In two editorials published soon after he was appointed senior editor of the Journal of Addiction Medicine, Richard Saitz, MD, MPH, FACP, DFASAM, briefly discussed a topic that is timely and among his favorites: terminology that stigmatizes people who use addictive substances—specifically, opioids.
International Anti-Stigma Statement
His first editorial, published online in November 2015, introduced an anti-stigma statement approved by a group of international journal editors. The statement begins:
The International Society of Addiction Journal Editors recommends against the use of terminology that can stigmatize people who use alcohol, drugs, other addictive substances or who have addictive behavior.
Rationale: Terms that stigmatize can affect the perception and behavior of patients/clients, their loved ones, the general public, scientists, and clinicians . . . Clinicians who read a clinical vignette about “abuse” and an “abuser” agreed more with notions of personal culpability and an approach that involved punishment than did those who read an identical vignette that replaced “abuse” and “abuser” with “substance use disorder” and “person with a substance use disorder.”
The statement added that “abuse” and “abuser,” or equivalent words in other languages, should be avoided, “unless there is particular scientific justification,” such as meeting DSM-IV criteria. Also stigmatizing: describing people as “dirty” because of a urinalysis finding.
A Proposal for Nonstigmatizing Language
In his second editorial, Dr. Saitz discussed his goal of setting a standard for “clear, scientific, nonstigmatizing language” for the addiction field and for his journal. His goal is not to achieve political correctness, but to avoid stigmatizing language that “can actually worsen the quality of clinical care.”
Dr. Saitz’ recommendations:
- Use “person first” language—e.g., a patient with addiction disorder—not “an addict.”
- Avoid the term “abuse”—unless referring to a diagnosis that precedes DSM-5 (the fifth edition [2013 update] of the Diagnostic and Statistical Manual of Mental Disorders).
- Always avoid the term “abuser.”
- Define “dependence” whenever using the term. Is physical dependence meant? Or dependence defined as a diagnosis in an International Classification of Diseases?
- Use “medication,” not “drug,” when referring to a pharmacological treatment.
- Avoid “medication-assisted,” unless referring to specific, named programs; instead, use the term “treatment,” or “opioid agonist treatment.”
- Avoid “substitution” when referring to starting treatment with a medication such as methadone after discontinuing use of an illicit drug.
In addition, Dr. Saitz strongly discourages using:
- “Dirty” or “clean” to describe test results or patients; instead use “positive,” “negative,” or “detected.”
- Imprecise terms that have an unclear meaning or do not meet criteria for a disorder. Examples: “misuse,” “inappropriate use,” “problem use,” and “binge,”—unless the terms are clearly defined, and there are no better ones; for example, “misuse” of a prescription medication is acceptable.
For use that risks health consequences, Dr. Saitz suggests “at-risk,” or “risky,” or “hazardous use.”
“Unhealthy use” refers to “the full spectrum, from risky use to a disorder.”
The nonspecific adjective “moderate” “implies associations with positive values or outcomes,” he explains; better to say “low” risk or “lower” risk.
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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Edited by the American Psychiatric Association. http://dx.doi.org/10.1176/appi.books.9780890425596. Accessed January 17, 2016.
Saitz R. Editorial. Things that work, things that don’t work, and things that matter—including words. J Addict Med. November/December 2015;9(6):429-430.
Saitz R. Editorial. International statement recommending against the use of terminology that can stigmatize people. J Addict Med. Nov.18, 2015; [Epub ahead of print]; PMID: 26588846.