As director of the Office of National Drug Control Policy (ONDCP) under President Obama, Michael Botticelli put a human face on recovery while successfully advocating strategies to combat a crippling opioid epidemic. Yet a significantly lower-profile action taken in the waning days of his tenure could prove to define his legacy, with a potentially monumental impact on how society views substance use disorders and the people who live with them.
On Jan. 9 of this year, Botticelli issued a memorandum to heads of executive-branch agencies and attached Changing the Language of Addiction, a document addressing the terminologies used to describe substance use disorders. While offering only voluntary guidance and not having the force of federal regulation, the document could serve as a roadmap for a more patient-centered approach to both the internal and public communications coming out of the federal government.
“In every talk I gave as director, I encouraged people to think about different language,” Botticelli tells Addiction Professional. “But if we expected other people to change their language, we at the federal level had to do the same thing.”
In many respects, Botticelli sees the document as fueling an effort to have the substance use disorder field catch up with other disciplines. For example, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) replaced “abuse” and dependence” categories with a “substance use disorder” construct in its fifth edition. “'Substance use disorder' is the clinically accurate term to describe the constellation of impairments caused by repeated misuse of a substance,” Changing the Language states.
Pointing to the substance use treatment community's closest peer, Botticelli says, “In the mental health field, think of the words we used to use” to describe a person with mental illness. “Then why would we [still] accept a word like 'junkie,' 'addict,' 'drunk'?”
Not mere semantics
Botticelli and some members of the treatment community have a long list of terms they would like to see eliminated from the substance use lexicon. They see much of the currently accepted language as perpetuating discrimination against persons with substance use disorders and their families.
“Think of the word 'addict,'” says Mary Woods, CEO of WestBridge, a treatment organization specializing in co-occurring disorders care with operations in New Hampshire and Florida. “When we hear that word, do we think of Michael Botticelli, or Marty Walsh, the mayor of Boston? No. We think of the guy robbing the liquor store.”
Woods adds, “The words we use do not support that this is a disease from which people recover.”
She does not see these problems with language as exclusive to the substance use disorder field, either. “When I was a nurse, people would refer to 'the gallbladder in Room 202,'” she tells Addiction Professional. “People can get drilled down to a very little bit of who they are.”
The document released by Botticelli in January includes a list of 15 commonly used terms in the field and 15 more patient-centered alternatives. In Botticelli's ideal scenario, “denial” becomes “ambivalence,” “relapse prevention” gives way to “recovery management,” and “graduate from treatment” is reframed as “commence recovery” (see table below).
The document offers strong evidence that this is no mere exercise in semantics. A study published in 2010 in the International Journal of Drug Policy demonstrated that participants' suggestions for how society should respond to a hypothetical person's problems varied greatly, depending on whether the person was described to the participants as an “abuser” or a less pejorative term. Amazingly, the participants in the study were substance use treatment professionals.
“These were trained clinicians,” Botticelli says of the study's subjects. “We're not just talking about people on the street.”
The effort to change the field's vocabulary appears to resonate with many patients and their allies. Michael Weiner, PhD, CAP, director of alumni services and research consultant for Seaside/Behavioral Health of the Palm Beaches in South Florida, says he has shared the Changing the Language document's table of terms with patients and their families.
“Family members think it's great,” Weiner tells Addiction Professional. “To a large extent, it takes the shame out of addiction treatment and recovery.”
He adds, “If we say someone 'has been in treatment three times,' that implies that they failed three times. When I talk to patients about their being in one continuous treatment, you can see the change in them.”
Language has become a topic of importance at both Behavioral Health of the Palm Beaches and at Woods' WestBridge. Weiner says that at morning meetings at Seaside, the term “recurrence” (promulgated by field historian William White) is largely replacing “relapse.” Woods says new hires at WestBridge are exposed to discussion of language as part of their orientation, and reframing language is always a part of team meetings.
There remains room for differences in interpretation. WestBridge refers to the individuals it serves as “participants” rather than “clients,” while Weiner believes “patients” should serve as the field's standard.
“We're treating a disease,” he explains. “We accept medical insurance. We have Joint Commission approval.”
Botticelli believes that some of the most problematic uses of language in the field stem in part from the lingo of the 12 Steps seeping into everyday parlance. What is perfectly acceptable in the context of an Alcoholics Anonymous (AA) meeting does not necessarily translate well to broader settings outside those confines, he says.
In preparing the Changing the Language document, ONDCP consulted with research, policy, provider and consumer stakeholders. Botticelli cites several criteria used to arrive at the suggested language in the document:
The presence of any direct research supporting use of certain language;
An effort to align the field with currently accepted medical terminology, such as that in the DSM-5; and
An attempt to move the field toward regular use of person-centered terminology.
An introduction to the document states, “By using accurate, non-stigmatizing language, we can help break the stigma surrounding this disease so people can more easily access treatment, reach recovery, and live healthier lives.”
Botticelli says he also understands the limits of this endeavor, in areas such as potentially changing the names of federal agencies to reflect a changing mindset. He consistently explains that the act of removing the word “abuse” from the name of an agency such as the National Institute on Drug Abuse would have to occur as part of agency reauthorization language in Congress.
Also accompanying the document's table of 15 commonly used terms and their alternatives is suggested language for describing persons' attempts to work within “a system that often tries to control them,” as the document states. For example, someone labeled as “manipulative” would have the situation reframed as needing “to work on more effective ways of getting his needs met.” Someone labeled as “non-compliant” should instead be seen as “looking for other options,” and so on.
Botticelli believes progress has been made in improving the field's language, but some stark examples of an older way of thinking linger.
“I can't think of another disease where we would identify the results of tests as 'dirty' or 'clean,' he says.
A director's impact
Botticelli, who is now heading Boston Medical Center's new Grayken Center for Addiction Medicine, was the first ONDCP director with a public story of personal recovery. He looks back proudly on numerous initiatives during his tenure, from highlighting the need for strong enforcement of the federal parity law to playing a role in congressional approval of $1 billion in funding for states to combat the drug crisis. At the same time, he does not hesitate to say that if the vocabulary of substance use disorders changes, that could have as important an effect as any of the other accomplishments.
“One of the things I feel proud of is that we really tried to ensure that substance use disorders were seen as health issues and public health issues,” he says. In that endeavor, he emphasizes, words truly do matter.
Language of Recovery
Treatment is the goal
Treatment is the only way into recovery
Treatment is an opportunity for initiation into recovery (one of multiple pathways into recovery)
Individual not yet in recovery
Substance use disorder/addiction/substance misuse
Drug of choice/abuse
Drug of use
Focus is on total abstinence from all illicit and non-prescribed substances the clinician identifies
A drug is a drug is a drug
Each illicit substance has unique interactions with the brain; medication, if available, is appropriate
Recurrence/return to use
Relapse is part of recovery
Recurrence/return to use may occur as part of the disease
Drug-free/free from illicit and non-prescribed medications
Mutual aid group
Graduate from treatment
Source: Office of National Drug Control Policy