Opinion: Stop using the term ‘substance abuse’

By Jason Renaud and Jenny Westberg, Street Roots, May 26, 2016

"Shame" by Max Klinger

“Shame” by Max Klinger

“What’s in a name?” Juliet muses from the balcony. “A rose by any other name would smell as sweet.”

Shakespeare was right – mostly. In general, things are not fundamentally altered by changing what we call them. But hate speech has its own rules.

What we’re talking about is the widespread use of the term “substance abuse.”

The term “substance abuse” perpetuates ignorant and moralistic attitudes toward people with chemical dependency. Few health professionals have the nerve to openly oppose the disease nature of chemical dependency because the facts of both science and insurance reimbursement stand in their way. Yet many of these same professionals still blame the victims of the disease for the problems which the disease causes. We who care for addicts and alcoholics face diminished hopes when we fail to challenge such attitudes.

Tagging something “abusive” implies both wrongfulness and willfulness. Child abuse can be prosecuted. Spousal abusers can be charged with a crime. You may abuse a privilege, a right or your authority, but excessive eating isn’t called “food abuse” and reckless driving isn’t called “gas pedal abuse.” The word “abuse” evokes something ugly, contemptible, abhorrent. It heaps more shame on individuals who are already sick and suffering. It helps keep them in denial – and at arm’s length.

“Abuse,” you may concede, can be a confusing word, but what is so objectionable about the word “substance”? At first glance the word seems merely vague, but deeper study reveals “substance” to be, in this context, intentional confusion. The word has been made into an instrument of denial. “Substance abuse” has served the interests of those who would criticize the drug involvements of others but excuse such use (including the use of alcohol) in themselves. Popular mental theories of the late ’60s and early ’70s popularized the term.

These mental theories tried to explain most life problems, including alcohol and drug problems, as basically arising from errors in upbringing. An overweight person was trying to compensate for some childhood upset by comforting the now-adult self with food. Food, a neutral substance, became a problem because of how the person chose to use it. Fashionable mental opinion at the time gave no value to the concept that genetic factors might affect weight gain. Back then, fat people were seen as “self-destructive,” if not just foolish or ignorant or weak and lacking willpower.

According to the same theories, a tobacco smoker was seen to be compensating for interruption of breastfeeding or some other oral deprivation. Quitting tobacco was hard simply because the user had become conditioned to the habit of smoking.

Clearly, then, smokers could have psychotherapy for their oral fixation or deconditioning for their behavior problem and be cured. Again, the substance of tobacco was not seen at the problem. Only today do we know nicotine is more addictive than even opioids, and willpower is irrelevant. But back then, smokers were just seen as people who were unwilling to change.

Convenient rationale

“Substance,” in the late 60s and early 70s, thus began to be defined in the sense of any material thing that was neutral in itself, but could be abused by mistake or perverse actions.  This definition turned out to be a convenient rationale. Those doing the defining, by and large, were people who themselves used drugs. Among them were mentally-oriented opinion leaders who, in search of an interesting livelihood, had become involved in various aspects of alcohol and drug problems. These opinion leaders included drug counselors, various flavors of therapists, writers, researchers and bureaucrats. This was a group strongly influenced by the drug experimentation fad then present among many educated, middle-class professionals. As one prominent promoter of the fad wrote in 1972, “I will insist that we accept the fact that drugs — intelligently used as tools to enter other states of consciousness — are potentially beneficial,” and “the drug problem is an effect of conceptions about drugs and…it can only be solved by changing those conceptual models.” (Andrew Weil, The Natural Mind, Houghton Mifflin, 1972).

Drugs as a tool of wisdom

So the term “substance” helped the new drug enthusiasts to feel better about their own choices and convince others as well. Like Weil, they believed that drugs themselves weren’t a problem, just how people felt about them. As long as drugs were feared, drugs would be troublesome. When drugs were no longer feared, the former source of trouble could become a source of wisdom. If drugs were just another substance, like food or tobacco, that could be used depending upon the choice of the enlightened person, then what was the problem with a bit of drug experimentation? Because, after all, who will admit to being among the non-enlightened? Given this analysis, drug experimenters could rationalize any ill effects. They could reassure themselves that the people who did actually develop problems with drug or alcohol use did so out of ignorance and narrow-mindedness. Such persons were clearly to blame for their own difficulties.

Today, the term “substance abuse” has become a socially convenient code phrase. On one hand, it sounds technical, professional, and therefore, permissible. On the other, by the negative associations with the word “abuse,” it expresses the real disdain which most people who use the term actually feel for addicts and alcoholics. Use of a code word allows the satisfaction of looking down on others while appearing not to. Disdain itself thus becomes deniable.

The willful abuse of alcohol and other drugs is concerning. However, abuse is not a major issue as compared to dependency. The area of abuse has more to do with law enforcement and behavior modification, while dependence deals with a disease process. Professionals have sincere disagreements as to the exact boundary between abuse and dependence, but none argue that they are the same thing.

The tail of the elephant

So how is it that common parlance has come to let the word “abuse,” especially in the form “substance abuse,” serve an entire field? Why is the addiction profession’s highest level of government visibility called the “Substance Abuse and Mental Health Services Administration” (SAMHSA)? Because the part is trying to stand for the whole, the tail defining the elephant. Even SAMHSA itself, as far back as 1988, declared: “When talking or writing about alcohol or other drugs, there are phrases that SAMHSA recommends and supports over previously used phrases … To emphasize that alcohol is a drug, it is recommended that the phrase ‘[use of] alcohol and other drugs’ be used instead of ‘substance abuse.’”

The cause for why this negative terminology persists lies in the semi-hidden public hostility toward chemically dependent people. Powerful interest groups stand to gain from continuation of this hostility. These interests excel in the manipulation of such code words to control public attitudes. They label addicts and alcoholics as “abusers” to paint these ill people as perpetrators, not victims. The heat thus moves away from the alcohol sellers and drug-pushing pharmaceutical companies. Blame shifts to those victims and brands them as self-gratifying misusers of otherwise benign products.

By blaming addicts and alcoholics as abusers, public officials justify police and jail as substitutes for treatment. They champion “safe” injection sites as a cheap way to get addicts off the streets, where the upright citizens don’t have to look at them. Out of sight, out of mind, out of the budget. So long as chemically dependent people are blamed for their illness, insurance companies will continue to refuse proper reimbursement for care. Employers, housers, governments and schools will continue to discriminate against them.

Even knowledgeable organizations all around our state use “substance abuse” and “addiction and alcoholism” interchangeably. It’s not just offensive, it’s dangerous. When addiction and alcoholism are viewed as a deliberate behavior or a choice, inappropriately trained people will try to treat it. Physicians, psychologists, social workers and miscellaneous therapists, without any sort of chemical dependency certification, will feel themselves qualified to treat and fail to refer. Their ineffectiveness is widely documented and costs lives.

Addiction can happen to anyone, including you. When you talk about alcoholics and addicts, drop the scornful language that accuses us, shames us and keeps us away from treatment. Show some respect for your fellow human beings. We are all in this together.

Jason Renaud and Jenny Westberg are with the Mental Health Association of Portland. Reprinted with permission from Counselor magazine.