Stigma expresses social disapproval of behaviors, meaning they are discouraged. The two most relevant examples of stigma for this discussion are the stigmas attached to cigarette smoking and drunk driving, both of which have been developed by the public health community in recent decades and prominently use the law, resulting in major public health gains. Each of these examples of stigma is clearly based on science and not prejudice.
There is more than social disapproval in much stigma that exists today. In some situations stigma is unreasonable—for example racial or ethnic stigma. Stigma against illegal and addictive drug use, however, is not only closer to the stigma associated with cigarette smoking and drunk driving, but like those examples, it is generally useful because it serves as a warning about negative health behaviors. Stigma can be socially useful or damaging, depending on the specific behaviors with which it is associated. In most applications of stigma there are varying points of view about the stigmatized behavior, with some people taking more favorable views of the behavior. This complexity is particularly true in the case of addiction where there are three distinct kinds of stigma related to addiction, each of which must be understood independently.
Stigma Related to Drug Use
Attaching stigma to drug use is useful in the prevention of addiction. Stigma warns off many would-be drug users. Data from the nationally representative Monitoring the Future study shows an inverse relationship between perception of risk of harm from a drug and its use. As perceived risk of harm of a drug increases, its use decreases; similarly, as perception of risk decreases, drug use increases.
Addiction does not strike people at random. While there are often biological and socio-cultural predispositions to developing addiction, substance use disorders mostly occur only after repeated heavy use of specific drugs, often drug use that is highly stigmatized. Few individuals become addicted without engaging in risky and/or illegal substance use behaviors over long periods of time. By not using any substances of abuse, anyone of any age can prevent the development of addiction. The longer one postpones initiation to any substance use, the less chance that person will experience later substance-related problems including addiction. But there is more to this fascinating story. The use of a potentially addicting drug does not alone lead to a substance use disorder. For example, taking prescription opiate medications as directed by the prescribing physician and informing the prescribing physician of all alcohol and other drug use generally prevents addiction or, failing that, leads to rapid intervention. The path to prescription drug dependence typically begins when the user takes the drug at far higher doses and/or by alternative routes of administration, and for different reasons than those recommended by the prescribing physicians.
Stigma Related to Addictive Behaviors
Substance use disorders are characterized by repeated use of the addicting substance in spite of negative consequences and usually at high doses for prolonged periods of time. Such behaviors should be stigmatized. Here an essential distinction must be made between the stigmatization of addictive behaviors and stigmatization of the addicted people. It is the unhealthy, often illegal, behaviors that deserve stigmatization.
How can the addictive behaviors be stigmatized and those around the individual insist that those behaviors stop without stigmatizing the addicted person? This is a challenge for everyone working in the field of addiction. Success requires a compassionate approach to the pain and self-destruction caused by addiction. We must recognize the fact that the addicted person is in the grip of an abusive chemical love affair. The addicted person’s brain is hijacked by addiction. It is essential that those around the addicted person show respect for the individual whether or not he or she is using or is in a state of recovery. One of the hallmarks of the 12-step fellowships is maintaining respect for the person and relentless optimism for that person’s recovery.
Stigma Related to Addiction Recovery
There should not be stigma associated with obtaining treatment and achieving recovery. Recovery takes hard work over long periods of time. Recovery includes abstinence from alcohol and other drugs as well as healthy living, wellness, and productive engagement in life. Persons in recovery, having escaped chemical slavery, have earned respect and admiration. Recovery must be celebrated not only to recognize this remarkable achievement but also to signal to others the strong social approval of recovery.
Individuals with substance use disorders need and deserve help with and respect for their struggles and deserve social recognition of their achievements. This is the direct opposite of stigma, even as they and those around them stigmatize the substance-using behaviors that led to their addiction.
Recognizing the Role of Others in Cultivating and Supporting Recovery
Few individuals with substance use disorders spontaneously decide they need to do the long hard work needed to achieve recovery. Almost everyone on the path to recovery is led to that destination by those who care about their health, safety, and welfare. One of the many miracles of recovery is the switch that occurs within the individual from involuntary and often resentful entry into addiction treatment to the joyful embrace of sobriety.
Family, organization-, and community-based contingencies for individuals with substance use disorders create important opportunities to force individuals to address their addiction by entering treatment and leading them on the path to recovery. The use of leverage provides consequences and interventions while at the same time providing hope and opportunity to make healthy, life-saving changes in the individual’s life.
Stigma is a strong social reaction to the use of addictive substances that must be managed wisely to always respect addicted people, and to preserve the hope of recovery, while also rejecting—stigmatizing—addictive drug use. Poorly managed stigma can discourage access to treatment and recovery and worsen the suffering of addicted persons whereas wisely managed stigma of illegal and unhealthy substance use can enhance prevention and promote both treatment and lifelong recovery.