Disapproving of destructive drug use should not be confused with stigmatizing drug addicts

Introduction

Professor Michael Vanyukov’s (2023) paper, “Stigmata that is desired,” sounds a brave and provocative challenge to widely accepted understandings of addiction. Provocative because it challenges the views of the National Institute on Drug Addiction (NIDA), the federal agency that funds most addiction research in the United States, and brave because his argument is not simply a minority view, but one which is likely to invite censure as unempathetic and unscientific. Nevertheless, his arguments are supported by much research, particularly the epidemiological and biological research that NIDA spokespersons and many addiction researchers and clinicians ignore. However, Vanyukov takes on a good deal more than received knowledge, delving into issues such as the history of the term “stigma” and the sins of reductionism—intellectual excursions that are likely to obscure the essay’s central and important message. Thus, I will begin with a summary of the paper’s basic argument.

The basic argument

Vanyukov makes a useful distinction between disapproval and stigmatization. Both involve reproof of an individual and/or their actions. However, stigmatization is by definition unfair and may interfere with remediation. For example, criticizing someone for ticcing who has Tourette syndrome is unfair, because under a sufficiently wide range of circumstances, the Touretter cannot control their tics. (For interesting cases in which control is possible, see A surgeon’s life, Oliver Sacks (1995), and the documentary Twitch and Shout, Chiten, Medley & Russel, 1994). In contrast, disapproval often entails the assumption that the “bad hat” can change, along with the hope that the change will be positive. For example, when we disapprove of someone who is rude and/or lies, we do so with the assumption that they could do otherwise and that censure will help ensure a better outcome.

In the context of addiction, these distinctions take the following shape. The destigmatizers are saying that individuals who meet the criteria for addiction cannot help but continue to take drugs in a destructive manner (they have a “brain disease”), so to hold them responsible for their destructive behavior is unfair and uninformed. In contrast, Vanyukov assumes that individuals who display the symptoms of addiction can stop using, and cites various empirical findings that support this key point. These include high remission rates, high “unassisted” (natural) recovery rates, and the role that disapproval played in reducing cigarette smoking in addicted smokers. (For summaries and a synthesis of these findings, see Heyman, 2013 and 2021. Also, and this is not sufficiently appreciated, the supporting studies that Vanyukov cites are compatible with recent findings regarding the biology of addiction, whereas, these same studies are not compatible with the disease interpretation of addiction.) Thus, whether you think disapproving of addiction is a legitimate first step in the path to remission or unfair stigmatizing depends on your understanding of the nature of addiction. My impression is that Vanyukov agrees with this summary, although it leaves out his historical and philosophical observations.

Implications for what drug users say about themselves

If Vanyukov’s claim that disapproval motivates heavy drug users to quit is correct then what they say about themselves should include much self-recrimination, particularly among those who no longer meet the criteria for substance dependence (and they are the majority of those who receive this diagnosis, e.g. Lopez-Quintero et al. 2011). Although, no one story applies to all ex-addicts, here are some representative examples.

One of the things that really gave me like a push when mama said, “I'll be the happiest woman if … when I left this earth … my son … [was] sober … he’s a better man for society, you know. If … you got your own place, your wife, I'll be a happy woman, I'll rest in peace.” So, that really like hit me. - I said, “She deserves it. If anybody does, she does.” pp. 127-128 (Gustav, former heroin user, Weiss et al., 2014)

One evening (while in the California desert) I climbed on this big rock, and just sat there alone waiting for the sunset. It was beautiful. Then I snapped… “What am I doing? God did not put me here on this earth to be using heroin!” For the first time I felt guilty about being a user. I began to have these powerful feelings for my parents to be proud of me again. And I thought about my son and my responsibilities to him. I stayed clean for about two weeks that time. p. 353 (Wendy, Jorquez, 1983)

It is a delicate balance to register disapproval yet do so in a way that proves helpful. However, we have examples. This is what happens in the many families that insist that “if their grandmother wants to see her grandchildren, she can’t be a crackhead” (Henwood et al. 2012); it is what happens in self-help programs, such as AA, that emphasize making amends and behaving less selfishly; and, as the narratives above suggest, it is a staple of the inner dialog that prompts drug users to get their life under better control. Put in more general terms the data and ideas that gave life to Vanyukov’s essay reflect three general principles that help us make sense of addiction: it involves destructive yet voluntary drug use, the motivation to use drugs is the universal drive to feel better (some might say, “feel less worse”), and, conversely, the motivation to quit using drugs is the universal drive to have more control over one’s fate (“to be free”). Remarkably, as attested to by the high remission rates, the desire to be free typically proves stronger.

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