Ending the Stigma and Prejudice Around Substance Use Disorders

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Apparently, among millennials and Gen Z, there is a growing interest in sobriety – sometimes deemed sober curiosity. Whether you go booze-free for a month to try it out (e.g., Dry January and Sober October), decide to cut down longer-term, or quit altogether, the physical and mental health benefits you’ll derive are substantiated by much empirical and anecdotal evidence.

For myself, I’m not trying out sobriety due to a cultural trend, fad, or passing interest. I’ve quit booze forever because I’m an alcoholic.

In this piece, I cover the term “alcoholic” and my sobriety; the unbelievable – or perhaps it’s not really that unbelievable – degree to which substance use disorders (SUDs), more broadly, are still stigmatized in contemporary societies; and the genetic, environmental, psychological, and sociocultural reasons people fall into substance misuse in the first place. 

Overall, I hope to underscore the unfairness of the widespread, deep-rooted prejudice, stigma, and discrimination against those with substance use disorders.

The Stigmatized Term “Alcoholic”

I know there is a shift away from the label “alcoholic.” Take a moment to think about the word and the connotations surrounding it. Would it damage your self-esteem to be called an alcoholic (self-stigma)? Would you want to be publicly associated with one (stigma by association)?

And what kind of person do you picture when you think of an alcoholic (public stigma)?

I know it’s uncomfortable to bring this up, but let’s face it, most of us will have some stereotyped representation of what an alcoholic looks like, acts like, and what their traits are. Maybe we think they are the disheveled loner at the end of the train carriage who looks like they haven’t showered in a month. Maybe we think alcoholics all just lack willpower. Maybe we think they should just behave as everyone is “supposed to” behave.

Personally, I don’t mind calling myself an alcoholic. There are two reasons. The first one is that it was thanks to Alcoholics Anonymous that I finally realized that I am an alcoholic (by their definition). I answered “Yes” to all 12 questions on their site, and I thought, yep, I get it now. It makes sense. That straightforward, non-judgmental validation helped me immensely – it helped me quit for good. The vast majority of AA members have no qualms about calling themselves alcoholics. Or “alcis” as one member cutely put it (that’s pronounced “al-keys”)!

On a short tangent, online AA meetings were also a much-appreciated source of solace and solidarity in the first month or so of my sobriety. Having just escaped from a corporate environment, I found the AA members’ honesty, vulnerability, and genuine support to be a refreshing change. (In the corporate world, “you can’t show signs of weakness; they’ll use it against you … They’re cold-blooded c**nts,” as another inpatient told me in hospital.)

Today is day 110 sober now. I love proudly displaying my monthly AA medallions.

The second reason I’m all right with the label “alcoholic” (and alco/alci) is that I kind of enjoy fighting against the stigma attached to certain words. Many people avoid admitting that they are an “alcoholic” – even to themselves. Speaking for myself, if it helps someone suffering out there to feel less alone or ashamed, then why not? So, it’s rewarding in that sense.

But even when group members are comfortable describing themselves with certain terms, it’s a completely different scenario when others, outside the group, label them as such. So, in the piece “Reducing the Stigma of Addiction,” John Hopkins Medicine advises opting for “person with a substance use disorder” rather than alcoholic, addict, drunk, abuser, user, etc.

Pretty much, the shift is towards terms and language emphasizing that the conditions are something you have rather than something you are.

Substance Use Disorders: The Most Stigmatized Health Conditions?

By any name, substance use disorders (SUDs) are among the most stigmatized of all health conditions. And their contemporary inclusion in both the DSM-5 and the ICD-11 indicates that, yes, they are medical conditions. According to the authors of the 2019 book The Stigma of Addiction, “addiction … is now recognized as a disorder and falls under the ambit of mental illness.”

All the most common stigmatizing stereotypes about those with psychosocial conditions are held about those with SUDs. Individuals with them are perceived as unpredictable, dangerous, weak, to blame for their condition, irresponsible, hopeless, and so on.

Substance use disorders induce the worst prejudice and ignorance. But when I can, I like to back up statements with quotes from the research literature (I’m no expert!). I like to substantiate my claims with evidence. So, here are a few extracted quotations.

  • This book chapter highlights that the “core indicators of stigma remain higher for people with schizophrenia and substance disorders than other conditions.”
  • Looking at drug addiction and alcoholism separately, this article states: “One WHO study found that of 18 different health conditions, drug addiction ranked as the first or second most stigmatized in 12 out of 14 countries surveyed and alcoholism ranked between second and seventh in 13 countries.”
  • While this paper begins with the sentence: “Substance use disorders consistently rank among the most stigmatized conditions worldwide.”
  • The authors of a Neuropsychopharmacology article write: “Stigma against people with substance use disorders has proven particularly intractable. The public continues to see these disorders as character flaws or even as deviance.”
  • Examining the attitudes of emergency department physicians, the results from this study reveal that they “had lower regard for patients with substance use disorders than other medical conditions with behavioral components.”
  • This review includes study results indicating those with a dual diagnosis “reported a feeling of being stigmatized and rejected because of their substance use … They also agreed on the fact that the dually diagnosed individuals are devalued and discriminated against.”
  • As yet another example, this systemic review found that “compared to substance-unrelated mental disorders, persons with AUD [alcohol use disorder] were generally less likely to be considered mentally ill … [and] were perceived as being more dangerous and responsible for their condition. Further, the public desire for social distance was consistently higher for people with AUD.”
  • Lastly, some statistics from a Health and Human Rights piece: “47% and 74% were unwilling to work closely with individuals with major depressive [disorder] or alcohol dependence, respectively.”

Need I add more?

Breaking down the stigma is important. Especially given how prevalent these conditions are. Around 29% will meet the AUD criteria in their life.

We always seem to forget that nobody chooses their genetics or brain, nobody chooses the social milieu they are raised in, nobody chooses to be traumatized or abused, and nobody chooses to become addicted to or dependent on a substance.

Genetic and Biological Underpinnings of Substance Use Disorders

In terms of alcohol, a well-cited 2013 paper titled “Genetics and Alcoholism” puts it quite plainly that “alcohol dependence (alcoholism), the most severe alcohol use disorder, is a complex genetic disease.” While most people can have a few and stop, there are those who cannot, and much of that is attributable to their genetic vulnerability to becoming dependent on alcohol.

The researchers remind us that there is “overwhelming evidence” that the risk for AUD is heightened due to heritable genetic variations. This, along with social factors, is why the condition often runs in families. The same piece also provides biological evidence from animal studies. (Unfortunately for them but) rats and mice have been “selectively bred for many traits associated with alcohol dependence, including alcohol preference, alcohol sensitivity, and withdrawal sensitivity.” 

I dunno about you, but that is pretty convincing evidence for me.

Further, the NIAAA in the US writes that genetic factors account for around half the risk of developing alcohol use disorder. As with most mental disorders, AUD arises from a mix of bio/psycho/social influences. Nature, nurture, and environment, and the interplay between them (e.g., epigenetics).

Similarly, there is no one gene responsible. Some combo of variations across numerous genes increases the likelihood, directly or indirectly. Researchers have identified more than 400 locations in the human genome, and over “566 variants within these locations,” that contribute towards alcohol use and smoking.

What about other substance use disorders? A 2021 article published in Psychological Medicine opens with the line: “Substance use disorders (SUDs) are heritable psychiatric disorders … influenced by both environmental and genetic factors.” Here, they are even defined as heritable psychiatric disorders. I guess that’s why there are addiction psychiatrists.

Environmental and Social Influences on Developing SUDs

The debate around nature vs. nurture is pretty old school. The general consensus is that both play fundamental roles in mental illness etiology and presentation. No individual is destined by biology to become addicted to a substance. External factors, like childhood experiences, traumatic events, and the sociocultural landscape contribute, too. And they influence one another.

Epigenetics, for example, illustrates how our DNA can be modified based on our lived experiences. Essentially, it is where nature and nurture meet. The word (epi + genetics) literally means “on top of or in addition to genetics,” with our epigenomes made up of chemical tags that modify the DNA of our genomes.

This resource provides us with a beautiful summary of epigenetics: “During the course of human life, we are exposed to an environment that abounds with a potent and dynamic milieu capable of triggering chemical changes that activate or silence genes.” 

The brains of children are particularly susceptible to molding by negative and positive life experiences. Especially extreme or repetitive ones. The Adverse Childhood Experiences Study (ACE Study) draws direct links between exposure to a greater number of adversities – traumatic events – in the first 18 years and correspondingly worse health and life outcomes as an adult. 

The higher a person’s ACE score, the higher their likelihood of developing chronic health problems, mental illnesses (depression, anxiety, suicidality, etc.) and SUDs later in life. Compared to that fortunate 30% with no exposure to the investigated adversities, those with a score of 4 or higher had “4- to 12-fold increased health risks for alcoholism, drug abuse, and suicide attempt; [and] a 2- to 4-fold increase in smoking” risk.

It may be that those with more ACEs turn to substances to cope with other mental illnesses that result from early life trauma. Either way, there is a robust, graded relationship between ACE score and substance addiction. You can see the ACE pyramid here.

Another environmental risk factor for SUDs is parental (or caregiver) substance misuse during your younger years. (Which is also an ACE.) Research has shown that individuals raised in a household with regular, ongoing substance use are notably more at risk for developing dependence on alcohol, cocaine, and/or opioids. 

Specifically, this study found that childhood “household substance use nearly doubled the risk of SD.” Household smoking elevated the chances by around two-thirds. And other research indicates that 30% of those with alcohol use disorder had at least one parent with the same condition (related to genetics and upbringing).

Along with traumatic, early life events and childhood household influences, broader sociocultural circumstances undeniably compound the odds that an individual will end up with one of the substance use disorders. We can take a bottom-up/micro approach, starting with tiny genes, or a top-down/macro approach, looking first at the social contexts in which all human behavior occurs. For instance, the following social aspects often play a role:

  • Cultural norms (e.g., some societies have more of a drinking culture, or greater shame surrounding mental disorders)
  • Peer pressure
  • The ubiquity of and easy access to some substances
  • Lack of access to appropriate healthcare for mental disorders (and/or a lack of trust in the health system, considering health provider stigma)
  • Marketing targeted at specific groups
  • Structural adversities faced as an adult (e.g., poverty, racism, and discrimination)
  • And so on

Final Thoughts

Although there is greater awareness of the genetic, traumatic, and environmental factors that culminate in an individual’s substance use disorder, unfortunately, there is still just as much stigma and prejudice directed toward that same individual. As though they were to blame for what is now recognized to be a psychiatric condition.

I’m no professional expert in these fields; I just come from a lived experience standpoint. And I thank you for reading this writing. I hope that readers will come away from it with a bit more understanding of substance use disorders, and a lot more compassion toward those experiencing them.

This piece was originally published on Psychreg

Image by marjan4782 via Deposit Photos

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