Don’t Call Me an Addict or a Victim

By April Wilson Smith, MPH 10/27/16

"When you call me an 'addict,' you make a judgment based on just one fact about my life. That makes me not want to trust you to help me when I’m sick.”

Don’t Call Me an Addict or a Victim
Break through stigma.

“Drunks, junkies, crackheads, potheads, dirty urine.” If addiction is a disease, why do so many people continue to use these terms? Although there is widespread agreement that such terms are stigmatizing, and that stigma prolongs suffering and interferes with positive outcomes, it remains pervasive. Stigma prevents people from entering treatment and promotes criminal justice interventions instead of biopsychosocial approaches. Are even the commonly used terms "addict" and "alcoholic" stigmatizing? April Wilson Smith speaks from personal experience about the impact of language…Richard Juman, PsyD

As a harm reduction researcher in an academic medical center setting, I’m often asked by clinicians for suggestions on how to refer to people who use drugs. Many are recognizing that the words "addict" and "alcoholic" are stigmatizing, and that identifying a person by the behavior that once caused or currently causes problems is not empowering that person to make positive change.

Here are some suggestions: 

1. Stick to the facts, not judgments.

Much of the academic literature simply uses the phrase, "People who use drugs." When discussing people who use IV drugs, "IV drug users" is common.

A participant in the SMART Recovery meeting that I facilitate said, “When you call me an ‘addict,’ you reduce my entire life into that one thing, that I used drugs. You don’t know anything else about me—like I’m good at math, I help my friends get clean needles, and I take care of my grandmother who has trouble getting around. When you call me an 'addict,' you make a judgment based on just one fact about my life. That makes me not want to trust you to help me when I’m sick.” 

2. Recognize that most people who use drugs never become addicted.

Yes, that's true.

Most people who get pain medication after surgery never become addicted, even if they develop a physical dependence. After the pain is gone, they wean off the drug and go on with life, never even thinking of using the drug in another context. The social environment and psychological history of the person are critical in determining whether or not someone develops a psychological dependence on a drug. Drug addiction is not like the flu, and drugs are not like a virus.

This is why I prefer to say, "People whose relationship to a substance causes them difficulty." For those who are not having problems as a result of substance use, we in public health need not intervene. 

Similarly, most people who at one point drink problematically do not remain addicted to alcohol, and most recover on their own, without AA or rehab. Most go on to drink safely, and do not need to maintain abstinence for life.

According to Stanton Peele, “The National Institute on Alcohol Abuse and Alcoholism (NIAAA) interviewed 43,000 Americans about their lifetime substance use. Remarkably, the research (called NESARC) shows that the majority of people eventually overcome addictions. Three-fourths of people will recover from alcoholism within 20 years of its onset. Abstinence and AA are not the only ways to beat an addiction—they are the minority routes: 75 percent of alcoholics recover on their own without rehab or AA. And over half of those who recover from alcoholism cut back instead of abstaining totally.”

One of the participants in a research project said, “I don’t tell my health care providers that I used to drink too much. I’m glad they can’t find the records of my hospitalizations. I don’t have a problem with alcohol now, but I know that if they knew I went to rehab, even though it was years ago, they’d treat me like a second class citizen.” 

3. It's a relationship.

Patt Denning, Jeannie Little and Adina Glickman write in Over the Influence that people have relationships with drugs, just like we have relationships with other people, our pets, our workplace, etc. Relationships with drugs are no different, except that our society has decided to stigmatize and criminalize some drugs, but not others.

You would never label someone who got into an abusive relationship with a boyfriend who was abusive a "victim" for life. Labeling people who have difficulty in their relationship to a substance with permanent labels such as "addict" is both inaccurate and cruel.

“After my parents were killed in a car crash, I got into a lot of trouble with alcohol,” said one of my meeting participants. “I never thought of myself as an ‘alcoholic,’ but the more they told me that’s what I was, the more I started to believe it. The more treatment I got, the harder it got to stop because they kept telling me I was this thing. I thought I had no choice but to do what they said I’d do—keep drinking. It wasn’t until I left treatment and left AA altogether that I figured out that I’m not a damaged or diseased person, I was a person going through a hard time. These days, though, I usually choose not to drink. I can have a glass of wine at a social event and be just fine. I know I’m the one in control.”

4. People have the right to choose their own identity.

Most of us are supportive of the right of people to identify as gay, lesbian, transgender or gender non-conforming. You would not tell a trans man who identifies as "he" that he must go by "she."

The same rights apply to people who choose to use substances that our society currently stigmatizes or criminalizes. It is not up to you, me, a doctor or psychiatrist or psychologist, to define an individual as "addict" or "alcoholic." Even the DSM describes a continuum of relationships to substances that ranges from mildly problematic to very dangerous.

I personally argue against diagnosis of any kind. Though it may be a necessary evil for those who need to bill a client's insurance, people are not collections of diagnosis codes. A diagnosis encourages a person to behave the way they think people with that diagnosis behave. Tell someone they have a panic disorder, and they will panic. People should be encouraged to define themselves, and offered options of positive labels. As a person who has experienced sexual assault, I always preferred the term "survivor" to "victim." I think you would agree that I have the right to choose my own term. 

Meghan Ralston wrote persuasively about breaking up with the word “addict.” We, as health care professionals, need to stop labeling our patients and clients with this stigmatized label. 

“Keep your labels off my body,” said a woman I worked with, a feminist who works in reproductive rights.

“A few years ago, I used drugs that happen to be illegal. I don’t use them anymore, though I use pot recreationally and it’s legal where I live. I don’t accept the label of 'addict' because I don’t need to order my life around NA meetings and confessions of my sins to a sponsor. What I put into my body is my business, and you can’t force me to wear your label like the Scarlet Letter.” 

5. People have the right to privacy. Yes, even in their medical care. Even in their mental health care.

Sticking with the sexual assault analogy from above: while the moment in my life when I was assaulted had long-ranging effects, it's not something I choose to discuss on a regular basis. I suspect you would respect my privacy in that regard. I don't discuss it with my primary care physician. I only discussed it with my therapist after I had worked with her for months and she had gained my trust.

People's use of a substance is a private matter, unless they choose to make it public. Yes, it would be helpful to therapists and counselors to know about this aspect of people's lives. However, it must be the person's decision whether or not to discuss this information. Controlling access to information about oneself is key to developing an autonomous identity.

Above all, never disclose a person's drug use to another person, unless the situation is truly a medical emergency. This is a traumatic violation of a person's autonomy and privacy. I can't count the number of times I've seen people's drug use escalate dramatically after it was disclosed to family members, employers or medical professionals without the person's consent. Whatever you've seen on TV about interventions is wrong. Violating people's privacy is just that—a violation—and can be as painful as a physical violation of their bodies.

The more compassionate a health care provider is, the more likely a patient will be forthcoming about his or her use of substances. Asking the right questions, in a non-judgmental fashion, is the best way to gain a patient’s trust and honesty. Patients who have been treated with contempt by health care providers—and we all know of instances where nurses or other clinicians have talked about “the junkie in the bed over there”—are less likely to share openly. As we know, a lack of transparency between patient and provider can lead to inadequate treatment and poor outcomes. By using neutral or supportive language, such as “a person who is working to change her relationship with x,” we can help mend the fractured patient-provider relationship and build a foundation for ongoing quality care. 

“After I had a crisis with alcohol, a supposed ‘friend’ went around interviewing my friends about my drinking and my sexual activity,” said a woman I work with extensively. “Seriously, I am not making this up. He published a long email chain with responses to what was supposed to be private emails, detailing the drinks I’d had and who I’d slept with. My family, therapist and psychiatrist were all horrified. I almost drank myself to death the night I read the emails. I ended up in the emergency room after I passed out on the street. His actions very well could have killed me.”

6. You never know who is in the room.

In one of my PhD classes, a fellow student referred to "drug seeking addicts." She had no way of knowing that just that morning, I had found out that a close family member had died after a 30 year long battle with prescription drugs. This description hurt me, as I remembered my family member’s battles to obtain even adequate health care for his multiple medical conditions in the years before he died. I had to hold back tears.

You never know who you're talking to. The well-dressed CEO might be currently using cocaine. Your nurse may have lost a child to a heroin overdose. Speak about people who use drugs the way you would speak about your brother, sister, son or daughter. You can never go wrong with respect and compassion. Imagine that in every room you walk into, there is someone who has lost a child to an overdose and someone who is currently struggling with their relationship to a substance. Choose your words with respect for these people.

I was in the emergency department of the hospital where I work when I started talking about my research. A nurse asked to speak to me privately. Sure enough, her daughter had died of an overdose. She was very upset because she heard fellow care providers speaking cruelly of people who use drugs. She was afraid to speak out, and wanted to know if I could help educate health care professionals about more compassionate ways to treat people who use drugs. 

She is the inspiration for the work I do now. 

7. This isn't about "political correctness." It’s about life and death.

People who use substances problematically are often in danger. The social and legal reasons are beyond the scope of this article, but remember that words can hurt. The choice between using a stigmatizing term and using a neutral or supportive term can make a difference in whether or not someone overdoses or feels safe seeking help. Choose wisely.

April Wilson Smith has a Masters Degree in Public Health and is a PhD candidate at Jefferson College of Population Health with a focus on harm reduction strategies in health care. She is a Certified SMART Recovery Facilitator and is Harm Reduction Epidemiologist at Families for Sensible Drug Policy. She can be reached at [email protected]

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April Wilson Smith, MPH, is the Director of Organizational Development for HAMS (Harm Reduction, Abstinence and Moderation Support). She holds a Master of Public Health from Thomas Jefferson University, where she focused on harm reduction approaches to problems with substances and mental health. She presented Masters' thesis work on the experience of LGBT individuals in traditional 12 Step rehab at the 2016 Harm Reduction Coalition national conference. She teaches in urban public schools in Pennsylvania.