To Address Addiction, Start With Words

In large part, the misperception of opioid use disorder stems from a failure of language. We are boxed in by an outdated lexicon that reflects the unfortunate view of individuals with addiction as moral failures and criminals.
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Addiction is finally coming out of its shadows. Thanks to interest from political leaders and media coverage about the ravages of heroin and misused prescription opioids, new attention is being paid to an old disease. But not since the 1980s with the appearance of HIV and AIDS has there been such misunderstanding about a medical condition.

When HIV first emerged, many feared the possibility of casual transmission, leading to unwarranted discrimination and stigma. The fear and misconceptions around HIV quieted after intense research, advocacy, and funding identified the HIV virus, clarified its transmission, and led to the development of effective medical treatments. While much work on HIV remains to be done around the world and here at home, it is no longer acceptable to question whether people with this medical illness deserve care.

Addiction is a brain disorder. Scientists have defined the neuroscience, identified genetic components, developed effective medical treatments for opioid and alcohol use disorder, and documented the chronic nature of substance use disorders with relapse risks and remission rates.

Yet public misunderstanding of addiction is profound. It is not yet recognized for the disease that it is. As a result, we continue to fill our jails with people with substance use disorders. Judges and parole officers make decisions about medications for offenders with opioid use disorder, which they would never think of doing for other medical conditions. And federal disability laws do not consider the presence of severe substance use disorders as sufficient criteria for receipt of disability benefits.

Why is this?

In large part, the misperception of opioid use disorder stems from a failure of language. We are boxed in by an outdated lexicon that reflects the unfortunate view of individuals with addiction as moral failures and criminals.

Take for example, the words "clean" and "dirty" to describe urine test results. Nowhere else in medicine do we describe laboratory test results done as part of clinical care in terms that reflect someone's state of hygiene. Instead, we use "positive" or "negative" or "expected" or "unexpected."

Similarly, for addiction, we describe an individual in remission as "clean" while people with other types of chronic diseases are either "managing or controlling" their symptoms, their high blood pressure or their glucose levels. Since the opposite of "clean" is "dirty," does this mean that people with active addiction are "dirty"? In fact, they are, like people with other conditions, "actively symptomatic."

Diseases have symptoms; people live with and manage these symptoms and our language should reflect this reality.

Elsewhere in medicine, people with chronic conditions also are not defined by their disease, especially when being seen for care. For example, patients admitted to a hospital for depression are not called "depressives" even if they are involuntarily committed after a suicide attempt. Yet individuals with substance use disorders are called "addicts" far more than "patients." "Addict" conjures up a bad person who belongs in a jail cell, not someone worthy of receiving high quality medical care.

Discussion around treatments for substance use disorders also reflect outdated thinking. Available services call themselves "drug-free," "abstinence-based," or "medication-assisted." In diabetes care, there is no term "medication-assisted treatment." It is accepted that some patients may need a medication or two or even three as part of their treatment to help them effectively manage their disease and reduce complications. Routine use of medications in hypertension help people reduce the complications of uncontrolled high blood pressure, including kidney damage, heart attacks, blindness, and stroke. Decisions about medications (when to initiate, which ones to recommend, and how to adjust) are made by clinicians and their patients jointly after weighing the severity of the disease, its prognosis, the benefits of each medication, risks and side effects, and taking into account other patient-specific factors.

The same goals of helping people manage their illness and reduce complications underlie the rationale for medications used to treat opioid use disorder. Methadone and buprenorphine are highly effective and broadly recommended therapies, associated with a lower risk of overdose, reduced use of illicit substances, improved employment, and reduced criminality. Injectable naltrexone is a more recently approved treatment, representing an additional tool in the toolbox. It is nonsensical to argue about what is "true" treatment and which recovery is "true" recovery.

As with other chronic diseases, management of addiction should be defined by outcomes, not ideology. It should be measured by improvements in health and reduction in complications no matter what the treatment.

At a time when addiction is finally beginning to come out of its shadows, now is the time to truly look at it through a healthcare lens -- and that starts with our language. Only then can we help more people gain control over their illness and their lives.


Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.

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