The Heterogeneous Nature of Substance Use and Substance Use Disorders: Implications for Characterizing Substance-Related Stigma

What Is an SUD?

Krendl and Perry’s article is titled “Stigma Toward Substance Dependence: Causes, Consequences, and Potential Interventions,” but most of the article focuses not on substance dependence per se but on SUD more generally (although they do note that some studies denote SUDs via dependence); the two terms are not interchangeable. The term “substance dependence,” which was still considered a subtype of SUD as late as the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 1994) was intended to refer to a more severe form of SUD than substance abuse but was jettisoned in the fifth edition of the DSM (DSM-5; APA, 2013) in favor of a single, graded model (mild, moderate, severe) of SUD. This change was based on the DSM-5 Workgroup’s conclusion that factor-analytic studies of the DSM-IV criteria revealed little support for distinguishing abuse from dependence subtypes as separate syndromes, as defined in previous editions of the DSM (Hasin et al., 2013; see also Vergés et al., 2010). That is, the diagnostic label “substance dependence” as used in the title of Krendl and Perry’s article is a bit narrow, if not anachronistic, at least for scholars adhering to the DSM, and denotes a more circumscribed concept of SUD than is typically held and is a term eschewed by some scholars. ¹

The denotations of substance dependence, SUD, and the commonly used term “addiction” are quite different (Bickel et al., 2019). That is, the SUD construct does a poor job of describing the exact nature of the user’s difficulties, and therefore labels such as “SUD” are grossly nonspecific, lack a clear denotation, and provide little information to the substance user and other individuals as to the exact nature of the problem (or problems) being referred to. This perhaps leads to a broader array of stereotypes (and their stigmatic sequelae) in comparison with more narrowly defined constructs. (Note that the most recent edition of the International Classification of Diseases [ICD-11], World Health Organization, 2021, has, unlike the DSM, retained the term “dependence,” which is defined more narrowly and maintains the conceptual core of neuroadaptation and compulsive use and potentially holds a more limited array of stereotypes.)

Notably, the ICD-11 incorporates the concept of harmful use (either a pattern of use that has resulted in harm to the self or others or an episode of use that has resulted in such harm; see Saunders et al., 2019) and, consequentially, connotes “threats” and “disruption” to people in the sphere of the user without implying an underlying pathology. As Karriker-Jaffee et al. (2018) note, with respect to alcohol, there are a wide range of harms to other people, including

[to] communities (such as noise, vandalism, and property damage), to families (such as spousal abuse and child neglect), in workplaces (such as absenteeism, coworker problems, and work-related accidents), and to friends, acquaintances, and others (such as victimization by physical and sexual assault). (p. 239)

These types of problematic use might not, in many cases, meet criteria for an alcohol use disorder (AUD) or another SUD but, nevertheless, represent highly stigmatized substance-related behavior, especially to the extent that they connote dangerousness and disruptiveness. The introduction of “harm to others” as an entity in its own right highlights a broader public health emphasis than a more personalized focus on consequences to the drinker and people in their near environment (Karriker-Jaffe et al., 2018; Martin & Sher, 2018) and is not well covered by the broad and only partially overlapping concept of DSM-5 SUD.

For the layperson, terms such as “dependence,” “SUD,” and “harmful use” may be irrelevant, but they are used to describe different conditions and are distinct from mere use of a substance. Moreover, they connote distinct types of difficulties that may differentially affect stigma. It seems likely that the broad definition of SUD (i.e., meeting two or more of 11 diagnostic criteria) along with its low threshold for diagnosis (see Martin et al., 2011) contributes to the high prevalence of both AUDs and drug use disorders (DUDs). For example, in the United States, one large, population-based study estimated that 29.1% of the adult general population had a lifetime AUD diagnosis, and the lifetime diagnosis rate under DSM-IV criteria was even higher, at 40% (Grant et al., 2015). The same study estimated a 9.9% lifetime rate for DUDs (Grant et al., 2016). Moreover, of adults with past-12-month DUDs, 56.8% had one or more co-occurring SUDs (McCabe et al., 2017). That is, SUDs are common and the majority of adults with DUDs have multiple SUD diagnoses. This makes the construct of SUD even more heterogeneous and presents challenges to identify what factor (or factors) make the label or designation stigmatizing. Although there may be some variation in the expression of prototypic mental health conditions such as panic disorder, bipolar disorder Type 1, or major depression, the denotations of the specific symptomatology of these conditions likely lead to a narrower range of stereotypes than for SUD where it is possible to have a large range of nonoverlapping symptom profiles, each with different stigma potential both within and across substances.

The 11 heterogeneous DSM-5 criteria for SUD (APA, 2013) are composed of symptoms that almost certainly vary across the degree to which they are threatening, controllable, and disruptive, dimensions Krendl and Perry highlight as key in differentiating SUD stigma from mental illness stigma. For example, some criteria, such as hazardous use (e.g., drinking and driving) and use despite social and interpersonal consequences (e.g., neglecting important responsibilities), would appear to hold potential to be both threatening and disruptive, whereas inability to quit or cut down or using more than intended would appear to lead to perceptions surrounding controllability (and perhaps changeability as well). Further, other criteria (e.g., those related to tolerance, withdrawal, and craving) might be central to a dependence syndrome and the concept of addiction but might not be high on a list of dimensions that figure prominently in stigmatic impact, as they are largely invisible to others. That is, although there may be stigma associated with the syndromal label “SUD,” it would seem likely that those stereotypes generating stigma might be largely irrelevant to the specific nature of a given user’s symptom profile. Unlike some diagnoses that require a specific symptom, DSM-5 SUD diagnoses are polythetic, meaning that no single symptom or criterion is necessary or sufficient. So a question arises as to whether a syndromal perspective, as exemplified in the DSM-5, contributes to a generalized stigma by way of being nonspecific and allowing the diagnostic label to represent an amalgam of diverse stereotypes.

Comorbidity

Krendl and Perry highlight a number of differences between mental health conditions and SUDs but largely neglect the fact that a substantial number of individuals with SUDs are also diagnosable with another (non-SUD) mental disorder. For example, in the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), AUDs were associated with other SUDs (as noted earlier), major depression, bipolar disorder, and antisocial and borderline personality disorder even after analyses controlled for a host of demographic variables and other conditions (Grant et al., 2015). Dimensional approaches to viewing psychopathology as hierarchically organized spectra, as defined in the Hierarchical Taxonomy of Psychopathology (HiTOP; Kotov et al., 2017), similarly reveal extensive co-occurrence of diverse psychopathologies with AUD symptomatology (Helle et al., 2020), as indicated by increasing pathology in the Disinhibited Externalizing, Antagonistic Externalizing, Internalizing, and Detachment spectra associated with increasing numbers of AUD criteria. As noted by Helle et al. (2020), “results suggest that an AUD diagnosis augurs risk not only for a range of comorbid conditions, but also for more severe variations of those conditions” (p. 640). Extensive comorbidity between SUDs and other psychiatric conditions does not necessarily suggest whether SUDs are stigmatized by virtue of their unique characteristics. However, it raises a question regarding the specificity of SUD-related stigma because many people affected by SUDs are similarly affected by co-occurring psychiatric conditions, and stereotypes of persons with SUDs are likely confounded by these co-occurring disorders.

Distinguishing the Substance Used From the SUD

Krendl and Perry note that there is variation in stigma across different SUDs. It is unclear to me whether they are referring to differences in the nature of specific SUDs with respect to symptoms displayed or to distinct stigma associated with the mere use of different substances (e.g., licit vs. illicit substances). For example, if opiate use disorder is more stigmatized that cannabis use disorder, is this because (a) the syndrome is seen as more severe or disruptive; (b) use of the different substances connotes different harms, threats, or norm-violating behavior; or (c) individuals who choose to use opiates are, on average, more “objectionable” because of premorbid character traits such as unconventionality and deviance proneness? (Krendl and Perry do highlight the issue of “perceived legality of use,” but, again, there is the issue of use vs. SUD.) These possibilities suggest, in many cases of SUDs, mere use is driving stigma more than disorder is.

Relatedly, one can have an extreme pattern of substance use and not qualify for an SUD diagnosis. For example, approximately one third of individuals who binge on alcohol on a daily basis do not qualify for a DSM-5 diagnosis of AUD (Vergés et al., 2018). Presumably, these undiagnosed daily bingers are engaged in a pattern of drinking that far exceeds healthy levels and suggests that it might be useful to think of heavy drinking patterns (and presumably other heavy substance use patterns) as problems in their own right that likely generate stigma regardless of an associated SUD. Rehm et al. (2013) have gone so far as to suggest that we jettison the current diagnostic framework for AUDs and replace it with the more neutral term of “heavy drinking over time” and that a similar change would work well for other psychoactive substances. They further argue that such a change would be more consistent with the scientific value of parsimony and, importantly, would be less stigmatizing than current terms such as “addiction” or “SUD.”

Distinguishing Among Varieties and Formulations of a Given Substance

Use of different forms of a given substance may be more or less stigmatizing, as indicated by the types of individuals who are drawn to different formulations of a drug and/or its routes of administration or their differential association with stigmatized groups (Heyman, 2009). For example, over the course of history, different forms of a drug have been more or less stigmatized as a function of the social status and race, ethnicity, and religion of the user. This is true with respect to opiates, for example, in Victorian England, where “opium eaters” were less marginalized than “opium smokers” (e.g., Berridge, 1978; Heyman, 2009; Kalant, 1997). In heavy-drinking, 18th-century England, a pair of Hogarth’s famous woodcuts contrasting beer and distilled spirits illustrate how consumption of two different forms of alcohol, beer and gin, connote different types of social values. “‘Beer Street’ portrays an image of an ideal and quintessentially British society fueled by patronage and England’s own produce. In contrast, the citizens of ‘Gin Lane’, are shown guzzling vast quantities of gin.” (Muldoon, 2005, p. 159). That is, beer consumption was largely viewed as a virtuous indulgence; in contrast, gin drinking was viewed as an urban blight affecting the poor of London (Coffey, 1966). In the current day, women portrayed as consuming whiskey are viewed as more sexually available than women portrayed as drinking wine or beer (George et al., 1988). The active ingredient in all of these alcoholic beverages is ethanol, yet the degree of stigmatization varies. Similarly, largely on the basis of media portrayals, crack cocaine use quickly became more highly stigmatized than powdered cocaine use and the intranasal administration that preceded it. However, even users of crack distinguished between “crackheads” (i.e., compulsive users) and “crack users.” Although such distinctions might not be highly salient to the outside world, viewing yourself as a “user” and not a “head” made the use of crack cocaine more socially acceptable and, possibly, less self-stigmatizing (Furst et al., 1999), highlighting the importance of labels and their referents. Regardless, social stigma and structural stigma (e.g., in the areas of drug enforcement, sentencing guidelines, and medical services) surrounding different drugs and drug formulations have been assumed to reflect racism both with respect to the “crack epidemic” (Palamar et al., 2015; Sklansky, 1995) and, more recently, the “opioid crisis” (Shihipar, 2019).

Distinguishing the Substance Used From the Substance User

In defining psychopathy, Cleckley (1955) wrote that psychopathic individuals exhibit “fantastic and uninviting behavior with drink and sometimes without.” The phrase “and sometimes without” suggests that some of the drinker’s behaviors that could lead to an AUD diagnosis are more accurately viewed as premorbid characteristics that are amplified by intoxication rather than as an SUD. These behaviors, although perhaps more salient after drinking, may reflect general externalizing personality traits that are manifest when not intoxicated. Although individuals classified as psychopaths or as having a history of antisocial behavior can certainly meet the full criteria for an AUD diagnosis, it seems likely that many such individuals misuse alcohol as part of their antisocial behavior pattern (Podolsky, 1960; Schuckit, 1973). But whether or not drunken excess among individuals with high levels of antisociality should be taken as part of an AUD diagnosis is unclear, even if the objectionable behavior is highly stigmatized. However, the strong association between SUDs and (especially externalizing) psychopathology raises the question of whether various stereotypes about SUDs stem from the acute or chronic effects of the substance on the individual or, to some nontrivial degree, the behavior or constitution of the person likely to misuse a substance. That is, a given behavior (e.g., physical fighting) may be highly stigmatized and more prevalent among people with SUDs. However, attributing specific behaviors to either an SUD or mere consumption of a substance can be challenging owing to individual differences in the likelihood of the problematic behavior being exhibited when the person is either intoxicated or sober. ² This is in addition to a host of contextual variables that confound the association between substance use and specific consequences (Martin et al., 2014). Relatedly, there is evidence that some individuals will deliberately become intoxicated in order to have something they can attribute their failure to, a phenomenon described as “self-handicapping” (Tucker et al., 1981). Presumably, people who self-handicap with, say, alcohol, view the stigmatic consequences of failure as lessened by the external attribution of intoxication, adding another complexity to understanding the stigma–substance use relation.

Stigma Surrounding the Progression and Remission of SUDs

Although Krendl and Perry primarily focus on manifest SUDs, as alluded to above, SUDs are more likely to occur in individuals with certain characteristics, develop over time, vary in severity and chronicity, and (as discussed below) remit. Consequently, SUD-related stigma can be viewed as occurring along multiple stages of risk and manifest disorder. That is, one can consider varying degrees and types of stigma as a function of risk, degrees and types of manifest disorder, and desistance, remission, and recovery.

For example, a familial history of SUDs conveys SUD risk to the individual even though a given individual, say a child with a father who has AUD, may manifest no premorbid signs of a future SUD, and only a minority of individuals with parental SUDs ultimately develop an SUD or other serious problem. Although Krendl and Perry focus on stigma of the affected individual, stigma can generalize to people associated with the stigmatized individual, a phenomenon known as courtesy stigma or stigma by association (Goffman, 1963/2009). There is an extensive research literature and lay self-help literature on children of alcoholics (COAs) and adult COAs with a number of stereotypes about their presumed characteristics. An early proponent of the COA self-help movement, Claudia Black (1981), went so far as to proclaim “All children raised in alcoholic homes need to be addressed. All children are affected” (p. 27). Although empirical research does not bear out this assertion, when high school students were asked to describe themselves as “typical teenagers,” “teenagers with an alcoholic parent,” or “mentally ill teenagers,” significant differences were found across most characteristics and with COAs rated most similarly to “mentally ill teenagers” (Burk & Sher, 1990, Study 1). In an experimental study where mental health workers watched videotapes of an adolescent described as a COA or non-COA, the adolescents labeled as COAs were rated as more pathological than those not so labeled regardless of their manifest adjustment and social success (Burk & Sher, 1990, Study 2). These and other findings suggest that people closely associated with those with SUDs may be stigmatized by association, and this dimension of the SUD–stigma association is worthy of the same kind of consideration given to those manifesting SUDs themselves.

Recently, influential addiction scientists (McLellan et al., 2022) have proposed a new diagnostic category for incipient SUDs called preaddiction, motivated by the prospect of intervening early in the development of SUDs with the hope of thwarting the emergence of more severe disorders in a way analogous to intervening in prediabetes with the hope of delaying or reducing the expression of clinical diabetes. Although the clinical utility of such an approach has yet to be demonstrated, the potential for creating a new stigmatized condition must be considered. Anticipating this concern, McLellan et al. (2022) note,

There may be concern that our suggested term preaddiction is ill advised because it is pejorative and will simply intensify stigma. We contend that preaddiction is exactly the right term for 2 reasons. First, the terms addict, schizophrenic, and diabetic are certainly pejorative because they describe a person by their disease state. In contrast, addiction, schizophrenia, and diabetes are simply descriptions of diseases. Second, the term addiction is well understood by clinicians and patients as a serious condition to be avoided. Thus, preaddiction has inherent motivational properties that convey the need for clinical action and patient change—just as prediabetes and precancerous currently do. (p. 750)

The issue of “recovery” is brought up by Krendl and Perry and brings in a number of important issues beyond controllability and changeability that are well beyond the scope of my comments, but three issues are worth noting in passing. First, individuals in recovery from serious AUDs often do not appear to have any concerns about using the term “alcoholic” (as in Alcoholics Anonymous), and “alcoholic” in this context is viewed as nonstigmatizing among scholars interested in stigma and SUD (e.g., Shi et al., 2022). Also, coping with stigma is often a major focus in recovery efforts (Romo & Obiol, 2023). Second, although recovery is typically viewed as an effortful process achieved through formal treatment and/or “natural recovery”/self-help efforts, it is commonly observed that much ostensible recovery or remission is not obviously attributable to deliberate self-change efforts, especially in people who never perceived a problem, but rather to various adult role transitions that place individuals in role occupancies or situational contexts that are incompatible with drinking or other drug use or abate as a function of general psychological maturation (Lee & Sher, 2018; Watson & Sher, 1998). Third, recovery can be abstinent or nonabstinent, but nonabstinent recovery can be viewed as more stigmatizing (Cunningham et al., 1993).

Concluding Comments

Krendl and Perry highlight many important considerations for scholars interested in conceptualizing and conducting research on SUD-related stigma and for developing interventions to minimize the harmful effects of stigma both intra- and interpersonally. In addition, they provide a useful framework for characterizing substance and SUD-related stigma. I have attempted to illustrate the complexity of the problem by highlighting multiple dimensions that one might consider when trying to identify those variables that relate to substance/SUD-related stigma and possible remedies. Although one of Krendl and Perry’s major thrusts is to compare and contrast mental illness and SUD stigma, SUDs are so multifaceted and diverse that drawing strong inferences about what exactly is being stigmatized can be a daunting task, especially when one considers comorbidities with other mental disorders and SUDs. Moreover, as noted at the outset, Room (2005) argues that although studies of stigma on mental illness (and physical disability) focus on the harmful effects of stigma on the affected individuals, scholars who study the effects of stigma on crime view stigma more benignly, as a form of social control. This suggests that we might want to consider the possibility that the overall harms and benefits of stigma vary as a function of the stage of substance involvement. For example, stigma may inhibit substance use exploration and experimentation (especially in people at risk) or compound the negative consequences of substance use (e.g., in people with a compulsive pattern of use) and lead to reduced treatment seeking and further marginalization. Full understanding of stigma associated with substance use and SUDs may require a more nuanced view of their determinants, their indicators, related conditions, and trajectory over the life course.