How to write about addiction without promoting stigma and bias: 4 tips for journalists

maia-szalavitzThe following guest post is by Maia Szalavitz, a journalist and author who writes frequently about addiction and drugs. She writes for TIME.comVICE, and the New York Times, among others, and is the author, most recently, of the New York Times bestseller, Unbroken Brain. She tweets as @maiasz.

As journalists, we know that the language we use matters. Many of us have worked hard to reduce the use of biased and stigmatizing wording when covering mental health. Unfortunately, this same care doesn’t always extend to the way we write about addiction—and this is adding to the public and political confusion over whether it is truly a moral or a medical problem.

Addiction may be unique among medical disorders in that some people who show symptoms (i.e. the compulsion to obtain illicit drugs) can be jailed simply as a result. We do not incarcerate people with diabetes for donut possession when they fail to maintain a healthy diet, nor do we arrest those who fail to exercise enough to bring their blood pressure down. But we do incarcerate thousands of people with addiction for possession of cocaine, heroin, marijuana and other substances.

Addiction is also the only disorder for which 80% of mainstream treatment involves promoting confession, prayer, surrender to a “higher power” and restitution, via instruction on twelve-step programs—treatment that would be viewed as “alternative” for cancer, depression or any illness. Moreover, it’s the only disorder in which judges, jails and prisons are legally permitted to deny access to the only treatment (opioid agonists like methadone and buprenorphine) proven to reduce the death rate by 50% or more.  All of this—in conjunction with the language we continue to use about it—suggests, at best, ambivalence about addiction as a health problem.

Consequently, if journalists are to cover addiction in an accurate way, we need to be extremely careful that the language we use does not reflect the history of moralizing, racism and bias that has marked the war on some drugs.  Here are some tips that can help:

1) Use “person first” language.  Yes, this is clunky, but as we increasingly move toward less stigmatizing language for mental health disorders — “people with depression,” not “depressives,” for example — it’s biased not to extend that same language to people with addiction. “Addict” is not an appropriate term. Using slurs like “junkie” or “druggie” or “crackhead” is even more problematic: unless people with addiction use these terms to refer to themselves, it’s no more appropriate than using similarly derogatory language about mental illness or minority groups.

addiction-terminology

2) Use appropriate DSM terminology. First, understand what addiction is. The NIDA defines it as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” This is important context for understanding changes in the DSM-5, the latest edition of psychiatry’s diagnostic manual, which updated its terminology for addictive disorders to reduce confusion and stigma.

The mild diagnosis— formerly called “substance abuse”— referred to people like college binge drinkers and others with drug problems that are potentially hazardous, but not long term or compulsive (and therefore not necessarily “addictions”). This is now called mild “substance use disorder” (SUD). The change was made because the term “substance abuse” connected drug users with child abuse, sexual abuse, etc.— and research finds that it increases stigma. Also, you can’t abuse a poor, innocent little drug. “Misuse” is OK for substance problems short of addiction.

Note: The National Institute on Drug Abuse (NIDA) would have dropped the term in its name but it takes an act of Congress for an NIH agency to make such a change and today’s Congress doesn’t act. NIDA is supportive of using alternative language, however.

The severe diagnosis—formerly called “substance dependence”—also has a new name.  It is now “moderate to severe substance use disorder.”  This change was made because dependence is not actually what goes wrong in addiction. As noted above, addiction—or if you like, severe SUD— is drug use or other behavior (e.g. gambling) that occurs despite negative consequences.

Dependence is simply needing a substance to function and so, dependence can occur without addiction, as happens with insulin for diabetes and oxygen for all of us.  Addiction can also occur without dependence:  people who are addicted to crack do not get physically ill when the drug is not available (though they do get irritable).  Ironically, calling addiction “dependence” had the effect of making cocaine appear to be not particularly addictive.

Moreover, people on maintenance treatment for opioid addiction with buprenorphine or methadone and people taking long term opioids for chronic pain are typically physically dependent on opioids— but if the treatments are working, these are NOT addictions.  That’s because the effects of the medications are positive and do not involve compulsive behavior occurring despite negative outcomes.

Yes, it’s extremely wordy to use “severe substance use disorder” every time you mention addiction – but if you are going to use the phrase “substance use disorder” without the “severe” modifier, be aware that it now encompasses drug problems, such as college binge drinking, that may fall short of addiction because they are not compulsive in nature.

To get around this problem, I generally avoid the DSM terminology. I use “addiction” for what was formerly called “dependence” (i.e. the severe form of the disease) and “misuse” for milder forms, which were previously called “abuse.” This also allows non-problematic drug use, which is the majority of all drug use, to simply be called “use.”

3) Recognize that babies cannot be “born addicted.”  As is clear from the above definitions, a baby can be physically dependent on opioids and suffer withdrawal after in utero opioid exposure. However, babies cannot be addicted because they do not know what they crave and therefore cannot seek drugs despite negative consequences to ease their cravings. (Also, it’s hard to score when you can’t even crawl or talk).

Research on children exposed to cocaine in utero showed that labeling them as “crack babies” was actually more harmful to their development than cocaine exposure itself because it led to maltreatment and lowered expectations.  Labeling babies born to mothers who use opioid maintenance treatment as “addicted” is especially dangerous because ongoing opioid maintenance treatment is the safest treatment for women who become pregnant while actively addicted or who are already in maintenance treatment.   Forgoing such medication can kill the fetus— it doesn’t prevent babies from becoming “addicted.”

4) Don’t use “clean” to refer to people in recovery or to urine testing that is negative for drugs.  We don’t say that people in remission from cancer are “clean,” nor do we call a negative HIV test “clean.”  We don’t call people who have active cancer “dirty”— nor should we use such loaded language to refer to those who have drug problems.  If you want to refer to someone whose drug problem has been resolved, “in recovery” or “formerly addicted” are preferable to “clean.”  (“Sober” is sometimes OK for alcohol recovery, but it’s not preferred by many because there are some people in recovery from illegal drug addictions and even alcoholism who drink alcohol moderately.)

Stigma and bias contribute to our failure to provide evidence-based treatments to people with addictions. Journalists can avoid making the problem worse by taking care with the language they use and avoiding terms that promote misconceptions.

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Comments (6)

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Deborah Garrett

September 28, 2016 at 8:59 am

I work for a recovery community organization in Detroit who battle this stigma all day, every day. Thank you for this piece!

ben sears

September 28, 2016 at 11:57 am

“the term “substance abuse” connected drug users with child abuse, sexual abuse, etc.— and research finds that it increases stigma.”

hmm, not sure i completely agree with this advice. the stigma –or lack thereof — of all terms such as “substance abuse” evolves over time. throughout all of human history, we have used varying terms to characterize others, for better or worse. the terms which you verbosely advocate in this piece may well have the opposite of your desired effect in short order.

Rich Saitz

September 29, 2016 at 7:11 am

Excellent piece.
2 minor comments–
First, the main reason DSM got rid of abuse was not because it is pejorative. It was because Abuse and dependence were not easily distinguished other than by severity. So disorder puts them on the same spectrum.
Second, I don’t think misuse is a great term. In healthcare it is used for when you take the wrong dose of a medicine or too frequently. But in this case the drug is being used as the person wants to. More importantly it is imprecise. Some (like the VA) use it to mean the full spectrum of unhealthy use which I find a bit insulting at both ends. Someone who uses on the mild end isn’t really misusing. More importantly someone with a brain disease isn’t simply misusing. The WHO calls use that risks consequences but without any yet hazardous. That’s not a bad term. ASAM likes that too or also suggests “at risk” or risky. Those are good options for that end of the spectrum.
Again thanks for laying this out very nicely.
As to whether it will impact stigma and care, I hope it does but that is an empirical question. Some atudiws already suggest it will have such a favorable effect but some others do not.

Harold A. Maio

September 29, 2016 at 10:07 pm

Please substitute “stigmatizing” for “stigma”. It is the act of stigmatizing you want to address, rather than say “stigma”, and lend credence to those who stigmatize.

THank you.

ral roncan

October 5, 2016 at 12:31 am

I think the first thing to do would be to use phrases like ‘alcohol and OTHER drugs’ … as things stand, it’s always ‘alcohol OR drugs’, as if alcohol isn’t a drug, when it’s actually the second-biggest killer after tobacco.

Tom Lewis

October 16, 2016 at 5:25 pm

Thank you for an excellent post! Being a psychotherapist I have seen an evolving path of change to hopefully reduce and eventually remove the stigma of this disorder from those afflicted. Your comparisons to cancer and diabetes are spot on. Rich Saitz comment on replacing “misuse” with “hazardous, at risk or risky” makes sense. Ral Roncan’s comment to use phrases like ‘alcohol and OTHER drugs’ is most valid. All professionals (medical and clinical) need to remember that alcohol and tobacco (nicotine) are drugs that kill the most humans. Thanks again for your post.