Language and Addiction: Choosing Words Wisely

Two recent articles in the American Journal of Public Health discussed the importance of educating trainees in social work¹ and medicine² in screening, brief intervention, and referral to treatment (SBIRT) technique for approaching patients with substance use disorders. In both articles the terms “substance use” and “substance abuse” were used somewhat interchangeably. Both articles contribute to the important recognition that training in addictions must be an integral part of any medical or social work training program. However, the language used to convey this educational content is important.

In medicine we use words as tools. Just as we utilize the bell and diaphragm of the stethoscope to transmit the inner landscape of cardiac pathology, we synthesize and communicate our clinical assessments with the language we choose. Every day, medical students and residents give patient presentations to the attending physicians who serve as guides, teachers, and role models. Trainees are coached explicitly and implicitly, guided to choose the proper terms to express their thoughts with the recognition that language shapes our medical judgments.

Firefighters salute as a hearse passes for the funeral procession of 7-year-old Sandy Hook Elementary School shooting victim Daniel Gerard Barden, at the firestation outside of the entrance to the school, on December 19, 2012, in Newtown, CT. Photograph by David Goldman. Printed with permission of AP Photo.

In recent years, as cultural competency has been recognized to be a key component in reducing health disparities, curricula on this topic have been required for medical schools to retain accreditation.³ Teaching culturally sensitive language is now an expected component of medical training. Professionalism, another trait identified as crucial in physician development, hinges on communication. One suggested means of assessing professionalism is whether trainees “communicate in culturally appropriate language with a variety of different patients.”^4(p1364) To teach professionalism, the most effective approach is faculty role modeling of ideal behavior.⁴ And yet within the medical community we have done a better job of this for some topics than others. When it comes to addiction, we describe patients as “substance abusers”; we refer to urine toxicology screens as “dirty” with drugs; with our language we imply patients are inflicting the morbidity of the disease on themselves and are thus undeserving of care.

“Abuse” is arguably the most pernicious and poorly chosen word in our medical addiction vernacular. No other syndrome in medicine in its very naming explicitly labels the patient as the perpetrator of disease. From a purely semantics approach the word is also technically incorrect.

To suggest that the addict mistreats the object of his or her deepest affection is a ridiculous notion. Alcoholics do not abuse alcohol… nor do addicts abuse drugs. Addicts, more than anyone, treat these potions with the greatest devotion and respect.^5(p4)

While “abuse” is defined in the Oxford Dictionaries as to “use (something) to bad effect or for a bad purpose,”⁶ which arguably could apply to addiction, the term “abuse” carries with it a history of moral condemnation. From the Latin word abusus, meaning “an abusing, using up,” the word has been used to reference shameful and willful commissions since the 14th century when abusion referred to a “wicked act or practice, a shameful thing, a violation of decency.”⁷

“Abuse” is a term anchored in our collective minds in association with behavior such as rape, domestic violence, and child molestation. To use such a term to refer to a chronic, treatable brain disease ignores decades of scientific research indicating the role of genetics, trauma, and exposure in the neurobiology of the illness. It favors instead a moralistic view that individuals “choose” such an outcome. Even highly trained mental health professionals are more likely to think that a patient is personally culpable and deserving of punitive measures when they hear the patient is described as a “substance abuser” as compared with having a “substance use disorder.”⁸ Thankfully, in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, “substance use disorder” will take the place of “substance abuse” and “substance dependence.”⁹

Historically, language has been used as a tool for alienation and the identification of out groups. But the reshaping of language has also been important in the recognition of equality and as a means of liberation from prior disenfranchisement. Patients with addiction continue to suffer from the stigma associated with the disease. Not surprisingly, they fear judgment and mistreatment when they encounter the medical system. That expectation often results in an interpretation of even subtle clues as evidence of a physician’s condescension and hostility.¹⁰ Using language that demonstrates an understanding and acceptance of the disease model of addiction will go a long way toward improving the medical treatment of patients struggling with this challenging disease.