Pediatricians across the United States encounter infants, children, adolescents, young adults, and families affected by substance use disorders in their daily practice. For much of history, substance use has been viewed as a moral failing for which individuals themselves are to blame; however, as addiction became understood as a medical disorder, clinical terminology has shifted along with a growing awareness of harm of stigmatizing language in medicine. In issuing this policy statement, the American Academy of Pediatrics (AAP) joins other large organizations in providing recommendations regarding medically accurate, person-first, and nonstigmatizing terminology. As the first pediatric society to offer guidance on preferred language regarding substance use to be used among pediatricians, media, policymakers, and government agencies and in its own peer-reviewed publications, the AAP aims to promote child health by highlighting the specific context of infants, children, adolescents, young adults, and families. In this policy statement, the AAP provides 3 specific recommendations, accompanied by a table that presents a summary of problematic language to be avoided, paired with the recommended more appropriate language and explanations for each. Pediatricians have an important role in advocating for the health of children and adolescents in the context of families affected by substance use and are optimally empowered to do so by avoiding the use of stigmatizing language in favor of medically accurate terminology that respects the dignity and personhood of individuals with substance use disorders and the children and adolescents raised in families affected by substance use.
Pediatricians across the United States encounter infants, children, adolescents, and families affected by substance use disorders (SUDs) in their daily practice. Amid the national overdose crisis, the rise of widespread cannabis and e-cigarette availability, and persistently high prevalence of alcohol use, there is a renewed focus on recognition and treatment of SUDs. In previous policy statements, the American Academy of Pediatrics (AAP)1 recognized the unique role of pediatricians in identifying and responding to familial substance use and has highlighted the importance of doing so in an empathetic, respectful, and supportive manner. Fundamental to this practice is an appreciation of the impact of language itself, with particular care paid to the terminology used in interactions with patients, family, and the public and in written materials.
A substantial hurdle to compassionately caring for patients and families affected by substance use is the widespread stigma against people with SUDs. For much of history, substance use has been viewed as a moral failing for which individuals themselves are to blame, particularly individuals of color.2–3 Stigmatizing language reflecting this implicit bias and moralistic view, such as “substance abuse,” “drug abuser,” and “addict,” have been commonplace not only in general conversation and the lay press7 but also in medical literature.8 Many of these pejorative terms have racist connotations, and derogatory terms like “crack babies” carry with them decades of legislation targeting communities of color with a carceral response to substance use, such as the War on Drugs.5,6 In the face of the increasing prevalence of the use of opioids, marijuana, and novel psychoactive substances, the medical community has recognized a great deal of scientific evidence revealing that addiction is a chronic illness that has the potential for recurrence similar to other medical conditions and is not a moral failing.9
As addiction became understood as a medical disorder, clinical terminology shifted, including that in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Previous versions of the DSM used the phrase “substance abuse”;10 however, the DSM-5 uses the less stigmatizing term “substance use disorder,” recognizing the chronic disease nature of addiction.11 This shift in DSM nomenclature aligned with a growing awareness of the power of stigmatizing language in medicine. The use of derogatory terms such as “substance abuse” and “substance abuser” has been shown to negatively affect both lay community members’ and health care providers’ perceptions of individuals who use substances,3,12–17 resulting in the view that these individuals need punishment as opposed to help or treatment. These internalized perceptions have tangible effects, as evidenced by a systematic review that found that health care providers’ negatively biased views of individuals with SUDs result in worse health care delivery.18
In response to this evidence, the US government, as well as major scientific and journalism organizations, continue to issue statements guiding the use of appropriate language in the discussion of substance use and SUDs, including:
The Pediatric Context
As the first pediatric society to offer guidance on preferred language regarding substance use to be used among pediatricians, media, policymakers, government agencies, and in its own peer-reviewed publications, the AAP aims to promote child health by highlighting the specific context of children, adolescents, and families. Pediatricians have an essential role in the prevention of, treatment of, and advocating for infants, children, adolescents, and young adults affected by substance use. They are empowered to do so by actively working to dismiss harmful stereotypes and avoiding the use of stigmatizing language in favor of medically accurate terminology that respects the dignity and personhood of individuals with substance use disorders and the children and adolescents raised in families affected by substance use.
Table 1 presents a summary of problematic language to be avoided, paired with the recommended more appropriate language and an explanation. The table is organized into 3 main topics. The first topic pertains to terminology regarding substance use, specifically covering the medically accurate diagnostic terminology for substance use disorders.
Recommended Terminology Regarding Substance Use
| Say This: . | Not This: . | Here’s Why: . |
|---|---|---|
| Terminology regarding substance use | ||
| ∘ Substance use disorder; [insert specific substance: opioid, cocaine, alcohol, etc] use disorder ∘ Addiction | Drug abuse/dependence Substance abuse/dependence | The diagnostic terms “substance abuse” and “substance dependence” described in the DSM-IV have been combined in the DSM-5 into “substance use disorder.” “Abuse” and “dependence” should only be used in specific reference to DSM-IV or earlier criteria or when using ICD-10 nomenclature, which still use the term “dependence;” “addiction” may also be used in conjunction with a severe substance use disorder. |
| ∘ Substance use ∘ Hazardous substance use ∘ Unhealthy substance use ∘ Problematic substance use | Substance abuse Drug habit Vice | Substance use exists on a continuum, not all of which constitutes a diagnosable substance use disorder; therefore, these terms describe substance use that risks health consequences or is in excess of current safe use guidelines, without necessarily referencing or meeting criteria for a substance use disorder; it is more precise in describing health hazard than simply “misuse.” Of note, any substance use in adolescents is considered unhealthy. |
| ∘ Nonmedical prescription opioid use ∘ Nonmedical prescription drug use ∘ Nonmedical prescription medication use | Prescription opioid abuse Prescription drug abuse | Refers to using opioids or other prescription drugs in a way other than as prescribed or by a person to whom they were not prescribed. |
| ∘ Intoxicated or in withdrawal | Strung out, tweaking, high, drunk (and other colloquial substance-specific terms) | Uses medically accurate language to describe the state of intoxication or withdrawal from a substance. |
| ∘ Using ∘ Drinking | Getting high Getting drunk | Less stigmatizing way to describe the act of using a substance to reach intoxication. |
| Terminology regarding persons | ||
| ∘ Person with a substance use disorder | Substance/drug abuser, addict, junkie, druggie, stoner, alcoholic, drunk (and other colloquial substance-specific terms) | Uses person-first language, as individuals are not defined solely by their substance use. If unsure of whether the individual has a diagnosed disorder, then the description of “a person who uses [insert specific substance]” is most appropriate. |
| ∘ Person who uses [insert specific substance: opioid, cocaine, alcohol, etc] | Drug user, heroin user, drinker, crackhead, pothead, drug-seeking (and other colloquial substance-specific terms) | |
| ∘ Person who injects drugs (PWID) | Injection drug user | |
| ∘ Treatment was not effective ∘ Patient in need of more support/higher level of treatment | Patient who failed treatment Noncompliant, nonadherent | Referring to the treatment not meeting the needs of the patient or the patient needing a higher level of treatment, rather than the patient failing. |
| ∘ Person with multiple recurrences ∘ Person with multiple treatment admissions | Frequent flyer Recidivist | Less stigmatizing way to denote someone with recurrence of substance use disorder, rather than referencing it as a criminal offense or a relapse, which is associated with the connotation of more blame. |
| ∘ Infant/baby with neonatal withdrawal syndrome ∘ Infant/baby born substance-exposed ∘ Infant/baby with physiologic dependence/withdrawal | Addicted baby Born addicted Drug endangered Neonatal abstinence syndrome baby or NAS baby Crack baby | Substance use disorders, characterized by repeated use despite harmful consequences, cannot be diagnosed in an infant; an infant can develop physiologic dependence to a substance such as opioids, for which the medical term is neonatal opioid withdrawal syndrome or neonatal withdrawal. |
| ∘ Concerned loved one | Enabler | Less stigmatizing way to describe a loved one who supports someone with a substance use disorder and at times may protect them from the negative consequences of their substance use. |
| Terminology regarding treatment | ||
| ∘ Treatment, pharmacotherapy ∘ Medication for addiction treatment (MAT) ∘ Medication for opioid use disorder (MOUD) | Medication-assisted treatment (MAT) Opioid substitution therapy Opioid replacement therapy | Medication is treatment and should not be referenced as “assisting” some other treatment, or as simply substituting one opioid for another; if use of acronym “MAT” is desired, recommend using it to refer to term “medication for addiction treatment.” |
| ∘ In early remission ∘ In sustained remission ∘ In recovery ∘ Entered recovery ∘ Stopped using substances ∘ Engaged in treatment | Clean Got clean | People with a history of substance use who are not currently using are deemed “in remission” or “in recovery,” more neutral words than “clean” which implies that people actively using substances are “dirty.” |
| ∘ Negative versus positive test result ∘ [Insert substance] detected | Clean versus dirty test/urine | Refer to the actual results of the toxicology test, rather than “clean” and “dirty,” which imply judgment. |
| Say This: . | Not This: . | Here’s Why: . |
|---|---|---|
| Terminology regarding substance use | ||
| ∘ Substance use disorder; [insert specific substance: opioid, cocaine, alcohol, etc] use disorder ∘ Addiction | Drug abuse/dependence Substance abuse/dependence | The diagnostic terms “substance abuse” and “substance dependence” described in the DSM-IV have been combined in the DSM-5 into “substance use disorder.” “Abuse” and “dependence” should only be used in specific reference to DSM-IV or earlier criteria or when using ICD-10 nomenclature, which still use the term “dependence;” “addiction” may also be used in conjunction with a severe substance use disorder. |
| ∘ Substance use ∘ Hazardous substance use ∘ Unhealthy substance use ∘ Problematic substance use | Substance abuse Drug habit Vice | Substance use exists on a continuum, not all of which constitutes a diagnosable substance use disorder; therefore, these terms describe substance use that risks health consequences or is in excess of current safe use guidelines, without necessarily referencing or meeting criteria for a substance use disorder; it is more precise in describing health hazard than simply “misuse.” Of note, any substance use in adolescents is considered unhealthy. |
| ∘ Nonmedical prescription opioid use ∘ Nonmedical prescription drug use ∘ Nonmedical prescription medication use | Prescription opioid abuse Prescription drug abuse | Refers to using opioids or other prescription drugs in a way other than as prescribed or by a person to whom they were not prescribed. |
| ∘ Intoxicated or in withdrawal | Strung out, tweaking, high, drunk (and other colloquial substance-specific terms) | Uses medically accurate language to describe the state of intoxication or withdrawal from a substance. |
| ∘ Using ∘ Drinking | Getting high Getting drunk | Less stigmatizing way to describe the act of using a substance to reach intoxication. |
| Terminology regarding persons | ||
| ∘ Person with a substance use disorder | Substance/drug abuser, addict, junkie, druggie, stoner, alcoholic, drunk (and other colloquial substance-specific terms) | Uses person-first language, as individuals are not defined solely by their substance use. If unsure of whether the individual has a diagnosed disorder, then the description of “a person who uses [insert specific substance]” is most appropriate. |
| ∘ Person who uses [insert specific substance: opioid, cocaine, alcohol, etc] | Drug user, heroin user, drinker, crackhead, pothead, drug-seeking (and other colloquial substance-specific terms) | |
| ∘ Person who injects drugs (PWID) | Injection drug user | |
| ∘ Treatment was not effective ∘ Patient in need of more support/higher level of treatment | Patient who failed treatment Noncompliant, nonadherent | Referring to the treatment not meeting the needs of the patient or the patient needing a higher level of treatment, rather than the patient failing. |
| ∘ Person with multiple recurrences ∘ Person with multiple treatment admissions | Frequent flyer Recidivist | Less stigmatizing way to denote someone with recurrence of substance use disorder, rather than referencing it as a criminal offense or a relapse, which is associated with the connotation of more blame. |
| ∘ Infant/baby with neonatal withdrawal syndrome ∘ Infant/baby born substance-exposed ∘ Infant/baby with physiologic dependence/withdrawal | Addicted baby Born addicted Drug endangered Neonatal abstinence syndrome baby or NAS baby Crack baby | Substance use disorders, characterized by repeated use despite harmful consequences, cannot be diagnosed in an infant; an infant can develop physiologic dependence to a substance such as opioids, for which the medical term is neonatal opioid withdrawal syndrome or neonatal withdrawal. |
| ∘ Concerned loved one | Enabler | Less stigmatizing way to describe a loved one who supports someone with a substance use disorder and at times may protect them from the negative consequences of their substance use. |
| Terminology regarding treatment | ||
| ∘ Treatment, pharmacotherapy ∘ Medication for addiction treatment (MAT) ∘ Medication for opioid use disorder (MOUD) | Medication-assisted treatment (MAT) Opioid substitution therapy Opioid replacement therapy | Medication is treatment and should not be referenced as “assisting” some other treatment, or as simply substituting one opioid for another; if use of acronym “MAT” is desired, recommend using it to refer to term “medication for addiction treatment.” |
| ∘ In early remission ∘ In sustained remission ∘ In recovery ∘ Entered recovery ∘ Stopped using substances ∘ Engaged in treatment | Clean Got clean | People with a history of substance use who are not currently using are deemed “in remission” or “in recovery,” more neutral words than “clean” which implies that people actively using substances are “dirty.” |
| ∘ Negative versus positive test result ∘ [Insert substance] detected | Clean versus dirty test/urine | Refer to the actual results of the toxicology test, rather than “clean” and “dirty,” which imply judgment. |
ICD-10, International Classification of Diseases and Related Health Problems, 10th Edition.
The second topic in the table relates to the use of “person-first” language that first and foremost acknowledges the innate personhood of an individual, rather than defining someone primarily on the basis of a condition or characteristic (in this case, substance use). The use of person-first (or people-first) language is consistent with the standard set in previous AAP policy statements for describing individuals with other chronic medical conditions or disabilities, such as “a child with diabetes” rather than “a diabetic.”32 A special circumstance to highlight in this section is the problematic language that has been used to describe infants born substance- exposed who, in the lay press and elsewhere, have commonly and inappropriately been referred to as “born addicted.” This language and the associated intense stigma surrounding SUDs in pregnant individuals can dissuade them from seeking treatment or cause them to abruptly end treatment, leading to worse outcomes for infants and families. The medically accurate terminology for infants who have withdrawal after birth is neonatal withdrawal.33,34 This is in contrast to a substance use disorder, which, by definition, includes “a problematic pattern of substance use leading to clinically significant impairment or distress, as manifest by at least two […maladaptive behaviors].”11 On the basis of this medical definition, infants unequivocally cannot display the behavioral patterns necessary to be “addicted” to drugs, and the use of this terminology is highly stigmatizing to families.
The last topic in the table covers terminology for use in the discussion of the treatment of SUDs. Medication for opioid use disorder has been demonstrated to be safe and effective31,35 and is recognized by the AAP, the Society for Adolescent Health and Medicine, the American Society of Addiction Medicine, and the American College of Obstetricians and Gynecologists as the recommended treatment for not only adults but also adolescents and pregnant people with an opioid use disorder.36–40 For this reason, it is most accurate to refer to medication as treatment in and of itself, as opposed to “assisting” other treatment or being used as a “substitution” or “replacement” therapy. As of 2022, there are no data to suggest that the term nicotine replacement therapy is associated with stigma or that this terminology dissuades individuals from seeking medication treatment for nicotine use disorder; future studies could examine this question.
At times, patients may use some of these problematic terms to describe their own experiences. While allowing patients to choose their own language out of respect for their lived experience, pediatricians themselves should, nonetheless, continue to use the preferred terminology, because modeling accurate terminology remains valuable even in these circumstances so as not to perpetuate the intense shame often associated with SUDs. Pediatricians can also use these opportunities as a catalyst for conversations with patients and parents about reducing stigma and why using nonstigmatizing language matters.
Lastly, individuals will undoubtedly encounter problematic terms in the existing literature and even in the International Classification of Diseases and Related Health Problems, 10th Edition;41 when referencing or summarizing this literature, it is recommended to replace the problematic terms with the preferred terminology. If an exact citation is necessary, one can use quotations and the notation “[sic],” accompanied by an explanation of the outdated problematic terminology.
Recommendations
The AAP recommends the following:
Pediatricians, policymakers, government agencies, and media should use medically accurate terminology as opposed to stigmatizing jargon (see Table 1) in interactions with patients, families, and the public as well as in written materials including medical record documentation, correspondence, manuscripts, editorials and opinion articles, and news stories.
Pediatricians, health care facility spokespersons, policymakers, government agencies, and media should use person-first language that respects the dignity of an individual first and foremost as a person (see Table 1) in interactions with patients, families, and the public, as well as in written materials, including medical record documentation, correspondence, manuscripts, editorials and opinion articles, and news stories.
Professional entities should encourage authors submitting manuscripts or materials for publication in their journals to use medically accurate and respectful person-first language (see Table 1).
Lead Authors
Rachel H. Alinsky, MD, MPH, FAAP
Scott E. Hadland, MD, MPH, MS, FAAP
Joanna Quigley, MD, FAAP
Stephen W. Patrick, MD, MPH, MS, FAAP
Committee on Substance Use and Prevention, 2020–2021
Lucien Gonzalez, MD, MS, FAAP, Chairperson
Deepa R. Camenga, MD, MHS, FAAP
Stacey Engster, MD, MS, FAAP
Stephen W. Patrick, MD, MPH, MS, FAAP
Joanna Quigley, MD, FAAP
Leslie Walker-Harding, MD, FAAP
Liaisons
Jennifer A. Ross, MD, MPH, FAAP – Section on Pediatric Trainees
Rebecca Ba’Gah, MD, FAAP – American Academy of Child and Adolescent Psychiatry
Staff
Renee Jarrett, MPH
Dr Alinsky conducted an extensive literature review, contributed to the development of the final recommendations, wrote the first draft of the manuscript, reviewed and revised the manuscript, and edited the final manuscript; Drs Hadland, Patrick, and Quigley contributed to the development of the final recommendations, reviewed and revised the manuscript, and edited the final manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This document is copyrighted and is property of the American Academy of Pediatrics and its board of directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the board of directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Address correspondence to Rachel H. Alinsky, MD, MPH. E-mail: [email protected]
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
Comments
Such an important and timely topic