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Individuals with a substance use disorder frequently experience stigma, which includes prejudice, stereotypes, and discriminatory treatment. Stigma results from a social process in which certain marks are constructed to indicate tarnished character. These marks are used to justify discrimination and power loss of people with that characteristic, such as addiction. The effects of stigma can hamper treatment, recovery, and reintegration outcomes. Individuals with substance use disorder (SUD) who experience stigma are more likely to continue engaging in substance use potentially as a way to cope with the stigma they are facing, manifest greater delayed treatment access and higher rates of dropout, and show reduced help-seeking behaviours. The National Survey on Drug Use and Health found that 22.7 per cent of individuals in need of treatment reported that stigma kept them from pursuing addiction treatment. Images and language are powerful communication tools and behavioural mechanisms; they identify, label, and alienate stigmatized groups. Although some research has identified stigmatizing language, little work to date has explored stigmatizing imagery. Research that identifies stigmatizing imagery can inform recommendations for best practices in communicating about substance use in the media, research publications, and other institutions.
Studies on stigmatizing language in the context of substance use have found that stigmatizing descriptions of people with SUDs (e.g., “addict” as opposed to “person with a substance use disorder”) can lead to more negative effects toward those individuals, increased implicit bias, more significant attributions of responsibility, and increased desire for punitive action. Recently, it investigated whether stigma message features directly affect stigma-related outcomes. They found that stigmatizing language that included stigma message features such as marks (e.g., “Alex appears unkempt”) and labels (e.g., “opioid addict”) was linked to greater perceptions of dangerousness and threat, as well as an increased desire for behavioural regulation (i.e., the desired isolation and intervention of the stigmatized group) and social distance. Interventions to reduce the stigma associated with substance use disorders include language modifications – replacing terms that reinforce discrimination and stereotypes like “substance abuser” and “addict” with person-first language, such as an individual with a substance use disorder.
Institutions and various systems have begun to change the language around addiction. In 2015, the International Society of Addiction Journal Editors released a statement and guidelines for addiction terminology that “recommends against the use of terminology that can stigmatize people who use alcohol, drugs, other addictive substances, or who have an addictive behaviour.” The Associated Press 2017 updated its stylebook with guidance to avoid addiction terms like abuse, addict, and abuser. The American Medical Association (2021) released guidance on stigmatizing language, which states that “certain words can make patients feel unsafe or excluded or impose limitations, which can affect their well-being.” Although changing language alone may not eradicate stigma, it can pave the way for more intensive stigma interventions.
The majority of research and advocacy to date has focused on stigmatizing language; however, language is not the only means by which stigma is perpetuated within communications about substance use. Stigmatizing imagery (i.e., images that implicitly or explicitly reinforce stereotypes and prejudice towards stigmatized individuals) depicting drugs or substance use also has the potential to foster SUD stigma. Similar to language identified as stigmatizing, these images may impact the way members of the general population think, feel, and respond to people with SUD. Stigmatizing imagery may additionally negatively affect people with SUD, leading them to perceive, anticipate, or internalize stigma. Given the potential power of imagery to activate affective solid responses, images of drugs and substance use may additionally trigger trauma or relapse responses for those with lived experience.
Besides promoting stigma associated with substance use, stigmatizing communications may promote intersectional SUD-related stigma (i.e., stigma related to other statuses experienced by people with SUD). This is particularly important to consider in imagery, given that visual communication can often convey more complex messages than written communication. For example, images depicting Black, Hispanic, LGBTQ, or justice-involved individuals using drugs may promote racism, xenophobia, homophobia, or criminal justice stigma alongside SUD stigma—various forms of “othering”. Of note, many people with SUD have a history of criminal justice involvement. The stigma associated with SUD and criminal justice involvement is associated with more significant psychological distress, decreased self-esteem, and more splendid social isolation.
Both imagery and language are used to document the opioid epidemic. While previous research has recommended against imagery that “marks” individuals with SUD, more evidence is needed to understand what constitutes non-stigmatizing imagery in substance use contexts. Our study addresses this gap by exploring responses from individuals with lived experience to imagery used to represent SUD and criminal justice involvement. Modifying imagery and language used to describe and represent individuals with SUD or criminal justice involvement is an intervention that researchers, institutions, and other perceivers can implement.
The language we use to describe mental illnesses and substance use disorders (addiction to alcohol and other legal and illegal drugs) can significantly influence whether people seek help and the quality of care they receive. Research shows that stigma—negative attitudes toward individuals based on distinguishing characteristics—contributes to poorer health outcomes in multiple ways. Consequently, addressing stigma has become a critical focus for research and interventions.
Researchers and clinicians can help reduce stigma by carefully selecting the words they use to describe mental health conditions, addictions, and the individuals affected by them. Language plays a crucial role in shaping thoughts and beliefs, and scientific communication can inadvertently perpetuate harmful stereotypes and assumptions. Using scientifically accurate language and terms that centre the experiences of patients with psychiatric conditions and validate their worth can positively impact how they are treated within healthcare and society at large.
Mental illnesses and substance use disorders have long been among the most stigmatized health conditions. Despite advances in educating healthcare providers and the public about the genetic and neurobiological underpinnings of these conditions, stigma persists. Reducing stigma is essential for removing barriers to care, especially given that 35% of people with serious mental illness in the U.S. and nearly 90% of people with substance use disorders do not receive treatment. Stigma is one of several factors that can limit the use of treatment services. For example, individuals with alcohol use disorder (AUD) who perceive high public stigma are about half as likely to seek help as those perceiving low stigma.
Even healthcare providers sometimes stigmatize individuals with mental illnesses. Bias among medical professionals and mental health service providers can reduce the likelihood that individuals with mental illnesses will receive appropriate treatment or be referred for specialty care. Efforts to minimize provider stigma show promise. In one recent study, testimony from patients who benefited from mental health treatment reduced stigma among medical students. Such approaches could improve the likelihood and quality of mental healthcare delivery.
Additional damaging effects of stigma arise when it is internalized, known as self-stigma. Self-stigma significantly decreases interest in seeking help for mental health concerns. Research shows that self-stigma negatively impacts the recovery of people with severe mental illnesses by lowering their self-esteem and self-worth, reducing their hope for recovery, affecting their social relationships, and worsening their psychiatric symptoms. Studies also suggest that self-stigma increases avoidant coping and suicide risk, as well as reducing treatment adherence and vocational functioning.
Stigma against people with substance use disorders has proven particularly intractable. The public continues to view these disorders as character flaws or deviance, contributing to a treatment-averse mindset even among some physicians and healthcare providers. Addiction is a brain disorder and should be treated like any other medical condition.
Pioneering research showing the power of word choice in determining professionals’ motivation to treat or not treat people with addictive disorders was conducted over a decade ago by researchers at Harvard. In one study using case vignettes, doctoral-level clinicians in mental health and addiction were more likely to favour punishment (a jail sentence) versus treatment for a character when that individual was described as a “substance abuser” versus when they were described as having a “substance use disorder”—all other words in the descriptions being identical. This finding has been replicated with mental health professionals and other groups.
Given the persistence of implicitly stigmatizing terms like “addict,” “alcoholic,” “abuser,” and so on, even in professional literature, it is perhaps not surprising that the treatment gap is even wider for substance use disorders than for other psychiatric conditions. Despite being in the midst of a devastating, widely publicized opioid crisis, and despite the existence of three effective medications to treat opioid use disorder (OUD), in 2019, only 18% of people with OUD received medications to treat it. AUD treatment rates are meagre (e.g., 7.6% in 2019). There are three effective medications to treat AUD, yet in 2019, fewer than 2% of people with AUD received any of those medications.
In 2019, over 17% of people with an alcohol or other substance use disorder reported not seeking treatment due to concerns about negative opinions from their neighbours or community. Additionally, previous painful experiences of discrimination in healthcare settings may cause people with addiction to avoid seeking treatment. Like stigma for other mental illnesses, stigma around addiction is internalized as an ongoing source of shame, and the resulting distressing isolation can lead to further substance misuse.
The stigma around treatments for addiction is also an issue. For instance, the persistent belief that agonist medications for opioid use disorder (OUD), such as methadone and buprenorphine, “just substitute one addiction for another” has helped perpetuate their low implementation in healthcare and justice settings. The widely used term “medication-assisted treatment” (MAT) also stigmatizes these pharmacotherapies as less than adequate in their own right and as distinct from medications for other medical conditions, which are referred to simply as treatments for cancer, HIV, or hypertension. Instead of MAT, terms like “medication to treat substance use disorder”—or more specifically, “medication to treat opioid use disorders” or “medication to treat alcohol use disorder (AUD)”—should be used. As with other mental disorders, there is a mutual benefit of both pharmacotherapies and behavioural treatments for substance use disorders.
Person-Centered Language
Language norms continuously evolve; not all patient groups agree on preferred terms. However, researchers, clinicians, and others who interact with or communicate about mental and substance use disorders are generally encouraged to replace potentially stigmatizing terms and labels with neutral, person-centred language. Person-centred language reflects that the disorder or illness is only one aspect of a person’s life, not the defining characteristic.
Using a person-centred approach, for example, someone should be described as “a person with schizophrenia” or “a person with psychosis” rather than being described as “schizophrenic” or “psychotic.” Similarly, instead of referring to a person with drug addiction as an “addict” or “abuser,” describe them as having a substance use disorder or having an addiction—both are acceptable, though the former is more precise. Likewise, refer to someone as “a person with an AUD” rather than “an alcoholic.” Moreover, the word “alcoholic” should not be used as an adjective; for instance, use the term “alcohol-associated liver disease” instead of “alcoholic liver disease” to lessen the potential impact of stigma on care for people with liver disease, including those in need of a liver transplant.
Care should also be taken to avoid terminology that implies a negative value judgment. For example, when referring to suicide, say “died by suicide” rather than “committed suicide,” since “commit” connotes criminality or sin. Suicide attempts should not be described as “successful” or “unsuccessful” (or “failed”). Instead, use “survived a suicide attempt,” just as one might describe an individual who has survived cancer or a heart attack.
Similarly, in the context of substance use, avoid the words “clean” and “dirty” when referring to drug toxicology results (i.e., negative or positive urine tests), and do not use “clean” to refer to being abstinent from drugs or in recovery from a drug use disorder. Importantly, replace the word “abuse,” both as a noun and verb, with “misuse” or simply “use.” Although “abuse” was once a diagnostic category and still appears in some surveys, its removal from the DSM-5 in 2013 reflected a major progressive shift toward conceptualizing people with addiction as having a treatable medical condition rather than being guilty of misbehaviour. The term “abuse” remains in the names of some NIH Institutes that study addiction. However, there is increased interest—both in the scientific community and among affected patient populations—in changing those names to reflect current understandings of addiction as a disorder.
Comprehensive guidelines for communicating about mental illness and substance use disorders in a non-stigmatizing way are available in the literature and on the websites of NIDA and NIAAA. However, since principles of non-stigmatizing language are not always consistent between groups and since language norms shift, it is essential for researchers and institutions to engage directly with communities affected by the conditions they study to understand what those communities prefer.
Stigma is challenging to eliminate, even with educational and other interventions, and carefully considered language is only one part of addressing it. However, it is also one of the most immediate ways researchers and others can communicate how stigmatized conditions affect change. Appropriate terminology can encourage a person-centred framing of the condition, one that implicitly reinforces that affected individuals deserve compassion and care and signals what science has shown to be true: that in many or most cases, mental illnesses and substance use disorders can be treated or managed, and that people can hope to achieve recovery.
This shift in mindset is essential for mobilizing the necessary resources to provide quality mental health and addiction services and for eroding the prejudices that prevent people from seeking or receiving the help they need. It is also vital for educating the broader public about conditions that have long been, and continue to be, greatly misunderstood.
To your health,
Nwabekee.
REFERENCE
Hulsey, J. et al. (2023) ‘Stigmatizing imagery for substance use disorders: A qualitative exploration’, health & Justice, 11(1). doi:10.1186/s40352023-00229-6.
Volkow, N.D., Gordon, J.A. and Koob, G.F. (2021) Choosing appropriate language to reduce the stigma around mental illness and substance use disorders, Nature News. Available at: https://www.nature.com/articles/s41386-021-01069-4
Stigmatisation is becoming a norm for PWUD, let's minimise it.