Addiction — The most stigmatized of diseases.
This stigma may be the result of a lack of understanding that addiction (more appropriately called substance use disorder, or SUD) is a disease, the “War on Drugs” intended to incite fear of substance use, or what happens when derogatory opinions, words and phrases are passed down through generations of families, politicians, and the media. But no matter the reason, the fact is, people with SUDs are routinely stigmatized.
They are referred to as “dirty” or “clean” depending on their current condition, a “user” or a “junkie” while under the influence, or forever an “addict” or “alcoholic,” implying they are irredeemable. In my work, opening new treatment programs, I’ve been at many zoning and community meetings where despite a serious need for treatment in that community, the meetings are filled with angry, judgmental townspeople who would rather turn a blind eye to the many deaths of those in the community than have a treatment program there to help those in need.
While ever-so-frustrating for those of us in the field of substance use disorder treatment and/or in recovery, addiction is still viewed as a moral failing, lack of willpower, or simply a bad choice. Even when science clearly tells us it is a chronic brain disease that responds to treatment and has the potential for both recurrence and recovery.
Of course, we never refer to someone with cancer as a “canceric” or call them dirty when scans indicate a recurrence of their disease. There are no shameful looks or speeches about how they messed up. We bring their family casseroles to comfort them and help them through their loved one’s recovery. This may be an imperfect analogy in that many cancers have inconclusive causes, that is, many are not the direct result of a volitional act which is how a SUD starts (i.e., picking up a drug in the first place). But consider how many types of skin cancer are indeed the result of people not properly protecting their skin, or lung cancer in patients who have smoked all their lives.
While stigma abounds, it came as a pleasant surprise amid our nation’s current opioid crisis that the Associated Press (AP) took a notable step to reverse the way the press identifies addiction by issuing word replacement recommendations in their 2017 Stylebook. They encouraged the omission of negatively connotated words like “addict” and “drug abuser,” encouraging the use of more appropriate terms like “a person struggling with substance use disorder.” Michael Botticelli, director of National Drug Control Policy under former President Barack Obama, called the changes “a great step forward,” saying “We’ve seen through research and practice that language plays a huge role in shaping how individuals think about themselves and in shaping public policy.”
Language can also shape people’s opinions. A 2010 study published in the International Journal of Drug Policy surveyed 516 clinicians asking if they felt punitive actions should be taken or treatment should be provided after reading identical vignettes referring to an individual as a “substance abuser” or a “person having a substance use disorder.” When described as a “substance abuser,” clinicians more often agreed that punitive action should be taken than when a patient was described as “having a substance use disorder.” The two phrases conjured “systematically different judgments.”
Unfortunately, while good-intentioned, the AP Style changes have been painfully slow to take effect, as evidenced in these recent headlines by media powerhouses Washington Post, New York Times, and USA Today. It is a vast undertaking to change American discourse, to be sure, but with the drug crisis costing Americans $1.45 trillion a year, the benefits of a better informed public will make real change possible.
In my role as Chief Scientific Officer at Recovery Centers of America, I recently worked with PhillyBite Magazine in association with the Philadelphia Police Department on a study to measure the impact of words when it comes to the opioid crisis. The online magazine ran two similar articles that I wrote, but with different headlines. The first “The Fatal Poison Killing Pennsylvanians” garnered considerably more reads than the second “Pennsylvania’s Opioid Emergency.” In this case, it would seem that the more dramatic headline and use of the word “poison” were more appealing to the public, something not hard to believe (the old adage “if it bleeds, it leads” holds true). The implications for disseminating information to the public are interesting because word choices matter and using less-stigmatizing language can make a difference.
It is my opinion that the most overlooked stigmatized word — and one not included in the AP’s 2017 recommendations — is “relapse.” Much of society associates the term “relapse” with failure because of an antiquated and baseless condemnation of individuals with substance use disorder who do not become “cured” with their first treatment. If someone says “John relapsed,” for example, you’re likely to get a grimace or wince. Very often, there is immediate judgment. Say that John had a second heart attack, however, and you receive looks of genuine concern and support. It wasn’t John’s fault, after all.
But “relapse” is defined as a recurrence of symptoms of a disease after a period of improvement. You CAN have a relapse of heart disease; we just don’t generally call it that. Most people use the less stigmatized term “recurrence” for other chronic diseases that, just like with SUD, have varying degrees of success or adherence after treatment.
I propose that if we want to help erase stigma, we choose to use the word recurrence rather than relapse. “Recurrence of substance use disorder” creates a more accurate connotation, one that is more consistent in the medical world.
It is clear that words matter. Dr. John F. Kelly, founder and director of the Recovery Research Institute at Massachusetts General Hospital and Harvard Medical School, says that “The language we use is more important than we think. It’s not about being politically correct or being nice — it’s much bigger than that. Our language activates implicit cognitive scripts that give meaning to what we try to convey and communicate. That’s why we need a language that unifies the field and reflects more of the true nature and understanding of addiction that’s been uncovered in the last 30 years.”
And with stigma being the biggest barrier to addiction treatment faced by patients, the language we use is as important as what we’re saying. Words like “relapse” work to reinforce the negative ideas associated with substance use disorder. By more carefully choosing language that is not stigmatizing, we can create more awareness and understanding of the disease of substance use disorders.