Substance use disorder vs. substance abuse – A disease NOT a personality flaw or moral failing
Substance use disorder is a disease, not a personality flaw or moral failing. Yet, the language that has evolved around this disease is stigmatizing and reinforces the concept that people with this disease have an innate defect, which results in poor choices and devastating consequences. This stigmatizing language needs to stop, and we need to confront this disease with the same level of research investment and scientific rigor that we dedicate to other chronic diseases.
Let’s examine the language that confronts a person with substance use disorder. First, there are judgmental terms such as “alcoholic,” “addict,” and “junkie,” which conjure terrible images that should not be attached to a person with a chronic disease. The images we associate with these words are sequelae of untreated disease and a failed societal duty to care for all in our communities. Those images aren’t pretty; not unlike untreated skin cancer or diabetes in their ability to present a pretty picture.
We need to acknowledge the fact that our health care systems have not developed effective substance use disorder treatments–whereby we define an effective treatment as one for which the majority of people suffering from the disease can achieve compliance with treatment and maintain a healthy lifestyle. This may not mean that someone is abstinent forever because that’s not achievable or realistic for everyone.
Improving the way we navigate substance use disorder
The current standard of treatment for substance use disorder is a system in which we remove people from their environment and install them in a separate world inhabited only by people suffering from the disease, often led by a privileged few who have successfully managed the disease. Substance use disorder is an isolating disease, and reconnecting people with this chronic illness in society is an important goal. However, creating parallel social structures, including exclusive meetings of people with disease and so-called “sober homes” may not be the solution.
For example, this system tends to reinforce the “personality flaw” aspect of the disease. Those who have succeeded in managing their substance use disorder are elevated to leadership positions from which they may urge others suffering from the disease to be strong and follow their example. If a person suffering with the disorder fails to manage the disease or “relapses,” it’s because they are not “working the program” hard enough. The abstinence-only path promoted by these systems is only one of many ways of managing substance use disorder. A person suffering from the disease who fails the abstinence-only pathway is diminished with a lower self-esteem and the vicious cycle repeats itself.
Understanding the negative connotations of using words like relapse, dependence, and substance abuse in conjunction with substance use disorders
The use of the word “relapse” deserves its own scrutiny. When a person has hypertension, they may be directed to control their blood pressure with a combination of medication, diet, and exercise. Perhaps there is a period of time during which their blood pressure comes down and then goes back up–this would rarely be described as a “relapse” in a medical context. The terms “lapse” and “relapse” have religious connotations from the temperance movements when temporary misjudgments resulted in the breaking of temperance pledges. A person with a chronic disease needs to manage the disease with a medical professional. Persons suffering from substance use disorder are no different from people with hypertension or diabetes.
A word like “dependence” has its own challenges. Chemical dependence is not a crutch, but a physiologic response to repeated use. Much like many of us who need caffeine in the morning to wake up or otherwise face an afternoon headache, tolerance to a substance can lead to increased use and negative effects. For some, repeated use can result in a rewiring of the brain’s reward pathway and may develop a substance use disorder.
The most commonly abused term with regard to substance use disorder is, ironically, “substance abuse.” The use of the word “abuse” immediately places the person with the disease at fault and makes it seem that substance use disorder is a “choice” to not use substances “safely.” Rather, someone is trying to meet a physical need and manage their brain chemistry; they are not “abusing” anything. Using non-stigmatizing language to describe a person with a disease accurately is only the first step to addressing this chronic disease.
The fact of the matter is, there is no such thing as “safe” substance use. The use of substances always increases risk of short-term injury and frequently increases the risk of long-term chronic disease. For example, alcohol is a Class I carcinogen associated with seven different cancers including, breast cancer, colon cancer, and many cancers of the upper gastrointestinal tract. Alcohol use increases the risk of 220 different diseases. One does not need to be “abusing” alcohol to experience increased risk.
Moving forward with positive societal change to fuel welcoming substance use disorder strategies
Harm reduction is the concept and practice of making substance use less risky. Strategies like not using drugs alone, carrying Narcan in case of overdose, using clean needles and syringes, and using substances under supervision, can reduce the negative effects of drugs for people who continue to use them. There are many other evidence-based strategies to make our society kinder and safer for people who use drugs.
The medical profession is moving in the right direction to remove stigmatizing language about substance use disorder. Doctors are learning to classify substance use disorder into degrees of severity ranging from mild to moderate to severe. There are medications that are effective in the treatment of substance use disorder. However, the current treatment infrastructure lacks equitable access, and investment in for-profit treatment centers needs to be reconsidered.
Additionally, as a society, we need to make a considerable investment in research that can be translated into prevention and treatment. A change in attitude about substance use disorder as a disease that merits compassion for the person suffering with this chronic health challenge is just the beginning of our society’s road to recovery.
Craig S. Ross, PhD, MBA Dr. Ross serves as Executive Director of the idea hub at Boston University School of Public Health and holds a faculty position in the Epidemiology Department. Dr. Ross conducts research at the intersection of commerce and public health. He has published more than 40 studies examining the influence of alcohol advertising on underage drinking. He is also interested in novel research designs using ecological momentary assessment methods to examine real-life contexts for substance use.
Marco Tori, MD, MSc Dr. Tori is an internal medicine and preventive medicine resident physician at Boston Medical Center. He is interested in the care of patients with substance use disorders. His research focuses on co-occurring use disorder treatment and opioid overdose response. He has interned at the Massachusetts Department of Public Health in the Bureau of Substance Addiction Services. He will be joining the Epidemic Intelligence Service with the Center for Disease Control and Prevention in July 2021.