Web edition: October 24, 2008
We have a well-honed ability for branding the undesirable attributes of “others.” This natural human tendency has evolved and persists for a reason: The definition of an outcast group helps society to delineate its “normal” boundaries. But this inclination can also breed counterproductive stigmas that are rooted in ignorance and that too often translate into staggering individual, social and economic costs. This makes the need to understand and confront these types of stigmas much more than a purely academic goal.
Sociologists like Gerhard Falk are quick to distinguish between “existential” stigmas (spurred by conditions like mental illness, over which the target has little or no control) and “achieved” stigmas (perceived as earned by the subject’s own actions, like criminal behaviors). At first blush, this tidy classification appears to provide a satisfying framework for deciding the ethical, moral and even legal standing of stigmas. But sometimes it fails—for instance, when deciding how to assign drug abusing or addicted individuals to either category. Clearly, while substance-use disorders are themselves recognized psychiatric conditions, their trajectories begin with seemingly voluntary action, often tinged with criminal—or at least deviant—overtones. In other words, the stigma associated with these disorders displays both existential and achieved qualities, a thorny state of affairs that poses unique challenges for public health stakeholders and policymakers.
Fortunately, it is possible to sidestep what would otherwise be a paralyzing social stigma and leverage substantial resources for the good of all. For example, as biomedical advances prodded society to recognize that AIDS was preventable and treatable, attitudes toward the disease and its victims evolved. As a result, the stigma associated with HIV status may not have been eliminated, but it is no longer the roadblock to effective health policy that it once was. This lesson should serve us well as we refine our stance vis-á-vis drug abuse and addiction, where multiple lines of research support an approach based on science, not on stigma.
First, we have gathered incontrovertible evidence showing that addiction is a disease of the brain. Most drugs of abuse exert their initial reinforcing effects by inducing dopamine surges in the brain’s reward centers. If they persist, such disturbances eventually disrupt other circuits, many of which are critical to a person’s self-control. Second, we now know that abuse and addiction do not occur in a vacuum. A smart approach to managing these disorders must consider contributions from a bewildering array of predisposing or complicating factors, such as poverty, urban decay, child abuse and neglect, chronic stress, comorbid disease, and genetic background. Third, cost-effective and efficacious treatments are available that can be adapted to many community settings. Research shows, for example, that the integration of drug abuse treatment into the criminal justice system facilitates an individual’s successful reentry into society, with positive impacts on public health and safety.
These and other developments are the products of a new generation of interdisciplinary scientists who have transformed our understanding of psychiatric disorders like addiction. The message is unmistakable: Whether addiction stigma is existential or achieved or somewhere in between, it is time to replace outdated and failed thinking with approaches that work. The evidence demands that we:
This agenda is admittedly lofty, but the scientific method, which has been successful at shattering prejudices and enlightening societies, is on our side. If we can translate the fruits of research into policies that work, building public confidence in the science of addiction treatment, we will be well on our way to making the addiction stigma a relic of the past.
We are at a historical crossroads. We can continue playing the blame game, piling up unimaginable health and economic costs. Or, we can parlay the transformative power of scientific discovery into a brighter future for addicted individuals, for their families and for society at large. Let us choose wisely.
Nora Volkow is the director of the National Institute on Drug Abuse.