Fighting Words is a column in which writers rub you the wrong way with their unpopular but well-argued opinions on fitness, health, nutrition, what have you. Got something to get off your chest? Send your pitch to firstname.lastname@example.org.
My cousin was a funny man. That was no surprise—Ralph was a funny kid, too. He was chubby. He had this adorable smile and big, round cheeks. He had a silly, often childish sense of humor, and he didn’t seem to take anything too seriously. When I saw him, usually for family trips and celebrations, he was always laughing.
Ralph died three years ago. He was 30 years old. Before he hanged himself in his home, he poured piles of cocaine around the room and rubbed his face with the white powder. Since I mostly saw him on festive occasions, it didn’t strike me as particularly concerning that he usually had a drink in his hand. In reality, I knew nothing about how frequently he drank or used drugs. People who knew him still hesitate to say that he had an addiction or a mental illness. Instead, they’ll say he “had a problem,” or even that the lifestyle was “what he wanted.”
I hear this rhetoric a lot. On a recent run through Central Park, I overheard two people jogging ahead of me. “He has a serious drinking problem,” the woman said to her companion. I’ve probably talked this way, too, especially in college and into my 20s, when it sometimes seems like we’re all drinking too much, smoking too much, or taking too much of something.
But we have to stop calling people’s drug and alcohol habits a “problem.” We’re almost always actually referring to one of three scenarios: First, we might use the term “drinking problem” or “drug problem” to refer to someone’s addiction, in which case we’re downplaying a mental illness. Second, we could be describing someone’s worrisome—but undiagnosed—substance use, in which case we’re assuming a certain level of severity. Third, we may be talking about someone’s low-key recreational use, which might not be problematic at all. In every case, there’s a more accurate way to broach the topic. And the way we speak about substance use inevitably affects the way we react to it.
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The current DSM-5—the classification of mental disorders used by mental health professionals—recognizes one diagnosis: substance use disorder. Not drug addiction, not drug abuse, and sure as hell not a drug “problem.” To have a substance use disorder, a person must meet at least two of 11 criteria, which include things like trying but failing to cut back, craving the particular substance, and flaking on important obligations because of use. These disorders are specific to the drug of choice (cocaine use disorder, opioid use disorder) and they’re measured on a spectrum: Meeting two to three criteria qualifies as a mild disorder, four to five as moderate, and six or more as severe.
The language we use to talk about addiction has implications for treatment. Not even medical professionals are immune to the effects judgmental language has on our view of this mental illness: Clinicians react more negatively and assign more blame to someone presented as a “substance abuser” compared to someone with a “substance use disorder,” according to research in the International Journal of Drug Policy.
The issue there is biased language, but at least the illness is part of the conversation. “Stigma holds us back from discussing it openly,” says Larissa Mooney, a California-based addiction psychiatrist. “There’s a benefit to having honest and open dialogue because many of these disorders are treatable.” Treating substance use disorders like a dirty or taboo topic—or avoiding the conversation altogether—can lead to unhelpful labelling, whereas using straightforward and accurate language can encourage people to seek treatment and save lives.
In the case of a real diagnosis, you shouldn’t say “So-and-so is an addict” or that a person is abusing drugs or has a drug problem, Mooney says. These terms have negative connotations and they put blame on the user. A drug use disorder is a mental illness, not a bad behavior for you to judge. “It’s an important distinction, because there’s scientific evidence to validate this understanding, the neurobiology of addiction, and it also takes the blame away from the individuals when we view it as a brain disease like other mental illnesses,” Mooney says. It’s best to say, “So-and-so has a cocaine/opioid/tobacco use disorder,” although she says that “So-and-so has an addiction to cocaine/opioids/tobacco” is also acceptable in everyday conversation.
If someone falls into the grey area, and you don’t know the extent of their use but you’re worried nonetheless, don’t criticize them by saying they have a “problem.” Are you noticing red flags? Does it worry you? Then say that. “You could just say, ‘I’m concerned about your drinking’ or ‘I’m concerned about your drug use,’” Mooney says, stressing that your role as a family member or friend is to be there for support, not to diagnose a disorder. “If you feel like there’s something concerning about their pattern of use, or the way that they’re acting has changed, it’s affecting their mood, it’s affecting their performance, encourage them to seek a professional evaluation from somebody who is qualified to make that assessment.”
Keep in mind that not all drinking and drug use warrants a reaction. “Not everybody who uses substances is addicted to those substances,” Mooney says. “Somebody might be using cocaine recreationally or may even binge drink once in awhile, and where do they fall on the spectrum?”
Well, if they don’t meet at least two criteria as outlined in the DSM-5, they don’t fall on the spectrum at all. “For someone who has high blood pressure, but not on a consistent basis, we do not categorize them,” says Indra Cidambi, an addiction psychiatrist based in New Jersey. “The ones who really have consistent high blood pressure, they are the ones who need to see a doctor.” In the same way, if someone uses drugs or drinks six vodka tonics on Friday nights but they don’t meet the necessary criteria for a substance use disorder, we shouldn’t say they have a problem, because it’s very possible that they don’t. “If they don’t meet the criteria for a full diagnosis, then we don’t have to label them as anything,” she says.
Substance use disorders are one of many mental illnesses that can benefit from treatment, but they can only be treated if they’re acknowledged. “We need to accept this as a chronic illness,” Cidambi says. “We shouldn’t be ostracizing people who are using.”
I do wonder if Ralph would still be alive today if he, and the people around him, talked about addiction and mental illness more openly. Maybe that dialogue would have helped him to recognize the seriousness of his situation and to seek help. If we want to make a meaningful effort to break through the stigma around mental health and addiction, we have to start having blunt and sometimes uncomfortable conversations.
“The scientific and medical community have come to view addiction as a brain disease and also as a chronic illness requiring longer term treatment, even if the needs for treatment may change over time,” Mooney says. “If family members and loved ones know that the extent of the substance use is serious and ongoing, we can do a better job of opening up the dialogue and getting more honest about the root of what caused somebody to behave a certain way or in the most tragic outcome, take their own life.”
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