Updated August 2023
Substance abuse in America is a steadily growing problem. As of 2021, according to the National Survey on Drug Use and Health (NSDUH), 46.3 million people aged 12 and older met the DSM-5 criteria for substance use disorders of some kind, with 64% of those having alcohol use disorders and 52% classified with drug use disorder. Between 2015 and 2021, national drug overdose death rates rose 104%, according to the National Center for Health Statistics (NCHS). These statistics have knock-on effects on crime, productivity and health care costs, and substance use stigma makes addiction even harder to fight effectively. This article looks at what factors influence stigma and how to address this problem.
What Causes Stigma in Addiction?
Many people want to know who or what is to blame. So, how do we confront the substance abuse stigma? Is it society? Are those who use drugs solely to blame, or do their families play a part? A report written by Nick Heather and published by the National Institutes of Health sheds some light on new ways of thinking about the social and political context of addiction. It asks whether addiction is truly a disease of the brain or if it is a moral failing.
How Should Addiction Be Seen and Treated?
The way professionals and the public have seen and treated people with addiction has evolved over history. It’s possible to lay out these changes in the form of waves. Initially, addiction was treated with scorn. The individual was isolated and blamed for his or her own actions. This first wave wasn’t effective in providing treatment or gaining public support to help those with addiction to obtain the care they need.
A significant movement changed this. As the initial wave receded the second wave of response was to view addiction as a brain disease. This is a popular viewpoint that many people stand by. By seeing addiction as a disease, some of the blame shifts away from the individual with the disorder. It also allows the public as a whole to be more receptive to treating an individual or ensuring that an individual gets the help he or she needs.
In the report, neuroscientist Marc Lewis’s theory is that a new response is necessary. In this third wave, he believes seeing addiction as a disorder of choice is ideal. Yet, there are problems with this theory as well. Specifically, it’s important to take a look at the political and social aspects of the condition. That is, what does the public need to believe in order to encourage care and for those seeking treatment?
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Does the Brain Disease Model of Addiction Fail?
For many years, people have been taught that addiction is a type of brain disease. Lewis does not believe the brain disease model is effective. Yet, the promotion of it may seem like the only way to ensure others — those who do not have an addiction — provide proper treatment of it.
The brain disease model encourages the general public, along with policymakers, to withhold placing the blame for addiction on the addict. In the first wave, for example, a significant amount of the blame was placed on the individual with the addiction. In the second wave — the brain disease model — the blame shifts away from the individual because the condition is seen as a disease, much like cancer or heart disease. It isn’t the fault of the individual.
If addiction isn’t a brain disease, then, does this mean it is a moral failing of the individual? The author of this report believes this is not an all-or-nothing scenario. Rather, there is a third option.
Understanding the Stigma
There’s no doubt drug addiction comes with a stigma, as the socio-political look at drug use makes clear. On the one hand, there is a common view that drug addicts are simply bad people. They are weak; they are unable or unwilling to lead a morally just life. They do not want to control their behavior; rather, they focus on gratifying their desires.
In this view, some people even believe those who have a substance abuse problem not only won’t help themselves but also don’t deserve for others to help them either. It’s their own fault, and they need to fix it on their own.
As the brain disease model became more prominent and promoted in society, it was clear a shift was taking place. As a result of this attitude about addiction, it was necessary to shift some of the blame to reduce the stigma. The brain disease model was seen as the only way to do so and, thus, to encourage the public to support the needed care of the individual.
An Acquired Disease of the Brain
The promotion of addiction as an acquired disease of the brain aims to remove some of the stigma of addiction — specifically, the formation of value judgments associated with the failure of addicts to control their own health. The most current approach to this is to see it as an acquired and complex disease of the brain, so attempting to shame or punish addicts isn’t likely to be an effective response. The National Institute on Drug Abuse lays out the fundamentals of this view, noting, “The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with their ability to resist intense urges to take drugs. These brain changes can be persistent, which is why [people in recovery] are at increased risk for returning to drug use.”
At the most basic level, taking this paradigm on board means accepting a version of the brain disease model as the starting point for addiction treatment that’s free of assumptions about moral failings. This can be an important first step in identifying and addressing what factors influence stigma, but is it the only viable approach, or are there alternatives?
How the Public Views Addiction
How the public views and understands addiction is critical. If the public aims to punish the addict for a moral failing, that individual isn’t going to have access to support and treatment. On the other hand, viewing it as a brain disease means that individuals have some type of inner demon they need to triumph over and, potentially, should not face punishment for their often illegal actions. Could either case be right?
A push-back against old traditions of blame and reaction has backfired to the point that many individuals with an addiction are never held responsible for their actions. Yet, a movement towards blaming the addict seems wrong.
Assuming It’s Not a Disease
In this report, Heather presents another view. Consider Lewis’s belief that addiction is not a disease or a neurological abnormality. If addiction was no longer seen or promoted as a disease, would this conceptually change the public opinion of it? If it was no longer promoted as a disease, would people revert to the theory that it is a moral failure?
Heather aims to show there is more to it. Specifically, he states, “Thus the question to be addressed in this article is whether it is true that there is no other way to persuade the public that addicts should receive sympathy and, when they ask for it, help to change their behavior.”
The belief that it is either a disease that’s not the fault of the addict or a choice the addict makes due to a moral deficiency, with no other option being viable, is not accurate, according to Heather. There are other options.
A Disorder of Choice
As noted, the third wave of belief could be called a disorder of choice. Here, the focus is on choice rather than blame. Does the individual have the ability to choose and, if so, what does it mean when that individual chooses drugs?
In a disorder-of-choice model, the nature of addiction is explained as a failure of the individual to self-regulate — specifically, a failure to make consistent choices over time. In other words, individuals have the ability to make a choice to use or not to use at any one time. The failure to make the right choice puts them on a path toward additional poor choices. Ultimately, autonomy is impaired when there is a pattern of negative choices over a period of time.
Heather explains that, in this view, a person makes a decision to not make a bad choice again. However, that individual fails to achieve that goal of avoidance. When this happens numerous times, a pattern of behavior becomes an addiction.
When an addictive behavior begins, it is voluntary — the individual makes the choice to use the drug or drink the alcohol. However, in this model, addiction becomes an interaction between voluntary and involuntary processes. It is this interaction that should reduce some of the moral failure-type blame.
By this token, it is possible to say that an individual is responsible for his or her behavior at the time they make the decision to use drugs or alcohol. Yet it is also possible to say that the individual should not be blamed for it. A lack of willpower or self-control could be a key here. Communicating this model to the public can be difficult, as a freedom to choose and personal responsibility can be easily manipulated by third parties.
A Weakness of Will
As a disorder of choice, addiction becomes a focus on a weakness of self-regulation. All people are weak-willed at some point. However, those who have an addiction have an extreme variant of this difficulty that leads them to be unable to control their behavior.
There are many examples of this, such as the over-consumption of food. Many people report today having a lack of willpower in eating healthy or getting enough exercise.
Heather believes that if addiction were presented to the public as a lack of willpower — something all people have suffered from at some point — but an extreme case of it, the public would not turn on those with an addiction. This view and promotion could remove some of the stigma associated with addiction while eliminating the ineffective, as he calls it, brain disease model. In his report, he writes, “Communications about addiction as a disorder of choice would emphasize the continuity of the experience of ‘addicts’ with that of people not so labeled and the intelligibility of addictive behavior and experience to ordinary people.”
Addressing the Stigma – What We Can Conclude
At FHE Health, we do not offer an opinion about right or wrong in any of these models of response to addiction. Rather, as noted, public perception of addiction is less important than seeking and obtaining care.
It’s true that the brain-disease model has allowed far more men and women to gain access to treatment because it focused public opinion less on a lack of morals and more on a condition that the individual cannot control. Yet, what is important to focus on here is just that: Individuals who have an addiction need treatment. Our focus is always on ensuring that individuals who need it get it so that they can move beyond this limitation in their lives to build a healthy future.
