In their own words: language preferences of individuals who use heroin.
Pivovarova E. & Stein M. D. (2019) Addiction, 114(10): 1785-1790. DOI: 10.1111/add.14699.
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What are the label preferences of individuals who use heroin and are in early recovery?

This cross-sectional survey study examines the label preferences of individuals who use heroin and are initiating substance use disorder (SUD) treatment. 263 participants in the USA were asked (1) what labels they used to refer to self and when talking with others who use drugs, with providers, families and at 12-Step meetings, and (2) to identify which label they preferred least and most for others to use when referring to them.

Key findings:

• The most-preferred label for others to call them was ‘person who uses drugs’.
• The most common label participants never wanted to be called was ‘heroin misuser’ or ‘heroin-dependent’.
• 71.9%-85% of participants used the term ‘addict’ to refer to themselves and when speaking with others. However, the use of ‘addict’ varied between contexts and was most common in 12-step contexts.

The authors concluded that the preferred labels were consistent with general guidelines about the use of first-person language, and suggest avoidance of language referring to drug misuse or dependence.

Commentary:

This thought-provoking paper will hopefully encourage us to reflect on the language we use with patients and our colleagues, both in person and in clinical documentation, when referring to people who use drugs. A number of widely used terms and labels have inherently negative connotations and can reinforce stigma. Terms such as ‘substance abuser’ and ‘addict’, whilst rooted in historical diagnostic terminology, can elicit punitive attitudes and individual blame, and can also be used as unsubtle code for difficult patient, or someone less worthy of best care.

Whilst a majority of participants used the term ‘addict’ to refer to themselves they preferred a more neutral term for others to use when describing them. This suggests that although someone may use one term to describe himself or herself, they may not necessarily accept someone else using the same term to describe them. The authors also suggest that participants may have been too early in their recovery to identify themselves in terms other than ‘addict’. It is not known how label preferences might differ as recovery progresses, and for people who are not currently receiving SUD treatment. The authors speculate that the preference for the ‘addict’ label may lessen as time in recovery increases and, through the transition to ‘non-addict’ identity, a new sense of self is constructed.

Interestingly, this paper shows that some terms that clinicians may consider to be free of stigma and safe to use, such as ‘misuse’ and ‘dependence’, may not be palatable to some. The term 'misuse' can infer that someone is using incorrectly or does not know how to use properly, whilst ‘dependence’ infers that someone is reliant on a substance, and unable to function normally without it. Both of these terms can appear judgmental and imply a person has an inferiority or shortcoming.

Whilst ‘heroin-dependent’ was a term that 19.1% of participants never wanted to be called, ‘person with heroin dependence’ was a preferred term for 42.4% of participants. These subtle differences highlight the importance of separating the person from the diagnosis, and seeing someone as a whole where heroin dependence is just one part of that individual’s experience and identity. Furthermore, the term dependence can be clinically useful when describing physiological dependence (the presence of tolerance to a substance and subsequent withdrawal symptoms when the substance is stopped), as this can inform risk assessment and guide treatment decisions.

The language a person uses to describe themselves can also provide valuable information to clinicians when planning treatment and targeting interventions. A patient who uses slang such as ‘junkie’, a term typically seen as shameful and used for someone with less control over their drug use, to refer to themselves may mean that they have higher levels of self-stigma and internalised shame, which may need to be addressed in treatment.

Stigma can prevent individuals from seeking treatment, so it is important that treatment services use language that does not reinforce negative, stigmatising stereotypes and risk alienating the people who are most in need of treatment. The variable label preferences seen between participants emphasises that in practice the needs and preferences of the individual must be prioritised as there is no single agreed upon term. If unable to elicit an individual’s preference, non-judgmental first-person language should be used (e.g. person who uses drugs), and in clinical documentation current diagnostic terms should be adhered to (e.g. substance use disorder) to provide clinically relevant, objective information.

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