Stigma and Discrimination

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  • Although substance use disorders are chronic and treatable medical conditions, studies show people with these disorders still face discrimination and stigma (a set of negative attitudes and stereotypes) that can impact their health and well-being in numerous ways. This stigma also affects people who use drugs who do not have a substance use disorder.
  • There are safe, effective, and lifesaving tools available to help people struggling with substance use. However, stigma often factors into the reasons why people who need help do not seek care.
  • Research shows the language we use contributes to stigma and discrimination against people with substance use disorders, including by healthcare professionals.

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Learn how to choose words that reduce stigma when talking about addiction: Words Matter: Preferred Language for Talking About Addiction
What is stigma against substance use and addiction? Why does it occur?

The stigma against people with substance use disorders is a set of negative attitudes and stereotypes that can create barriers to treatment and make these conditions worse.1 Although substance use disorders are chronic, treatable medical conditions, studies show people who have them often face stigma and discrimination in part because others do not understand these disorders or how they can be effectively treated.

Many people do not know that a substance use disorder is the result of changes in the brain that make drug use compulsive (difficult or impossible to stop without adequate support).2 Some people with severe substance use disorders may become aggressive, lie, or steal to support their drug problem or during withdrawal. These behaviors may alienate them even further from family, friends, and society and reinforce certain negative stereotypes around substance use.1 Importantly, the compulsive behaviors and brain changes in substance use disorders are not necessarily permanent. People can and do recover, especially with the help of treatment.3,4

There are many reasons why a person may be more susceptible to substance use disorders, including genetic and social factors that may be beyond their control.2 Still, many people see addiction as a personal or moral failure.5 As a result, people may feel fear and anger toward someone with a substance use disorder, even if they are a friend or family member.6 For many, it can be hard to see – and help – the individual behind the illness.

How do language and criminalization perpetuate stigma against people who use drugs or have substance use disorders?

Commonly used terms referring to people with addiction often reflect the misconception that their drug use and related behaviors are a choice, rather than a compulsion, and that they are to blame for their medical condition. Studies show that terms like “junkie” and “addict” feed negative biases and dehumanize people.7,8 Research shows that language can even sway clinicians’ attitudes. In one study, clinicians rated a person described as a “substance abuser” as more worthy of blame and punishment than someone described as “having a substance use disorder.”9

Treating drug use as a criminal activity may also contribute to the stereotype of people who use drugs as being dangerous and a risk to society. It can further marginalize disadvantaged groups. For example, in the United States, punitive policies disproportionately affect Black people and communities of color, who are more likely to be arrested for illegal drug use.10,11 Black people were nearly four times more likely to be arrested for cannabis possession than white people in 2018, even though the two groups use the drug at similar rates.12

How does stigma affect people with a substance use disorder?
  • People who need care may not seek it. People with substance use disorders may face mistreatment, stereotyping, and negative bias from society, including in healthcare settings. These challenges may lead them to avoid seeking medical help.13 In fact, in 2020, about 12% of people who felt they needed substance use treatment but did not receive it in the past year said they did not seek treatment because they feared attracting negative attitudes from their communities.14
  • People fear disclosing their substance use. If a person conceals their substance use in a medical setting due to fear of bias or mistreatment, they may miss important opportunities for care. For example, clinicians may not know to offer information about how drugs may interact with their prescribed medications or may not screen them for conditions related to substance use, like HIV, hepatitis, and mental illness.15 Pregnant women especially may avoid talking about substance use, feeling shame and fearing social disapproval or loss of parental rights.16
  • People receive a poorer quality of care. Some health professionals also have bias toward people with addiction and may fail to provide evidence-based care as a result. A national survey of primary care providers in 2019 showed that while they generally understood opioid use disorder is a treatable condition, most also had stigmatizing attitudes against it, which affected the care they provided.17

    Racial disparities and other kinds of discrimination add an extra barrier to care for many people in health care settings. For example, Black people experience delays of up to five years in getting treatment for a substance use disorder compared to White people, and young Black people are less likely to be prescribed medication for opioid use disorder than their White peers.18,19
  • People have reduced access to health programs. Medications for opioid use disorder, including methadone, buprenorphine, and naltrexone, are safe and effective treatments that help people recover.20 Yet because they must be taken regularly, and because methadone and buprenorphine can produce euphoria (a “high”) in people without opioid use disorder, these medicines are often mistakenly seen as mere substitutes for illegal drugs and carry a similar stigma.21

    Similarly, syringe services programs, also known as needle exchanges, help link people to addiction treatment and help prevent health risks associated with using drugs, including HIV, hepatitis, and endocarditis. Yet some people shy away from these programs, fearing stigma from police, friends, family, and healthcare professionals.22 However, many cities and towns have been slow to implement these and other harm-reduction programs, due in part to stigma-related policy and funding challenges. and the misconception that they promote illicit drug use.23,24
  •  People may increase their substance use. People with substance use disorders may already feel guilt and may blame themselves for their illness.25 They may have self-stigma, or adopt negative attitudes towards themselves around their substance use.26 These feelings of shame and isolation may in turn reinforce drug-seeking behavior.27

How can we address stigma against people with substance use disorders?

Every person in our society can play a role in reducing stigma and discrimination against people with substance use disorders—from health professionals and addiction researchers to the general public and those directly affected by drug and alcohol problems.

  • Understand substance use disorders as chronic, treatable medical conditions. To eliminate the stigma surrounding substance use disorders, we need to see these disorders for what they are: chronic, treatable medical conditions. People with substance use disorders deserve compassion and respect—not blame for their illness. Learn more about substance use disorders.

    The medical community can also better train health professionals on how to treat patients with substance use disorders. This begins with ensuring clinicians approach these disorders as treatable, chronic health conditions and use appropriate language.28 The NIDAMED website includes evidence-based screening tools, treatment resources, and continuing education for providers and providers-in-training.
  • Replace stigmatizing language. An important step toward eliminating stigma is replacing stigmatizing language with preferred, empowering language that doesn’t equate people with their condition or have negative connotations.29 However, people experiencing substance use disorders or in recovery may choose to describe themselves and their own disorder with terms that work best for them, especially in certain contexts such as recovery support groups.30,31 NIDA has developed Words Matter: Preferred Language for Talking About Addiction, a guide for the general public on non-stigmatizing language.

    Choosing appropriate language is of particular concern for health professionals. NIDA has developed the guide Words Matter - Terms to Use and Avoid When Talking About Addiction for health professionals and trainees. NIDA has also developed Your Words Matter – Language Showing Compassion and Care for Women, Infants, Families, and Communities Impacted by Substance Use Disorder, a guide for clinicians on discussing substance use with pregnant patients and mothers.
  • Address systemic discrimination. Systemic racism, sexism, and other forms of discrimination lead to multiple layers of stigma for many people with addiction. Just the stress of feeling discriminated against can increase the likelihood that someone will use substances.32 NIDA conducts and supports research to better understand stigma’s impact on marginalized groups, and on interventions that promote equitable, effective treatment and services. NIDA also funds research on the effects of alternative ways of regulating and decriminalizing drugs in countries that already have these policies.12 
How does NIDA research address stigma and discrimination?

NIDA’s research on the biomedical and environmental factors around substance use and addiction contributes to an evidence-based understanding of substance use disorders. This helps bust myths and upend stereotypes and promotes appropriate treatment and services. NIDA also conducts and supports research into stigma’s causes and effects, and interventions that work to confront it.

References
  1. Volkow ND. Stigma and the toll of addictionNew England Journal of Medicine. 2020;382(14):1289-1290. doi:10.1056/nejmp1917360
  2. Volkow ND, Koob GF, McLellan AT. Neurobiologic advances from the brain disease model of addictionNew England Journal of Medicine. 2016;374(4):363-371. doi:10.1056/nejmra1511480
  3. Volkow ND, Chang L, Wang GJ, Fowler JS, Franceschi D, Sedler M, Gatley SJ, Miller E, Hitzemann R, Ding YS, Logan J. Loss of dopamine transporters in methamphetamine abusers recovers with protracted abstinenceJ Neurosci. 21(23):9414-9418, 2001.
  4. Volkow ND, Boyle M. Neuroscience of Addiction: Relevance to prevention and treatmentAm J Psychiatry. 2018;175(8):729-740. doi:10.1176/appi.ajp.2018.17101174
  5. Zgierska AE, Miller MM, Rabago DP, et al. Language matters: It is time we change how we talk about addiction and its treatmentJ Addict Med. 2021;15(1):10-12. doi:10.1097/ADM.0000000000000674
  6. Yang LH, Wong LY, Grivel MM, Hasin DS. Stigma and substance use disorders: an international phenomenonCurr Opin Psychiatry. 2017;30(5):378-388. doi:10.1097/YCO.0000000000000351
  7. Muncan B, Walters SM, Ezell J, Ompad DC. "They look at us like junkies": influences of drug use stigma on the healthcare engagement of people who inject drugs in New York CityHarm Reduct J. 2020;17(1):53. Published 2020 Jul 31. doi:10.1186/s12954-020-00399-8
  8. Ashford, R.D., Brown, A. and Curtis, B. Expanding language choices to reduce stigma: A Delphi study of positive and negative terms in substance use and recovery. Health Education. 2019; 119(1), 51-62. doi.org/10.1108/HE-03-2018-0017
  9. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used termsInt J Drug Policy. 2010;21:202–7. doi.org/10.1016/j.drugpo.2009.10.010
  10. Mitchell O, Caudy MS. Examining racial disparities in drug arrestsJustice Quarterly. 2013;32(2):288-313. doi:10.1080/07418825.2012.761721
  11. National Center on Addiction and Substance Abuse, Columbia University. Behind Bars II: Substance abuse and America’s prison population. Published February 2010. Accessed June 9, 2020.
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  14. Substance Abuse and Mental Health Services Administration. (2021). Key substance use and mental health indicators in the United States: Results from the 2020 National Survey on Drug Use and Health (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Available at: https://www.samhsa.gov/data/. Accessed Nov. 8, 2021.
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  16. Frazer Z, McConnell K, Jansson LM. Treatment for substance use disorders in pregnant women: motivators and barriersDrug Alcohol Depend. 2019 Dec 1;205:107652. doi: 10.1016/j.drugalcdep.2019.107652
  17. Stone EM, Kennedy-Hendricks A, Barry CL, Bachhuber MA, McGinty EE. The role of stigma in U.S. primary care physicians’ treatment of opioid use disorderDrug and Alcohol Dependence. 2021;221:108627. doi:10.1016/j.drugalcdep.2021.108627 
  18. Lewis B, Hoffman L, Garcia CC, Nixon SJ. Race and socioeconomic status in substance use progression and treatment entryJ Ethn Subst Abuse. 2018;17(2):150-166. doi:10.1080/15332640.2017.1336959
  19. Hadland SE, Bagley SM, Rodean J, et al. Receipt of timely addiction treatment and association of early medication treatment with retention in care among youths with opioid use disorderJAMA Pediatr. 2018;172(11):1029-1037. doi:10.1001/jamapediatrics.2018.2143
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  21. Madden EF, Prevedel S, Light T, Sulzer SH. Intervention stigma toward medications for opioid use disorder: A systematic review. Subst Use Misuse. 2021;56(14):2181-2201. doi:10.1080/10826084.2021.1975749
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  23. Jones CM. Syringe services programs: An examination of legal, policy, and funding barriers in the midst of the evolving opioid crisis in the U.SInt J Drug Policy. 2019;70:22-32. doi:10.1016/j.drugpo.2019.04.006
  24. National Research Council (US) and Institute of Medicine (US) Panel on Needle Exchange and Bleach Distribution Programs; Normand J, Vlahov D, Moses LE, editors. Preventing HIV transmission: The role of sterile needles and bleach. Washington (DC): National Academies Press (US); 1995. 7, The Effects of Needle Exchange Programs.
  25. Hammarlund RA, Crapanzano KA, Luce L, Mulligan LA, Ward KM Review of the effects of self-stigma and perceived social stigma on the treatment-seeking decisions of individuals with drug- and alcohol-use disorders - PubMed (nih.gov)Substance Abuse and Rehabilitation. 2018:115-136. doi:10.2147/sar.s183256
  26. Volkow, N.D., Gordon, J.A. & Koob, G.F. Choosing appropriate language to reduce the stigma around mental illness and substance use disorders. Neuropsychopharmacology. 2021. doi:10.1038/s41386-021-01069-4
  27. Volkow ND. Stigma and the toll of addictionNew England Journal of Medicine. 2020;382(14):1289-1290. doi:10.1056/nejmp1917360
  28. Kelly JF, Wakeman SE, Saitz R. Stop talking ‘dirty’: Clinicians, language, and quality of care for the leading cause of preventable death in the United StatesThe American Journal of Medicine. 2014;128(1):8-9. doi:10.1016/j.amjmed.2014.07.043
  29. Kelly, JF, Saitz, R, Wakeman, S (2016). Language, substance use disorders, and policy: the need to reach consensus on an “addiction-ary”Alcohol Treat Q. 2016;34(1), 116-123. doi:10.1080/07347324.2016.1113103
  30. Pivovarova E, Stein MD. In their own words: language preferences of individuals who use heroinAddiction. 2019;114(10):1785-1790. doi:10.1111/add.14699
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  32. Amaro H, Sanchez M, Bautista T, Cox R. Social vulnerabilities for substance use: Stressors, socially toxic environments, and discrimination and racismNeuropharmacology. 2021;188:108518. doi:10.1016/j.neuropharm.2021.108518

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