On paper, Robert Ashford, MSW, has a bright future: He's a doctoral student in health policy and a graduate research assistant at the Substance Use Disorders Institute at the University of the Sciences in Philadelphia. In reality, he has had to overcome many obstacles and continues to face many more. As a person in recovery from a substance use disorder since 2013, Ashford has faced housing discrimination and barriers to accessing and financing his education.
"All of my research and advocacy work draws on my lived experience with a substance use disorder and the discrimination and bias I've faced over the last six years," he says.
These and other discriminatory practices are rooted in stereotypes of people with opioid use disorder. This population is often seen as criminals, poor employees and lacking a moral compass. Not only do such biased attitudes fuel unfair treatment toward people who use substances, they can also undermine health-seeking behaviors (Brener, L., Drug and Alcohol Review, Vol. 29, No. 5, 2010).
"People who feel more stigmatized are less likely to seek treatment, even if they have the same level of addiction severity," says John Kelly, PhD, founder and director of the Recovery Research Institute at Massachusetts General Hospital in Boston and associate professor of addiction medicine at Harvard Medical School. "They're also more likely to drop out of treatment if they feel stigmatized and ashamed."
As part of a broader effort to spread destigmatizing messages, psychologists are studying stigmas among various populations, getting involved with policy efforts and educating the public about addiction. "There are roughly 22 million people in recovery for substance use disorders in the United States, but you may not even know that your colleague or neighbor is one of them because of the high degree of stigma," Ashford says. "We shouldn't have to live in a society where people can't disclose their history of addiction."
Language, identity and stigma
The stigma against substance use runs deep. It's embedded even in the language we use to describe it, which is often medically inaccurate and can do more harm than good (see How to talk about addition).
For example, the commonly used terms "drug abuse" and "drug abuser" carry an implicit association with physical, sexual or emotional abuse.
"This gives rise to the idea that people with addiction are willfully and maliciously engaging in substance misuse, when in reality they have lost the choice of use," says David Eddie, PhD, clinical psychologist and research scientist at Massachusetts General Hospital's Recovery Research Institute.
In a study, Kelly found that physicians and clinical psychologists exposed to the term "substance abuser" in a vignette were more likely to blame a hypothetical patient for his or her condition than were those exposed to the phrase "having a substance use disorder." Clinicians in the first group were also more likely to say that punishment was required as opposed to treatment (International Journal of Drug Policy, Vol. 21, No. 3, 2010).
"Words matter—the words we use convey what's normal and frame how clinicians, health professionals and society at large view a problem," says Howard Koh, MD, MPH, a professor in Harvard's T.H. Chan School of Public Health and former assistant secretary for health at the U.S. Department of Health and Human Services. "If we don't choose our words carefully, we perpetuate bias, cloud understanding and end up distancing ourselves from the people we want to help."
As a result of research by Kelly and others, Michael Botticelli, director of the White House Office of National Drug Control Policy during the Obama administration, initiated changes in language use at the federal level. In 2015, the International Society of Addiction Journal Editors also agreed to remove the terms "abuse" and "abuser" from addiction journals around the world, and in 2017, the Associated Press recommended that journalists use nonstigmatizing language when reporting on substance use disorders.
Other research has explored how stereotypes about addiction interact with racial, gender and other biases to affect different groups in different ways. For example, Kimberly Goodyear, PhD, and colleagues conducted a nationwide survey of more than 2,600 people, using vignettes to measure stigmatizing attitudes, and found that males and individuals who started using opioids not prescribed by their doctors were rated more negatively (Drug and Alcohol Dependence, Vol. 185, 2018).
Stigma even exists within the recovery community. Compared with those in abstinence-based recovery programs, people who rely on safe injection sites or medications such as methadone and buprenorphine in their treatment are viewed by others in recovery as not being truly sober, says Kelly, even though such treatments significantly reduce overdoses and cravings and increase the chances of remission.
How psychologists can help
Studies also indicate that the public understanding of addiction, while not entirely accurate, may be more nuanced than previously thought. A survey of 1,300 community college students and administrators, conducted by Ashford and his colleagues, found that many Americans believe that addiction is both a disease and a moral failing (Substance Use & Misuse, in review). "We need to better understand how people conceptualize this problem so we can develop health messaging that can both reduce stigma and support evidence-based practices," Ashford says.
Moving forward, psychologists can continue to study—and use—medically accurate language around opioid use disorder. They can also promote the use of nonstigmatizing language among health-care providers, politicians, journalists, law-enforcement officers and other groups involved with the opioid crisis.
More extensive education in medical schools and psychology doctoral programs around the genetic and neurobiological bases of addiction can also increase compassion, reduce blame and cut back on discriminatory practices among health-care providers, Kelly says. For example, research shows that genetics account for roughly half of a person's addiction risk, while chronic exposure to opioids leads to measurable changes in brain activity and structure.
And perhaps most important, psychologists—especially those who work with people recovering from addiction—can help redefine what recovery looks like by providing what Kelly calls "personal witness" to addiction and recovery. This may include inviting people in recovery to speak to faculty, staff or patients or partnering with a national anti-stigma effort such as Faces and Voices of Recovery, which uses online networking to strengthen the recovery community.
"To fight these stigmas, we first need to normalize the process of recovery, providing positive examples of what recovery looks like," Kelly says. "When people see that up close, their stereotypes begin to break down."
