Mark Twain was quoted as saying, “The difference between the right word and the almost right word is the difference between lightning and the lightning bug.”1 Semantics is a subdivision of linguistics that studies the meaning of the words in use. Words reflect one's attitudes, understandings, unconscious biases, and often one's intentions. Words can have the power to instill hope, comfort, and inclusion, or they can negate the experience of the very same feelings. Dan Coyhis states in The Garden of Life, “If you want to care for something, you call it a flower; if you want to kill it, you call it a weed.”2 Negative word choices used to address or reference a person seeking assistance are identified as stigmatizing. Stigmatizing words can cause shame, dishonor, disgrace, and discrimination, and are based on stereotypes and misconceptions. More significantly, these negative words imply a disapproval of the person that is based on their current behavior or situation.
Knowledge deficits, stigmatizing words, and negative attitudes can gain societal acceptance as stereotypes. These negative stereotypes then can promote a biased judgment of individuals or groups. Research has shown that individuals diagnosed with substance use disorders (SUDs) report that they encounter a higher number of stigmatizing experiences than any other social group, including criminals.3 In fact, SUDs ranked number 1 and alcohol use disorders ranked number 4 out of a list comparing the number of stigmatizing experiences in 18 social groups. This phenomenon was reported in World Health Organization studies collected in 14 countries.3
Aftermath of the war on drugs
The US has fought a “war on drugs” since the Nixon administration in the 1970s. This “war” and its derogatory language that is used against anyone who is involved in illicit drug use became a strategic plan. The plan intended to deter any individual from experimentation with any illicit substance. Almost 50 years later, an assessment of this failed plan as a deterrent has resulted in human loss, individual isolation, and decreased access to treatment.
As a result, the White House held the first Drug Policy Reform Conference on December 9, 2013.4 At that time, the experts attending the summit proposed a paradigm shift from a “war on drugs” to the adoption of a public health perspective of the issue as “an addiction epidemic.” The opioid epidemic is compelling action from the public citizens and from its local, state, and federal leaders.
One of the first actions proposed at the summit was the need to look at the unprofessional, off-putting language used by professionals when communicating about individuals with SUDs. Kelly and Westerhoff in an investigative study randomly assigned 500 doctoral-level mental health and addiction students to similar clinical case studies.5 The only exception noted in the clinical case studies was that in one case study, the central patient was described as a “substance abuser,” and in the other case study, the central patient was described as having a “SUD.”
The results showed that the students were much more judgmental and punitive toward the patient described as a “substance abuser” than they were toward the patient described as having a SUD. This same study was repeated using the general public and resulted in significant judgment and blame toward the “substance abuser” as well.
Stereotypes against patients with a SUD
Kelly and colleagues' discussion of the findings identifies this reaction of judgment and blame as a form of cognitive bias resulting from stereotyping, even among students preparing to work in the addictions specialty.6 When this cognitive bias is internalized by an individual (self-stigma), it then affects the person's feelings of self-worth, self-value, and self-esteem.7,8 These feelings of self-stigmatization can have a direct result on a person's treatment success and recovery outcomes. The use of language affects whether a cognitive bias becomes an internalized experience of stigma.
To refer to an individual as having a SUD is a clinical term that describes a syndrome consisting of a cluster of signs and symptoms, which result in significant distress and/or impairment during a 12-month period. In the assessment that results in a clinical diagnosis, one assumes a medical disorder is not the fault of the individual. One also assumes that the person is not choosing to have a disorder, and therefore, stigma is decreased and empathy is exhibited.
Kelly and colleagues propose that the experience of stigma is prompted when an individual is assessed as having caused their situation intentionally (meaning the individual is willfully making bad choices is implied in the case of the “substance abuser”). In stigmatized cases, the individual is assessed as being in control of their decisions. This assessment resulted in an increase of punitive, pejorative language, and negative attitudes observed in the perspective providers.
It is important to remember that not all illicit drug use is considered an addiction, and not all addictions are the same. According to the National Council for Behavioral Health, more than 10 million full-time workers in the nation have a SUD.9 This fact is estimated to cost the US $442 billion annually in healthcare costs, lost productivity, and criminal justice expenses.10
Research substantiates that SUDs are neurobiological conditions. What is now understood is that changes result in the neurocircuits of the brain when these circuits are chronically exposed to drugs. These circuit changes are global in nature and affect judgment, impulse control, the reward pathway, and memory. These brain changes complicate treatment, abstinence, and recovery. Genetic predisposition is the other major contributing factor to this disorder.11
New scientific evidence requires ever-evolving changes in the way healthcare providers (HCPs) think, understand, build constructs, communicate, and develop policies. One example of practice advancement is NP prescriptive authority for medication-assisted treatment (MAT), including methadone, buprenorphine, and naltrexone. These medications are not substitutions for illicit drugs but are known to increase effectiveness when provided in combination with psychosocial support. It is important for HCPs to use the word “medication” versus “drug” when referring to a MAT to avoid confusion regarding a medication/treatment such as MAT with that of an illicit drug.12
Updates to the language
The behavioral criteria used to meet a medical/clinical diagnosis is documented in American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.13 This newest edition makes a major shift in the language used to describe addiction by replacing the terms “abuse” and “dependence” with “substance use disorder.” The word “abuse” has an implication that the person has choice and control over their behavior, and as previously addressed, this is not always the case once physiologic changes have resulted in the brain.
The language—specifically the words—used by nurses and NPs is powerful. Patients in their care trust that nurses will have a positive regard for them and that nurses will provide a therapeutic alliance and assistance in achieving their optimal wellness. Changing the language/words used, when working with those diagnosed with a SUD, can build trust and thereby increase the HCP's ability to positively engage and treat the patient (see Inappropriate vs. appropriate terminology).
This article is a call to NPs to remain current with the latest evidence on the impact and experience of all forms of stigma resulting from the careless use of language. It is a call to communicate accordingly and sensitively with one's patients and colleagues, in one's grant writing and publications, and in one's lectures. Choosing one's words carefully when working with patients diagnosed with SUDs can be a matter of life or death for these individuals.
All HCPs need to become adept in using “person-first” language; this type of language does not identify a whole person based on their medical disease, diagnosis, or on their ability but rather describes the whole person. This language is accepted when describing those who are differently abled (as opposed to saying “disabled”), those with chronic conditions, and with those who are transgender or nonbinary.
A person-first diagnosis of a SUD is a medical description that acknowledges the complexity of the individual and is one aspect of their circumstance. Whereas, using the descriptors “an addict” or “an alcoholic” identify the individual's actions as a compulsive behavior that negates any of their other strengths, behaviors, and accomplishments. Person-first language is clinically informative, descriptive, and factual in a nonjudgmental, respectful, and neutral manner.
The American Society of Addiction Medicine, the American Psychological Association, and the Office of National Drug Policy promote the use of nonstigmatizing language and terminology.14-16 In healthcare service delivery, addiction research, and in the media, information dissemination experts are focused on the use of precise, scientific, nonstigmatizing communication.17,18
Changing the names of some governmental agencies such as the Substance Abuse and Mental Health Services Administration, and the National Institute of Drug Abuse would literally require an act of Congress. Change is slow because many media companies continue to use old terminology and perpetuate the stereotype of the abuser, and controversy on the most effective language continues to be a focus in opinion editorials and in professional discussions. Many professionals in the addictions field want the scientific evidence regarding person-first language usage to be reflected in the terminology used and in the names of the federal agencies.
On the Providers Clinical Support System, Facing Addiction and the Recovery Research Institute has developed a comprehensive “addictionary” replete with stigmatizing language alerts.19 This ongoing process is building consensus among HCPs and is opening continuity in assuring informed, evidence-based responses for those accessing and providing addictions treatment.
The experience of isolation and stigma are deterrents to recovery, and a punitive approach has not worked in developing healthy outcomes for individuals with a SUD. Nursing's power is in its ability to engage clients in therapeutic relationships and to provide equity, competency, and compassion. NPs also possess the power of numbers. As of March 2019, there were 165,480 NPs actively practicing in the US, among more than 270,000 licensed NPs.20,21 The NP workforce is key to expanding capacity and providing access to quality care and treatment. All nurses are implored to use inclusive, person-first language that conveys their attitudes of hope and continual respect for individuals requesting care regardless of where they are in the process of their recovery. No matter what the healthcare issue, an informed nursing workforce is the solution to reducing stigmatizing language.
1. Twain M. The Wit and Wisdom of Mark Twain: A Book of Quotations
. Mineola, NY: Dover Publications, Inc.; 1999.
2. Coyhis D. The Red Road to Wellbriety: In the Native American Way
. Center City, MN: Hazelden Publishing; 2002.
3. Room R, Rehm J, Trotter RT II, Paglia A, Üstün TB. Cross-cultural views on stigma valuation parity and societal attitudes towards disability. Disabil Cult Universalism Divers
5. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy
6. 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 States. Am J Med
7. Crapanzano KA, Hammarlund R, Ahmad B, Hunsinger N, Kullar R. The association between perceived stigma and substance use disorder treatment outcomes: a review. Subst Abuse Rehabil
8. Luoma JB, Twohig MP, Waltz T, et al An investigation of stigma in individuals receiving treatment for substance abuse. Addict Behav
9. National Council for Behavioral Health. The business case for effective substance use disorder treatment. 2016. http://www.thenationalcouncil.org/wp-content/uploads/2015/01/14_Business-Case_Substance-Use.pdf
10. Office of the Surgeon General. Time for a change: Surgeon General's report on alcohol, drugs, and health. 2016. https://addiction.surgeongeneral.gov/index.php/vision-future/time-for-a-change
11. Volkow ND, Boyle M. Neuroscience of addiction: relevance to prevention and treatment. Am J Psychiatry
12. Samet JH, Fiellin DA. Opioid substitution therapy—time to replace the term. Lancet
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th Edition)
. Washington, DC: American Psychiatric Association; 2013.
14. American Society of Addiction Medicine. Comments on ONDCP changing the language of addiction documents. 2016. http://www.asam.org/resources/publications/magazine/read/article/2016/11/01/asam-
15. American Psychological Association. Guidelines for non-handicapping language in APA journals. 1992. http://www.apastyle.org/manual/related/nonhandicapping-language
16. The White House Office of National Drug Control Policy. Changing the language of addiction. 2017. https://obamawhitehouse.archives.gov/blog/2017/01/13/changing-language-addiction
17. Broyles LM, Binswanger IA, Jenkins JA, et al Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus
18. Wakeman SE. Language and addiction: choosing words wisely. Am J Public Health
19. Recovery Research Institute. Addictionary. 2019. http://www.recoveryanswers.org/addiction-ary
20. The Henry J. Kaiser Family Foundation. Total number of professionally active nurses. State Health Facts. 2016. http://kff.org/other/state-indicator/total-registered-nurses/#