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

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Organization: Public Health Agency of Canada

Date Published: January 2020

A Resource for Canadian Health Professional Organizations and their Membership (2019)

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.

**Table 1. Terms related to people with lived or living experience of substance use**
Avoid these stigmatizing terms	Alternative non-stigmatizing terms	Background/rationale
People who use substances
drug users drug abusers	people who use substances people who actively use drugs people with a substance disorder (context dependent)	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.
addicts	people living with a substance use disorder people with living experience of a substance use disorder	-
injectors	people who inject drugs	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.
alcoholics	people with alcohol use disorder	-
binge-users binge-drinkers	people who engage in heavy episodic drinking	-
recreational substance users	people who use substances for non-medical reasons (in some contexts) people who occasionally use substances (in some contexts)	“Recreational” implies that substance use is something people choose to do “for fun”. “Recreational substance user” to denote someone who uses substances outside of a medical context can be stigmatizing to people with substance use disorders. This term downplays the seriousness of substance use disorders as a medical condition and doesn’t reflect the fact that many people self-medicate with substances to manage physical and/or emotional pain. “Recreational substance use” can be used to describe non-problematic contexts of substance use (e.g., having a few drinks with friends in social gatherings, occasional use of cannabis among adults, etc.), though are better described using terms like “occasional” or “non-medical”, depending on the intended meaning. When referring to a person who engages in this form of substance use, it is always best to use person-first language.
jargon or labels, such as: junkies, potheads, crackheads, etc.	-	-
[reference to a person being] dirty	-	-
People who have used substances
former drug addicts ex-addicts	people with lived experience of substance use [disorder] people who have used substances people who formerly used substances people who have a history of substance use	-
recovering addicts	people in recovery [from a substance use disorder]	Being in recovery from a substance use disorder can, but does not have to mean, abstinence from substances.
former alcoholics	people with lived experience of alcohol use disorder	-
[reference to a person being] clean	-	-

**Table 2. Terms related to substance use behaviours**
Avoid these stigmatizing terms	Alternative non-stigmatizing terms	Background/rationale
Substance use
substance abuse substance misuse substance habit	substance use substance use disorder (in some contexts)	“Misuse” and “abuse” and “habit” are highly stigmatizing as the terms express judgement, and suggests deliberate misconduct or a moral failing. Not everyone who uses substances has a substance use disorder, so the use of these terms will be appropriate only in cases where it is medically accurate.
alcoholism	alcohol use disorder	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.
drug of choice	substances used	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.
recreational substance use (in some contexts)	medical/non-medical substance use occasional/regular/daily substance use	“Recreational” implies that substance use is something people choose to do “for fun”. “Recreational substance use” to denote use of substances outside of a medical context can be stigmatizing to people with substance use disorders. This term downplays the seriousness of substance use disorders as a medical condition and doesn’t reflect the fact that many people self-medicate with substances to manage physical and/or emotional pain. “Recreational substance use” can be used to describe non-problematic contexts of substance use (e.g., having a few drinks with friends in social gatherings, occasional use of cannabis among adults, etc.), though are better described using terms like “occasional” or “non-medical”, depending on the intended meaning.
jargon, such as: (getting) strung out, hopped-up, blasted, ripped, loaded, hammered, blitzed, etc.	using substances intoxicated, inebriated binge drinking, heavy episodic drinking	“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
prescription drug/opioid abuse prescription drug/opioid misuse non-adherence/compliance [use] against medical advice	use of prescription drugs use of prescription drugs/opioids not prescribed to the individual use of prescription drugs/opioids in a manner other than as directed by a health professional	“Misuse” and “abuse” are highly stigmatizing as the terms express judgement, and suggests willful misconduct or a moral failing. These terms also do not acknowledge that potential harms (including dependency) can arise from using medication exactly as prescribed by a health professional. “Non-adherence/compliance” and “[use] against medical advice” implies carelessness or a purposeful act of disobedience.
Recurrence of substance use
relapse, lapse slip on/off the wagon used again setback	recurrence of substance use recurrence of substance use disorder [symptoms]	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
black market illicit drug market illicit drugs/opioids street drugs	illegal supply drug market unregulated market/ substances illegally obtained drugs/opioids diverted prescription drugs/opioids illegally produced drugs/opioids	“Illicit” has a moral connotation that can be stigmatizing. “Illegal” is more plain-language than “illicit” and does not carry the same judgement. “Black” is often used as an adjective to convey that something is illegal or otherwise “bad” (e.g., black market, blacklist, black sheep, blackmail, etc.), which has clear racist underpinnings. “Diverted prescription opioids” can refer to prescription opioids not taken as directed by a healthcare professional, including those bought and sold on the unregulated market.

**Table 3. Terms related to substances**
Avoid these stigmatizing terms	Alternative non-stigmatizing terms	Background/rationale
Proper name of substance
booze	alcohol	There are hundreds of “street names” and slang words to describe various substances, and these terms can change rapidly over time. The terms listed here represent only a small sample of these terms. Instead of using informal/slang words for a substance such as “booze” or “dope” it is important to use the proper/formal name of the substance to reduce harmful stereotypes and racial undertones that are often associated with slang words.^{Footnote ii} It is best for substance use education efforts (i.e., through patient interactions, in publications, etc.) to emphasize substances’ formal names. These efforts can also acknowledge related slang terms for educational purposes (i.e., given their common usage) without endorsing these terms or using them as the default descriptors. Though commonly used, it is recognized that the term “marijuana” has racist origins. This “exotic-sounding” name became widely adopted by prohibitionists more than a century ago as a means of emphasizing the substance’s “foreignness” and use among non-White Americans, appealing to the xenophobia at the time. The term “cannabis” is less historically fraught and stigmatizing.
ice	methamphetamine
dope	heroin
molly	ecstasy, MDMA
dope, weed, marijuana	cannabis

**Table 4. Terms related to diagnosis, treatment and recovery**
Avoid these stigmatizing terms	Alternative non-stigmatizing terms	Background/rationale
Results of substance tests
clean drug test	negative drug test drug free	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}
dirty drug test failed drug test	positive drug test
Substance use disorder
addiction (in some contexts)	(mild/moderate/severe) substance use disorder dependence	Substance use disorders can be diagnosed according to severity (low, moderate or severe). The term “addiction” has historically been adopted to describe the severe end of substance use disorders. Many substances and behaviors can become addictive; however, addiction itself is not, and has never been, an independent diagnosable condition. ^{Footnote iv} The term “disorder” is more medically accurate than “addiction” and helps to signify substance use disorders as a legitimate medical condition. Its use is only appropriate in cases where the individual meets the conditions required for diagnosis of a substance use disorder specified in DSM-V.
Opioid agonist treatment
replacement therapy substitution therapy liquid handcuffs medication assisted therapy	opioid agonist treatment opioid agonist therapy opioid maintenance therapy	The terms “replacement” or “substitution” may imply that opioid agonist treatments (such as methadone or buprenorphine) are analogous to street drugs and alludes to a simple lateral change from one substance to another. This minimizes the potential merits of this approach to treatment/therapy and its role in medically comprehensive treatment plans. Some health professionals prefer the term “therapy” over “treatment” when referring to this type of care, since it is often a long-term commitment. “Treatment” often implies a more time-limited cure compared to “therapy”.
Acknowledging the various pathways and barriers to recovery
non-compliant unmotivated resistant	opted not to [receive care/particular service] [the person is] choosing not to [receive care/particular service] [the person is] experiencing barriers to accessing services not ready at this time to consider recovery options [choosing to] engage in lower-risk use	“Non-compliant” or “unmotivated” are negatively charged terms and imply that behaviour is strictly a reflection of personal failing and poor choices, detracting from the importance of contextual factors. Using statements like “person is choosing not to receive [care/particular service]” promotes agency, compassion and the right for the person to choose what type of recovery best suits their individual needs.^{Footnote v} For various reasons, individuals may not be able or open to access particular services and/or receive certain types of care. A person’s individual agency and unique context should be respected through attempts to “meet them where they are at”. This approach to care is reflected in efforts to create opportunities for individuals to have choice and control in their care-related decisions and not presupposing particular goals related to treatment and/or recovery. Health professionals are encouraged to respect and accept a person’s readiness. Likewise, individuals may be unable or not open to discontinue their substance use completely for various reasons, and choose to adopt lower-risk substance use-related practices (i.e., by moderating the frequency, quantity, form, potency, method of substance use, etc.) as a part of their individual recovery. Any individual effort to decrease harms associated with substance use should be supported, versus labelled as being “not enough” or “unsuccessful” because the person is not discontinuing substance use.
Addressing substance use issues
front-line workers	direct service/care providers	“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.
combatting/fighting/tackling war (on drugs)	addressing/taking action/responding to supporting people who use substances	Typically, something that is fought is bad or evil (i.e., in war or in superhero movies), and when applied to substance use, it is not always clear that the ”fight” is against the condition/behaviour versus the person. This language can make people who use drugs feel threatened and/or marginalized. Reference to the “war” on drugs suggests an emphasis on enforcement and criminality (versus one more centrally linked to improving public health), and has clear militaristic connotations.

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
- Overcoming stigma through language: A primer (2019)
- When it comes to substance use disorders, words matter (2017)
Canadian Public Health Association
- Language matters: Using respectful language in relation to sexual health, substance use, STBBIs and intersecting sources of stigma (2019)

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.

Return to endnote i referrer

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.

Return to endnote ii referrer

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

Return to endnote iii referrer

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

Return to endnote iv referrer

Endnote v

the Heart. Reducing Stigma. Language Matters. Retrieved May 15, 2019 from https://towardtheheart.com/reducing-stigma

Return to endnote v referrer

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