By Johann Hari
For the past year, I've been publicly arguing that we need to think very differently about addiction. For a century, we've been punishing addicts, and waging war on them -- and we've ended up with a catastrophic addiction crisis. I've been to the countries that have instead adopted the opposite approach -- compassion and love for addicts -- and their addiction crises are shrinking over time.
As I've been making this case, alongside a huge number of other people, I've kept coming across an interesting internal debate among those of us who are basically all on the same side. When I argue for greater compassion towards addicts, I often get somebody replying who says something like: "Then you shouldn't call them 'addicts.' Stop using that word."
It's a serious argument, and one that is worth thinking through in public. I feel divided about it.
The argument is that the word "addict" is itself a form of stigma. It is an insult, and it hurts the people it is used to describe. It's like saying, they believe, "We need to be more compassionate towards spastics," the old, degrading term for people with cystic fibrosis. By saying that, I would in fact be insulting people with cystic fibrosis, even if I meant well.
The people making this case are right that the words we use to describe people matter. There are extreme examples that are obvious -- anyone who uses the "N-word," or calls gay men "faggots," would rightly be drummed out of public life. But there are more subtle examples. Sometimes, you will hear people refer to a person with Down's Syndrome as "a Down's Syndrome" -- as if all they are is that, their condition. It's reducing, and it subtly -- if unwittingly -- deepens negative views about them.
Is the term "addict" like that? There are several possible arguments about this.
The first comes from some people who argue that addiction itself does not exist -- that it is a false concept. We should junk the "addict," they argue, because it doesn't describe anything real. I have heard this in the past year from the conservative commentator Peter Hitchens, who says that addicts are simply weak people making bad decisions; and from a small number people who work in the U.S. rehab industry, who say compulsive behaviors are a straightforward choice that people make, and they simply need to have that taught to them to stop.
"To me, saying addiction doesn't exist is like saying love, or grief, or anger don't exist."
I don't think this is what most people arguing against using the term "addict" mean, but it's worth engaging with. To me, saying addiction doesn't exist is like saying love, or grief, or anger don't exist. It is a very widespread human phenomenon, and the vast majority of people, when they hear the word, know what you mean. It's when you feel compelled to engage in a behavior, even though some part of you doesn't want to, and even when it has negative consequences in your life.
That's real. It happens. Everyone reading this will know somebody who has struggled with an addiction. I can no more understand thinking it's fake, than thinking shock or dreaming or excitement are fake.
That doesn't mean that all the other ideas that have become attached to addiction over the years -- like sea-creatures sticking to the bottom of a boat -- are right. Lots of them are wrong. It is wrong to think that addiction is caused simply by heavy alcohol use, or by heavily using other drugs. It's wrong to think the main cause of addiction is the "chemical hooks" within those drugs. (If it were, there'd be no such thing as gambling addiction). And it's wrong to think that the solution is to lecture people living through it that they are weak, or morally flawed. This animation I scripted distills down why I think that:
So I absolutely think we need to change how the term is used, and what many people think it means.
But part of me instinctively thinks we shouldn't discard the term -- because it does describe something real. If we stopped using the word "addict" (or some rough equivalent) we would lose the ability to describe a real phenomenon, that is happening all around us, and that we urgently need to respond to.
The second argument is -- yes, the phenomenon is real, but the word has become too loaded with negative associations. Lots of people hear the word "addict" and they picture a homeless, shiftless vampire, poised to commit any crime to get their drug; or a person raging on a meth-binge. If you're triggering those mental pictures, you're not undoing stigma, they argue. You're reinforcing it.
It's true -- lots of people do picture that when they hear the word "addict," and it's a disaster. I agree with the flinch lots of people feel when they know that.
But my (again) instinctive response is to say: That's precisely why I think we need to challenge those assumptions, and to undo the stigma. We need to explain that even the most extreme addicts are only trying to deal with their grief and internal pain as best they can; and that to do that, they need love and connection and support (along with significant social change, so they can build a meaningful life for themselves). We need to show them that their negative picture of addicts is false--and give them a truer, more accurate picture of addicts to replace it with.
To do that, we need to redefine the term. But redefining the term is different to abandoning it.
For example: I'm gay. If I'd communicated that to you in the U.S. or Britain in, say, 1959, you'd have made a series of catastrophic assumptions about me. That I was mentally diseased; that I wanted to have sex with children; that I could never have a normal romantic relationship; that I was a pervert. Today, very few people make those grotesque assumptions; we'd think they were crazy. It wasn't changed by abandoning a term. It was changed by challenging what people thought the term meant -- patiently, person by person, year after year, until it altered.
"...even the most extreme addicts are only trying to deal with their grief and internal pain as best they can..."
There are other terms littered with negative and false ideas -- to choose one, feminist. We don't abandon the term. We say -- it doesn't mean what you think; here's what it does mean -- and we're going to fight for this real vision, because we believe it's essential and right, and we won't stop until we have an equal society where women are treated decently.
And yet, as I put forward this argument, I have some doubts in my mind, and I feel unsure.
There are times when we do adjust how we talk about people, in a way that's helpful. We don't talks about "blacks and gays" -- we talk about "black people and gay people," precisely because it's more respectful; it doesn't reduce people down to one aspect of themselves. That, for me, is the most persuasive argument of the people arguing against just using the word "addict." So when some people argue instead for using terms like "people struggling with addiction," I think there's a lot to be said for it -- I have started using those phrases more.
We have abandoned the terms "negro" and "homosexual," because they do have older, uglier associations that nobody wants to revisit. I can understand why people think -- over time -- the word "addict" may go that way.
That's why I'm open-minded -- despite having some reservations -- to the idea that a better term may come along. But my biggest worry is that the alternatives that have been proposed so far are actually, alas, worse.
One of the most popular, in the small world where we debate this, is "People Who Use Drugs," often abbreviated to PUDs.
There's a huge problem with this term. Around 90 percent of the people who use drugs -- as Professor Carl Hart and others have shown, and even the UN Office of Drug Control has admitted -- are not addicts. They are using drugs for the same reasons that 90 percent of people will be drinking alcohol if you walk into a random bar tonight: to help them relax, to unwind, to feel better, to feel amped up; whatever floats their boat. They don't feel compelled to do it, and it's not harming their lives.
By erasing the verbal difference between the roughly 10 percent who are addicts with the 90 percent who aren't, we create a whole slew of problems. We lose the ability to argue for compassion for addicts specifically, as opposed to just drug users. Yet addicts urgently need compassion: their lives may depend on it. I don't think drug users need more compassion than the average guy, because they're not in pain, and they're not in danger. (Don't misunderstand me: They should be free to do what they want, and they shouldn't be judged or criminalized; they just don't need our urgent help, unless they get busted.)
By lumping together drug users and drug addicts, we might actually -- unwittingly -- end up reinforcing the arguments of drug warriors like Harry Anslinger and Richard Nixon and Nancy Reagan: that drug use and drug addiction are the same thing; that there is no recreational drug use. There is, and it's the norm.
Drug users and drug addicts are different categories. Everyone who thinks about it knows that. It's obvious. We need to maintain that distinction -- because it does a disservice to both if we pretend it's not there.
A different term some people have suggested is some variant of "People With Substance Dependencies." I think this would actually reinforce once of the biggest myths about addiction-which is that it's about the drug itself. People in hospital in Europe are given heroin after operations for really long periods of time, and virtually none become addicted -- my grandmother didn't leave hospital after her hip replacement operation trying to score some smack on the street. Some do become dependent -- and it's worth explaining the difference.
"By lumping together drug users and drug addicts, we might actually -- unwittingly -- end up reinforcing the arguments of drug warriors like Harry Anslinger and Richard Nixon and Nancy Reagan...""
Dependency is when you experience some withdrawal symptoms if you stop a drug -- the headache that comes if you stop caffeine, or the flu-like symptoms that can come when you stop heroin after being given it in hospital. Addiction is something different. Addiction is feeling that you need the drug, in order to deal with your pain -- it's a desperate attempt to not be present in your life, because your life is too painful a place to be.
Most of us would develop some kind of physical dependency if we took a substance for a long time. Most of us wouldn't develop an addiction, because most of us are not in such deep and profound pain that we need to numb ourselves.
So saying it's a "substance dependency" actually plays into an outdated idea of what addiction is. The substance didn't cause the problem (though in many cases it makes it worse) -- what caused the problem is the pain and distress you were carrying before and during the drug use, that made compulsively taking it seem a better option than living in agony.
If we relabel addiction as substance dependency, we're actually feeding the idea that the solution is somehow to eradicate the drugs from the face of the earth. It's not. When a specific drug disappears -- this happens sometimes, for short periods -- if you haven't dealt with the pain the addict is carrying, they just transfer to another drug, or another compulsive behavior. No heroin available? They'll often seek out prescription meds, or fentanyl, or massive quantities of alcohol. The substance is a symptom of the deeper problem -- and that's what we need to deal with. This relabeling feeds a mindset that actually takes us further away from the solution to addiction.
Another term that has been proposed is "People with Substance Abuse Disorder." I think this is equally problematic, for a different reason.
There are people who argue that addiction is primarily a brain disease, caused by something that goes wrong inside your head when you use too many drugs. This seems to be their preferred term: It evokes precisely the medicalized air they want. There believe that this way of thinking reduces stigma, and they are right to want to do that.
This theory has strains of truth: There are things happening in your brain when you become addicted, of course, and it plays a role in your addiction. But it's only one part of the picture. After Portugal decriminalized all drugs and transferred the money they used to spend on ruining addicts' lives into job creation and loving support for people with addiction problems, injecting drug use fell by 50 percent. Did their brains all spontaneously stop malfunctioning? Of course not. Their lives got better, so they wanted to be present in their lives more. It's important to research what happens in the brain during addiction. But to shift our language so we present it as only or primarily a problem with the brain actually leads us away from the real solutions, and I fear -- although I could be wrong -- that it unwittingly helps to shore up the drug war.
Another response is to say we should simply not use any term. As one commenter on the Facebook page for my book Chasing The Scream: The First and Last Days of the War on Drugs wrote: "Let's start by calling them people instead of addicts."
It's an admirable sentiment -- but we lose the ability to talk coherently about this subject if we don't draw some distinction between addicts and non-addicts.
There is a lot of stigma towards people with HIV, and it needs to be challenged. Imagine if, in response, I stopped using the term "people with HIV" and just called them "people." Hey, Joe-you shouldn't stigmatize people; it's not their fault they became people; any of us could become people with a little bad luck; there is a way people can become non-infectious with the right meds; when you discriminate against people, the virus actually spreads.
Your response would be -- huh? What the hell are you talking about?
And this, perhaps, is my biggest worry when it comes to this argument.
We urgently need to change people's minds about addiction. There's a global war going on. Huge numbers of people die every day, in hellish circumstances.
To change people's minds, you need to talk using words that they understand. I have seen people on social media trying to persuade ordinary others to change their minds by talking about PUDs -- not realizing that no ordinary person has the faintest idea what they're talking about.
"We urgently need to change people's minds about addiction. There's a global war going on."
If we retreat into language that sounds obscure, or incomprehensible, we cut ourselves off from 99 percent of people. And they are the very people we need to persuade. It paralyzes us, at the very start of our conversations with people. It seals us off in a bubble where we're only talking to ourselves, and congratulating ourselves on our own purity while ensuring we will have zero effect on the world.
That's why I use the phrase "people with addiction problems" sometimes, but not all of the time. If you put it into a tweet, that's a quarter of your tweet gone. It's a clunky term, and it slows down what you're trying to say. It is better -- but not ideal.
So -- here's my reluctant, tentative conclusion. The people arguing for reconsidering or abandoning the word "addict" are overwhelmingly decent people, with decent motives, and they may be right. There are some strengths to using the current term, and some weaknesses. But the other terms suggested so far are (sadly) worse.
We need to keep having this conversation, in the hope we might find something better.
Yet in the meantime, another person with addiction problems died while you read this; and another will die in the next ten minutes; and on, and on. They didn't have to die. If we had a different approach, most of them would live. Keep your eyes on the prize: We're in this fight to save the lives of the people we love, whatever we call them.
Johann Hari is the author of the New York Times best-selling book Chasing The Scream: The First and Last Days of the War on Drugs. His last piece for The Influence was "Three Concepts You Need to Grasp If You Want to Know Whether to Legalize Drugs (Yes, Even Heroin)."
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