Addiction: Avoiding the Stigma

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By Mary Carpenter

PERPETUATING THE myth of the “addictive personality”—along with magnifying the stigma that accompanies it—is one of the more egregious wrongs committed by Purdue Pharma, makers of the heroin-like painkiller OxyContin. According to Empire of Pain by Patrick Radden Keefe, Purdue countered blame for OxyContin addiction and deaths that occurred even among those with legitimate prescriptions by denouncing everyone affected as having serious prior personality disorders.

As happens with other mental health disorders—among which addiction is officially classified —stigma creates significant barriers to treatment (albeit serving Purdue well because untreated users remained desperate for its product). According to the National Institute on Drug Abuse (NIDA), “stigma may stem from antiquated and inaccurate beliefs that addiction is a moral failing instead of what we know it to be—a chronic, treatable disease from which patients can recover.”

“Although addiction was originally framed by both Alcoholics Anonymous and psychiatry as a form of antisocial personality or ‘character’ disorder, research did not confirm this idea,” according to a book excerpt by Maia Szalavitz in Scientific American. Instead, longitudinal studies of addiction risk have pinpointed alterations in three major pathways in the brain that are responsible for self-regulation and are affected by the brain chemical dopamine, which is involved in reward and motivation.

The high likelihood of relapse for addiction is similar to that for other chronic diseases, notably those with both physiological and behavioral components. For hypertension and asthma, relapse occurs in 50 to 70% of cases. For addiction, the official number is 40 to 60% of cases— although counting the many relapses of each addicted person could bring that number closer to 99%. Explains Harvard psychologist Gary Sachs, “treatment of chronic diseases involves changing deeply imbedded behaviors,” and “no single treatment is right for everyone.”

Efforts to alleviate stigma recently prompted NIDA to update its vocabulary, for example, replacing “abuse” with “misuse.” And the latest description of “substance use disorder” (SUD) in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) eliminates not just “abuse” and “dependence” but also “addiction”— because the word “carries too much negative connotation and is ambiguous,” according to Addiction Center, a clearinghouse for patients seeking treatment resources.

(Ambiguity afflicts many words associated with addiction. “Dependence,” for example, can occur with many prescribed medications: the body naturally adapts and then experiences sometimes-unpleasant readjustments when the regimen ends. Even when dependence does indicate addiction, it can refer to mental or physical changes, or both. “Tolerance,” referring to the need to take ever-higher doses of a drug to get the same effect, is a clearer indicator of addiction, because it occurs rarely with medications taken as prescribed (OxyContin is a notable exception).

Also to reduce stigma, recent descriptions create a spectrum of addiction-related problems in place of the all-or-nothing diagnosis. In the DSM-5, SUD can range from “mild” to “severe,” based on the number of diagnostic criteria present—out of a list of 10 or 11 possibilities (different depending on the substance) that includes tolerance as well as “craving, or a strong desire or urge to use the substance” and “use..recurrent in situations in which it is physically hazardous.”

For NIDA, the spectrum starts with “misuse” and extends to “addiction”—defined by changes in behavior, specifically the “inability to control the impulse to use;” along with “changes in brain function.” The physiological changes further support the claim that addiction is “a brain disorder, not a personality issue,” according to Healthline.

Genetics may account for 40 to 60% of the risk of addiction, with a role in affecting the brain processes responsible for self-regulation. “Environment” is another risk factor: having someone with an addiction in the household both creates easier access to addictive substances and  models addictive behaviors. Other risks include experiencing abuse or other trauma as a child or adult; and ongoing mental health issues such as depression, anxiety and bipolar disorder.

Along with updated descriptions, NIDA has published a long list of “terms to avoid.” One is “addicted baby” —because “addiction” has a behavioral component, and because a baby’s symptoms are those of withdrawal, not addiction. Another is “habit,” which implies that a person can choose to stop as well as undermining the seriousness of the disease. Also on the to-avoid list are “alcoholic,” “drunk” “junkie” and “addict” —which should be replaced by “person-first language,” such as “people who are addicted to…”.  And terms like “abuse,” “dirty” and “clean” have problems with accuracy as well as stigma.

Responsibility for the terrible toll from OxyContin belongs not just to Purdue Pharma but also to the FDA, which continued to approve the drug for “broad use” despite a dearth of research.  The FDA also approved labeling that indicated the formulation reduced abuse liability and that addiction was rare, both allowing Purdue to market the drug as much safer than any opioid competitor.

When the original Oxycontin patent was about to run out in 2010, Purdue slightly altered its formulation, successfully obtaining a new patent but also making the pills more difficult to crush for injection. These changes coincided perfectly with the new, massive importation of cheap heroin from Mexico that contributed to an ongoing explosion in overdoses and deaths attributed to opioids.

Also ongoing is the difficulty for people who have no personal experiences with addiction— in themselves, or among friends or family—to stop perpetuating the stigma. Even with such personal experiences, I still struggle to remember that addiction begins with or becomes changes in the brain that control behavior — and to remember not to blame those who are addicted, but instead to support them by avoiding or arguing against the language of stigma.

—Mary Carpenter regularly reports on topical subjects in health and medicine.