How removing the veil of anonymity from substance abuse can prove to be monumental in the de-stigmatization and progression of recovery in the United States.
The magnitude of the problem
It’s no secret that the American addiction crisis is gaining more and more attention. With opioid overdoses sweeping the nation in record numbers, there appears to be a call to arms for all government health agencies. Though many are alarmed, for those who have been in the trenches, this fight is nothing new. Even though we have seen high numbers in deaths from overdose, the statistics show it is far from a spike and more of a steady progression.
While it appears that a fleet is coming to aid the already seasoned “soldiers of substance abuse,” one cannot truly predict what the outcome of this added attention will be. There are things inherently wrong with the modus operandi of substance abuse recovery in the United States. Its insistence on anonymity has unwittingly aided in the further stigmatization of those who suffer.
While remaining unidentified may be part and parcel to the framework of many recovery ideologies, it appears to be doing more harm than good. Stigma and anonymity make it impossible for our society to grasp the magnitude of the problem. An inability to handle this leaves substance abuse issues in the United States grossly underestimated.
The current state of addiction
Before we talk about what needs to change, lets first discuss the current state of addiction in America and lay to rest the idea that this problem is something new. If you talk to anyone who has worked in the field of substance misuse and addiction, you may get a cold look if you try to speak to them about “how bad addiction has become.” It isn’t because they are apathetic, it is because they know that this fight has been going on for years, and despite all their efforts, things appear to be getting worse.
According to the CDC Wonder, there were over 16,000 overdose deaths in 2000. When compared to the most recent numbers analyzed in 2017, deaths increased over four times that amount to over 70,000 deaths.[i] Examining how the number got so high, one can see it wasn’t a spike, but a gradual progression. American health professionals were aware of the problem, and to a certain degree, so was the public. We have all heard about the “war on drugs” or “just say no.” Active campaigns against drug abuse have been underway for decades.
So why are things getting worse? To answer that question, we would need to examine multiple factors. One rarely discussed, however, is how our society views and handles substance abuse and recovery.
A brief history of society’s view of addiction
It the past, substance abuse was seen strictly as a moral issue. This viewpoint answers the question of why we see drug users and addicts subjected to stigma and harsh treatment. The full explanation depends on a variety of complicated historical, socio-political, and economic forces. But from an ideological perspective, attitudes and policies resonate with the moral model of addiction, which was dominant in the first half of the twentieth century.[ii]
In other words, individuals viewed addiction as a character defect, much like that of the thief or rapist, and society has been punishing “perpetrators” accordingly with criminal charges and stiff sentences. Fortunately, as our culture evolves, its viewpoint on addiction has begun to as well. The idea that addiction is a disease, rather than a lack of moral fiber, has gained more acceptance. This shift in view, though controversial, has led to a more open outlook on those who suffer from substance abuse.
Society has proven to be more understanding when it comes to addiction. But despite this, stigma still largely persists. Stigma is a mark of social disgrace that carries condemnation and ostracization by society. It creates corresponding shame and isolation on the part of the stigmatized person. These impact the self-identity and self-esteem of drug users and addicts themselves while simultaneously presenting a psychological obstacle to seeking treatment.[iii] Given the past viewpoint toward addiction, it is easy to see how our society created the stigma we see today.
Even those who acknowledge that addiction isn’t entirely a moral issue can still behave in a condemning way that acts as a double-standard. Combine this with legal repercussions, and we frequently find that addicts go to great lengths to hide their addiction. Those affected by substance abuse pursue any attempt at recovery under the veil of anonymity out of fear that seeking help is essentially an admission of guilt. That is if they seek help at all.
The anonymity of recovery
When we look at recovery, we find that anonymity has been the cornerstone of nearly all models of treatment. The forerunner of modern recovery, Alcoholics Anonymous, embraced anonymity but also helped usher in the idea that addiction is a medical issue. It’s a bit of a paradox, but AA founders appear to have been all too aware of the stigma associated with addiction and adopted a model that made people feel safer getting help. It’s been effective in that AA has stood the test of time. While many feel it’s an old-fashioned and potentially less successful method than more modern forms of recovery, it’s still the most common medically accepted approach.
Rather than fight the stigma, AA plays ball with it while simultaneously trying to usher in a new school of thought. This paradox may be confusing, but in a survey conducted in 2000, the study discovered that when genetics or stressful circumstances were the underlying causes of addiction, individuals were more willing to engage in social interaction with those with substance abuse disorder.[iv]
This phenomenon shows that education and understanding of the “disease” model are critical factors in improving attitude and reducing stigmatization towards addiction. And, while emphasizing anonymity does get more people to accept help who likely wouldn’t, it would be wholly unnecessary if we eradicate stigma. Of course, the hole is deep, and climbing out isn’t an overnight process.
The stigma-anonymity relationship
Now that there is a better understanding of where things were and where they are going. Let’s further examine how the problems of the past are affecting the present. To tackle any issue such as substance abuse, you first must know what you’re facing. Unfortunately, this is where another significant consequence of the stigma-anonymity relationship rears its head.
Research done by the Boston Globe showed that they do not count more than half the people with opioid addiction because they have not obtained health care services related to opioid misuse.[v] Though this sample exists on a relatively small scale, it demonstrates a more significant issue. If people refuse to come forward to seek help, then they remain anonymous. This inability to go forward results in a gross underestimation of affected peoples. Which, in turn, creates an inaccurate assessment of the need for effective treatment.
Furthermore, due to the anonymity that protects them, the efficacy of treatment is also hard to determine. The Atlantic explains how Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works.[vi] This observation is not an attack on AA, merely an illustration of our lack of understanding. And it exposes one of the major pitfalls of this stigma-anonymity relationship. If it continues, the problem is going to perpetuate. By playing ball with society’s stigmatization, the collective community surrounding substance abuse has essentially prevented adequate research and understanding of itself.
Learning from the past
History shows us that the public stigma of addiction has the unfortunate tendency to feed into, sustain, or exacerbate the very practices it sets out to reproach.[vii] The way society views and treats those who suffer from substance abuse makes it hard to help them effectively. It’s quite literally a self-fulfilling prophecy that nearly all minority groups have had to face, some with more success than others.
Once deemed as “less-than,” they have the choice to either come forward and fight against an already biased culture or hide to avoid even worse personal consequences. The aids epidemic of the 1980s is a perfect example that mirrors this dilemma but also provides a basis for a solution.
By coming forward, speaking out, and raising awareness, the stigmatized group achieved proper research and public understanding. They made substantial progress in a battle that otherwise could’ve further festered in a dark corner filled with hate, fear, and prejudice. Those who suffered stood up to the stigma and “showed their faces,” achieving considerable progress in a relatively short period.
By examining past successes, it’s clear that what’s needed is an improved public perception and understanding of addiction and recovery. Not to say that coming forward is easy or that society is fully ready to embrace such a shift. There’s an intrinsic relationship between secrecy and stigma, each worsening the other in a way that seems inextricable. Regardless of which came first, or who’s to blame, hiding does nothing to increase acceptance.
A need for understanding
Research done by Johns Hopkins Bloomberg School of Public Health showed in a 2014 survey that people still held negative views significantly more toward persons with drug addiction than those who were mentally ill.[viii] This study at once makes clear why people still seek anonymity, and why those who provide treatment offer it.
People generally don’t appreciate what they don’t understand, or what seems foreign to them. Fortunately, we’re entering an era where speaking out and going public is becoming a social movement, and other stigmatized groups such as victims of sexual assault or LGBTQ activists are finding success in stepping out of the shadows.
A younger generation of recovery activists believes the only way to end this cycle is to acknowledge their struggles publicly and encourage others to do the same. And history would seem to indicate that they’re not wrong.
Responsibility and change
In conclusion, both the general public and those intimately involved with substance abuse have a responsibility. These groups need to shed the stigma of the past and work together on solving the problem. When our friends, family, and coworkers feel the need to hide in the shadows out of fear, it makes addiction a faceless monster that we just wish didn’t exist.
But this is a sad sign that significant change is overdue.
It may very well fall on the shoulders of addicts themselves and those in recovery to start this motion by putting faces to the statistics and relating their truth and humanity. It’s not feasible for treatment providers to reject anonymity or advocate for their clients in a way that exposes their identity, as this is firmly illegal and unethical. But, encouraging their clients to be open, relatable, and honest about their struggle could give stigma less of a foothold in the minds of those subjected to it and usher in a new, empowering approach to getting better.
In this way, a better understanding of the issue can occur, and better study can take place that truly reflects what we’re dealing with and how to treat it effectively. To sufficiently educate society on the reality of substance abuse, we need actual data. And we can’t study what we can’t see…. or in this case, what we refuse to look at.
[i] https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
[ii] Pickard H. (2017). Responsibility without Blame for Addiction. Neuroethics, 10(1), 169–180. doi:10.1007/s12152-016-9295-2
[iii] Pickard H. (2017). Responsibility without Blame for Addiction. Neuroethics, 10(1), 169–180. doi:10.1007/s12152-016-9295-2
[iv] Henderson, Nicole & Dressler, William. (2019). Cultural Models of Substance Misuse Risk and Moral Foundations: Cognitive Resources Underlying Stigma Attribution. Journal of Cognition and Culture. 19. 78-96. 10.1163/15685373-12340049
[v] https://www.bostonglobe.com/metro/2018/10/25/new-study-says-opioid-addiction-mass-much-worse-than-thought/x08PkYughh6IBJ2yASdUoL/story.html
[vi] https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/
[vii] Matthews, S., Dwyer, R., & Snoek, A. (2017). Stigma and Self-Stigma in Addiction. Journal of bioethical inquiry, 14(2), 275–286. doi:10.1007/s11673-017-9784-y
[viii] https://www.jhsph.edu/news/news-releases/2014/study-public-feels-more-negative-toward-people-with-drug-addiction-than-those-with-mental-illness.html