De-Stigmatizing the Language of Addiction #429

Background

Discrimination and stigmatization of patients who use psychoactive drugs or who have addiction is common in health care.^1–4 Using people-first, medically accurate, and stereotype-reducing language with colleagues, trainees, and in documentation⁵ is fundamental to dispelling stigma⁶ and misperceptions, such as the myth of addiction as a willful personal choice or moral failing. The right words can convey empathy and reduce mistrust in health care for patients who have often faced a history of marginalization. This Fast Facts discusses health care stigmatization of patients who use drugs or have addiction, and will present preferred language that respects personhood, supports recovery, promotes accurate knowledge about the full spectrum of substance use, and supports an understanding of addiction as a chronic treatable condition (see Fast Fact #127).

Stigma in Health Care

Stigma is a social process that occurs in the context of power,⁷ characterized by labeling, stereotyping, and discrimination based on real or perceived attributes. Stigma toward people who use drugs or develop addiction, as well as medications to treat this condition, are long-standing. Opioid use disorder (OUD) has long been treated apart from mainstream medicine in the United States, from the 1914 Harrison Narcotics Act that separated treatment of OUD away from routine health care,⁸ to the racist “War on Drugs” that treated drug use as a criminal-legal issue removed from public health. Clinicians themselves commonly have negative biases about addiction,^9–11 which is often reinforced during medical training through stigmatizing language.¹² For example, patients described as “substance abusers” were perceived by clinicians as more threatening, more worthy of blame, and less likely to benefit from treatment compared with “persons with an SUD.”¹³ Altogether, stigma worsens the mental and physical health of people who use drugs,^14–16 disproportionately affects communities of color,¹⁷ and harms patients on long-term therapeutic opioids.^18,19 It even underlies the crisis of overdose deaths, as only 12.5% of people with OUD receive medication proven to reduce accidental overdose.^18,19 The following table presents preferred language for clinicians:

Preferred language20,21	Nonpreferred language
Substance use disorder (SUD), opiod use disorder (OUD), alcohol use disorder, unhealthy/risky use (preferred to misuse), nonmedical use, addiction (which can be used to mean severe SUD per the DSM 5)	Substance/drug/alcohol abuse, drug/drinking problem. The terms dependence and addiction may be used by patients; however, dependence clinically refers to physiological withdrawal reactions when a substance is stopped. It may occur without a SUD and should not be used synonymously by clinicians with SUD/addiction.
Addiction is a chronic condition characterized by the compulsive use of a substance despite harmful consequences.	Using language such as choice, lifestyle, moral failing, lack of will power, or personal failure to describe SUD/addiction
Person with a SUD, person with addiction, person who uses drugs, person who injects drugs (PWID)	Addict, drug/substance abuser, person with a drug habit, alcoholic, IV drug user, drug-seeker
Person not actively using, person in remission from SUD, person in recovery	Clean, former addict. The term sober is generally not used by clinicians, although some patients use it themselves.
Substance present/not present in urine screen	Dirty/clean urine. Describing urine as positive or negative for a substance can be clinically confusing.
Medications for OUD (MOUD), Medication for addiction treatment (MAT), Opioid agonist therapy (OAT)	Opioid replacement therapy and opioid substitution are not preferred as they stigmatize MOUD as “replacing one addiction with another.” Medication-assisted treatment is not preferred because MOUD alone can save lives without additional treatment for some patients.
Patient-directed discharge, patient left before treatment completion despite medical recommendations, patient declined further treatment after informed consent	Leaving against medical advice, AMA, eloped: these clinical designations have no clinical, regulatory, or professional standards. As such they can stigmatize patients, worsen health outcomes, and disproportionately affect vulnerable populations.22
Undertreated pain, risky opioid use (e.g., self-titration of meds, etc.) related to undertreated pain (instead of pseudoaddiction) Using opioids to treat nonpain symptoms (instead of chemical coping)	Pseudoaddiction, chemical coping: these nondiagnostic euphemisms are applied inconsistently and subject to unconscious bias by, for example, clinicians to describe patients with OUD, for whom the clinician does not feel comfortable “labeling” as having OUD. This stigmatizes OUD and can prevent appropriate treatment.23
Opioids	Narcotics (which is used in a legal context to refer to multiple classes of illegal substances not just opioids)

Summary

The language used to describe substance use and addiction must convey respect for individuals, an accurate understanding of the full spectrum of substance use (from nonproblematic use to chaotic use and addiction), and effective treatment. Avoid perpetuating negative stereotypes by first recognizing, addressing, and combatting misunderstandings and stigma.