Stigma is never justified

Assertions about behavioral and social phenomena related to addictions should be grounded in research, especially when seeking to influence practice guidelines and health policy. This applies to descriptive and treatment research about addiction as well as studies on the effects of stigma. The National Academy of Science (The National Academies of Sciences Engineering and Medicine (NASEM) 2016) summarized hundreds of peer reviewed reports on the stigma of behavioral health using its consensus method. A subsequent edited book did a deeper dive into the stigma specific to substance use disorders (SUD) based on the most recent literature (Schomerus and Corrigan 2022). None of the references cited in the Vanyukov paper included these two sources nor research by the standard bearers of empirical research in stigma: Link, Thornicroft, Stuart, Rusch, Angermeyer, Pescosolido, Schomerus, Yang, Hatzenbuehler, McGinty, Yanos, or Corrigan. I am concerned not only about inaccuracies in Vanyukov’s statements, but also publication of a seemingly scholarly work that legitimizes stigma. I consider three examples of assertions made in his paper that do not hold up to empirical scrutiny. I admit describing clear assertions was a bit hard for me given the paper ranges from Jesus, St Theresa, and stigmata to use of Merriam-Webster’s definition and Greco-Roman etymology. Research support for my responses can be found in the NAS (The National Academies of Sciences Engineering and Medicine (NASEM) 2016) summary and the book by Schomerus and Corrigan (2022).

Separating substance use from substance use disorder

Vanyukov described justifiable stigma alternately aimed at addiction and illicit substances that lead to addiction. First, and contrary to Vanyukov’s discussion about DSM labels, language does matter. Researchers and advocates agree that ‘addiction’ worsens stigma because it exacerbates the blame experienced by people using substances; substance use disorder (SUD) is currently preferred. Second, opinions about substance use versus SUD need to be disentangled. Vanyukov suggests all substance use leads to SUDs which is clearly NOT where science or societies find themselves. Vanyukov also suggests ‘illicit’ damns corresponding substances as amoral and hence justified to be stigmatized. This ignores the social construction of substance use and labels. Some substances are illicit because some governments labeled them as illegal. The changing landscape of previously illegal drugs such as marijuana highlights the fallacy between ‘illicit’ labels and justified stigma. Harm reduction, as an evidence-based approach, challenges notions that using substances leads to SUD and is therefore reason for stigma.

Substance use and SUDs are all about crime

This statement is the epitome of stigma. It ignores significant factors that mediate associations between substance use and crime, most notably social determinants and social disadvantage. It once again ignores the role of social construction. The only reason use of any substances is linked to crime is because some government decided to create such linkage. The war on drugs is now recognized as one of the most egregious social mistakes of the twentieth century.

But what about the fact that stigma stopped smoking

The equation of stigma and smoking cessation seems to be incontrovertible evidence of the value of stigma. While attitudes and actions about smoking have changed over the past few decades, stigma has not stopped tobacco use. Of more concern however, is that Vanyukov’s simple equation once again ignores the complex moderating and mediating effects of social determinants on health. He also failed to do the careful empirical work of sorting out correlation – significant associations between health knowledge, smoking cessation, and stigma – and causation: that stigma caused smoking change. Public health and communications experts who know the literature do not recommend using stigma to decrease behaviors related to modifiable health risks: smoking, alcohol use, substance use, unsafe sex, diet, exercise, and medication administration

What might the person with lived experience say?

Much of Vanyukov’s paper is written for professional readers to impact their attitudes and actions related to SUD and the value of stigma. Priorities and perspectives of the lived experience of people who use substances in the world are largely absent. This kind of myopia reflects recurring limitations of the professional’s hubris in terms of health behaviors in society. People with lived experience of substance use and SUD are best experts of their impact. I admit that people who use substances do not speak with a single voice. Their beliefs about substances, SUD, and stigma may vary, in part based on their understanding of recovery. Is recovery an outcome, such that abstinence is the only legitimate treatment or is it a process, where the lived experience of substance use and personal goals is paramount. Regardless, work on SUD stigma and stigma change needs to be led by people with lived experience. I am certain their work will not start with justifying stigma.

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