Words matter

In the United States, only about one in 10 people who need drug or alcohol treatment actually gets it, according to the most recent National Survey on Drug Use and Health. Many people go without treatment because they lack insurance or other resources to pay for it. But the survey found another, more subtle barrier as well: stigma. People avoid treatment because they worry about what their friends, neighbors and employers will think of them if they admit to being a "substance abuser."

It's time to stop using that term and other outdated words that contribute to the stigma, according to John F. Kelly, PhD, director of the Recovery Research Institute at Massachusetts General Hospital. Health-care workers, researchers, government agencies and others should drop the description "substance abuse" in favor of "substance use disorder," among other changes, he says.

"The word ‘abuser' implies volitional acts of willful misconduct, and is associated with things like child abuse," Kelly says. "Saying ‘substance use disorder' conveys something very different — a medical disorder. Substance use is the only thing we talk about this way. People with eating problems are referred to as individuals with eating disorders, never as food abusers."

Kelly spoke about the issue at the White House Conference on Drug Policy Reform in December, the first-ever such meeting sponsored by the Office of National Drug Control Policy. At the conference, Kelly described two studies that show the impact words can have on stigma, even among people educated in mental health treatment.

In one study, he surveyed more than 500 mental health care providers. Each clinician read one of two vignettes about a character with a substance use problem who was in a court-mandated treatment program but had relapsed and had positive urine tests. The vignettes were identical except that in one, the character was described as a "substance abuser" and in the other as someone with a "substance use disorder." He found that the clinicians who read the vignette about the "substance abuser" were significantly more likely to say that the character was personally responsible for his actions and should be punished for them (International Journal of Drug Policy, 2010).

In a similar study with the general public, Kelly found an even stronger correlation between terminology and how people felt about the character in the vignette. He found that the character described as a "substance abuser" elicited less sympathy from participants and that participants were more likely to think that the character could stop his substance use without help if he wanted to (Journal of Drug Issues, 2010).

In order to distinguish among different levels and types of substance-related problems, Kelly suggests, in addition to "substance use disorder," using such non-stigmatizing words as "misuse," "hazardous use," "harmful use" and "unhealthy use."

Michael Botticelli, deputy director of the Office of National Drug Control Policy, says that Kelly's research fits in with the office's focus on shifting from a national drug policy based on the criminal justice system to one that treats it as a public health issue.

"Part of that is reducing stigma and increasing access to treatment," he says. "Fear and shame play a big role as barriers to seeking care, and unfortunately our terminology hasn't caught up with the science in many ways."

Some things won't be easy to change. The word "abuse" is embedded even in the names of federal agencies such as the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration, Kelly points out.

Those names are set by federal statute, but at a day-to-day level agencies can and are changing the words they use, Botticelli says. At the Office of National Drug Control Policy, he says, staff use non-stigmatizing terms in their own communications, and have even reached out to news organizations to talk them about the issue of stigmatizing language in news reports.

"I think [the way people use stigmatizing language] is largely not intentional because people really don't understand the power that language can have," he says.