The Way We Talk About Drug 'Abuse' Is Harmful -- And It Needs To Change

Substance use disorder is a medical circumstance a brain disease that can be targeted and treated. But when we use words like “junkie” and “crackhead,” we frame the issue in moral terms, suggesting that people with substance use disorders simply lack the willpower to get better.

And that’s not helpful for anyone.

That’s the contention of Michael Botticelli, the director of the White House Office of National Drug Control Policy, which is working to change the way Americans talk about addiction .

The problem with much of the existing language in this area is that it carries judgmental connotations. That can increase the stigma associated with substance use disorders, and end up driving people away from the treatment they need. You don’t want to seek help from someone you feel is looking down on you.

“Commonly used terms can imply, or even explicitly convey, that individuals with [substance use disorders] are morally at fault for their disease,” Botticelli wrote in an essay published Tuesday in The Journal of the American Medical Association.

Pejorative terms like “junkie,” Botticelli wrote, describe people “solely through the lens of their addiction or their implied personal failings. These word choices matter.” 

ONDCP’s guidance draft, called “Changing the Language of Addiction,” encourages the adoption of various new phrases to replace older terminology that may perpetuate stigma.

Instead of using words like “abuse,” “dependence” or “drug habit,” the guidance recommends the term “substance use disorder.” Alternatively, one could talk about the “misuse” or “unhealthy/harmful use” of a substance. 

“Science shows that a substance use disorder is a chronic brain disease,” the draft guidance reads. “’Substance use disorder’ is the clinically accurate term.”

The guidance also recommends using person-first language to describe people with addiction, as is standard for describing other individuals with chronic conditions or disabilities (e.g., “person with autism” rather than “autistic person”). For example, the term “person with a substance use disorder” would be preferred over terms like “abuser,” “addict” or “alcoholic,” all of which can lead to negative perceptions about the very people they describe.

Much of the vocabulary ONDCP endorses is studiously neutral. The terms “clean” and “dirty,” the office says, should be abandoned when describing a “person in recovery” who may or may not be currently using substances. ONDCP recommends instead using terms like “negative” and “positive,” a reference to one’s toxicology results, or else describing a person in recovery as either “currently using substances” or “not currently using substances.”

For people with substance use disorders who use medication as part of their treatment, ONDCP recommends saying “medication assisted treatment” instead of “drug replacement” or “drug substitution” terms that can imply that medication merely “substitutes” for one drug, or addiction, for another.

“The basic message is that words matter,” said Dr. Howard Koh, professor at Harvard’s T. H. Chan School of Public Health and the Harvard Kennedy School and co-author of the JAMA essay. “The stigma associated with addiction can discourage people from coming forward to seek treatment... [and] millions of people who need treatment are not receiving it. Reasons for not seeking treatment include the fear of negative reactions from neighbors, community members and employers.”

Although questions of word choice might seem beside the point when dealing with life-and-death matters like drugs and disease, Botticelli and Koh’s call for more accurate and humane language is rooted in science. 

One recent study found that even a group of mental health professionals with significant experience working with people with substance use disorders were more likely to view a patient as personally culpable for their drug use and more likely to conclude that the patient should somehow be punished  when the person was merely described as a “substance abuser” rather than a “person with substance use disorder.” In another study comparing the use of the same two terms, mental health professionals were found to view quote-unquote “substance abusers” as engaging in “willful misconduct,” representing a “greater social threat” and deserving of punishment.

Writing at JAMA, Botticelli and Koh say that it’s common for the language around health issues to evolve as our understanding of those issues becomes more sophisticated. They note that people with mental illness used to be labeled “lunatics,” and patients in the early days of AIDS were described as having “gay-related immune deficiency” language that obscures the reality that AIDS has nothing to do with sexuality, and that mental illness can affect anyone.

In all of these examples, Botticelli and Koh argue, “stigma and discrimination can arise when patients are labeled, linked to undesirable characteristics, or placed in categories to separate ‘us’ from ‘them.’”

“Changing the language can reduce stigma that isolates people and remove barriers that hold too many people back from receiving the treatment they need and deserve,” Koh told The Huffington Post. “Such changes, when combined with education and policy improvements, could foster a healthier future for our society.” 

ONDCP’s guidance is a working draft, and the agency is currently seeking public comment  on the document.