The language we use is a vivid reflection of the type of society we wish ourselves to be. A compassionate society that believes in equity, equality and justice must strive to stamp out words or terms that belittle, that ostracize and that exclude.
The old adage that sticks and stones hurt but names don’t is a lie. Language and imagery perpetuate exclusion and marginalization. They can hurt and demean. While progressive societies have generally accepted that it is unacceptable to humiliate people for their gender, sexual identity, physical impairment or race, a crisis of addiction in North America has shown us that we haven’t come as far as we think, including those of us in the media.
Sure, terms like “broad,” “whore,” “slut” and “tramp” are rightly reviled as sickening misogyny. We rightly recoil when words like “fag,” “retard” and “wetback” are used. They are offensive in the extreme and often would be considered hate speech. But when we talk about people living with addiction, there remain embers of bigotry and hatred in our language, even the language of those who don’t consider themselves to be bigots and haters. People who are unable to control their substance use are “addicts” or “junkies.” Only when they are abstinent are they “clean.” Otherwise, they’re “dirty.”
A 2001 study by the World Health Organization found that drug addiction was the most stigmatized condition internationally. A 2010 paper in the International Journal of Drug Policy found that even among clinicians there was prejudice toward patients with addiction, connected to particular phraseology, and a 2013 study found that such negative perceptions of patients could result in suboptimal health outcomes. These results show the corrosive impact that language can have on perception, and to the extent that we as a society can address it, we will go a long way to fostering a more receptive, supportive climate for addicted patients.
Addiction, as defined by the US National Institute on Drug Abuse, is a chronic relapsing brain disease characterized by drug-seeking and drug-using behaviour that has harmful effects on an individual. It shares the traits of other chronic diseases such as asthma, hypertension and diabetes: genetics can play a role; severity is variable; the primary treatment is lifestyle modification; medications can help; patients do not always comply with treatment; and, ultimately, the disease is controllable but not curable. However, few if any of the patients with asthma, hypertension and diabetes contend with the same level of scorn and acrimony as the addicted patient, despite the fact that their relapse rates are the same as or worse than relapse rates for addiction. Indeed, 40 to 60 percent of patients with drug addiction relapse, compared with 30 to 50 percent of patients with type II diabetes and 50 to 70 percent of patients with hypertension or asthma.
Despite these numbers, only in addiction do we expect perfection from patients, in terms of both treatment compliance and outcomes. We have for too long refused to treat addiction as a medical condition, instead viewing it as a moral failure — and our words, and the words of the media and policy-makers, fuel that view. Viewing addiction as a moral failure makes it easier to dismiss it as a “choice,” and it is a key reason why the zero-tolerance approach to relapse exists. Have you ever seen an asthmatic dragged off to prison for not taking her Ventolin? Do we refuse to treat a cardiovascular disease patient with statins because he chooses to eat junk food when his physician has advised a diet rich in produce and lean meat? Do we take away somebody’s insulin if her urine comes back glucose positive? The answer to each of those questions is no. And yet, with addiction, if you’re caught relapsing, or using, our current criminal justice model too often demands that we punish you, not treat you.
A January 2017 article in the Globe and Mail, “Cheque Day in the Downtown Eastside,” was replete with terminology that implied drug use and addiction is confined to the margins, that it is a disease of poverty. This is not unusual. In many media reports the dismissive terms and the condescension are on full display: imagery of discarded needles or used condoms, an upper-middle-class Canadian parent decrying what “these people” have done to a neighbourhood, a politician calling for harsher penalties or the inevitable shot of a user in a back alley, cloaked in dim light. Imagery and words, in these cases, serve to reinforce the notion that addiction is voluntary and those living with it are bad people doing bad things who deserve scorn, rejection and punishment with the full weight of the law.
Although a voluntary choice taken at one point in somebody’s life may lead to an involuntary addiction, it doesn’t make that patient a criminal. Indeed, in almost every respect, patients living with addiction — whether it is alcoholism, opioid use disorder, tobacco use or addiction to gambling or amphetamines — are often sick people trying to get well.
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A 1963 book, Stigma: Notes on the Management of a Spoiled Identity, found that addiction was the most stigmatized medical condition. Fifty-four years later, that is still the case. Few individuals want to publicly acknowledge a substance abuse disorder — the stigma it carries feeds into very real fears that coming forward for help will result in job loss or being ostracized by family and friends. And that fear of coming forward can have a very real negative impact on a patient’s chance for recovery. Yet, in my years of working in the addiction and drug policy advocacy field, I have yet to meet one addicted patient who tells me, “I took that first hit so that I could become addicted.” No person wants that for a life — nobody wants to wake up each morning, and go to bed each night, worrying about going into withdrawal, wondering where they will find drugs to quell the urges and to dull their pain; and nobody wants to put their lives or their families’ lives at risk — the very real risks associated with drug-seeking behaviour. Most of these patients want help, they want support, they want — they need — treatment. And they want to be respected.
So how do we change the narrative about addiction and the individuals living it? We can start referring to them, first and foremost, as patients who are moms, dads, sons, daughters, sisters and brothers. We can tell their stories, from their perspectives, so we can better understand the person beneath the illness. In doing so, we raise these men and women up to a level where the next logical step is discussing how we can best support them — we normalize the individual patient living with drug addiction, and by extension we medicalize the condition they are battling. We can all stop referring to somebody staying “clean,” because that implies that previously they were dirty. Instead, we should talk about the empowering aspects of being a “patient in recovery.” Physicians, instead of saying patients have “dirty urine,” can tell them they have provided a negative drug test and then work with each patient to better understand what is happening in their lives and in their environment that may have triggered a relapse. If patients feel that they aren’t automatically stigmatized by the words used to define them or their condition, they’re much more apt to discuss — openly, transparently and honestly — what their triggers are and how to best design their treatment paradigm for optimal effectiveness. It’s the philosophy of viewing the patient as a partner, not as a problem.
Media can take the lead on reframing how we talk about addicted patients by doing a better job of highlighting the full spectrum of who this condition affects: individuals from every demographic, income bracket, race, creed, sexual orientation and geographic location. They can start choosing pictures of addicted patients that reflect each of those aspects, not just whatever stock photos they can rustle up that serve only to reinforce the false notion that addiction is just chosen criminality, depravity and poverty. They can meet with patients in recovery, and their families, to hear their stories of hope, of treatment — and, yes, of relapse — in a way that conveys compassion and optimism; they can listen to the progress being made in improving health outcomes related to addiction; and they can highlight policies that are pulling addiction and its patients into the public health sphere.
Words matter, because they tell a story. They also define a society — and in that respect, it’s long past time that we started referring to patients living with addiction, or patients in recovery, with the compassion and dignity they deserve. In doing so, we will raise them up — and we will gain a better understanding of their battles.
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