Since the early 1970’s, the primary Federal agencies that fund substance use prevention and treatment research and services have included the word “abuse” in their names—i.e., the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. These names were established in legislation from an era when abuse reflected the current understanding of this behavioral phenomenon (Kelly and Earnshaw, 2021). The current appropriations legislation pending in Congress today, however, promises to correct what many organizations and institutions have been advocating for over the past several years. The legislation will be renaming all of the Federal substance use-related agencies to remove “abuse” from the names in order to promote language to reduce the stigma associated with the concept. When the appropriations legislation is passed, the names will become:
Substance Use and Mental Health Services Administration
Center for Substance Use Service
Center for Substance Use Prevention Services
National Institute on Drugs and Addiction
National Institute on Alcohol Effects and Alcohol-Related Disorders
The focus on reducing stigma by changing the term “abuse” to “use” is the result of research that found the following (Kelly and Earnshaw, 2021):
Exposure to the terms substance “abuse” and substance “abuser” have been shown to increase stigmatizing and discriminatory attitudes toward individuals suffering from drug and alcohol problems both in the general population and among clinicians.
These terms appear to convey a meaning synonymous with addicted persons choosing to “abuse” drugs, thereby seemingly engaging in “willful misconduct,” increasing attributions of personal blame and increased need for punishment versus treatment.
Such stigmatizing and discriminatory attitudes are associated with suboptimal clinical care delivery among clinicians and lower clinician empathy resulting in patient disempowerment and poorer treatment outcomes.
The American Society of Addiction Medicine (ASAM) (Saitz, et al., 2021) presented these preferred terms when discussing what they called “unhealthy alcohol and other drug use”.
1. Low-risk use (or lower risk) or no use refers to consumption of an amount of alcohol or other drugs below the amount identified as physically hazardous and use in circumstances not defined as psychosocially hazardous….
2. ‘‘Unhealthy’’ covers the entire spectrum including all use related to health consequences including addiction. Unhealthy alcohol and other drug (substance) use is any use that increases the risk or likelihood for health consequences (hazardous use) or has already led to health consequences (harmful use).
They further point out that “unhealthy use” is a useful descriptive term referring to all the conditions or states that should be targets of preventive activities or interventions.
As summarized above, the stigmatizing impact of the concept of abuse can negatively affect the perceptions of substance users by clinicians; and thus potentially affect the quality and effectiveness of care. In addition, stigma discourages people from seeking help for themselves and remains a contributing factor to the very low treatment rates. For example, SAMHSA’s National Survey on Drug Use and Health in 2020 found that among those aged 12 and older reporting substance use disorder in the past year, only 6.5% had received treatment.
Accordingly, several leading Federal organizations have been recommending preferred substance use terminology to help reduce stigma and improve understanding and promotion of treatment for substance use and substance use disorders. In January 2017, the White House Office of National Drug Control Policy (ONDCP), called for changing Federal terminology suggesting “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.” Such negative perceptions can discourage users from seeking help, but also interfere with clinicians’ ability to treat substance users with “person-first language” and focus, which has become the accepted standard for discussing people with disabilities and/or/chronic medical conditions.
NIDA has been promoting “preferred language” in outreach to the public and the clinical community with the attached “Words Matter” summary as a quick guide to reflect some of the current thinking in the field. These terms while mostly focused on substance use disorders can provide a helpful guide for prevention language as well.
Substance Use Language and Prevention
As prevention professionals, we recognize the impact of stigma on our work as we struggle to engage families in prevention; or face denial among community leaders in regard to real substance use problems; or try to bring law enforcement to the table to help support collaborative efforts. While most of our efforts operate at the nonuse and earliest stages of use level, we recognize that we are often responsible for explaining substance use to the community as we try to build support for our prevention efforts. We set the tone of respect and inclusion, at the same time, we try to alert our constituencies to the real threats that we may face.
We invite your comments on these issues. How does stigma affect you in your prevention work? Please write and let us know.
References
Centers for Disease Control and Prevention. National Center for Health Statistics, November 17, 2021.
Kelly, J. and Earnshaw, V. (2021). Society of Behavioral Medicine (SBM) position statement: End the fatal paradox: change the names of our Federal Institutes on Addiction. Translational Behavior Medicine, 11(5):1160-1161
National Institute on Drug Abuse. Words Matter: https://nida.nih.gov/research-topics/addiction-science/words-matter-preferred-language-talking-about-addiction#table; retrieved October 25, 2022
Office of National Drug Control Policy. Changing the language of addiction. 2017.
Saitz, R., Miller, S.C., Fiellin, D.A., and Rosenthal, R.N. (2021). Recommended use of terminology in addiction medicine. Journal of Addiction Medicine, 15(1):3-7. doi: 10.1097/ADM.0000000000000673. PMID: 32482955.