Stigma causes people to hide their addiction, preventing them from seeking help. The stigma of being an “addict” implies that person is to blame for their actions. The words we use to describe someone not only affects how we view that person, but how that person comes to view themselves.
When I started as a paramedic, others told me about the junkies and addicts I would encounter. These were people who rather than living the norms of society were members of an estranged group that was a drag on the rest of us. They were “dirty,” while those who didn’t use were “clean.” Health care and other public money spent on them, including our time, was considered a waste because it was unnecessary and due only to their bad characters. Our taxes were higher because of their weakness.
My coworkers, like many in emergency health care, including doctors, were never well trained, if trained at all, in addiction, mental health or the dangers of stigma. We passed on a culture, biased against drug users, that had been passed on to us. For a while I carried the torch.
My friend, Kelley, is a heroin and cocaine addict. I have known her for over eight years now and she has helped me to understand much about the epidemic. When I first met her, early in her addiction, I was surprised to learn that she used drugs at all. She was a bright clear complexioned twenty-something with purple hair and half her head shaved, sort of a punk girl next door type. Later, when she had bad abscesses on her arms and legs, I urged her as, I often did, to go to the hospital with me and get checked out, get treatment for her wounds, and maybe even get into rehab again or get on suboxone or methadone. They could help her there, I said. But she’d just shake her head. “They treated me like shit the time I overdosed. They don’t like me there. I will never go back to the hospital.” I heard similar stories from others I knew. What upset me the most was when one user told me how she was treated by one of my fellow medics, who said to her, “I’m tired of scraping your ass off the pavement.” Both EMS and the ED were not welcoming places for them. They felt judged there, and so barring being unresponsive, they did everything they could to avoid going there. I was thrilled when the local harm reduction group opened up a drop-in center and staffed it with a nurse who I could send them to see. She could treat them, and do her best to try to get them the care they needed.
Stigma means stain. When we stigmatize someone we put a stain on them. It suggests not just moral judgment against a person, but it also inspires fear in others, works to isolate people, and criminalizes their behavior. The user becomes a stereotype and not a person. A “dope fiend” is not someone considered capable of positive human interaction.
The World Health Organization (WHO) studied stigma in 14 countries to determine what conditions (homeless, AIDS, obesity, mental disorders, alcoholism, criminal record for burglary) were most likely to be stigmatized. Drug use was number one.
On TV and on the news, the visuals and images that accompany stories on the drug crisis often show people living in squalor, rooting through garbage cans, and trying to inject their necks or feet. Their drug use in public is portrayed as a crime not the result of a disease and social situation. Headlines blame addicts for unsafe streets rather than focusing on homelessness and mental health. People who use drugs are often seen as inhuman. A recent article about drug use in San Francisco drew the headline “Zombie Apocalypse.” Who wants to read about human tragedy and unaddressed social needs when zombie terror gets all the clicks?
On Youtube there are plentiful videos, such as one that has received over a million views titled “Skin Rotting ‘Zombie Drug’ Causes Havoc Across The US, “ that portray drug users like characters in horror stories, complete with terrifying ominous soundtracks. Local news stations covering the crisis typically show footage of people using drugs near dumpsters. The term junkie came from junk men, people who went through trash. The association is that junkies are human trash.
One day I was dispatched to an overdose. I was in the paramedic fly car and a BLS crew was in the ambulance. We were driving around looking for the victim. I didn’t see anyone on two passes, but then I heard the BLS unit radio that they’d found the patient. I swung around to where they were now parked at the curb with their lights still going. An EMT was already wheeling the stretcher down a short alley where his partner knelt by the dumpster. As I approached I saw he had the ambu-bag out and was providing ventilations to a man who was dusky with agonal respirations.
“Thought I’d check behind the dumpster,” the EMT said to me.
“You found him.” I marveled at his simple logic.
In EMS when we meet persons with opioid use disorder we often find them at rock bottom. I have done many overdoses like this one of people who were in fact down alleys and behind dumpsters. From TV news coverage many would assume that all drug users seek trash cans out to hide behind while they stick “dirty” needles in their scab and abscessed filled wasted arms. The young EMT did and it helped us find this lost soul.
Rock bottom means there is no lower that someone can go. It is a common belief that someone needs to hit rock bottom before they are really ready for help. I think of my early remarks to the users I revived before I thought to ask them their stories, when I just saw them as people who needed to get a grip. “Get your life together, just say no or you are going to end up dead or in jail. Look at yourself.” I held up to them not a picture of who they could be again, but who many in society saw them as — junkies, human trash. It is hard to make something of yourself in this world, much less when your current position is at rock bottom with the world looking down on you.
Stereotypes produce negative judgments and negative judgments lead to discrimination. Would you give a job or rent an apartment to a “drug abuser?” Would you reallocate money to them away from people who are not considered abusers? Would you give a sandwich and some change to a zombie?
Language affects how people feel about people who use drugs; it also affects how people who use drugs feel about themselves. Steven Biko, the great South African human rights leader, said, “The most potent weapon of the oppressor is the mind of the oppressed.” If you can destroy a man’s self-worth, you can cripple his ability to stand up.
You have just overdosed. A large first responder stands over you and says, “Tell me what drugs you used. How many bags? What’s wrong with you? You’re going to kill yourself. Think of your family. Get some self respect. I’m being honest with you bro, keeping it real. You’re a mess. Look in the mirror. You’re at rock bottom.”
Do you want to be in this person’s care? Do you want to go to the hospital and be lectured at by people with similar views who think you are a scumbag? You are an abuser. You are a junkie. What are you going to do? Everyone looks down on you. You just want to crawl back into your own hole. You want to forget. Even if someone was there to help you, you would likely just mess it up again. With no one else to turn to, you turn back to the needle. The damage has already been done. Not only do we need to help people at rock bottom, we need to start helping them before they get there.
Science has shown that social pain is felt in the same area of the brain as physical pain and thus responds to pain medicine in the same way physical pain responds. In an opinion piece in the New England Journal of Medicine, Dr. Nora Volkow cites a study in which lab rats chose interacting with other lab rats over self administering drugs, but when they were punished with electrical shocks for their social interactions, they reverted to drug use. She concludes that stigma “spurs further drug taking.”
People who use drugs hide their use for fear of being stigmatized. They are worried they will lose the respect of others as well as cost themselves economically. It is hard to seek treatment for a problem that you don’t want the world to see. Even when people do need to get medical treatment either for the disease or its sequelae, they may not be treated as other people seeking medical attention are due to the negative views many health care providers have about people who use drugs.
Anti-stigma advocates are working hard to get the media to pay attention to the language they use. The Associated Press’s stylebook now attempts to steer media people in the right direction, urging them to avoid stigmatizing or punitive words that can deter people from seeking treatment. Instead of abuse or problems, reporters are encouraged to use the words use or misuse. They are warned to avoid the words “addict,” “abuser,” “junkie”, and “crackhead.” These words stereotype and dehumanize rather than recognize the humanity of the person with the medical condition.
Recently the Hartford Courant ran a story about xylazine, the animal tranquilizer that is being used as an adulterant to fentanyl that is capable of causing skin lesions and necrotic wounds. The headline of the story on their internet page read “‘Modern day leprosy’: Xylazine hits Connecticut with devastating impact.” Some people only read headlines, others just skim stories, many read the stories and believe every word and implication in the story. I emailed the reporter, who likely was not the one responsible for the headline. I wrote “calling xylazine wounds leprosy (I know it’s a catchy quote) can be very stigmatizing and may keep some people from providing aid to overdose victims for fear of catching ‘modern day leprosy.’ Xylazine wounds are not contagious.” The paper’s website changed the headline to read. “Zombie drug hits Connecticut with devastating impact.”
In a December 2023 article in the Atlantic, Keith Humphreys and Jonathan Caulkins argue that the United States must walk the line between destigmatizing drug addiction, which they see as noble, and destigmatizing drug use, which they see as dangerous. They argue that harm reduction campaigns that encourage people to “Do it with friends,” rather than using alone, “promote a positive image of a drug that is killing 200 Americans a day.” They argue that harm reduction is geared toward people who are already using and that we have to consider people who have not yet started if we want to truly end the epidemic. They approve of campaigns like “One Pill Can Kill.” They cite how stigma has helped curtail smoking by deglamorizing it. I don’t feel harm reduction glamorizes drug use in any way. Its foremost concern is saving human lives. One of the National Harm Reduction Coalition’s Eight Principles of Harm Reduction is “Does not attempt to minimize or ignore the tragic harm and danger that can be associated with illicit drug use.”
Ending stigma can change the course of this epidemic. People who use drugs are human beings knocked off course by a larger epidemic not of their making. None of them set out to become addicted to drugs, to become homeless, lose their families or their lives. An addictive gene, an accident, a doctor’s prescription, an innocent experimentation, sexual abuse, mental health, so many factors were behind their use. We have to stop driving people into the shadows or locking them up because we don’t like their disease. Drug treatment, housing, health care, job support and human empathy and love will go farther than hurtful words and prison bars.
We need to truthfully educate people about drug use. Scare tactics are not as effective as plain truth. Cut the zombie nonsense, and tell it like it is. Fentanyl kills. People who use illicit opioids must know that they cannot effectively judge the dose. People who buy illicit pills must know that those pills may not be what they say they are; they may contain a lethal dose of fentanyl. People who use illicit drugs should never use alone. Fentanyl plus using alone is deadly. That is the rock truth.