DRAFT: Changing the Language of Addiction

Office of National Drug Control Policy, October 2016 Draft
Please submit comments by November 3, 2016 at feedback@ondcp.eop.gov

Background

Substance use, misuse, and substance use disorders[*][†] impose a devastating health and emotional burden on individuals, families, communities, states, tribes, and our Nation as a whole, causing injury, illness, and death and endangering public safety.  In 2015, an estimated 20.1 million Americans aged 12 or older had alcohol or other drug use disorders, while approximately 27.1 million people aged 12 or older reported past-month illegal drug use.^[1]  More Americans now die every year from drug overdoses than in motor vehicle crashes. Yet 89 percent of individuals estimated to be in need of treatment for a substance use disorder do not receive services.¹

Substance use disorder (the severest form of which is commonly referred to as addiction) is a chronic brain disorder from which people can and do recover.  Nonetheless, sometimes the terminology used in the discussion of substance use can suggest that problematic use of substances and substance use disorders are the result of a personal failing; that people choose the disorder, or they lack the willpower or character to control their substance use.  The evidence is clear that this is not correct; instead, research has shown that substance use disorders are neurobiological disorders.

However, research also has shown that people with substance use disorders are viewed more negatively than people with physical or psychiatric disabilities.^[2],[3]  Researchers found that even highly trained substance use disorder and mental health clinicians were significantly more likely to assign blame and believe that an individual should be subjected to more punitive (e.g., jail sentence) rather than therapeutic measures, when the subject of a case vignette was referred to as a “substance abuser” rather than as a “person with a substance use disorder.”^[4]  In a public perception study the term “abuse” was found to have a high association with negative judgments and punishment.^[5]  Negative attitudes among health professionals have been found to adversely affect quality of care and subsequent treatment outcomes.⁶ Shame and concerns about social, economic, and legal consequences of disclosing a substance use disorder may deter help-seeking among those with substance use disorders and their families. 

The American Medical Association has called on physicians to help reduce stigma and support treatment for substance use disorders. The American Society of Addiction Medicine and major addiction journals have urged the adoption of clinical, non-stigmatizing language. The current Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association, replaced the earlier categories of substance “abuse” and “dependence” with “substance use disorder.”

In addition, “person-first language” has been widely adopted by professional associations and scientific journals to replace negative terms that have been used to label people who have other types of health conditions and disabilities.  For instance, expressions such as “person with a mental health condition” or “person with a disability” carry neutral rather than pejorative connotations, and help place the focus on individuals rather than on their health condition or perceived membership in a group.⁷ Language related to substance use, misuse, and substance use disorders can do the same. 

This document draws attention to terminology that may cause confusion or perpetuate stigma around substance use disorders. It is not intended to serve as a glossary of clinical terminology, nor does it offer a comprehensive list of all the potentially stigmatizing words used in association with substance use disorders. Many casual and slang terms are so clearly negative and stigmatizing that they need not be repeated here. In addition, while this document aims to promote non-stigmatizing language in the Federal Government, individuals who have substance use disorders or those in recovery may choose to identify themselves with different terminology.

Executive Branch agencies are encouraged to consider the importance of language and the terminology discussed below in their communications related to substance use or substance use disorders. (Examples of communications developed by agencies include grants, contracts, fact sheets, reports and publications, press releases, presentations, newsletters, web-based [including social media], and other materials). 

Substance Use Disorder

The current Diagnostic and Statistical Manual of Mental Disorders replaced older categories of substance “abuse” and “dependence” with a single classification of “substance use disorder.”  Alternatives include “misuse” or “unhealthy/harmful use” of a substance. 

Similarly, terms such as “drug habit” inaccurately imply that a person is choosing to use substances or can choose to stop. However, science shows that a substance use disorder is a chronic brain disease. “Substance use disorder” is the clinically accurate term.

Person with a Substance Use Disorder

Person-first language is the accepted standard for discussing people with disabilities and/or chronic conditions.  Research shows that use of the terms “abuse” and “abuser” negatively affects perceptions and judgments about people with substance use disorders, including whether they should receive punishment rather than medical care for their disease.^4,5  Terms such as “addict” and “alcoholic” can have similar effects.  As a result, terms such as person with a substance (or replace with specific substance) use disorder are preferred.

Person in Recovery

Various terms are used colloquially to label people with substance use disorders, including the terms “clean” and “dirty.”  Clinically accurate, non-stigmatizing terminology that is similar to how we describe other medical conditions is strongly preferred.^7-9   Instead of “clean,” the terms  “negative” (for a toxicology screen) or “person in recovery” or “not currently using substances” are preferred when describing a person.  Instead of “dirty,” the term “positive” (for a toxicology screen) or “a person who is currently using substances” may be used.

Medication Assisted Treatment

With respect to the use of medications in the treatment of substance use disorders, the terms “replacement” and “substitution” have been used to imply that medications merely “substitute” one drug or “one addiction” for another.  This runs counter to the evidence that medication-assisted treatment improves outcomes for patients.^10,11,12,13   Preferred terms include “medication-assisted treatment” or “medicine/medication,” or simply “treatment.”⁹