The misnomer of substance use “stigma”: beneficial disapproval should not be conflated with mistreatment of users

This rejoinder replies to the three responses to my paper, ‘Stigmata that are desired: Contradictions in addiction’ (Vanyukov 2023), which have been kindly provided by prominent experts in the field. Two of those responses are broadly supportive. I will first address the unsupportive response by Dr. Corrigan (2023), because it recapitulates the very reasons I wrote my paper, and it is important to highlight the misconceptions. I welcome this opportunity to clarify my position.

First, it is worth mentioning that while it may be challenging to respond to criticisms of the actual points raised in an article, such a discussion could be useful. The difficulty, however, is much greater when what is critiqued is not there. That also renders a discussion barren. Thus, the terms and concepts criticized in the first commentary do not represent the article’s content. Most importantly, that pertains to the notion of ‘justified stigma’. This term is not used in the article and is a misattribution, from which most of the other criticisms ensue. Far from legitimizing stigma, the aim of the article, reiterated throughout, was to separate that notion, connoting malign unjust mistreatment that may be hindering recovery from substance use/addiction, from the justified and constructive societal disapproval of a lethally dangerous behavior that may motivate a change of that behavior. Many stigma experts consider factors such as perceived danger and social distance regarding substance users as attributes of ‘stigma’ rather than natural and normal societal corollaries of substance use and motivators of behavioral change.

As currently prevails in the literature, the concepts of stigmatization and societal disapproval are consistently and inappropriately conflated. It is precisely for that reason that I felt it unnecessary to cite more ‘stigma’ publications based on and maintaining that conflation. The ‘justified stigma’ misnomer is an example of such unhelpful conflation.

It is not a ‘stigma’, however, that resulted in the decrease in smoking but the smokers’ internalization of the beneficial and increasingly widespread societal disapproval – often mislabeled as ‘self-stigma’ – of the dangerous behavior in question. It is for a similar reason and not solely out of fear of punishment or because criminals are mistreated by society that the majority of the population does not commit crimes. It is not prejudicial to negatively view crimes and it would be preposterous to abandon the disapproval of crimes, labeling it ‘stigma’. Societal disapproval, including its legal forms, places both external and – when internalized – internal boundaries on behaviors that are harmful to the individual and society. That pertains to the entire spectrum of externalizing/antisocial behaviors, which includes illicit substance use (Krueger et al. 2002; Vrieze et al. 2012; Kirisci et al. 2015). By not distinguishing between the ‘stigma’ mistreatment and the justified societal disapproval, the tests of the influence of stigma on the outcome of substance use are substantially biased, tainting that disapproval by whatever may have been caused by potential stigma while also potentially underestimating the effects of actual mistreatment.

To argue for the abolition of societal disapproval and conflating it with malicious stigma risks construing manifold behaviors as stigmatized and is to call for anomie. It is societal disapproval that needs to be capitalized on in dealing with addictions, as the article suggests, rather than any effects of stigmatization. Ignoring the goal and substance of the article and substituting its terminology and concepts – particularly justified disapproval with the oxymoron of ‘justified stigma’ that is not used in the article – both denies and discredits a common factor motivating people to rectify their behavior. The indiscriminate application of the stigma concept to substance use, with the accompanying call for its unconditional removal, threatens to deprive users, their families, and society of an important mechanism for withstanding this noxious behavior.

Contrary to another criticism, the article also specifically points to a lack of objective criteria for dividing substances into either licit or illicit. Instead of the illogical view ascribed to me, that ‘‟illicit” damns corresponding substances as amoral’, it is behavior – not substances – that is considered from a moral standpoint when, by definition, it violates societal norms. Substances are indeed ‘amoral’, having no inherent morality as they are inanimate. It is, to be sure, the societal rules, not the properties of substances per se, that determine the statistical grouping of addictions to licit and illicit substances into two corresponding genetically distinct classes (Kendler et al. 2007). Importantly, however, while it could be disputed whether some substances could or should have been left licit (e.g. cannabis), their ongoing legalization will not correct the original mistake of banning them, if that was a mistake, but will and does already have far-reaching negative consequences.

I agree with Dr. Corrigan that language matters. In fact, the paper contains virtually exactly that very statement, criticizing the misapplication of the ‘stigma’ concept also by the actual proponents of the addiction stigma’s legitimacy (Satel 2007). Aware of the significance of semantics, he cites unreasonable and easy-to-defeat but nonexistent assertions – such as ‘all substance use leads to SUD’. In reality, the article discusses the arbitrariness of psychiatric diagnostic labels as well as the advantages of using a continuous trait perspective, a view I have maintained for decades (e.g. Vanyukov et al. 1993, 1994, 2016, 2023; Vanyukov and Tarter 2000, 2019). While still not implemented in addiction and in general psychiatric practice, this view has finally merited a section in the Introduction to DSM-5 (American Psychiatric Association DSM-5 Task Force 2013, p. 12–13). Another point at variance with the criticism is that many consequences of substance use, including lethal poisoning (so-called ‘overdose’), do not require a career of use and the development of an addiction. To be sure, it is a truism that not ‘all substance use leads to SUDs’. All substance use and addictions, however, can be mapped on the same latent trait continuum, as attested statistically, neurobiologically, and genetically (Vanyukov et al. 2012). Absent an objective boundary between the norm and pathology, substance use and substance use disorder cannot be ‘disengaged’, as called for by the critic.

The article also points out that the terms used to designate an addictive disorder are immaterial to the problem’s solution. Again, as argued in this and other articles (e.g. Vanyukov et al. 2012), any term denoting a censured behavior such as persistent substance use will attain a ‘pejorative’ or otherwise unsavory connotation corresponding to that censure. It is the proscribed behavior that results in the negative societal reaction, not a term that denotes it, despite all attempts to put the cart before the horse. Contrary to Dr. Corrigan’s opinion, there is currently neither a consensus on, nor a need for, abandoning the term ‘addiction’, including its routine use by NIDA as well as in publications and journal titles around the world (e.g. Addiction Research & Theory). Whereas DSM-5 does not employ ‘addiction’ as a substance-related diagnostic category, it is used as an adjective (‘addictive disorders’); DSM also mentions, without any negative comment, ‘repetitive behaviors, which some term behavioral addictions…’ (American Psychiatric Association DSM-5 Task Force 2013, p. 481). The other current standard set of diagnostic criteria, ICD-11, turns this expression around into ‘addictive behaviours’ that include ‘Disorders Due to Substance use’ (WHO 2019), BlockL1‑6C4).

Another misstatement of the article’s content and false target for criticism is the wrongful assertion that ‘[s]ubstance use and SUDs are all about crime’. Moreover, in Corrigan’s stated opinion, drugs are criminalized only ‘because some government decided to’, as if any such decision had been taken for no socially significant reason. This myopic viewpoint ignores the tremendous harm that substance use causes individuals and society regardless of whether it is criminalized or not. That viewpoint confuses the cause and the effect. Although ‘the war on drugs’ has nonoptimally dealt with supply rather than demand, it resulted from societal concerns regarding harms associated with substance use, just like Prohibition was a consequence of what, at the time, was a societal view regarding pernicious effects of alcohol (Blocker 2006). How lawmakers and law enforcers transcribe that perception into law and legal action is a separate issue. Janis Joplin’s death of heroin poisoning and Amy Winehouse’s death of alcohol poisoning are essentially no different, even though one substance is criminalized and the other is not. The potential lethal harm of a substance does not derive from societal or governmental views of it.

In contrast to the above discussed criticisms, Drs. Baumeister and André’s (2023) response is supportive of important points of my paper. They note that societal disapproval of substance use is legitimate, may help users by motivating them to quit, and that users maintain free will to do that. Moreover, anticipating guilt that can result from a person’s conflict with societal rules may (and often does) prevent involvement with substances.

Unfortunately, however, these authors also make the very mistake against which my major argument was directed. Namely, they also appear to conflate legitimate disapproval that does not need to have any special label (and Baumeister & André do implicitly accept ‘legitimate disapproval’ as a term) with the notion of stigma, which I hoped to have shown to be invariably an unjust judgment (such as that leading to persecution of minorities and people with mental illnesses). To reiterate, no other interpretation of the term is implied in the persistent calls for removing ‘stigma’ from substance use/addiction even when the positive effects attributed to it are discussed (e.g. decrease in smoking). The misapplication of the stigma concept ensues from the erroneous ‘disease model’ of addiction and unjustifiably renders willful substance use/addiction equivalent to the involuntarily contracted mental disorders such as schizophrenia, which need destigmatizing.

Since ‘stigma’ invariably connotes injustice and unjust labeling, society does not ‘stigmatize’, contrary to what Baumeister & André state, racism, rape, and child abuse, just as it does not ‘stigmatize’ murder. It justly outlaws those behaviors and punishes those who manifest them – a legal form of societal disapproval. Nobody would think to ‘destigmatize’ them, because there is no stigma there. Rather, society cannot tolerate dangerous behaviors, and it is a misnomer to equate such intolerance of a behavior with unjustly labeling or ‘stigmatizing’ it. Similarly, substance use does not require destigmatization because, any mistreatment of users aside, its ubiquitous societal disapproval is no stigma. That disapproval is not the indelible mark implied by ‘stigma’, and it can be lifted by ceasing the behavior in question. Moreover, discontinuing habitual substance use may serve as a source of personal pride and societal approbation.

The distinction between the legitimate disapproval and the unjust stigma is recognized by Dr. Heyman (2023) in his response, as is the fact that the misapplication of the notion of stigma to substance use stems from the misperception of addiction as a ‘brain disease’. I fully agree with him. In sharp contrast to the actual and historically common stigmatization of involuntary mental or neurological disorders, such as Tourette syndrome, the negative societal reaction to drug use encourages quitting and helps individual to refrain from engaging in substance use. As summarized by Heyman and addressed in other work as well (Vanyukov 2021), addiction, with its arbitrary diagnostic threshold, does not render an individual immune from the disapproval of this behavior that remains voluntary and thus does not constitute a disease. Its voluntariness is supported by the numerous examples of recovery (the majority of those with a lifetime addiction diagnosis), often with no professional intervention. Rather, recovery is motivated in part by the justified disapproval by society, including the family, as illustrated by the personal accounts cited by Dr. Heyman and documented in the literature (Winick 1962; Prince and McGuiness 2018; Lindell 2019).

In summary, the environmental pressure of societal disapproval is an active factor of resistance (Vanyukov et al. 2016; Vanyukov 2021; Stephenson et al. 2022) to substance use/addiction, which needs to be employed in prevention and treatment. We need to decouple beneficial societal disapproval from the notion of malicious ‘stigma’ and abandon the ‘destigmatization’ campaigns. As aptly expressed by V., a drug counselor for a small First Nation community in British Columbia, in response to the provincial government’s recent destigmatization/decriminalization activities, ‘But ‘stigma’ is all we have!’¹

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No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported in part by the National Institutes of Health grant R01DA054313. The content is solely the responsibility of the author and does not represent the official views of the National Institute on Drug Abuse.

Notes

1 Donald Gordon, MES. Personal communication, 10/19/2023