Peter R. Martin: Historical Vocabulary of Addiction, Vol. II

Stigma

According to the electronic version of the Oxford English Dictionary (OED), the noun stigma is a borrowing from Latin.  The Latin word stigma is derived from the Greek στίγμα (“mark made by a pointed instrument, brand”).  The root of this word is in turn, *stig-, in Greek στίζειν (*stigy-, meaning to prick, puncture as in stick).  The OED definition of the first recorded use of stigma in the English language is: “A mark made upon the skin by burning with a hot iron (rarely, by cutting or pricking), as a token of infamy or subjection; a brand.” 

This first English use of stigma is exemplified by a quotation of Sir John Harington (1560 –1612), an English courtier, author and translator, in A new discovrse of a stale svbiect, called the metamorphosis of Aiax (Harington 1596): “Circumcision? impressing a painefull stigma, or caracter in Gods peculiar people.”  The quotation refers to an important religious ritual in Judaism, the ceremonial removal of the foreskin from a male newborn, which leaves a life-long anatomic mark, an immutable symbol designating the individual as a member of his faith.  Since the Middle Ages, what was originally a religion-based viewpoint of circumcision has become stigmatized beyond its association with Judaism to include negative ideas about the lack of potency and worth of the Jewish male due to his anatomically altered genitals (Gallaghe 2023).

An early quotation from the English clergyman Martin Fotherby (c.1560–1620), who became Bishop of Salisbury, in Atheomastix: clearing foure truthes, against atheists and infidels, exemplifies a figurative definition of stigma (Fotherby and Okes 1622): “They set a stigma, and a note vpon all that impugne it.”  Another relevant quotation by John Henry Blunt (1823–1884), an ecclesiastical historian and theological writer, provides an excellent example of how stigma can present often insurmountable life-long challenges through no fault of the individual in question due to prejudices held by society despite there not being an obvious anatomical deformation or other inadequacy which identifies the individual in question (Blunt 1878): “Branded with the stigma of illegitimacy.”

There have been various other meanings for stigma since the first use listed in OED, including biblical references to the “wounds on the crucified body of Christ said to have been supernaturally impressed on the bodies of certain saints and other devout persons”; those from the field of Pathology depicting “a morbid spot, dot, or point on the skin, especially one which bleeds spontaneously”; from Zoology and Anatomy referring to “respiratory openings or breathing pores in insects and other invertebrates”; from Botany, “That part of the pistil in flowering plants which receives the pollen in impregnation;” and even from Geometry, wherein “Ellis's Stigmatic Geometry [indicates] A point whose movement in a certain plane is determined by that of another point (the index) in the same plane.”

The history of the various uses of the noun stigma shows that the meaning of the word was at first concrete, a distinct anatomic alteration exacted upon an individual to symbolize belonging or ownership, e.g., a brand that was visible to all and indicating the individual was a slave, criminal or traitor.  Sometimes an anatomic change considered to be stigmatizing is not exacted by one man on another.  Illnesses associated with what was often believed to be a mark of evil spirits were highly feared and carried stigma for the harm that might come from any contact with the affected individual. 

A classic example of this is the skin lesion of leprosy which has carried tremendous stigma since Biblical times (Kellersberger 1951).   The word also acquired a meaning in medicine indicating “a distinguishing mark or characteristic” which was useful for identifying a specific medical disorder.  Thus, stigma was considered a specific diagnostic feature, e.g., pretibial myxedema, the skin lesion associated with thyrotoxicosis (French 1949).  While stigma initially was meant to represent a bodily sign to designate something unusual or bad so that the stigmatized individual might be avoided, with the advent of Christianity, this perspective eventually came to mean the disgrace that was represented by a “moral failure” rather than any bodily evidence of it (Goffman 1963). 

Currently, stigma tends to be used predominantly in a figurative manner.  Of the diverse meanings of stigma, most relevant to a discussion of addiction is the figurative sense defined in OED as: “A mark of disgrace or infamy; a sign of severe censure or condemnation, regarded as impressed on a person or thing; a ‘brand’.”  This meaning pertains to the consequences of prejudicial views held by individuals concerning other human beings who are suffering from a condition for which they may not even be responsible.  Lack of responsibility for such “inadequacies” does not excuse the stigmatized person in the minds of those who, likely due to their prejudice or lack of knowledge, harbor biases and discriminate against the affected individual.    

The figurative meaning of stigma is interpretive, an attribution concerning an individual with significant implications and consequences for them.  Since there might be no anatomic alteration visible to an observer, these characteristics are often hidden and can be denied by affected individuals because of the fear of being stigmatized.  Such stigmatizing attributions seem particularly appropriate for the consequences of various forms of mental illness, including addictive disorders. 

The contemporary understanding and broad relevance of stigma in a social and medical sense is discussed by Link and Phelan (2001):

“We define stigma as the co-occurrence of its components–labeling, stereotyping, separation, status loss, and discrimination–and further indicate that for stigmatization to occur, power must be exercised.  The stigma concept we construct has implications for understanding several core issues in stigma research, ranging from the definition of the concept to the reasons stigma sometimes represents a very persistent predicament in the lives of persons affected by it.  Finally, because there are so many stigmatized circumstances and because stigmatizing processes can affect multiple domains of people’s lives, stigmatization probably has a dramatic bearing on the distribution of life

chances in such areas as earnings, housing, criminal involvement, health, and life itself.  It follows that social [and medical] scientists who are interested in understanding the distribution of such life chances should also be interested in stigma.”

Stigma is a harmful attribution by an observer concerning another individual afflicted by a socially “unacceptable” condition.  There is a real danger that any potentially wounding opinion declared or maintained by those who come in contact with a stigmatized individual becomes appropriated by that person, whether this is justified or not.  This can change the self-image or sense of self-worth of the stigmatized person causing them to believe that they have a physical or moral “failure” (Goffman 1963).  This condition, whether visible or not, is thought to be a “fundamental defect” that can lead to profound shame and denial in the affected individual and resistance to seeking treatment (Yanos, DeLuca, Roe et al. 2020) as well as unequal and even malignant treatment by others. 

Stigma likely enhances the effective severity of the condition so considered, presenting a significant obstacle to the patient seeking treatment (Keyes, Hatzenbuehler, McLaughlin et al. 2010) or reducing the likelihood of achieving a successful outcome should treatment be undertaken (Langdon-Down 1927; McGinty and Barry 2020).  That most people suffering from addiction have, indeed, appropriated the stigma associated with their condition underlines the profound need for and beneficial potential of mutual support recovery groups (Martin 2020a,b).  The Twelve Step Program allows for many of those suffering from addiction to view themselves in a more positive light.  Moreover, they may begin to consider that they also can achieve recovery if they actively pursue the well-traveled road that many of their peers have successfully chosen.

Stigma significantly impedes recognition and treatment of their disorders in individuals affected by addiction and also adversely affects the prioritization by government of policies intended to prevent and to help individuals with these disorders.  Resistance to assisting individuals suffering from addictive disorders is fueled by the commonly held notion that “it is their fault” (Erickson 1992) and that violence and other forms of criminal behavior often associated with this “lifestyle” are unacceptable.   In essence, this means that addiction is thought to be due to a conscious choice and moral failing by the affected person not a mental illness (Volkow 2020).  

Interestingly, this biased viewpoint of addictive disorders is in striking contrast to that held for othermental disorders, which in recent years have become increasingly accepted as bone fide medical illnesses that can be treated.  Perhaps this discrepancy goes beyond attribution of fault to the patient and is in part a consequence of the emergence of a highly profitable scientifically based pharmaceutical industry in the past century (Shorter 2021). 

So-called “ethical” pharmaceutical companies have developed through innovative research a plethora of psychopharmacological agents of variable efficacies for the treatment of mental disorders.  These psychopharmaceuticals are manufactured and distributed very much as medications for other medical disorders and their utilization has come to be considered an essential component of medical education and practice.    

Treatment of addiction has not received an equal emphasis in the pharmacopoeia or in medical education (Institute of Medicine 1995).  Nevertheless, effective integrated pharmacopsychosocial treatment approaches are available for drug use disorders (Martin, Weinberg and Bealer 2007).   However, the use of evidence-based medications to treat addictive disorders are underutilized. 

The use of medications to treat opioid use disorders are themselves stigmatized (Carl, Pasman, Broman et al. 2023), much as are the disorders they are intended to treat.  This is despite the fact that these pharmacologically based treatments, if widely used, may well have lessened the severity of the opioid epidemic and even now, are predicted to have a remarkable impact in reducing lives lost to overdoses and decrease complications of opioid use disorder (National Academies of Sciences, Engineering and Medicine 2019). 

As a result of substantial stigma associated with the (need for) treatment of opioid use disorders with medications that themselves are considered “addictive substitutes,” they are underutilized (Krawczyk, Rivera, Jent et al. 2022) and employed at lower than effective doses (D’Aunno, Park and Pollack 2019).  Interestingly, medication-assisted maintenance of opioid use disorder with depot formulations of the opioid antagonist naltrexone has become idealized as less stigmatizing and possibly preferable to the opioid agonists methadone and buprenorphine, even though the latter two are somewhat more effective (Bell and Strang 2019).

The notion that addiction is a “conscious choice” is incompatible with the recognized pathophysiology of addictive disorders (Martin 2016, 2019a).  These conditions are fundamentally disorders in which loss of control over self-destructive behaviors results in impaired decision-making attributed to altered brain functioning (Charland 2020; Minkoff 2024).  The source of dysfunctional decision-making in these disorders has biological and psychosocial underpinnings that result in an individual engaging repeatedly in addictive behaviors that eventually alter the entire behavioral repertoire.  The mechanistic explanation of such changes is attributable to plasticity of cellular components of neuronal circuits, the so-called “reward pathways” of the brain, related to conditioning and neurobiological phenomena akin to learning (Martin 2019b, 2020c). 

Neither should addictive disorders be considered a “moral failing.”  Rather, these conditions should be grouped with other mental illnesses which have come to be viewed as “neurobiological abnormalities” of the brain, or brain disorders (Leshner, 1997).  Acceptance of the fundamental similarities between addiction and other mental disorders would result in a shared approach to management of the most harmful consequences of all mental illnesses, namely suicidality or risk for violence to others, by committal to treatment rather than incarceration (Martin 2020d, 2021, 2022).  Most important, this acceptance of commonalities among all the mental illnesses may lead to diminished stigmatization and accelerated research for pharmaceuticals that can become part of integrated pharmacopsychosocial treatment approaches for addictive disorders. 

Probably as a result of stigmatization combined with fallacious attributions of fault for addictive disorders, only a small proportion of individuals suffering with addiction seek or receive care despite the availability of evidence-based treatments (Corrigan and Nieweglowski 2018).  The lack of treatment in the majority of those suffering from addiction may also be related to the reluctance of many physicians to address addiction in their patients (Campopiano von Klimo, Nolan, Corbin et al. 2024).  This is thought to be predominantly because of a lack of institutional support for such treatment and a deficiency of physician knowledge and skills in this domain.  How much these institutional and educational shortcomings are each caused by stigmatization of addiction is open to conjecture.  All the same, the skills required for treatment of addictive disorders must be considered a part of medicine, readily available for all patients who need them and presumably fully compensated by insurance plans.

One way that has been employed to assist patients who suffer from drug use disorders is to legally safeguard the medical records of all patients who bear this diagnosis.  In the United States, Title 42 Code of Federal Regulations Part 2 (42 CFR Part 2 or Part 2) was enacted in 1975 to protect from discovery patients receiving treatment for substance use disorders so that this would presumably not deter treatment-seeking (Karway, Ivanova, Bhowmik et al. 2022).  

While stigma was ostensibly one reason for enacting this legislation, this issue still affects accessibility and treatment-seeking behaviors for patients with addictive disorders (see above).  Whether the legislative strategy has helped or perpetuated stigma associated with addictive disorders has not been investigated.  Patients need to be protected, but undue secrecy in availability of medical records goes counter to considering addictive disorders as we do other medical conditions.  

Even among highly trained mental health professionals how one refers to individuals with substance use disorder (“substance abuser” as opposed to an “individual with substance use disorder”) evokes systematically different attitudes, judgments and likely enhances stigmatization (Kelly and Westerhoff 2010).    These distinctions are not trivial, if one recognizes that stigma is also contributory to pathogenesis of addictive disorders and may also compromise availability of evidence-based treatment to these patients.  Similar observations of the role of stigmatization have also been made in other specialties of medicine in addition to those for addiction (Goddu, O’Conor, Lanzkron et al. 2018). 

The profound effects of stigma on treatment outcomes in patients who suffer from addictive disorders is of great relevance to this discussion and promises to be an important research domain (McGinty, Goldman, Pescosolido et al. 2015; McGinty and Barry 2020).  The negative impact of stigmatization on patient care performed by different healthcare professionals (Weiner, Lo, Carroll et al. 2023) and when care is delivered using newer treatment platforms like telemedicine (Couch, Whitcomb, Buchheit et al. 2024) have also been reported. 

In a retrospective medical record review in U.S. academic health systems among patients with opioid use disorder admitted for infectious complications, summaries were reviewed for language usage (Carpenter, Catalanotti, Notis et al. 2023).  Stigmatizing language was common in this study and “best-practice language” was relatively uncommon, but when it was used it was associated with increased odds of appropriate addiction treatment and specialty care referrals.  Importantly, familiarity with medications used for treatment of opioid use disorder was associated with fewer negative attitudes towards patients with this condition and more frequent prescribing of these medications to treat them.  Both observations support the potential for education to enhance stigma-related lacunae in knowledge and quality of treatment of these patients (Piscalko, Dhanani, Brook et al. 2024). 

As a result of findings suggesting an association between improved patient care and outcomes with less stigma and more knowledge concerning addictive disorders, it has become an ethical imperative to attempt to teach “best practice” language to health care providers so as to begin to overcome the effects of stigma (Adams and Volkow 2020).  It is not surprising that these ethical concerns related to stigma apply to all of psychiatry (Volkow, Gordon and Koob 2021) and also to medicine (Himmelstein, Bates and Zhou 2022). 

The beginning of non-stigmatizing language in healthcare providers toward their patients originates in greater familiarity with those who are affected by addictive disorders and improved behaviors modeled by the teachers of the next generation of physicians and other healthcare professionals.  The ultimate goal is to view, speak of and treat patients who suffer from addictive disorders with the same dignity and respect given to any other patient group who come to the healthcare system for succor and treatment.  Knowledge and understanding are the foundational elements that underpin the needed changes and can lead to true empathy.

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September 26, 2024