“Language is a virus from outer space” ― William S. Burroughs
I was taken to task a few weeks ago by a reader, who took exception to my use of the word addiction in one of my writings. It got me to thinking about our shifting language over time. The historic use of terms around problematic alcohol intoxication and drug use and how they have shifted over time. Our language over the millennia is fascinating. Consider the old English term “Fordrunken,” which was first in use around 1513. It is still the term most often used over five hundred years later. A person who drinks too much became known as a drunkard or even a habitual drunkard. I found this interesting article from ten years ago in the LA Times – Op-Ed: English language is loaded (or fou, or blotto) with ways to say ‘drunk’. Another early term was inebriate or inebriety. It was in common use for a very long time, I have a board member who started in the field in the late 1960s and worked in what was termed an inebriate program.
It all got me thinking about the William S Burroughs quote above from a favorite song of a bygone era. Language is a virus. What we call things matters, the words influence how we think. But meanings also mutate over time. In respect to addiction, the words we use are also influenced by powerful and often invisible negative perceptions about the condition and those of us who have them. It is one of the most stigmatized conditions in world history. These negative perceptions are so powerful, none of us are left untouched. We are raised with these negative perceptions. We pick them up from our very earliest experiences.
The underlying message, despite all the efforts to the contrary is that it is a condition that flawed people get, because they chose to use drugs, including alcohol in harmful ways. These notions are of course false, but they are so ingrained in our society that all of us have them within us. Even when we may know cognitively, they are false, they hide on a deeper level. It creates such a powerful undertow that even attempts to use terms in a more enlightened way become stained with negative connotations over time.
Inebriate was considered the dignifying term of a bygone era. The term is not used in this way at this juncture in history, which highlights one of the main problems with relabeling. Stigma runs much deeper than the labels we use to describe the condition. As this article, Erasing Stigma Is Much More Than Changing Words (2014) notes, while it may have some short term benefit, “eventually, pairing a new term with a condition that continues to be stigmatized by a culture will eventually stain that term too.” So, we should not put all of our eggs in the basket of changing terms that will eventually be tarnished over time with the negative connotations as the words they replace. Negative perceptions about us that are deeply entrenched in society. Ultimately, we need to change the attitudes and not the associated descriptors to make real forward progress.
Let’s consider efforts to eliminate the use of the word addiction. I use it intentionally and this has upset some on the social media spaces. Something gets lost when we use the term substance use disorder (SUDs). It is used as shorthand for a continuum of conditions from mild to severe. The term addiction has more specificity. Not all forms of SUDs are addiction. The confusion of which has led to a great deal of spilt ink. The current definition of the term by the American Society of Addiction Medicine is that it is “a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.” A mild substance use disorder is not addiction. In some but not all instances, it can progress to that point but at other times it does not. It is all very complicated. We do not like complicated, we want simple concepts and answers to complex conditions, which is a whole other matter entirely.
In exploring why some are calling for the elimination of the term addiction, I found this 2020 document, Moving beyond ‘people-first’ language: A glossary of contested terms in substance use. It reasons that the term suggests hereditary factors (which it does include based on evidence and as referenced in the ASAM definition). It asserts that problem substance use is closely related to poverty and childhood trauma. This is certainly true, but not universally so. There are genetic risk factors for addiction. While no one is born predestined for addiction, the genetic facets increase the risks in relation to a myriad of environmental factors. Eliminating poverty and trauma would not eliminate addiction. Well to do people without trauma get addicted too. Again, there are no simple answers to the spectrum of this complex condition.
The call to stop using the word addiction is not as widely accepted as the move to stop calling people drug addicts and alcoholics. These are our most stigma laden terms at this point. As someone in recovery from addiction who has worked with thousands of people over the decades, I can attest that each and every one of us is diminished by the use of these labels in public. Many in 12 step fellowships use these terms behind closed doors within mutual support settings to identify with each other. It has utility in these settings that those outside of them may not easily understand. Suffice it to say that it is really no business of anyone outside of these fellowships to suggest what is done within, but that is a far different matter than people using the terms addict or alcoholic in public settings.
A History of ‘Drunk’ Words explains the evolution of synonyms for “intoxicated,” including how English got “wasted,” “bombed,” and “lit.” it is fascinating to consider “three sheets to the wind” which if you were a sailor in the early 1800s, you would know that the three corners of each sail were bound down with ropes. They were called “sheets,” and they served to keep the ship steady in the wind. When the sheets came loose, the vessel would zig-zag to and fro, meandering around the sea like a drunken sailor. In fact, around 1821 people realized that this might be the best possible way to describe drunken sailors—or drunken anyone, for that matter. It was like they were “three sheets in the wind.” What an interesting point of historical context.
The notion of wine mania developed in the 1850s and became known as “oinomania.” It came out of the work of Benjamin Carpenter. One of the earliest and most influential classifications was introduced by Carpenter in his 1850 essay, On the Use and Abuse of Alcoholic Liquors in Health and Disease. Quoting extensively from the Report of the Glasgow Lunatic Asylum published in 1842, Carpenter proposed three categories of oinomania: acute, periodic, and chronic. We can see the origins of our concepts of different forms or severity of alcohol use disorder begin to be conceptualized even then at what was the beginning of what was considered the scientific era of understanding SUDs.
In the 19th century the term Dipsomania or in German Trunksucht was used to describe the uncontrollable craving for alcohol of other drugs. Just like how terms in the SUD space are used in our era, they were applied in confusing ways. Dipsomania initially described episodic substance use problems and then began to be used to describe what we now would consider a severe SUD. In this era German-Russian doctor C. von Brühl-Cramer describes substance use conditions in terms of continuous, remittent, intermittent, periodic, and mixed forms. They understood the complexity even then.
In 1784, Benjamin Rush, fellow Pennsylvanian, surgeon general of the Continental Army and signer of the Declaration of Independence published An Inquiry Into the Effects of Ardent Spirits Upon the Human Body and Mind describing habitual drunkenness as a medical condition. This was one of the key moments in which it began to be viewed as a medical condition and not a moral failing, which Rush was able to see as an enlightened physician.
The language used to describe this condition changed over time. The notion of “inebriety” was dominant throughout much of the 19th century. Although inebriety was principally applied to alcohol, it could encompass other substances too. Towards the end of the century, the terms “alcoholism” and “addiction” began to be used as the science of addiction began to be considered with some rigor (the eras before this were considered the prescientific era).
As alluded to earlier, in contemporary times, there is a fairly significant body of literature with compelling evidence that calling a person an alcoholic in public spaces is stigmatizing and should be avoided. We advocate for the use of terms that are not as heavily laden with negative perceptions. Yet, it is worth noting that in earlier times, as the shift was from calling a person a drunk, a lush or a sot, the term alcoholic was seen as the less stigmatizing term of that bygone era.
Negative perceptions surrounding people who use drugs or who are in recovery are so pervasive that whatever new terms we chose will become laden with negative connotations over time. I am not saying that efforts to change our language moving forward are not important, but what I am saying is that we are likely to never get to a point in which language referring to people like me does not have stigmatizing connotations until we have a world with significantly fewer negative perceptions about who and what we are.
We can perhaps use our energies more effectively to change public attitudes rather than beating each other up overusing the words considered inappropriate in this moment in history. We can safely say that whatever new words we choose will also become sodden with negative connotations until we change the underling biases and attitudes so very pervasive across our society.
Like a virus, we should address the underlying environmental conditions to change these powerful negative views to keep the contagion from spreading. Moving words around is ultimately not going to address the underlying issues. That would start by acknowledging that these negative views are everywhere, including within us and taking steps to unpack them and work systematically to reduce their influence on our policies and processes that deal with how we treat people with substance use disorders. Perhaps that should be our main advocacy thrust in changing public perceptions about who and what we are.
Sources
American Society of Addiction Medicine. (2019, September 15). Definition of Addiction. ASAM. https://www.asam.org/quality-care/definition-of-addiction
Babor TF. The Classification of Alcoholics: Typology Theories From the 19th Century to the Present. Alcohol Health Res World. 1996;20(1):6-14. PMID: 31798163; PMCID: PMC6876530. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6876530/
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Moving beyond “people-first” language: A glossary of contested terms in substance use. (2020). IDPC. https://idpc.net/publications/2020/10/moving-beyond-people-first-language-a-glossary-of-contested-terms-in-substance-use
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Sarkar, P. R. (2021). Spirits From the Past: Stigma in Historical Medical Literature on Alcohol Addiction and Implications for Modern Practice. American Journal of Psychiatry Residents’ Journal, 16(4), 8–10. https://doi.org/10.1176/appi.ajp-rj.2021.160405
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