Recovering Individuals’ Feelings About Addict and Alcoholic as Stigmatized Terms: Implications for Treatment

Origins of person-first language

Person-first language dates back to the 1970s to 1980s and the disability rights movement, ²⁰ wherein advocates pushed for language recognizing that people are not defined solely by their disability ²¹ As Bedell et al ²¹ write, “labels can serve to ‘other’ people and signify a lower social position based on a conflation of a person with a socially devalued trait” (p. 1141). Other fields (medicine, epidemiology) were slower to adopt this, but the philosophy has since permeated much of the health fields. Person-first language is championed by the American Psychological Association ²² ; supported by advocates for individuals with autism^23,24,25; and widely used in nursing and other healthcare fields.^4,26, Losorelli et al ²⁷ recently recommended purging medical and surgery literature of prejudicial terminology, and instead choosing language that is clear, descriptive, precise, and non-stigmatizing.

Word matters: Use of person-first language across disciplines

Person-first language emphasizes the individual first—their abilities, needs, strengths—rather than their disability.^4,5 Word choice and how it is perceived by others matters, particularly between patient and care provider. ²⁶ Poor language choice can contribute to poor treatment and patient outcomes, ultimately wasting resources and increasing healthcare costs. ²⁶ The use of person-first language can also help reduce stigma around a condition. ⁵ One study ⁵ found that when person-first language was used regarding individuals with autism, additional stigmatizing language was subsequently avoided as well.

That said, there is some disagreement on the utility of person-first language. Debate around the use of person-first versus identity-first language has been particularly passionate in the autism community. ²⁸ Surveying over 700 U.S. autism stakeholders, Taboas et al ²⁹ found differing preferences across different groups, including professionals, parents of autistic youth, and adults with autism. Whereas a majority of surveyed autistic adults preferred self-identifying using identify-first, a non-small minority preferred person-first language. By contrast, professionals tended to use person-first language. ²⁹

Person-first language, addiction and stigma

In the past 2 decades, there has been a sizeable increase in overdose-related deaths, much of this linked to an epidemic of opioid use.^30,31 In addition to shouldering an addiction, individuals with substance use disorders are confronted with the stigma often attached to drug use, a ubiquitous phenomenon that can adversely affect treatment outcomes, care providers and research and policies more broadly.^6,32 Stigmatizing language around drug use can communicate—both intentionally and unintentionally—that not being able to stop using substances is rooted in weak willpower and a lack of personal self-control; in other words, personal failings.^6,31 By contrast, a destigmatized view frames addiction as a brain disease. ⁶ A review ⁷ of 28 studies of health professionals’ attitudes about addiction found that negative opinions about patients with a substance use disorder were frequent, and linked to poor care provision toward these patients.

In general stigma is associated with stereotyping, discrimination and the loss of a person’s status. ³¹ With regards to stigma around substance abuse, individuals anticipating being stigmatized for their substance abuse may conceal it, engage in high-risk practices and socially isolate. ³¹ Having internalized the stigma, individuals with a substance use disorder may avoid seeking out help. At the broader societal level, public stigma around addiction contributes to discrimination in employment and housing, and resistance to have community-based resources established in some neighborhoods. ³¹ As an example, harm reduction initiatives such as safe injection sites have traditionally received low support from the public, ³³ underscoring policy implications of stigma around addiction.

The issue of stigma around substance addiction has been studied both in the U.S. and internationally. ¹⁸ A review ¹⁸ of published studies, 15 of which were non-U.S. based, found that stigma reactions to substance addiction were stronger than toward other types of mental health disorders. Individuals with substance use disorders were often blamed for their condition. A U.K. study ³⁴ of smoking during pregnancy found that women who smoked while pregnant typically faced negative judgment from the public, including healthcare providers, which contributed to them smoking in private. In other words, the stigma achieved no positive outcome (ie, it did not decrease the women’s smoking) and served only to shame the women. A recent study ³⁵ of addiction stigma conducted in Australia notes that stigma can undermine trust between an individual and their healthcare provider, weakening the quality of the care. A 2021 cross-national study ³⁶ (U.S., Canada, Australia) of public stigma toward substance addiction found that substance addiction was more stigmatized than other types of medical or psychiatric disorders, and was viewed as a personal moral failing.

To begin to tackle the issue of stigma around substance abuse, some^37,38 have called for using person-first language (eg, an individual with a substance use disorder, an individual with an alcohol use disorder) rather than terms like “alcoholic” or “addict,” viewing them as both stigmatizing and non-medical in nature. Change in language may result in greater public support for the treatment for opioid addiction, ³² for example. Sattler, Escande, Racine et al ³⁹ note that while stigma-rooted negative attitudes toward people with a substance use disorder can adversely affect those individuals’ lives, there remains a lack of research on this area compared to other areas (eg, the effect of stigma on other mental illnesses). The focus now shifts to how recovering individuals feel about the words “addict” and “alcoholic,” and whether they consider those terms to hold stigma.

Recruitment

Approval from the PI’s university’s institutional review board (IRB) was obtained prior to subject recruitment beginning. To recruit subjects, the PI visited and announced the study at 12-step meetings of the Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) fellowships that were designated as open to the public, meaning that an attendee does not need to be in recovery from substance abuse themselves to attend. The PI initially selected 12-step meetings in a city with a population around 44 000 (recruitment location #1); a rural, poor town (recruitment location #2); and an affluent, suburban town (recruitment location #3). Twelve-step meeting times and locations were obtained through 2 apps that were downloaded to the PI’s phone. The PI also hung recruitment signs in recovery centers, clubhouses, and church basements where 12-step meetings sometimes convene. Additionally, PI asked subjects if they knew anyone else with whom the PI might speak (ie, snowball sampling ⁴³ ), at the conclusion of an interview. Subjects were offered a $20 Amazon gift card as an incentive to participate in the interview.

While the language varies slightly between the 2 fellowships, the twelve steps^44,45 of the AA and NA are essentially the same, recommending a sequence of behavioral changes beginning with admitting to having no control over the individual’s abuse of substance(s) (step 1). Subsequent steps include the individual committing to participate in the program (eg, attend regular meetings) (step 3); writing down a personal inventory of past misdeeds connected to substance abuse, and people they had harmed (step 4), and then sharing the personal inventory with an AA or NA sponsor (step 5). (A sponsor is a mentor with more time in the fellowship than the individual.) In later steps, the individual asks a higher power (eg, God, in whatever form they understand God to be) to remove their character defects (steps 6-7); and makes amends to individuals they have harmed in the past (steps 8-9). In the final step (step 12), individuals may choose to participate in fellowship service such as going on speaking engagements in rehabilitation facilities and/or prisons, to carry the recovery message to other individuals struggling with substance addiction.

Subjects

Of the 35 subjects, 19 are male, 13 are female, and 3 are gender non-binary. All but 2 were White, in keeping with the largely White population of the state. (Of the 2 non-White subjects, 1 female was Hispanic and 1 male was Native American.) Subjects’ ages ranged from 22 years old to 75 years old, with a mean age range of late-30’s. For comparison purposes, the demographics ⁴⁶ of the greater U.S. are 75% of the population is White-alone; 13.6% of the population is Black-alone; 1.3% is Native American and/or Alaska Native; and 3% is multi-racial. Nearly 14% of the U.S. population is Hispanic. The biggest notable difference between the present study’s sample and the greater U.S. population is the lack of African Americans in the study’s sample. As per the U.S. Census, ⁴⁶ male persons comprise 50.6% of the U.S. population and female persons comprise 50.4% of the U.S. population. According to Pew Research Center data, ⁴⁷ 1.6% of the U.S. population is transgender or non-binary. The mean age of the greater U.S. population is 38.9 years. ⁴⁶

Fourteen individuals self-identified as an addict; 17 self-identified as an alcoholic; 3 individuals self-identified as both an alcoholic and an addict; and 1 individual did not use a label in self-identifying. Ten subjects indicated they attend NA exclusively; 15 attend AA exclusively; 7 subjects attend both 12-step fellowships; and 3 subjects do not attend 12-step fellowship meetings but rather other types of recovery mechanisms such as intensive outpatient meetings or medication assisted treatment (MAT) meetings. Nine individuals indicated that they had recently relapsed with substances.

Demographic comparison of the sample by location (ie, city, affluent suburb, rural poor town) did not show meaningful differences in gender, race or ethnicity. There were differences in mean age (50’s) of subjects recruited from the affluent suburb, as compared to individuals from the other 2 recruitment locations (30’s). These differences should be interpreted with caution given the small sample size and non-random nature of the sampling. There were some non-significant differences by recruitment location in the type of 12-step fellowship attended, with individuals from the rural site being more likely to indicate they attended N.A. mainly or exclusively; individuals from the suburban site more likely to say they attended AA mainly or exclusively; and interviewees from the city site more likely to indicate they attended both fellowships equally. There were no differences by recruitment location in terms of length of recovery or attendance at virtual meetings. Individuals recruited from the suburban location were more likely to report having encountered Internet obstacles (eg, buffering, URL link not working) to attending virtual meetings during the pandemic period than individuals recruited from the other 2 locations.

Interview protocol, data, coding, analysis

Subjects’ interviews were recorded and subsequently transcribed using an outside transcription firm. The interview transcripts were uploaded into Atlas Ti qualitative analysis software which has been used in other qualitative public health research.^48,49 Subject answers to open-ended questions were coded using a code list created based on the interview protocol. Using codes from a code list is an initial step in conducting a content analysis ⁵⁰ of responses to open-ended questions. Content analysis is a method of analyzing written communication, such as interview transcripts. ⁵¹ The researcher tags sections of text (sentences and paragraphs) with content-relevant codes ⁵² in the software program (Atlas Ti, in the present study). Once all text has been appropriately coded, the researcher then performs a search in Atlas for all so-coded text, beginning the content analysis process. Two student research assistants independently performed the initial coding of the qualitative data (ie, words and phrases) in the transcripts, and for interrater reliability checked each other’s coding. The PI subsequently checked the research assistants’ coding.

Once all the verbatim text from the interview transcripts was coded with the broad code “stigma,” a qualitative data analysis approach ⁵³ was employed, reviewing and downloading coded text into an Excel spreadsheet. Coded text was then further categorized into 8 recurrent themes pertaining to whether or not the subject felt the terms “alcoholic” or “addict” were stigmatizing. The recurrent stigma-relevant themes were then further categorized into 2 opinion dimensions (see Table 2): whether the terms carry a stigma, and other thoughts about the terms. The results are discussed both in terms of the number of subjects that responded a particular way (Table 1), as well as the number of comments linked to a particular theme (Table 2).

OPEN IN VIEWER

Table 1.

Respondents’ feelings about the terms “alcoholic” and “addict” being stigmatized.

	N	Percent
Yes, the terms are stigmatized	14	41.2
No, the terms are not stigmatized	19	55.9
Not sure	1	2.9
Total	34 a	100.0

a

One subject did not give a clear response to the question. One subject did not answer the question.

OPEN IN VIEWER

Table 2.

Common themes about stigma of the terms “addict” and “alcoholic” across the interviews.

Opinion dimensions	Do the terms carry a stigma?			Other thoughts about the terms
Recurrent themes	Yes	Yes, but don’t internalize it	No	Pride, identity	Uses the term because it’s the convention of the 12-step program	Critical of person-first language	Stigma depends on the type of substance	Not sure they’re an addict or alcoholic
Total number of comments	16	5	30	12	8	6	2	2

Pride, identity

Rather than expressing fear of stigma around use of “addict” or “alcoholic,” 12 comments reflected a sense of pride and identity about the terms’ use. “I want to call myself an alcoholic because I want to own that every day.” “I think of it more of a—not a right of passage but like a privilege, you know, to say that I’m an addict who’s still alive and, you know, in recovery more than a stigma . . . it’s not a bad label today.” “I like to identify as alcoholic ’cause that’s how I first came to kinda identify when I first came into the room.” “But like being called, you know, being an addict or an alcoholic, like, that’s how we self-identify, you know?” “If I were to say it any other way of putting it, I would be putting it lightly and not giving it the importance that the word ‘alcoholic’ to me gives it, and that it would be taking away of like the seriousness of it, just in my opinion, for me, that it’d be, like, taking away the seriousness of what alcoholic says.” “I say I’m an alcoholic because I go to AA meetings, and I feel like it’s not so much honoring the program as some people put it, it’s more about, I guess, just being simple and humble.” “I think we just call a spade a spade. I’m an addict. I’m addicted to drugs. I’m addicted to alcohol, pretty much anything that alters my state of mind.” “Openly admitting out loud that I’m an addict has really helped me to see that I’ve spent a long time not being real with myself, not really being honest about what I was doing, or how I was acting. So, now when I say I’m an addict, it makes me feel more like I’m being true to myself.”

Use of the terms because of the convention of 12-step programs

Eight comments reflected the subject’s self-identification as an addict or an alcoholic out of respect for the norms of 12-step programs. “People in meetings don’t use the person-first language. You’d be kicked out.” “People say it because it’s like, let’s just get this part of the meeting over with, we’re just introducing ourselves. Like I don’t ascribe any—when I say I’m so and so, I’m an alcoholic, or I’m so and so, I’m an addict, I do it for the sake of time and convenience.” “Like what’s the problem with just using the term alcoholic? Because you definitely drank in a problematic way, and used everything the same, so why not? And I also got sober in like, kind of a more conservative AA type of community.” “But I think in these rooms specifically, in the AA room specifically, in my experience, it feels like a safe space to use those words.” “It was important for me to identify that way [as an alcoholic]. And honestly, I think because that was sort of the cultural norm within AA. That was relatively easy for me to latch onto, and do it because that’s what the majority of people also did.” “That doesn’t define me as a person, but that defines who we are in those meetings.” “But in AA meetings, I do like to say an alcoholic and an addict because I’m not just an alcoholic.”

“Softening everything” and “more of a mouthful”: Critical of person-first language

In response to the PI’s question about whether the terms “alcoholic” and “addict” were more stigmatizing than, for example, “person with a substance use disorder,” subjects made 6 comments that can be considered critical of person-first language. “Like they can change the name, it doesn’t change what the actual disease is, you know?” “My belief is that there is an enabling that has occurred by the government and by society generally—not that that’s not needed, I believe that an alcoholic or addict is gonna hit their bottom, and maybe my approach is wrong, but, you know, that you don’t hit until you hit it and I’ve seen people die because of not getting there.” “It’s a load of shit. They don’t know what they’re talking about. You have to be in the culture in order—it’s like, that’s my word, motherfucker.” “I think it’s society’s way of softening. Not a supporter of that.” “I’m not up to par with that kind of world of softening everything, I guess.” “I think that also, the term ‘disorder’ kind of like, it makes me . . . When somebody says that about me, that makes me feel like there’s something about me that’s defective, which that might be the case. But for me, that language is not helpful; it’s more of a mouthful.” “There’s a big part of me that wonders if the people who decided that these terms are stigmatizing are people who are not addicts or alcoholics themselves.”

Stigma depends on the type of substance (alcohol)

A small number of comments made the point that stigma related to addiction varies by substance type, specifically referencing alcohol. Both comments were made by subjects who primarily identified as alcoholics and were recruited via AA. As 1 subject explained, “there’s still stigma—but for alcohol, there’s not as much stigma as it sorta used to be.” Another interviewee explained, “I never felt stigmatized by being an alcoholic . . .. And I wished I was an alcoholic, because to me, that seemed more acceptable, so I didn’t think of being an alcoholic as stigmatized. I did have to deal with stigma with bipolar and mental health, I did have to deal with stigma being more—you know, I mean, there was stigma like for people that are heavy [overweight], you know, I had to deal with that more.” The stigma of any other specific substances (eg, heroin) did not emerge in any of the comments.

Unsure of whether they’re an alcoholic/addict

Finally, 2 subjects indicated that even though they use the term addict and/or alcoholic, they don’t fully accept that the terms apply to them. As 1 individual said, “When I say I’m so and so, I’m an alcoholic, or I’m so and so, I’m an addict, I do it for the sake of time and convenience. It’s not like, that I actually believe that I’m an addict or an alcoholic. I mean I really, in the truest sense of those definitions, I really don’t believe that I am one.” Another interviewee explained, “I remember the first time I ever went to rehab, and it was in 1995, and I was 23, 22 years old, and everybody kept telling me I had to define myself as an addict. And at the time, I knew that I had a problem with drugs, but I didn’t, I believed that deep down, I wasn’t really addicted, like I had a physical dependence, but like, I wasn’t—it wasn’t a lifetime thing, I wasn’t an addict, I didn’t wanna, I just remember it being, feeling resistance . . . everybody kept saying, just say you’re an addict, and I’m like, but I’m not, I don’t believe that, like I’m not doing this forever fucking thing, whatever this is. And when I finally said it, it was just to like, ease the tension in the room, it wasn’t because I really believed it.”

Limitations

Given the modest sample size and how subjects were recruited, it is not possible to generalize the results to the larger state- or U.S.-population and the results should be interpreted with that caveat. As was discussed, the demographics of the sample differ from those of the greater U.S. population, in particular the lack of subjects who are African American. As individuals recovering from a substance use disorder sometimes exist on the fringes of society and grapple with additional issues such as homelessness, a convenience sampling approach seemed most feasible as opposed to random sampling. As additional individuals are recruited for interviews, the PI anticipates seeing more patterns in response types. It is possible, for instance, that patterns by type of substance used or program attended, and views on stigma, may emerge.

There may be bias in the data in that subjects were recruited primarily from 12-step treatment programs where acceptance of one’s addiction is central to participating in the fellowships. (See, for example, the “Who is an addict?” brochure ⁵⁴ published by N.A., typically available at meeting locations.) In this way, the subjects who were interviewed may not be representative of individuals who have not (yet) sought out treatment for substance addiction.

Treatment Implications

The current emphasis in the addiction treatment community is to use person-first language with patients that have a substance-use condition, with the goal of reducing the stigma around addiction and thereby breaking down barriers to accessing treatment. At the heart of this practice is treating individuals with respect and kindness, which is a noble endeavor. That said, a take-away from the present study is that some people seeking treatment through a 12-step program may prefer to use “old-school” terminology (addict, alcoholic) when interacting with healthcare and medical professionals, for a variety of reasons (eg, it synchs with their 12-step program, they find the language more succinct, they do not internalize the stigma of such terms). The best approach for a treatment or other healthcare provider may be to ask the person, “How would you like me to refer to you?” and take the cue from the patient—even if it does not neatly fit with the provider’s understanding of how individuals in their care like to be described. Some will like being “an individual with a substance use disorder,” while others will find this a “mouthful.”

Anecdotally, a number of subjects recounted interactions with doctors and nurses where the subject faced the dilemma of whether and how to explain to medical staff about their addiction history. In the U.S., fentanyl is linked to many opioid deaths, and yet it is commonly and safely used in hospitals and emergency rooms, ⁵⁵ such as with patients recovering from surgery. One subject facing an operation whose past drug of choice was “pain killers” expressed notable fear about post-surgery medication. By contrast, another subject whose preferred substance was alcohol expressed ambivalence about receiving fentanyl post-surgery. (“I never liked the way opioids made me feel. I didn’t like heroin. Like, I’m going to relapse on that [fentanyl]? No.”) The hope is that should a recovering individual choose to disclose to treatment professions about their (past) substance abuse, this would not change the quality of care they receive.

Twelve step programs occasionally update their language as AA recently did to be more gender-inclusive, approving a change to the wording in its preamble statement to replace “men and women” with “people.” ⁵⁶ This change was not universally embraced, ⁵⁷ with some responding that the fellowship had strayed from its original purpose. Anecdotally, the author observed some variations in these types of gender-language preferences by recruitment location. In recruitment location #1, for example, at 1 meeting participants typically introduced themselves by first name, their addiction status (usually either “alcoholic” or “alcoholic/addict”), and then their preferred pronouns (eg, she/her, they/them). The reason behind this practice is to create a safe space for transgender recovering individuals who face additional stigma ⁵⁸ beyond just that of their substance addiction. By contrast, at a treatment location #3 meeting, an attendee prefaced his sharing by first explaining that he is “just” an alcoholic and did not require any other terms to make him “special” such as being a “left-handed alcoholic.” The implication of such comments is that straying from originalist language of a 12-step program is unnecessary, and reflects a lack of understanding of why inclusiveness is necessary.

Changing language to try and reduce stigma around addiction is a good thing, although in and of itself it does not fix the underlying problem (addiction). Additionally, not everyone will “get the memo.” One subject described a painful anecdote at work. He was assigned to be a liaison between a town’s police department and local individuals not yet in recovery for their substance addiction. His status as a recovering individual was central to his professional role. While most of the police officers he interacted with were polite, 1 officer saw him through the lens of how he was unfortunately introduced to the police department: “a drug addict with mental health problems.” That officer took the subject on a ride-along that included a tour of a legal marijuana dispensary. Afterwards, the officer asked the subject whether the tour had triggered him to want to use marijuana. Moving toward destigmatized language around addiction may have a mixed impact on public stigma. In short, there will always be jerks who say disrespectful things.

In summary, the take-away from the study’s findings is that there is no one-size-fits-all when it comes to recovery from substance addiction, or the terminology around it. There may come a tipping point in terms of the “best” language to use—particularly if the push to overhaul terms to eliminate stigma originates with experts working in the addiction field but who are not themselves addicts or alcoholics. Treatment professionals should not assume that all individuals in recovery are comfortable with person-first language, despite this being the preferred approach du jour. Recovering individuals who opt to use straightforward (if potentially stigmatized) terms like “addict” should not be told they are wrong. The choice of language around a person’s addiction should be left to that individual.