Communicating about Substance Use in Compassionate, Safe and Non-Stigmatizing Ways

Download the alternative format
(PDF format, 2.57 MB, 20 pages)
Organization: Public Health Agency of Canada
Date Published: January 2020
A Resource for Canadian Health Professional Organizations and their Membership (2019)
Table of contents
- Acknowledgements
- Introduction
- How to use this resource
- Key guiding principles
- Lexicon of non-stigmatizing substance use-related language
- Related resources
- Endnotes
Acknowledgements
This resource was informed through consultation with people with lived and living experience of substance use and their loved ones, health professional organizations and other stakeholders in the Canadian health system. This project would not have been possible without their invaluable and diverse expertise. Engagement with these stakeholders highlighted their differing values and perspectives on the language used to describe substance use topics, as well as the rapid pace at which this language is evolving. As such, this resource is meant to reflect the range of views sought, recognizing that complete consensus on the appropriateness of language is not feasible and that the resource content will require re-evaluation and revision in the future.
Introduction
People who use substances experience considerable stigma and discrimination and in various contexts of daily life. Notably, substance use stigma is salient within the health system, where it contributes to poorer quality of care, negative health outcomes and significant social and health inequities. Within the health system, substance use stigma manifests through policies, practices, training, work culture and aspects of the built environment, as well as interactions between people who use substances and direct service providers.
Each of these elements is shaped by the language we use to describe substance use and people who use substances. In turn, these elements set a standard for and reinforce how we talk about substance use topics.
For these reasons, language is a powerful tool that can both reinforce and counter stigmatizing attitudes, views and actions. It is critical that health professionals and their organizations reflect on the language used internally, when communicating with the general public and with patients and clients in clinical settings. Remember, language evolves with time and alongside our understanding of social and health problems. There are many terms that were once commonly used that are now recognized as stigmatizing and harmful to individuals and communities.
In some cases, specific words and terms are stigmatizing, such as “substance abuse” or “junkie”. These instances can be easily identified and corrected by substituting the word or term with a more appropriate alternative. However, in other cases, it is the overall tone of the message, or the beliefs or perspectives underlying it, that are stigmatizing and that may reinforce narrow or negative assumptions related to substance use or people who use substances. These instances can be more difficult to detect and necessitate a greater level of self-reflection and sensitivity in order to adjust.
The purpose of this resource is to facilitate safer, more compassionate and non-stigmatizing language related to substance use within the health system. The primary intended audience is Canadian health professionals and health professional organizations. There are several complementary language-focused resources available that may have greater relevance for a more general audience (see Related resources).
How to use this resource
This resource can be used in various ways. First, this resource can be used to facilitate reflection on and efforts to enhance language on substance use topics used by professionals and organizations within the Canadian health system. These stakeholders are often regarded as trusted sources of health information. As such, their language choices sets the tone for others, and can help reduce both public and systemic substance use stigma.
Second, it can be used to inform the development and content of communication products on substance use topics within health organizations, including new products and those being updated or revised. These products can include reports, social media communications, posters, web pages and fact sheets related to substance use.
Thirdly, this resource can be used to reinforce the importance of broader system-level changes within the health system to reduce substance use stigma. The language used by health professionals and their organizations is not “just semantics”; it represents the values and biases that are reflected in organizational norms, culture and practices that affect the care of people who use substances. To meaningfully reduce systemic substance use stigma, the reflection, care and sensitivity applied to language should be mirrored by complementary changes to the way our health system supports individuals who use substances.
Key guiding principles
These guiding principles can help individuals and organizations in communicating about substance use in a more compassionate, non-stigmatizing way.
1. Take some time to “check yourself” (the basics)
Be self-reflective and aware of one’s personal biases when communicating about substance use.
Avoid slang, derogatory and discriminatory terms, recognizing that many are commonly used yet inappropriate and/or harmful.
Champion safe, compassionate language without policing oneself and others on language choices. Be forgiving and patient, recognizing that stigmatizing language is often used habitually (versus deliberately) and can take time and practice to change.
2. Recognize that individuals who use substances are human beings with unique and complex identities and life experiences
Use people-first language that focuses on individuals first rather than a specific health condition or behaviour (e.g., “people who uses drugs” versus “drug users”). Labels meant to capture real or assumed health conditions or behaviours (e.g., “addict”) do not allow space for the other identities that a person who uses substances may hold, and imply that their only identity is related to their substance use (i.e., they are just a person who uses substances). Labelling individuals by a health condition or behaviour first also implies a false level of homogeneity within a group (e.g., “all addicts are the same”) and that these labels are a fixed part of a person’s identity.
Use language and tone that expresses care and compassion, rather than judgement and discrimination about substance use. This includes not making assumptions about a person’s character or situation (past, present or future), demonstrating empathy and considering the complexity of individuals’ life experiences.
3. Acknowledge that substance use disorder is a medical condition
Avoid language that suggests that substance use disorder is a choice or a moral failing.
Recognize that substance use is a health issue shaped by complex health and social factors, much like diet, physical activity and stress management, which are not subject to the same level of stigma or scrutiny as substance use.
Use language that reflects the fact that treatment, safer substance use and recovery are possible.
Use neutral, medically and contextually accurate terminology when describing substance use, recognizing that preferred language evolves within the medical community along with our understanding of substance use-related issues.
Avoid emphasizing the legality of particular substances or contexts of use to encourage behaviour change. Individuals who use illegal substances are generally acutely aware of possible legal consequences of their substance use. Treating substance use as a criminal issue in health contexts may foster fear of these consequences, distrust and avoidance of health settings among those who use substances.
Avoid conflating “substance use” with “substance use disorder”. Inappropriate use and/or overuse of “substance use disorder” undermines the meaning of this term and the seriousness of this medical condition.
Consult substance use disorder clinical practices guidelines for guidance on delivering care and services in ways that are individualized, patient-centred and non-stigmatizing.
Be aware that some people with substance use disorders do not identify with or endorse the term "disorder" for various reasons (e.g., views that substance use disorder is not a disease). In medical contexts it is appropriate to use accepted medical terminology (e.g., substance use disorder), though health professionals should allow people to use the words that they feel best describe their identity or experience.
4. Recognize and leverage the resilience, expertise and capacity of those with lived or living experience of substance use
Meaningfully engage people with lived and living experience of substance use in the development of policy, messaging and matters relating to substance use.
Whenever possible, use strengths-based language that values the capacities, skills and knowledge of people with lived or living experience of substance use and supports personal recovery and empowerment.
Respect the right of individuals with lived and living experience to refer to themselves using language that might otherwise be considered stigmatizing (e.g., “junkie”). Recognize that these types of self-labels often reflect internalized/self stigma. The use of these self-labels does not give “permission” to adopt similar labels or make it okay to “correct” someone for how they self-identify.
5. Avoid language that reflects assumptions about individuals’ motivations or goals related to their substance use or their desire and readiness for certain kinds of care
Avoid suggestions that abstinence should always be the goal for people who use substances. Recovery is a continuum and a process that will look different for everyone.
Respect the medical uses of opioids and the role they can play in managing various health conditions. Avoid messages that stigmatize people who use prescription opioids under the direction of a health professional (e.g., by suggesting suspicion about motivations for use or how a prescription is being used), or that compare one group of people who use opioids to another.
Engage patients in clear, nonjudgmental dialogue about available treatment, therapy and other service options related to their substance use. Respect their autonomy and readiness for accessing these services. Shift the focus from “facilitating abstinence” to “facilitating wellness”, which may include continued substance use for certain individuals.
Communicate in ways that foster cultural safety and humility. This includes allowing space for and being respectful of culturally-influenced beliefs and knowledge about health, including what is considered to be a health problem, how and why symptoms are expressed and forms of treatment and therapy. These actions can make a patient feel like they are being heard and understood, improving their relationship with service providers and increasing their engagement and sense of control in their care.
6. Take special care when developing published materials related to substance use
Avoid reinforcing stigmatizing language that is used by other communicators. For example, when referencing other materials, stigmatizing terms should be replaced with alternatives, when possible, and without misrepresenting or changing the intent of the referenced material. If the reference is a direct quote, this alternative should be denoted with square brackets.
Consider the implicit messages that images, as well as language, can communicate; avoid choosing images that reflect narrow, stereotypical portrayals of people who use substances (e.g., according to age, appearance, social class, etc.) and imply that certain “types” of people are more likely to use substances.
Lexicon of non-stigmatizing substance use-related language
This lexicon identifies a number of stigmatizing, or potentially stigmatizing, terms grouped by topic. For each topic there are alternative terms provided, along with relevant background information and rationale. Often, the particular context will determine which choice of alternative is the most appropriate. For some topics, there may be additional, more medically precise language being used by health professionals or organizations than the terms listed within this lexicon; the intent is not to replace this more precise language, provided it is non-stigmatizing.
The terms in this lexicon vary in the degree to which they are stigmatizing, which has implications for their use. For example, some terms convey considerable shame and blame related to individuals who use substances or are linked to other types of stigma (e.g., racism). These terms should be avoided altogether. Other terms are less explicitly stigmatizing, though are colloquial or dated, and are more appropriately described using the provided alternatives.
Note: Reference to “substance(s)” in this lexicon includes: both medical and non-medical drug(s), including specific drugs such as opioids, cocaine, methamphetamine, cannabis and alcohol.
Avoid these stigmatizing terms | Alternative non-stigmatizing terms | Background/rationale |
---|---|---|
People who use substances | ||
|
|
Not everyone who uses substances, including in ways that cause social or physical harms, has a substance use disorder, so the use of this language depends on the context. |
|
|
- |
|
|
Substance use-related stigma varies by many factors, including substance and methods of use. Since injection is more stigmatized than other methods of substance use,Footnote i the label “injectors” conveys greater prejudice. |
|
|
- |
|
|
- |
|
|
|
|
- | - |
|
- | - |
People who have used substances | ||
|
|
- |
|
|
Being in recovery from a substance use disorder can, but does not have to mean, abstinence from substances. |
|
|
- |
|
- | - |
Avoid these stigmatizing terms | Alternative non-stigmatizing terms | Background/rationale |
---|---|---|
Substance use | ||
|
|
|
|
|
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-V) lists “alcohol use disorder” as a type of substance use disorder, replacing “alcohol abuse” and “alcohol dependence”. Alcohol use disorder is a medical condition with various sub-classifications that can be diagnosed using specific criteria. Though still widely used, the term “alcoholism” is decreasing in use in both clinical and policy contexts internationally, since it lacks a common language to describe the continuum of heavy drinking behaviours. |
|
|
Referring to an individual’s “drug of choice” minimizes the potential seriousness of their substance use and related harms and implies that substance use merely reflects personal choice. When applied to an individual (e.g., “what’s your drug of choice?”) the term also suggests that some level/form substance use is assumed. In a clinical context, it is better to ask individuals if they use any substances and, if so, which substances. |
|
|
|
|
|
“Binge drinking” historically referred to drinking heavily for several consecutive days (i.e., “going on a bender”) and typically related to people living with alcohol use disorder. However, binge drinking is now widely recognized as a single episode of drinking heavily enough to increase the risk of negative consequences for the individual consuming alcohol and/or others. |
Use of prescription drugs not as directed by a health professional | ||
|
|
|
Recurrence of substance use | ||
|
|
Though terms like “lapse” and “relapse” are commonly used, they may be stigmatizing as they can imply failure or choice, and are disempowering. These terms are inconsistent with the chronic, and possibly recurring, nature of substance use disorders and the fact that improvements in managing substance use (disorder) is often not linear. They also create dichotomies of “abstinence (good)” and “using substance (bad)”, which do not account for forms of recovery that are not abstinence-based. These binaries can create unrealistic expectations related to recovery and management of substance use disorders. |
Illegal drugs/market | ||
|
|
|
Avoid these stigmatizing terms | Alternative non-stigmatizing terms | Background/rationale |
---|---|---|
Proper name of substance | ||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Avoid these stigmatizing terms | Alternative non-stigmatizing terms | Background/rationale |
---|---|---|
Results of substance tests | ||
|
|
While “dirty” and “clean” are commonly used to refer to people who use drugs, these phrases are stigmatizing and imply a value judgement.Footnote iiii |
|
|
|
Substance use disorder | ||
|
|
|
Opioid agonist treatment | ||
|
|
|
Acknowledging the various pathways and barriers to recovery | ||
|
|
|
Addressing substance use issues | ||
|
|
“Front-line”, though commonly used to describe health professionals working in non-specific disciplines, is also seen as a military term. “Direct service/care providers” is more appropriate and is more patient/client-centred. |
|
|
|
Related resources
- A primer to reduce substance use stigma in the Canadian health system (guide)
- Stigma: Why Words Matter (fact sheet) (one-pager)
- Canadian Centre on Substance Use and Addiction
- Canadian Public Health Association
Endnotes
- Endnote i
-
Simmonds, L., & Coomber, R. (2009). Injecting drug users: a stigmatised and stigmatising population. International Journal of Drug Policy, 20(2), 121-130.
- Endnote ii
-
Steiner, Leela & Nicol, Anne-Marie & Eykelbosh, Angela. (2019). How we talk about “Pot” matters: strategies for improved cannabis risk communication. Environmental Health Review. 62. 8-13. 10.5864/d2019-005.
- Endnote iii3
-
Boticelli, M.P. Memorandum to Heads of Executive Departments and Agencies: Changing Federal Terminology Regarding Substance Use and Substance Use Disorders. Executive Office of the President, Office of National Drug Control Policy (ONDCP). January 9, 2017, retrieved August 1 from https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing%20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20Substance%20Use%20Disorders.pdft
- Endnote iv
-
Hasin, D.S., O’Brien, C.P., Auriacombe, M., Guilherme, B., et al. DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale. American Journal of Psychiatry. (2013). 170(8):834-851. doi: 10.1176/appi.ajp.2013.12060782
- Endnote v
-
the Heart. Reducing Stigma. Language Matters. Retrieved May 15, 2019 from https://towardtheheart.com/reducing-stigma
Page details
- Date modified: