The medical profession and stigma against people who use drugs

Corrigan et al ¹ argue that stigma against people who use drugs is ‘in some ways socially, politically, and/or legally sanctioned’ and discuss this with reference to the criminal justice system, the workplace and health promotion strategies. How the medical profession, medical diagnosis, medical language and medical models of addiction might be propagating stigma is not discussed and we offer some examples.

First, terms widely used by the medical profession to describe people who use drugs are apparently neutral and objective, but in fact convey negative attributes. For instance, ‘drug abuse’ can be taken to imply that people who use drugs do so to deliberately inflict harm upon themselves. The use of this term also implies that there is a universally recognised standard for the ‘proper use’ of a given substance, when there is not.

Second, medical diagnosis is normative. The ICD-10 and DSM-5 define addiction by identifying normative standards of behaviour that people with drug dependency fail to achieve. For instance, one DSM criterion identifies drug use ‘resulting in failure to fulfil major role obligations at work, school, or home’. As Matthews et al ² put it: ‘to be diagnosed with addiction under these systems […] is to be classified as morally compromised or deficient’.

Third, medical models of understanding cast people who use and/or are dependent on drugs in a negative light. The cause of dependent drug use is contentious. Is it the result of moral choice, a disease, or normal brain changes that result from habit acquisition? The ‘moral model’ of drug use holds drug use as a choice, and has a critical stance against this choice, legitimising stigma. The ‘disease model’ sees dependent drug use as a result of neurobiology. This model underpins the medical approach to dependent drug use, where a diagnosis, based on symptoms and history, leads to prescribed treatment. Although this approach absolves responsibility, and therefore the potential for stigma via blame, it nevertheless influences stigma by casting dependent drug users as helpless victims. ³

Fourth, healthcare professionals are unsympathetic to people who use drugs. There is evidence that negative attitudes of healthcare professionals towards patients who use drugs are widespread. ⁴ This may affect drug users' self-stigma. Gilchrist et al ⁵ found that healthcare professionals appear to attach lower standing to working with people who use drugs than to work other patient groups. Since healthcare professionals are influential, these negative attitudes may engender stigma elsewhere.

Fifth, there is the matter of doctors and drug policy reform. As Corrigan et al point out, criminalisation fuels stigmatisation. Criminalisation is also responsible for many of the harms associated with drug use, for instance violence associated with the black market in drugs, and adulterated supply. Doctors are in a position to influence drug policy away from blanket criminalisation towards a more nuanced approach which more closely correlates to the potential for harm. Some organisations representing doctors have called for changes but ‘such calls are far from universal – and far from loud enough’. ⁶