https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/07/25/le-langage-cest-le-pouvoir
Eliminating stigma can improve quality of care and prevent avoidable deaths
By Amber Heyd
July 25, 2024
istockphoto.com/SDI Productions
Language is a powerful tool capable of either perpetuating or challenging stigma and stereotypes associated with substance use. The language we use to discuss substance use and individuals who use substances significantly impacts patient care and outcomes.
This article is part of the Canadian Nurse series, Harm Reduction Saves Lives.
Substance use stigma
Individuals who use substances experience considerable stigma and discrimination, with studies demonstrating that alcohol and substance use disorders are among the most stigmatized health conditions. Stigma can be described as any attitude, belief or behaviour that discriminates against individuals based on attributes, characteristics and/or qualities. Nurses and other health-care providers may unintentionally contribute to substance use stigma, leading to harmful and/or negative health outcomes among individuals who use substances.
Courtesy of Amber Heyd
“As nurses, it is critical to participate in reflective practices, examining the language we use and acknowledging any biases we hold around substance use and individuals who use substances,” Amber Heyd says.
It can be helpful to look at substance use on a continuum. People may use substances experimentally, recreationally or regularly, and not everyone who engages in substance use is diagnosed with a substance use disorder. When substance use leads to physical and/or mental health issues and causes problems at home, work or school and/or with family and friends, a substance use disorder may be diagnosed. This can range from mild to severe. The stigma and negative stereotypes associated with substance use are complex, arising from factors such as limited biopsychosocial understanding, the criminalization of substance use, and the tendency to judge those who use substances as morally deficient. In individuals diagnosed with a substance use disorder, labelling substance use as a “choice” and attributing repeated use to a lack of “self-control” further contribute to stigma.
Substance use stigma has real-world consequences. It is prevalent within the health-care system, contributing to negative health outcomes, poorer quality of care, and significant social and health inequities among individuals who use substances. People seeking health-care services report encountering stigma from nurses, and research indicates that many nurses hold negative biases toward those who use substances, with experienced stigma identified as a significant barrier to accessing health care. Substance use stigma can also negatively impact public health interventions and evidence-informed services, including supervised consumption services, needle exchange programs and drug testing.
It is critical that stigma is addressed to improve quality of care and outcomes for those who use substances and to prevent additional avoidable deaths, especially in the context of the ongoing drug poisoning crisis.
The power of language
Language is a powerful tool capable of either perpetuating or challenging stigma and stereotypes associated with substance use. The language we use to discuss substance use and individuals who use substances significantly impacts patient care and outcomes. The impact of language not only occurs at the relationships level, between patients and providers, but also extends across policies, practices, training and work environments. Research demonstrates that the use of stigmatizing language adversely affects patients’ well-being and influences attitudes, perspectives and actions toward patients who use substances, including nurses’ decision-making processes. Terms such as “addict,” “abuse,” “clean” and “dirty” carry negative connotations, leading to harmful effects on individuals and communities. For example, if an individual has a negative encounter while receiving care in the emergency department, such as being called an addict or drug-seeking, they may be less likely to seek care in the future when it is needed. These negative interactions can discourage individuals from seeking support, impacting the quality and accessibility of health-care services.
Our role as health-care providers
As nurses, it is critical to participate in reflective practices, examining the language we use and acknowledging any biases we hold around substance use and individuals who use substances. This is an essential first step to implementing changes that facilitate a non-stigmatizing, person-centred approach to care. We can engage in reflective practices by carefully considering the language we use when interacting with, referring to, or thinking about individuals who use substances and/or those diagnosed with a substance use disorder. What words come to mind? What are our attitudes toward substance use? Identifying the origins of these thoughts and beliefs is important. Asking such questions facilitates our participation in the reflective cycle, akin to peeling back the layers of an onion to gain deeper insights into ourselves, the biases we may possess, and how these aspects impact our professional practice.
Nurses hold a pivotal role in driving language and practice changes that facilitate a person-centred approach to care. Our influence extends across multiple levels, from the individual and family to the broader community and systems levels, having a meaningful impact on patients and individuals across a variety of settings.
Individual and family level
At the individual and family level, nurses can implement person-first language, prioritizing individuals as people before emphasizing personal attributes or health conditions (see following table). For instance, using terms such as “person with an alcohol use disorder” instead of “alcoholic” respects individual identity, avoiding defining someone by their substance use or health condition(s). Nurses can also adopt strengths-based language that supports recovery while acknowledging that the continuum of recovery is unique for each person. In care plans and case management discussions, replacing terms such as “non-compliant” with “chooses not to” upholds autonomy and patients’ right to consent, and avoids reinforcing paternalistic health-care models . Applying these language changes extends to patients’ family members, fostering a supportive understanding of substance use disorders as medical conditions.
Table: Alternative terms and phrases related to substance use
| Terms and phrases to avoid |
Alternative terms and phrases to use |
| Drug users/abusers; addicts; alcoholic; junkie; pothead; crackhead (any other jargon or labels); binge-user/drinker |
People who use substances; person living with a substance use/alcohol use disorder; people who inject drugs; people who engage in heavy episodic alcohol and/or substance use |
| Substance abuse and/or abusing substances; substance misuse; problematic substance use; alcoholism |
Substance use; substance use disorder (where diagnosed); alcohol use disorder |
| Former drug addict; recovering addict; former alcoholic; sober; clean |
People with lived experience of substance use (disorder); people who have used substances/alcohol; people who have a history of substance/alcohol use; people in recovery (from a substance use/alcohol use disorder) |
| Relapse; slip; used again; on/off the wagon |
Recurrence of substance/alcohol use; return of substance/alcohol use; recurrence of substance/alcohol use disorder |
| Overdose; overdosed; OD’d |
Substance/alcohol poisoning (e.g., opioid poisoning, stimulant poisoning, alcohol poisoning) |
| Illegal drugs; illicit drugs; street drugs; black market |
Unregulated drug supply/market/substance |
| Dirty/clean urine and/or other drug screen |
Negative drug test/screen; positive drug test/screen |
| Resistant; refuses; non-engaged; non-compliant |
Person disagrees/chooses not to/declines |
| Rehab; detox; checks into rehab |
Withdrawal management programs; medical treatment for substance use disorder |
| Addicted baby/infant/newborn |
Newborn exposed to substances; infant with signs of withdrawal from prenatal substance use exposure; infant with neonatal opioid withdrawal/neonatal abstinence syndrome |
This table is not an exhaustive list. Please see listed resources for more examples and information.
Community level
At the community level, nurses can employ anti-stigma strategies when speaking about people who use substances, encouraging others to reflect on the language they use and its impacts. It’s important to avoid slang, derogatory and discriminatory terms such as “junkie” or “drug abuser” as these terms have significant levels of stigma and negative connotation attached to them.
Furthermore, when engaging with the public, it’s important that nurses use language that reflects the medical nature of substance use disorders and treatment. Nurses can draw attention to the broader social determinants of health, such as poverty, adverse childhood experiences and intergenerational trauma, which have been linked as risk factors for developing a substance use disorder. When engaging with the public, nurses can consider the implicit messages that images, as well as language, can communicate, avoiding images that depict stereotypical portrayals of people who use substances (e.g., people experiencing houselessness, people involved in the criminal justice system or “before and after” photos associated with substance use).
Systems level
At a systems level, nurses can advocate for the integration of substance use and harm reduction education within nursing curricula. They can contribute to educational materials, orientation and/or training resources that emphasize a person-centred approach when working with individuals with substance use.
Nurses can also advocate for changes to governance documents (e.g., policies and procedures) that replace stigmatizing language with strengths-based, person-centred terms to reflect the medical nature of substance use disorders.
Most importantly, as nurses we can advocate for the meaningful involvement of individuals with lived and living experience of substance use in shaping policies and health-care services, adopting the concept of “nothing about us without us.”
Conclusion
Nurses are positioned to lead the charge in transforming language and professional practice toward a non-stigmatizing, person-centred approach. Nurses can use non-stigmatizing language at the individual/family, community and systems levels, influencing a diverse range of partners. By actively participating in this language shift, nurses can reframe the narrative around substance use and disorders, changing attitudes, reducing stigma and fostering improved health outcomes for individuals who use substances and those living with a substance use disorder.
Resources
Overcoming Stigma Through Language: A Primer, a free document with more examples of stigmatizing language, published by the Canadian Centre on Substance Use and Addiction.
Respectful Language and Stigma: Regarding People Who Use Substances, a free three-page brief on stigma published by the British Columbia Centre for Disease Control.
Communication About Substance Use in Compassionate, Safe and Non-stigmatizing Ways. A Resource for Canadian Health Professional Organizations and Their Membership, a web page and downloadable resource from the Public Health Agency of Canada.
Amber Heyd, RN, BN, M.Sc., is a registered nurse with Alberta Health Services and a research coordinator at the Addictive Behaviours Lab, University of Calgary.
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#stigma
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