Scientists investigating substance use are making progress on eliminating stigmatizing language that can perpetuate negative biases and worsen outcomes, according to a new analysis of published research articles. Nevertheless, the field has further to go. The use of pejorative and outdated terminology — such as “abuser” and “addict” — has been shown to reinforce negative judgment, both among the public and in medical settings. Clinicians’ biases related to stigmatizing terminology have been linked to decreased quality of care and worse treatment outcomes. For people with substance use disorders (SUDs), terms implying immorality and blame are a known barrier to seeking treatment. Consequently, over the past decade, research organizations have recommended a shift toward non-stigmatizing language. In 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM) replaced “alcohol abuse” and “alcohol dependence” with “alcohol use disorder” (AUD). In 2015, the International Society of Addiction Journal Editors (ISAJE) endorsed the new diagnostic terminology and person-first language, such as “person with an alcohol use disorder” rather than “alcoholic.” In 2018, the Research Society on Alcoholism (RSA) and its journal, Alcoholism: Clinical & Experimental Research (ACER), adopted a similar position. For this study in ACER, researchers at Yale University examined the use of relevant terminology in the same journal.
Investigators reviewed papers published in ACER from 2010 to 2020 that had been funded by the National Institutes of Health (NIH) and published on Pub MedCentral (PMC). This resource, PMC, is freely available to the public, and therefore has the potential to perpetuate stigma in the scientific and broader social community. The study included 1,903 qualifying articles, 63% of papers published in ACER in the relevant decade. The researchers screened these articles for stigmatizing terms, including “alcohol abuse,” “alcoholic,” addict,” and the preferred language, “alcohol use disorder” and “substance use disorder”. For comparison, they reviewed a random sample of ACER papers not funded by the NIH or published on PMC. They adjusted for the non-stigmatizing use of “alcoholic” (e.g., “alcoholic beverage,” “Alcoholics Anonymous”).
The use of pejorative and outdated terminology in ACER articles has decreased over time. Even before the terminology changes and recommendations, fewer than 10% of ACER articles contained the terms “abuser” or “addict.” Since the diagnostic shift, the use of “alcohol dependent” and “alcoholism” declined, while “alcohol use disorder” increased. Nevertheless, the researchers found room for improvement. About 30% of articles included “alcoholic” in a stigmatizing way, and 5% of articles published in 2020 included “abuser” or “addict”. The ACER papers not published to PMC contained stigmatizing and outdated language at similar rates. Some use of terms such as “alcohol abuse” may reflect data collected before 2013.
The decline in stigmatizing and outdated terminology use is promising. Terms such as “alcoholic,” “addict,” and “abuser” are known to trigger negative responses in implicit bias tests. Such language risks implying that people with AUD or SUD are undeserving, and erases the contributing factors, a bias that has been shown to influence even trained behavioral health clinicians. The researchers urge the scientific community to consolidate the shift away from negative labels describing people with AUD or SUD. They recommend person-first terminology and replacing “alcoholism” in the names of journals and organizations with “alcohol.”(AK/NW)