as “inebriates”. There are several reasons for the evolution of language, but one important factor is simply new knowledge. As our knowledge of addiction as a disease of the brain has greatly increased through neuroscience over the past 30 years, it is now necessary to change our language and approaches with this new information.

This shift in language has become even more urgent in the midst of an opioid epidemic and increasing recognition that certain terms used in the addiction field may actually undermine our nation’s clinical and public health efforts to more effectively address this current crisis.

The attention to word choice and terminology is fueled by current language that implies that suffering from a substance-related condition is a moral failure, or is a character flaw of the individual. It is an attempt to replace antiquated and stigmatized terminology with evidence-based medical terminology that reflects the biological, psychological, and social attributes of the condition.

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There is intense ongoing debate regarding which words, in particular, should be used or avoided. Many words we still use today pertaining to addiction have long-held moralistic connotations, can create double standards and belittle the gravity of addiction. Part of the issue pertaining to substance use, is that people are viewed as choosing to use the substance, and therefore are perceived to be “doing it to themselves”, “indulging”, or “engaging in willful misconduct.” It is true, people do choose initially to try a substance, whether alcohol or opioids, but I’ve never met anyone who chose to become addicted. Such are the brain changes involved in addiction, that people in the end often are using the substance against their will and despite suffering terrible personal consequences directly resulting from use. It turns out, like many other illnesses from which humans are likely to suffer, addiction risk is conferred through personal vulnerabilities (e.g., genetics; childhood abuse/neglect, trauma) coupled with exposure to environmental stressors or agents (e.g., an intoxicating substance in the case of addiction). We have known for decades that our genetics and biology strongly influence how likely we are to become addicted with about half the risk conferred by genetics.

We now know that stigmatizing language referring either to the individual or the condition can serve as a barrier to treatment seeking, which has become increasingly important in the midst of a national crisis of overdose deaths. In both 2015 and 2016 more than 50,000 Americans died of drug overdoses each year, making overdose the leading cause of accidental death in the United States.

Importantly, research has found also that our choice of language is not just about being polite, nice, or “politically correct.” This goes beyond that. Scientific studies conducted by Kelly and Westerhoff have found that exposure to certain terms can actually affect the attitudes of healthcare providers and may impact the quality of clinical care for addiction. In a randomized controlled study (Kelly and Westerhoff, 2010) it was found that describing someone suffering from addiction as “a substance abuser” compared to describing them as “having a substance use disorder” invoked significantly more stigmatizing attitudes in a large sample of mental health and addiction clinicians, and led them to prescribe more punitive measures (e.g. punishment). In a similar follow up study, (Kelly, Dow, Westerhoff, 2010) study participants believed that patients described as “substance abusers” were less likely to benefit from treatment, more likely to benefit from punishment, more likely to be socially threatening, more to blame for their substance related difficulties, and better able to control their substance use without help, than the exact same individuals described as “having a substance use disorder.” This research suggests that exposure to terms like “substance abuser” - invoking the idea that the person is engaging in willful misconduct - may induce more punitive implicit cognitive biases against individuals suffering from substance-related conditions. Such research is critical to informing us all about the nature and magnitude of the impact of the use of different terms used in highly stigmatizing conditions like addiction.

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To help increase understanding of the gravity of the addiction and ameliorate this growing public health crisis, five prominent medical addiction treatment organizations recently released a joint statement in the British Medical Journal on the stigmatizing nature of a number of commonly used addiction-related terms that work to belittle the impact of substance use disorders. Ambiguous or non-specific language, and a great deal of slang, can undermine clinical and public health approaches to effectively addressing these challenges. The authors recommended against the vague term “drugs,” which could mean substances that are either prescribed or non-prescribed, and use specific terms such as “medications” or “non-medically used psychoactive substances” instead. The authors suggest also moving away from terms such as “lapse” or “slip” suggesting instead using specific medical terms such as “relapse” or “a reoccurrence” of symptoms, in order to better convey the seriousness of such an event and its medical nature.

This is an attempt to move away from individual blame and stigmatization, and a move towards care and collective engagement, a move that will fundamentally change the way in which the general public perceives and interacts with addiction. For this to happen, we need to use the right words to symbolize and represent the condition in a way that evokes compassion rather than contempt. In support of this, the Office of National Drug Control Policy released a statement in 2016 outlining the guiding principles of non-stigmatizing language for addiction, which include the guideline to use “person first” language (e.g. not abuser, but a person with, or suffering from, an addiction or substance use disorder).

More and more scholars and organizations are coming out against the use of stigmatizing language, and talking in greater detail about specific word choice. Scholars are addressing word choice that may imply a double standard, and are emphasizing terminology that treats substance use disorders like any other medical condition. Terms such as medication assisted treatment are being re-evaluated, as clinical leaders such as Sarah Wakeman have drawn attention to the fact that medications used to treat other health conditions are not referred to in this way. Medications used to treat addiction symptoms and cravings (e.g. methadone, buprenorphine (Suboxone)) should be labeled no differently, and the word “assisted” should be removed. Research has shown that with or without psychosocial support, medications are effective and often life-saving treatments for addiction. Wakeman instead recommends saying more simply, “medications for addiction treatment”.

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Peer reviewed academic journals in the addiction field are filling with commentaries on language, and the national non-profit Facing Addiction, took on the “Addiction-ary,” a glossary of over 200 terms hosted on recoveryanswers.org, created to exemplify the gold standard in addiction terminology and word choice, shaped with feedback from over 500 national partnering organizations. The Associated Press also has just released recommended terminology for reporters when writing on the addiction issue.

Despite much progress and growing discussion, there is still much work to be done. The International Society of Addiction Journal Editors (ISAJE) released a statement in 2015 against the use of stigmatizing language in addiction science journals, but academic journals and medical communities have yet to adopt policies that more stringently guard against the use of stigmatizing language, and national government agencies continue to have stigmatizing words within their very titles (e.g. the National Institute on Drug Abuse (NIDA), Substance Abuse Mental Health Administration (SAMSHA). Changing these names takes an act of congress, which means a serious amount of work; but there is no better time to make this change than now. Such a change would send a powerful message that the nation and the federal government is serious about making significant changes to address this devastating public health crisis.

More and more voices are joining the conversation on how to talk about alcohol and other drugs. More and more entities are coming together to find common ground and consensus on terminology and definitions for how best to talk about, and symbolize substance use disorders. There is no inherent meaning to words, but as a society, we give meaning to words over time. As substance use disorders become an ever-larger public health crisis, our choice of language and terminology will truly shape how we respond. If we want addiction destigmatized, we need a language that is unified, and that accurately portrays the true nature of what we are dealing with.