Stigmata that are desired: Contradictions in addiction

Abstract

Many experts in the etiology, assessment, and treatment of substance use/addiction view stigma and stigmatization — negatively branding addiction and substance users — as obstacles to the solution of the substance misuse problem. Discussions on this topic impact research and policy, and result in oft-repeated calls to remove the stigma from substance use and users. The goal of the article is to analyze the stigmatization concept as applied to substance use/addiction. It is widely accepted in the literature that stigmatization negatively affects substance users because addiction stigma interferes in both seeking and receiving professional care. It is argued that the societal disapproval of substance use/addiction is inappropriate because it is a mental disorder, involving biological processes. Nonetheless, neither those processes nor negative attitudes to substance use affirm the concept of stigmatization as currently applied. This concept conflates potential mistreatment and malpractice with the prosocial justified societal disapproval of a lethally dangerous behavior. Consequently, the stigmatization concept suffers from internal contradictions, is either misleading or redundant, and may do more harm than the supposed mistreatment of substance users that stigmatization connotes. On the contrary, the justified disapproval of harmful behavior may be a factor raising individual resistance to substance use. Instead of mitigating the effects of that disapproval, it may need to be capitalized on. If it is employed explicitly, conscientiously, and professionally, its internalization may be one of the resistance mechanisms needed to achieve any progress in the still elusive prevention of substance use and addiction.

Introduction

“Stigmatization” is a term loaded with numerous meanings and connotations. Its origins are in the literal branding of people with a hot iron, applied historically to slaves and criminals. The term is also related etymologically to the “stigmata” that denote bleeding from what was described as wounds mimicking those of Jesus’ crucifixion. Referring to those, the Soviet dissident writer Venedict Yerofeyev (1938–1990), in his Moskva-Petushki (1973), an alcoholic’s satirical monologue, ponders, “But what are stigmata for to Saint Theresa? She really does not need them… But she yearns for them.” The protagonist irreverently draws a parallel between that yearning and his own desire for a drink: the drink is unneeded but longed for. As analysis will show, the latter description may also be appropriate for the concept of “stigmatization” of substance use/addiction itself: this concept is employed by professionals as well as substance users, but may be unneeded and, moreover, counterproductive.

In many if not all cases of religious stigmata, they are self-inflicted as fraud or are due to emotional disturbance or stress (Kechichian et al. 2018). Nonetheless, historically, the societal attitude toward those stigmata, perceived as a sign of saintliness, was morally positive. According to the Merriam-Webster online dictionary, “stigmata” can also be “a specific diagnostic sign of a disease,” with a morally neutral meaning. “Stigma,” in the singular, however, can be “a mark of shame or discredit.” It is the latter meaning that is often attached to a set of similar societal attitudes to various phenotypic characteristics that are related to behavioral choices—e.g., obesity, certain infections, and (illicit) substance use. This paper focuses on the latter, but its conclusions may have a wider application, pertaining to the individual’s own role in being an object of the presumed stigma.

In contrast to the religious and diagnostic “stigmata,” the meaning of the term “stigma” is morally invariably negative. This negativity is double-edged: it pertains to the behavior-disapproving attitude itself, but also to the views about that attitude, disapproving that disapproval as unjust and harmful. According to the Encyclopedia of Global Bioethics, “[s]tigmatization involves identifying and marking an undesirable characteristic in a way that narrows a person’s social identity to that characteristic” (Chen and Courtwright 2016, p. 2706). Although stigmatization, so defined, is hard to ascertain and operationalize, once this concept is applied to a phenomenon, such as it is to substance use/addiction, the implication is that the negative attitude to it is as inappropriate as the stigmatization of ethnic and religious minorities.

The view on stigmatization of substance use/addiction thus has a specific peculiarity: whereas shame (Schaumberg and Skowronek 2022) or guilt (Dearing et al. 2005) are emotions that call for adjustment to social norms and may therefore incentivize an individual to either not engage in or cease a behavior, “stigma” has a connotation of society’s unjustified mistreatment of those who bear the effects of their substance use. These emotions are thereby considered “self-stigma,” resulting from the internalized stigmatization by society (Matthews et al. 2017) and so also targeted for eradication. The concept of stigma as currently applied thus envelops both mistreatment and justified disapproval causing shame and/or guilt. As discussed below, substance use is justifiably disapproved as is any behavior that is perceived as harmful to society and the individual. Accordingly, the concept of stigmatization itself, suffering from internal contradictions, may do more harm than the supposed or actual mistreatment that this concept implies. Namely, it is misleading and may misinform professional care when the assumption of mistreatment is unfounded, neutralizing instead of employing internalized justified disapproval as an important preventive and therapeutic factor; it is redundant if mistreatment does occur: there exist legal measures that deal with that. This article aims to separate the two concepts.

Stigmatization vs. justified societal disapproval

Negative consequences of stigmatization may be especially dangerous if and when it “impedes access to treatment and care delivery” (Volkow 2020b, p. 1289). Given the possibility of such mistreatment, the attitude of health professionals to patients with substance use problems is thus most germane. This attitude is reported to be often negative, which may influence the quality and outcome of care (van Boekel et al. 2013). By itself, however, when not acted upon, this negative attitude is arguably as normal as any normative human reaction to a deviant behavior, particularly associated with crime, even when society, at least periodically, may be shifting to greater anomie. In using an illicit substance, crime is committed not only by the very fact of use, but it also often involves additional criminal and self-destructive actions by the user, while the entire market of illicit drugs is dominated by organized crime. That is the inescapable background for forming attitudes to substance use/addiction, largely negative.

Nonetheless, such attitudes have received the general label of “stigmatization” that censures the negative perception of substance use. Indeed, common disapproval of this clearly noxious behavior is viewed as synonymous with deleterious stigmatization (e.g., “[i]llicit drug use is a highly stigmatized, or socially disapproved, behavior throughout society” [Palamar 2013, p. 367]). As the authors of a book on stigmatization indicate (Brewis and Wutich 2019, p. 3), while “stigma” is “the process by which people become classified within society as less valuable, undesirable, or unwanted,” public health has “used [that very same—MV] stigma” to turn public attitudes away from smoking, thereby saving millions of lives by the “power of stigma”—clearly a positive development despite the use of the negatively connoted term. There is therefore a tension, an internal contradiction in how the concept is deployed in the substance use domain. What is recognized as beneficial, on the one hand, is rejected, on the other. Although the boundary between justified disapproval and stigmatization may be not clear-cut, the latter term as currently applied to substance use implies mistreatment, with no objective benefit to that person or, at least, with the benefit’s being outweighed by the cost associated with disapproval.

Another possible implication is illustrated by the anecdotal case of a lung cancer never-smoker patient who “knew others suspected she must have done something wrong, like sneaking cigarettes” (Brewis and Wutich 2019, p. 1) and received compassion only when she started to hide her type of cancer. The authors, therefore, apply the notion of “stigma” with no distinction even between the unjustly imposed guilt by association and beneficial life-saving disapproval. As the Brewis and Wutich book itself, its review in Nature (Pulerwitz 2019) also recognizes that the change in social norms did motivate smokers to quit, but—illogically—considers that change, the recognition of the smokers’ responsibility for their addiction, a “negative consequence,” contrary to its positive effects. In other words, a clear benefit is presented as a cost.

Importantly, however, the unjustified negative attitude toward that non-smoker patient is not directed at the behavior per se that potentially causes cancer, i.e., smoking that is wrongly assumed. It is, illogically, directed at lung cancer itself. That situation is dramatically different from the negative attitude to substance use/addiction where the target of opprobrium is the directly observed, rather than assumed, behavior itself—not the physiological/pathological changes that may be associated with it. The cessation of that behavior, substance use, results in the removal of disapproval, regardless of any possible remaining physical dependence. It has been noted, for instance, that the attitude of professionals treating addiction depends on the current behavior and is more positive to the patients in recovery compared to those who relapse (Rao et al. 2009). The disapproval is thus not indelible, as the original meaning of “stigma,” the Greek/Latin word for a brand, would imply. The statements about the relationship between the healthcare providers’ attitudes to substance use and their treatment of patients are not necessarily well-founded. For instance, a review presents results of one study as showing that “injecting drug users who were cared for by doctors with negative attitudes had a significantly lower rate of exposure to antiretroviral therapy than those cared for by doctors with positive attitudes” (Lloyd 2013, p. 87), but the actual paper referred to in that review states the opposite, “[p]hysician attitudes toward HIV-infected IDUs were not significantly related to the average HIV patient’s quality of care” (Ding et al. 2005, p. 622).

This disapproval is also not directed at an involuntary condition (like schizophrenia) or at the probabilistic consequences of behavior like diabetes and obesity or lung cancer. It also stands to reason that mistreatment by health professionals, if any, is supposed to be dealt with in a common manner as malpractice, without involving inferences about mental attitudes that may or may not contribute to it. Malpractice, like that alluded to in an anecdotal report about refusal of a heroin user with a leg injury to go to an emergency room because he had been mistreated there as a “drug addict” (Volkow 2020b), does not require introduction of a special concept, specific to substance users.

Nonetheless, the “stigmatization” literature makes no distinction between legitimate disapproval and the pernicious stigma, or what the individual may perceive as such or indeed experience as medical or other professional mistreatment and malpractice. Consequently, calls for the unconditional “destigmatization” of substance use and addiction are heard not only from the media but also from the scientific and funding leadership of the field (Volkow 2020a). This lack of distinction characterizes not only the literature promoting the concept of stigmatization, but also where this concept’s deficiencies are recognized. Elucidating many of the same points that are discussed here, including the potential harms of the “destigmatization” campaign, Satel (2007), in a thought-provoking paper, presents stigma itself as needed and “a normal part of human interaction” (p. 151).

Semantics do matter, however: when justified opprobrium is conflated with the mistreatment connoted by “stigma,” the measures taken to remove the latter will also tend to counterproductively neutralize the former. In contrast to disapproval, which would call for a beneficial correction of behavior, application of the stigma concept in the absence of mistreatment mitigates, if not reverses, the individual’s obligations to comply with societal norms, including legal ones, regarding substances. The inconsistent application of the norms may result in an effect akin to the “reinforcement trap” of inconsistent discipline that maintains the child’s difficult behavior (Kirisci and Vanyukov 2022).

The conceptual contradictions persist in the stigmatization literature in general. An example is a heated discussion of what term to select as appropriate to denote persistent substance use for another revision of the DSM (Diagnostic and Statistical Manual) nomenclature—“addiction” or “dependence” (Erickson and Wilcox 2006; O’Brien et al. 2006). The proponents of both terms referred to stigmatization as a main shortcoming of the alternative label: “addiction” is pejorative, and “dependence” labels patients with a withdrawal syndrome regardless of whether they do or do not pursue addictive drugs beyond treatment needs. That is curious but understandable: once introduced, any label in that regard will acquire the same negative connotations. This is an inevitable consequence of potentially destructive and criminal behaviors’ evoking negative reactions from a large proportion of the population, including placement of those behaviors beyond the legal boundaries. Changes in the term, like changes in the name of the Shakespearean rose, will not by themselves change those reactions. Whereas a person persistently using addictive substances may have lost some control over behavior, becoming slave to a habit (close to the original meaning of the Roman term “addictus,” a slave-like status of a debtor assigned over to the creditor [Smith 1859]), this slavery is commonly viewed as voluntarily self-inflicted and thus reprehensible. That is why the calls for removal of “derogatory terms” not only from the professional language but from society as a whole (e.g., Atayde et al. 2021) are likely to fail: as the attitude to substance use is not formed by a prejudice, it is unlikely to become tabooed, in contrast to the virtual desuetude of labels related to prejudice (at least in the professional language).

Biologization of behavior

The notion of stigmatization of addiction and equating/conflating stigmatization with justified societal disapproval likely stem from addiction’s frequently being categorized as a mental disorder/disease. Stemming from antiquity, the perception of mental disorders, i.e., of “madness” or “insanity,” has been either as a divine punishment for sins (as goes the proverb regarding those whom the gods wish to destroy) or, on the contrary, a special blessing for saintliness, “holy foolery” (Ivanov, 2006). In modernity, inasmuch as the origins of madness have been generally drawn to (as yet unknown) biological brain malfunction, it has become clear that it is not a personal failure and thus is not subject to moral judgment. Hence, any negative labeling of mental disorders is generally indeed an unjust stigma, to be abolished. Naturally, however, that view extends to addiction—when it is viewed as a “brain disease” (Leshner 1997) reduced to biological malfunction. Since biological differences of users from non-users can be detected at any level of substance use, such differences too can be viewed as indicative of malfunction despite reflecting normal variation in the physiological response to substances. As discussed below, that removes distinction between the disease and non-disease and renders biology-based reification of addiction as a disease tautological.

A recent article (Szutorisz and Hurd 2022) is illustrative of the biologization approach. It is noted therein (p. 1611) that “[a]ddiction is often viewed today on one hand as a choice by the user, and on the other hand as an intractable condition to which users are powerless.” It is uncertain which of the two positions, if any, the authors take, but they do point out that substance use disorders (SUDs) do not qualify for what they call the “classical definition of stigma.” The reason cited is that SUD is not an “indelible mark,” owing to the developmental malleability of underlying mechanisms. In contradiction, however, it is also stated that “the stigma around SUDs… is not only ingrained in society but often gets internalized by affected individuals (p. 1611),” which seems to render the stigma indelible for such an individual. The contradiction appears to come from a lack of clarity in what, or who, supposedly bears the stigma: the disorder (a pernicious behavior and results thereof), the individual (who, however, is responsible for his/her behavior, being neither born with addiction nor doomed to develop it as an “intractable condition”), or society, in which the stigma is stated to be ingrained, which does seem to also mean indelible.

While the indelible mark is correctly denied, so is, wrongly, personal responsibility for addiction, similar to how the brain-disease definition of addiction (Leshner 1997) displaces responsibility, undermining the needed behavior change (Heim and Monk 2022). The apparent reason for that, again, is the behavior’s association with biological processes. These processes are also presented as indicators of underlying biologically-based discrete pathological categories marked by “sensitivity to substance abuse” and “aberrations in neuroplasticity and underlying molecular epigenetic mechanisms that encode early life environmental memories… key neural processes to account for the long-lasting behavioral vulnerability evident in SUDs” (Szutorisz and Hurd 2022, p. 1612). Thus, addiction is described as a neurobiological—rather than behavioral—disorder. Moreover, it is referred to as “the disruption of the areas of the circuits that enables us to exert free will,” so that “it’s not a choice to take the drug” (NIDA 2015). Interestingly, however, while presenting loss of free will as the mechanism of addiction, the same source indicated that it was one of “powerful myths and misconceptions” that “people addicted to drugs were … lacking in willpower.” The biological inability to exercise free will could potentially relieve one of responsibility for any behavior, not only substance-related.

Nevertheless, the behavioral essence of addiction, a condition appropriately defined by the DSM (American Psychiatric Association DSM-5 Task Force 2013, p. 483) as a “pattern of behaviors related to use of substances” and presenting generally as persistent substance use despite negative consequences (as per eight out of 11 DSM-5 diagnostic criteria), cannot be ascribed to any inborn biological “sensitivity.” It is also not reducible to the physiological effects of substances. Notably, the physiological symptoms that comprise the small non-behavioral group of the DSM-5 SUD criteria, viz., withdrawal, tolerance, and craving, do not fit—either conceptually or statistically—the underlying construct accounting for the symptoms’ covariation (Vanyukov 2021; Kirisci and Vanyukov 2022). The biological reductionism also contradicts NIDA’s prior conclusion that “[u]nlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing” (Volkow and McLellan 2016, p. 1256), which effectively separates those physiological symptoms from addiction. The authors suggest, referring to other researchers’ work, that there are instead other “molecular mechanisms underlying addiction [that] are distinct from those responsible for tolerance and physical dependence, in that they evolve much more slowly, last much longer, and disrupt multiple brain processes” (p. 1256–1257). The cited paper (Christie 2008), however, makes no such qualitative distinction and lists tolerance and withdrawal as core features of addiction. As noted therein, “changes in neural excitation produced by chronic opioid exposure in one component of a neural network can indirectly produce homeostatic adaptations to excitability of other neurons and synapses throughout the network… Similar to cellular adaptations in opioid-sensitive neurons, network adaptations contribute to tolerance, withdrawal and long-term features of addiction” (p. 392). While the neuroadaptations in substance use are not fully known, and withdrawal and tolerance cannot account for some of the attendant behavioral problems, such as relapse, the SUD symptom analysis (Kirisci and Vanyukov 2022) suggests that tolerance and withdrawal are causally related to the behavioral criteria of addiction and thus to whatever other brain processes are involved.

The differences between the physiological and behavioral levels of organization, as well as the retention of free will under addiction, are underscored by the data on opiate-addicted Vietnam veterans, the overwhelming majority of whom did not continue their substance use upon their return stateside, with no treatment accounting for that (Robins 1993; Robins et al. 2010), by the numerous examples of “maturing-out” (Winick 1962) of addiction, and by the eventual remission if not recovery of the majority of people with SUD (rev. in Vanyukov 2021; Kirisci and Vanyukov 2022). For instance, for the general population, according to National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, the lifetime probability of remission from DSM-IV “dependence” (remission defined as “finally stopped” having dependence criteria) was estimated at 84% for nicotine, 91% for alcohol, 97% for cannabis, and 99% for cocaine (Lopez-Quintero, Hasin, et al. 2011). Similarly, high rates of remission were calculated for the Epidemiological Catchment Area (ECA) data (Heyman 2013). The true probabilities may be lower due to the study limitations, e.g., its being based on self-reports, inability to include more severe cases (institutionalized, severely impaired, and fatal), recall bias, and lack of information on possible relapse upon remission. Nonetheless, the figures are sufficiently strong to question the diagnosis’ finality that is usual for other disorders recognized as chronic. Notably, time to remission for half of the cases was much longer for legal substances (26 years for nicotine and 14 years for alcohol, reaching their respective ceiling after 50 years of age) than for illegal drugs (six years for cannabis, and five years for cocaine, with respective ceilings at about 40 years of age) (Lopez-Quintero, Cobos, et al. 2011). This suggests that the societal/legal pressure provides an additional incentive to make a choice to quit: there is no other explanation for the ostensibly counterintuitive relationship between the time to remission and the legality of substances. In turn, a plausible expected consequence of their expanding legalization is an increase in the chronicity of (formerly illegal) substance use.

According to the National Survey on Drug Use and Health data, out of the 29.2 million adults in 2020 who perceived that they ever had a substance use problem, 72.5% considered themselves to be in recovery or to have recovered (SAMHSA 2021), while treatment does not appear necessary for remission (Heyman 2013). The ability to control substance use in those who report having had and resolved a substance use problem is evidenced not only by over half of them endorsing continuous or current abstinence but also, perhaps even more convincingly, by almost half of them currently using substances in moderation (Eddie et al. 2022). Involuntary cravings notwithstanding, and contrary to the opinion that in addiction “a person’s brain is no longer able to produce… free will” (Volkow 2015), individuals with addictions “typically retain their faculty of self-control” (Holton and Berridge 2013, p. 239). Moreover, equating addiction to physiological dependence has been noted to cause “tremendous harm” (O’Brien et al. 2006) to the patients who were denied treatment benefits based on that. Only recently, the CDC has removed—with reservation—the arbitrary limits on quantity and duration of opioids in treatment for pain (Dowell et al. 2022) that were established with the 2016 guidelines (Dowell et al. 2016). It is therefore apparent that conflating addiction as a behavior with its biological mechanisms is justified neither theoretically nor by the patients’ interests.

The voluntariness of taking an addictive substance, a known hazard, drastically differentiates addiction from other psychiatric disorders (e.g., schizophrenia, bipolar disorder), whose causes are unknown let alone not persistently pursued, as substances frequently are. A voluntary behavior’s becoming habitual does not annul one’s responsibility for it (e.g., except for rare cases of “settled insanity” due to use of intoxicants, addiction does not provide grounds for insanity defense [Morse 2000]). This obvious proposition, to be sure, does not comport with the notion of addiction as a “brain disease.” Neither the biologically deterministic “developmental path of neural vulnerability” (Szutorisz and Hurd 2022, p. 1611) nor the possible quantitative statistical biological differences of people with addictions and their relatives from the rest of the population establish that substance use is not a volitional goal-directed act, which is the source of the opprobrium. No biological phenotype categorically separates these groups.

Nonetheless, one reason for the biologization and medicalization of behavior is exactly a logical misstep of the reification of nonexistent discrete entities. Phenotypically, the disorder diagnosis denotes the suprathreshold portion of the population distribution of liability to addiction/SUD, a continuous latent (unobserved directly) trait (Falconer 1965). The threshold phenotype, a point on that trait’s axis, is indicated by a certain number of diagnostic symptoms, a matter of convention among the medical profession, law enforcement, and lay public. The threshold is artificial for a behavioral disorder like addiction: there is no natural division between affected and unaffected individuals in the liability distribution, a long-known observation for mental conditions (Kent and Rosanoff 1910), and the diagnosis is heterogeneously defined by hundreds of unique combinations of symptoms (Vanyukov et al. 2003). Diagnostic systems and “disease models” in the field of mental/behavioral conditions may be useful for clinical work and the economic aspect of healthcare (e.g., Medicare covers only what is needed for the diagnosis or treatment of a disease or injury [CMC 2022]). Nonetheless, the categorical diagnosis arbitrarily dichotomizes that continuous distribution while “[d]iagnostic categories based on clinical consensus fail to align with findings emerging from clinical neuroscience and genetics” (Insel et al. 2010, p. 748)—the very disciplines that are frequently used as the basis for labeling a condition a “disease” (e.g., Volkow and Li 2004). Unsurprisingly, relapse to a SUD related even to a single substance remains defined as inconsistently as the original diagnosis (Sliedrecht et al. 2022). The inability to define addiction in objectively categorical terms leaves the negative societal attitude to it (sans possible mistreatment/malpractice) as justified as the disapproval of any illicit substance use before it meets the diagnostic criteria.

Insofar as any behavior, including addiction liability phenotypes, is ultimately a product of the brain interacting with the environment, its association with characteristics of brain activity and related biological functions, as well as with other behavioral traits, is expected regardless of medical or other labels. The common substrate may account for the frequent psychiatric comorbidity and the possibility to extract a common dimension across diagnosis-specific liabilities to psychiatric disorders (Caspi and Moffitt 2018), associated with biological characteristics (Hoy et al. 2022). Unsurprisingly, liabilities to addictions related to specific substances are highly correlated, sharing virtually the entirety of genetic mechanisms of phenotypic variation (Tsuang et al. 1998; Kendler et al. 2003). The common phenotypic variance is termed common (general) liability to addiction (Vanyukov et al. 2003; Vanyukov 2012). Consistent with these data, most of the genetic association findings for addiction are not substance-specific (Bierut et al. 2007; Saccone et al. 2007; Bergen et al. 2008; Maher et al. 2011; Palmer et al. 2015; Schwantes-An et al. 2016). These associations, therefore, do not prove the labels’ correctness or, indeed, the existence of the categories labeled. For instance, “phenotypes of SUD risk,” listed by Szutorisz and Hurd (2022, p. 1612) as reflecting ‘cumulative aberrations in neuroplasticity’ due to epigenetic encoding of “early life environmental memories” (aggression, anxiety, depression, attention deficit hyperactivity disorder, etc.), are in reality psychological variables/constructs and their underlying neurobiological mechanisms, including epigenetic and genetic ones, that are correlated with liability to substance use/addiction (Vanyukov and Tarter 2019). Arguably, any environmental input, let alone the powerful impact of a psychoactive substance, can leave a neurobiological and epigenetic trace, which is not synonymous with a disease but is indicative of neuroplasticity and other physiological adaptations. Neither those mechanisms nor the fact that addiction results from a developmental process, long known to be extended, nonlinear, and individually variable (Tarter and Vanyukov 1994), can invalidate the societal disapproval of substance use, negatively mislabeled “stigma.” It is likely the juridical aspect of this disapproval, the illegality of substance use/addiction, that causes its association with externalizing behavior to the degree of being considered part of the same behavioral spectrum (Krueger et al. 2002), as well as divides liabilities to disorders related to licit and illicit substances into two genetically correlated but different groups (Kendler et al. 2007). In short, alterations in the brain function under the influence of addictive substances, even if stable, and their associations with behavioral traits do not lift responsibility for substance use off the user.

In contrast to diabetes, a physiological disorder, or, indeed, to physical substance dependence, a behavioral phenotype of addiction cannot be reduced to its metabolic correlates, such as corticosteroid sensitization (Carmack et al. 2022), or to neurobiological deficiencies (e.g., “reward deficiency syndrome” [Blum et al. 2014]). Biological variables (physiological, neurobiological, genetic, epigenetic) that contribute to variation in behavior including addiction liability are, naturally, statistically associated with that liability. So are, to a lesser degree, other biological correlates of those variables, e.g., non-functional genetic polymorphisms in linkage disequilibrium with the causal ones. These correlations translate into group differences between the high-liability/risk individuals (addicts and their relatives) and the rest of the population. Correlations and group differences, in turn, translate into the false reification of the diagnosis—i.e., biologically “confirming” the disorder as a true entity. This confirmation is, however, circular and thus illogical.

Medicalization and biologization have now expanded to what used to be viewed as premorbid behavior, labeling it “preaddiction” (McLellan et al. 2022), a “diagnosis” in the absence of a “severe” disorder. The latter is redefined with “impaired control as the core defining diagnostic construct” (p. E1), thus lifting responsibility off the individual even before that stated impairment develops. Meanwhile, impaired behavior control can be deduced only from observing behavior, thus making explanation by behavior control impairment also circular: behavior indicates impaired control, which is then used for explaining the behavior, with consequent research relating that control to biological variables. A further labeling arbitrarily delimits addiction only to the presence of six or more out of the 11 DSM-5 SUD symptoms, whereas previously “addiction” and “substance use disorder” have been viewed as synonymous (O’Brien et al. 2006). It is therefore apparent that biological data do not provide grounds for treating addiction as an involuntary condition rendering the user inculpable.

Effects of justified societal disapproval and of its decline

Addiction is certainly not a choice—in the sense, trivially, that it is not a goal to be chosen. It is not the disorder or its symptoms that are pursued as the objects of willful behavior, but access to the substance and its effects. It is that pursuit that is a matter of choice (difficult as that choice might gradually become), the goal-directed behavior that is necessary for the maintenance of addiction and its development. In turn, as noted, cessation of substance use, a behavior, is virtually synonymous with addiction remission or recovery. It also often precedes recovery from physical dependence, if any. “Destigmatization,” if it were at all possible, would deincentivize quitting substance use, while the presumption of “stigma” in the absence of mistreatment/malpractice may be used as another justification, among the many used by substance users (Weinstein 1980), for not attempting or not persisting in quitting. Employing the negatively connoted term “stigmatization” implies unfairly malign societal treatment of users and thus to a degree encourages their continued substance use (e.g., for self-medication—see below). Arguably, however, this ignores the fact that societal opprobrium is an ancient mechanism of behavior regulation and socialization. It is applied to any behavioral excesses, especially those legally banned, while the legal measures in that regard reflect, albeit often inadequately, the perception of harm from those excesses.

Shunning and ostracism are varieties of that mechanism, which in the human and other primates’ evolutionary history were threats to inclusion in the group and related to early death and low chances of mating (Spoor and Williams 2007). This may explain their persistence as facilitators of behavioral change in various areas of human activity. Societal disapproval, including the unjustified stigma, derives not only from behavioral threats to group survival but also likely from the need to avoid communicable pathogens (Kurzban and Leary 2001). The societal censure’s lay and legal forms, while not without their own historic excesses, errors and abuses, protect the majority of the population from dangers associated with substance use, as they do against other antisocial behaviors and overindulgence that is frequently detrimental to health, social status, and society as a whole. For instance, while Prohibition is commonly considered a failure and is not argued here to be reinstated, it has been noted that it did in fact result in a sharp decrease of the negative consequences of alcohol use (Blocker 2006). Prohibition resulted from a century-old temperance movement that was strongly influenced by religious morals, and, by the time of the 18^th Amendment and the Volstead Act (1919), it was overwhelmingly supported by the population.

It is also the rising disapproval of smoking that has likely been one of the factors that have led to the dramatic decrease of this behavior since the 1960’s, raising resistance to it in the population. Suppression of the negative attitudes to smoking, i.e., destigmatization, instead of capitalizing on them, would obviously lead to the loss of millions of lives. It would be similarly harmful not to disapprove of substance use. The increase in substance use and related deaths upon legalizing or decriminalizing substances clearly testifies to that. For instance, drug decriminalization in Oregon in 2020 (“Measure 110”) has not resulted in a meaningful increase in accessing treatment, as intended, but has been followed by a 58% growth in opioid-related deaths within a year (Oregon ESSENCE 2022), compared to the national growth of total drug deaths of 15% for about the same period (CDC 2022).

There are no data suggesting that lifting societal disapproval off a harmful behavior results in that behavior’s improvement or discontinuation. Moreover, removing (legal) societal boundaries from that behavior, thus effectively normalizing it, inevitably enlarges the proportion of those who practice it, as the data on cannabis use upon its decriminalization also show (Hamilton et al. 2019; Smyth and Cannon 2021). The atypical decrease in adolescents’ substance use in 2021 can likely be accounted for by the diminished access to drugs due to the pandemic (Johnston et al. 2022). In contrast, in young adults, who no longer have similar restrictions, substance use has reached “historic highs” (Patrick et al. 2022). Similarly, facilitation of the availability of a substance in a different manner, e.g., as in an alcohol price reduction in Finland in 2004, has resulted in elevated alcohol-related morbidity and mortality (Lahtinen et al. 2022).

These data underscore the influence of the social environment. Avoiding people who use substances facilitates prevention of one’s own substance use, and changing social environment by avoiding (i.e., shunning) other people who use substances (“build[ing] escape routes from deviant peers and drugs” [Liddle 2010, p. 422]) and affiliating with those in recovery (e.g., AA and NA support groups) (Buckingham et al. 2013) are often conditions for one’s recovery. An individual with addictions may have no other motives to quit but those ultimately induced by the (internalized) negative societal attitudes to substance use and the related social norms. Notably, those attitudes have dramatically changed: e.g., from 12% in the U.S. supporting legalization of cannabis in 1969 to 68% in 2022, according to Gallup polls (Jones 2022). It follows that one of the important factors of recovery may have been substantially diminished.

The societal opprobrium that is conceived of as stigma is due to the perceived failure of personal responsibility in substance use and thus in the resulting disorder, originating in the cognitive representations regarding this condition (Bos et al. 2013) (the authors, as per the common trend, do not differentiate between “stigma” and the legitimate disapproval of the behavior, despite noting that “[f]rom an evolutionary perspective, social exclusion of deviants protected against infectious diseases and thus contributed to survival,” p. 2). These representations include onset controllability, perceived severity, perceived dangerousness, and perceptions of norm violation, all of which are high, rather than merely “perceived,” for illicit substance use. As pointed out above, it is noteworthy that it is behavior that is disapproved in presumed “stigmatization,” rather than its biological mechanisms, the pathological consequences, or the individual as such. While the diagnosis of addiction, SUD, is defined by the changing set and number of symptoms, the disapproval extends to any illicit or—in case of licit—excessive substance use, often regardless of whether it has reached the severity of a diagnosable condition and meets the diagnostic criteria. Similarly, lethal drug poisoning, the most publicized and dramatic consequence of substance use, commonly misnamed “overdose” (which wrongly implies existence of a correct/normal dose of an illegal substance), requires neither addiction nor physiological dependence to occur. Just like the quarantines enforced in dangerous infections, far from being a purely moral issue, the negative societal attitude to substance use (combined with the involvement of healthcare) is therefore justified by the mortal danger this behavior presents to the user and society. Arguably, it is poorly internalized barriers for committing volitional acts necessary for substance use that lead to further discomforts ensuing from those acts, including guilt and shame, if any. The situation is arguably exacerbated by society’s lowering those barriers via spreading decriminalization and legalization of substance use, in conflict with still extant federal law. It does not seem too big of a stretch to surmise that this conflict brings about devaluation of law and relaxation of legal boundaries in general, particularly for behaviors historically associated with substance use. This is de facto destigmatization or, rather, the growing leniency of social controls that is related to the rising severity of substance use and related problems.

One such problem is the increasing and increasingly earlier exposure of the population to drugs. It would be an error to infer causality merely from a temporal sequence, and causality is hard to establish in observational studies. Both early exposure and higher disorder risk may result from a third variable, e.g., high genetic predisposition to addiction, mediated by physiological reinforcement mechanisms and expressed in genotype-environment correlation (Scarr and McCartney 1983). Nonetheless, whether itself a cause or an effect, early exposure is undoubtedly indicative of the greater accessibility of drugs, an unambiguous common-sense risk factor, and falls on the period of active brain maturation, thus potentially mediating risk increase.

To sum, the effect of justified societal disapproval is an increase in the probability of non-use or cessation of use, i.e., in resistance to substance use/addiction, in contrast to factors elevating risk, the opposite aspect of liability (Vanyukov et al. 2016). Resistance-raising factors, however, are generally seldom an intended target of investigation and scientific discussion, and few are known as actionable for substance use. Assigning to one of such factors a negative label of “stigma,” conflating it with mistreatment, stigmatizes and thus neutralizes a positive societal influence, throwing the proverbial baby out with the bathwater.

Conclusion

A greater level of comfort is a goal yearned for in all cases of substance use. When unrelated to medical purposes, drugs are taken purely for a positive affect change—regardless of the baseline level, thus covering both positive and negative reinforcement. Encouraging substance use by mislabeling its justified societal disapproval as stigmatization, in effect stigmatizing that disapproval despite this behavior’s being harmful, destructive, and often illegal, can only facilitate substance use with all its negative consequences. Society’s refusal to control that behavior, lifting its medical, legal, and traditional boundaries and personal responsibility for it, may raise the substance-using individual’s level of comfort but decrease, instead of increase, the chances of recovery and prevention. Constructively and conscientiously utilizing the negative individual and public perception of substance use along with positive perception of non-use may be an important factor of raising resistance to addiction (Vanyukov et al. 2016)—both in preventing substance use and assisting in recovery.