Raising Public Awareness About Addictions

Raising Public Awareness About Addictions: Creating Momentum for Action Discussion Paper

DRAFT

Prepared by: Anne M. Lavack, Ph.D. Associate Professor, University of Regina

March 10, 2005

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Raising Public Awareness About Addictions: Creating Momentum for Action

Raising Public Awareness About Addictions: Creating Momentum for Action TABLE OF CONTENTS 1. Introduction ......................................................................................................................1 • Scope of the Issue • Questions to be Answered by the Roundtable • Roundtable Outcomes 2. Substance Abuse in Canada – An Overview ...................................................................4 • Alcohol • Cannabis • Other Illicit Drugs • The Cost of Substance Abuse in Canada 3. Substance Abuse and Addiction ......................................................................................6 • The Continuum of Substance Use • Addiction 4. Stigma Associated with Addictions .................................................................................8 • Definition of Stigma • When Does Stigma Occur? • Attribution-Emotion Model of Stigmatization • Dual-Process Model of Stigmatization • Stigma Coping Strategies 5. Stigma and the Disease Models of Addiction ..................................................................11 • Alcohol Dependence as Disease • Stigma and Alcohol Nomenclature • Drug Addiction as Disease • Women, Addiction, and Stigma • Addiction as Disease: Socioeconomic & Policy Aspects • Critics of the Disease Model • Comparing the Stigma Associated with Cigarette Smoking • Summary of Benefits & Criticisms of Disease Model 6. Existing Efforts to Raise Public Awareness About Addictions .......................................16 • SAMHSA – Changing the Conversation – 2000 • Central East ATTC – Addiction Stigma Reduction Toolkit – 2000 • CAMH – Community-Based Anti-Stigma Campaign – 2000 • The Providence Summit - 2004 7. Parallels with Mental Health Anti-Stigma Campaigns ....................................................23 • WPA – Open the Doors – 1999 • USDHSS CMHS – Resource Centre to Address Discrimination and Stigma

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New Zealand – StigmaWatch Australia – Anti-Stigma Program

8. Where To From Here? .....................................................................................................18 9. References ........................................................................................................................19

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Raising Public Awareness About Addictions: Creating Momentum for Action Discussion Paper

1. Introduction This discussion paper has been prepared in order to provide some background information to participants in the 2005 Roundtable Meeting entitled Raising Public Awareness About Addictions: Creating Momentum for Action. Many participants in the cross-country consultations on a National Framework for Action on Substance Abuse mentioned the need to organize a Roundtable Meeting on the issue of Public Awareness and Addictions. Repeatedly, participants stressed that there is a stigma associated with addictions that results in this issue having a low profile. This contributes to a lack of political and public support for a comprehensive and coordinated approach to prevent and address the problems associated with addiction. The proposed Roundtable Meeting will be attended by a national group of experts in addictions, who collectively will try to determine what can be done to de-stigmatize addictions, as well as create public awareness about addictions.

Scope of the Issue The key issue at stake is that there is a need for an attitudinal shift in society, in order to destigmatize addictions: To the reality that addictions have a significant impact on a substantial number of Canadians in all walks of life, either directly or indirectly, and that this issue should be treated no differently than many major illnesses

From a belief that addictions have a minimum impact on a minimum number of Canadians, and that this is really a problem of street people or injection drug users

To create this attitudinal shift in society, it will be necessary to gather more information about the issues: • Accurate and current information regarding the prevalence of addictions o Understanding of the demographic / psychographic profile of persons with addictions. • Better understanding of the root causes of addiction. • Better understanding of the impact of addiction (monetary impact as well as human impact). 1

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Better understanding of solutions to the problem and the payoffs for applying the solutions.

The profile of persons with addictions is often quite negative. Society’s knowledge about persons with addictions is most often shaped through its perceptions regarding organizations like the Anonymous Groups of AA or NA, or through the visible, marginalized street populations of persons with addictions. However, these groups represent only a fraction of the population of persons with addictions, and this represents the challenge. It is important to put a mainstream face on addictions, in order to de-stigmatize addictions. This will help to ensure that those who need help will be willing to come forward and get it, and that they will be treated with respect by family, friends, employers, and society as a whole.

Questions to be answered by the Roundtable: The Roundtable Meeting will attempt to answer a number of key questions: 1. What are the key pieces of information that the public needs to hear and understand in order to successfully “de-stigmatize” addictions? Note that the “public” includes: o The general public; o Professional stakeholders such as educators, health professionals, law enforcement personnel, etc.; o Politicians; o Funders, o Etc. 2. Can we identify a single message that, through repeated reinforcement, will result in an attitudinal shift in society? 3. What are the key strategies for disseminating the above information/message? 4. Who are the key players in implementing the strategies identified above? 5. What baseline measures will provide a benchmark to measure progress over time in the process of “de-stigmatization”? 6. What have we learned from other significant attitudinal/societal shifts and how can these lessons be imported here? (i.e., DWI, Cancer, Tobacco, Mental and Health Challenged persons).

Roundtable Outcomes: It is anticipated that the outcomes resulting from the Roundtable Meeting will include the following:

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1. Identify 4-6 specific priority information pieces that, through dissemination to the public, will initiate a paradigm shift towards a de-stigmatization of addictions. 2. Identify a single easy-to-understand message that, through repeated delivery via various communication mechanisms, will begin to shift the cultural attitude toward addictions. 3. Identify key strategies and players that will lead the dissemination of the above information pieces and key message; 4. Identifying baselines measures that will provide a benchmark for monitoring the attitudinal shift in society over time. This Discussion Paper is intended to provide background on these issues, so that Roundtable participants will have a common basis for discussion.

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2. Substance Abuse in Canada – An Overview The 2004 Canadian Addictions Survey1 interviewed 13,909 Canadians aged 15 and older by telephone. Highlights of the survey indicate that substance abuse is quite prevalent in Canadian society, which suggests that addictions may also be fairly common among the substance-abusing population: Alcohol: • 17.8% of Canadians had exceeded the drinking guidelines in the past year (i.e., more than 14 standard drinks per week for males and 9 standard drinks per week for females) o Males, those aged 18-24, and single persons were the most likely to exceed the drinking guidelines •

13.6% of Canadians engaged in hazardous alcohol use (as indicated by the Alcohol Use Disorders Identification Test, AUDIT) and are considered high-risk drinkers o High-risk drinkers included 8.9% of female drinkers and 25.1% of male drinkers. More than 30% of those under the age of 25 were identified as highrisk drinkers.

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Nearly a quarter of former and current drinkers report that their drinking has caused harm to themselves/others at some time in their lives, and 8.8% of current drinkers report experiencing harm from their drinking during the past year.

Cannabis: • 44.5% of Canadians report using cannabis at least once in their lifetime. o Nearly 70% of those aged 18-24 report having used cannabis at least once in their lifetime. •

14.1% of Canadians report using cannabis during the past year. o 2.5% of Canadians report daily use of cannabis during the past year.

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About 5% of Canadians report cannabis-related concerns, such as failing to control use.

Other Illicit Drugs: • 16.5% of Canadians report using illicit drugs (other than cannabis) at least once in their lifetime. •

3.0% of Canadians report using illicit drugs (other than cannabis) during the past year. o 1.9% of Canadians have used cocaine/crack during the past year. o The rate of illicit drug use during the past year is highest among men, and among those aged 18-24.

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Among those who have used drugs (other than cannabis) during the past year, 42.1% report risk indicator symptoms indicative of the need for intervention.

The above figures indicate levels of problematic substance use, but leave unanswered questions regarding the level of addiction. In a five-year follow-up of 1300 men and women in the U.K., only 3% of alcohol/drug abusers met the criteria for dependence five years after being diagnosed as abusers.2 As well, studies have shown that different drugs are associated with different rates of dependence. In a ten-year study it was found that 15-16% of cocaine users, 12-13% of alcohol users, and 8% of marijuana users become dependent.3 Of those who became dependent on cocaine, only 5-6% became dependent in the first year of use, but 80% became dependent during the first three years of use. This suggests that while substance abuse may be an indicator of the potential for addiction, substance abuse does not automatically turn into addiction. The Cost of Substance Abuse in Canada Substance abuse creates a significant drain on Canada’s economy in terms of health care costs and costs within the criminal justice system. It also has an indirect impact on productivity as a result of ill health and premature death. The Canadian Centre on Substance Abuse (CCSA) is in the process of updating its 1996 study entitled The Costs of Substance Abuse in Canada, which estimated the costs of alcohol, tobacco and illicit drugs substance abuse in Canada to be $18.45 billion or 2.7% of GDP. Costs were estimated to be $7.5 billion for alcohol, $9.5 billion for tobacco, and $1.4 billion for illicit drugs. A new Canadian Substance Abuse Costs Study (CSACS) is in the process of being completed by the CCSA, and it will present costs according to substance, province, and sex and age group. The CSACS study will include alcohol, tobacco, and illicit drugs, with a specific focus on cannabis. For alcohol, both costs and benefits will be calculated in light of accumulating evidence that moderate use of alcohol can protect some people against coronary heart disease. Given the enormous costs associated with substance abuse, the need for prevention and treatment becomes clear. The cost effectiveness of treatment has been shown in a number of studies. For example, in the United States, domestic drug enforcement costs 4 times as much as treatment for a given amount of user reduction. A dollar spent on cocaine treatment yields societal cost savings of $7.48.4

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3. Substance Abuse and Addiction Continuum of Substance Use There are various degrees or stages of substance use that commonly occur. The following chart shows a continuum that represents a useful means of understanding the progression from occasional drug use to full-blown addiction:5

Experimental substance use

Social / recreational substance use

Situational substance use

Intensive substance use

Dependence

Experimental substance use occurs in the beginning, when it is limited to just a few exposures and motivated by curiosity.

Social/recreational substance use occurs when a person seeks out and uses a substance to enhance a social occasion. At this stage, substance use is irregular and infrequent, and usually occurs with others.

Situational substance use occurs as a regular pattern of use, where the person associates substance use with a particular situation. At this stage, there is some loss of control, but the person is not yet experiencing negative consequences.

Intensive substance use, also called ‘bingeing,’ occurs when the person uses a substance in an intensive manner. A large amount of the substance may be consumed over a short period of time, or continuous use of the substance may occur over a longer period of time.

Dependence is a state that can be physical, psychological, or both. Physical dependence consists of tolerance, where more of the substance is needed to obtain the same effect. It may also consist of tissue dependence, where cell tissues have changed in such a way that the body needs the substance to stay in balance. Psychological dependence occurs when a person feels that the substance is needed in particular situations, or to function effectively. There are various degrees of dependence, from mild to compulsive, with the latter being characterized as addiction.

It should be noted that not every person who uses substances will progress through all five of the above stages. For example, some persons experiment with substances, and then stop using them completely. However, once a stage of dependence has been reached, the individual will often experience negative consequences. While the decision to begin to use 6

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drugs is voluntary, by the time the compulsive dependence stage is reached, drug use is no longer entirely voluntary, and may be viewed as a chronic relapsing disease. Addiction is not caused by moral weakness, or lack of self-control or willpower.6 It is the shame and negative consequences associated with dependence that lead to a significant stigma being attached to substance abuse. Part of the reason why it is difficult to remove the stigma from addiction is the result of addiction being at the end of a continuum of substance use and abuse. A social stigma attached to recreational substance use amounts to a social veto against such substance use, and some believe this may be a good thing in terms of prevention. What is needed, however, is to convince the public to remove the stigma from substance addiction, since addiction usually represents a loss of ability to change behaviour unless treatment is sought. Some suggest that it is desirable to stigmatize the substance misuse behaviour, but to de-stigmatize the substance misusing individual, in order to reduce the barriers involved in coming forward for treatment.7

Addiction Addiction is commonly thought of as being a harmful preoccupation with substances like alcohol or illicit drugs, or behaviours like gambling. Addiction is a disorder identified by loss of control, preoccupation with disabling substances or behaviour, and continued use or involvement despite negative consequences.8 While use, or even abuse, of drugs such as alcohol and cocaine is a behaviour over which the individual exerts control, addiction to these substances implies a significant loss of that volition or control. Risk factors for addiction and/or problem substance abuse include:9

A genetic, biological or physiological predisposition

External psychosocial factors, such as community/school attitudes; values and attitudes of peers or social group; family situation; level of stress

Internal factors, such as coping skills and resources (e.g., communication and problem solving skills)

The interaction between these vulnerability factors can also exacerbate the risk of substance abuse. A recent U.S. survey found that nearly two-thirds of American families have been touched by addiction to alcohol or drugs.10 An estimated 10% of American adults are either suffering from an addiction problem or are in recovery.11 In spite of the widespread prevalence of addictions, and the many people who are affected by the addictions of others, a strong stigma still exists against people in addiction recovery.12 For example, employers are less likely to hire a job candidate if that person is in recovery from drug or alcohol addiction.13

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4. Stigma Associated with Addiction Definition of Stigma The word stigma is said to have originated with the ancient Greeks. One story says that slaves who were caught in the act of trying to escape were branded with the letter F for fugitive, and the word for the F mark was stigma.14 Another story explains that the ancient Greeks physically marked individuals who were deemed undesirable with marks or brands, indicating that these individuals were to be avoided.15 The meaning of stigma has been expanded to include any mark or sign of a perceived deviation from the norm.16 According to Crocker et. al. (1998, p. 504), “a person who is stigmatized is a person whose social identity, or membership in some social category, calls into question his or her full humanity – the person is devalued, spoiled or flawed in the eyes of others.”17 Jones et al. (1984, p. 6) have defined a social stigma as being a discrediting condition that marks a person as “deviant, flawed, limited, spoiled, or generally undesirable.”18

When Does Stigma Occur? Stigmatization occurs when differences in human behaviours or characteristics are labelled, and these labelled persons are linked with negative stereotypes.19 Stigmatized persons have a devalued and denigrated identity in society.20 A stigma is usually attached to undesirable qualities, and a defining immediate reaction to stigma is avoidance of the stigmatized person.21 People may choose to stand or sit further away from those who are stigmatized, and are more likely to cut short their interactions with the stigmatized. Disgust is also a common emotion evoked by many stigmas. Stigmatized individuals regularly encounter prejudice and discrimination.22 Some have argued that stigma has evolutionary origins, whereby humans possess cognitive adaptations that cause them to avoid poor social exchange partners, resulting in the social exclusion of stigmatized persons.23

Attribution-Emotion Model of Stigmatization The attribution-emotion model of stigmatization suggests that emotional reactions such as anger or pity may be derived from attributions made about the stigma.24 25 26 If the stigmatized individual is not considered to be responsible for the onset of the stigma (e.g., in the case of a physical disability), then bystanders are more likely to have a reaction of pity. If the stigmatized individual is deemed to be responsible for the onset of the stigma (e.g., in the case of an addiction), then bystanders are more likely to have reactions involving anger or irritation, and are less likely to offer help.27 As well, research has shown that people are more willing to become close to a stigmatized person who has an uncontrollable stigma 8

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compared to a stigmatized person who has a controllable stigma; in other words, allowances are made for the uncontrollability of the stigma, which results in a more favourable attitude toward the stigmatized person.28 There is also a general belief that controllable stigma behaviours (like addictions) are less stable and may be subject to reversal; in other words, because the onset was controllable, it may be possible for the condition to be reversed. However, research has found that if an ordinarily controllable stigma, such as drug addiction, can actually be attributed to causes that are not controllable (e.g., drug addiction developed as a result of the treatment of pain after a serious injury), then it takes on the characteristics of an uncontrollable stigma, eliciting more pity and less anger, and eliciting more helping behaviours from other people. In other words, people are much more willing to be sympathetic toward someone who became addicted through no fault of their own, and are much less willing to be sympathetic toward someone who became addicted as a result of wilful experimentation with recreational drugs.

Dual-Process Model of Stigmatization The dual-process model of reactions to perceived stigma suggests that social perception involves two processes: an automatic, swift, reflexive, emotional process and a controlled, slower, reflective, rule-based process.29 The initial automatic emotional process is where immediate negative attitudes toward a stigmatized person are formed. The secondary controlled process is where cognitive processes can be used to change these negative attitudes into more positive attitudes, by presenting information about possible mitigating circumstances surrounding the stigmatized person or behaviour. Therefore, an immediate reaction to the stigma of addiction might be disgust or anger. However, it is still possible to educate the public to embrace a learned reaction to the addiction stigma. For example, a public education campaign could be used to urge greater tolerance, sympathy, and humanity toward persons with addictions. This cognitive learned response would eventually replace and submerge the more automatic responses associated with perceptions about the addiction stigma.

Stigma Coping Strategies Public stigma is one part of the stigmatization issue. However, individuals commonly also possess a self-stigma, wherein they believe the prevailing stereotypes and internalize the reactions of society.30 31 Effects of self-stigma include reductions in self-esteem and selfefficacy, and reduced feelings of self-worth. It should be noted that it is possible for stigmatized individuals to still lead successful lives, and avoid being debilitated by their stigma. This is accomplished through three primary strategies.32 • Compensation allows the stigmatized individual to develop skills that compensate for the stigma, so that they can overcome any disadvantages associated with the stigma.

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Strategic interpretation of the social environment is a way in which stigmatized individuals can make selective social comparisons (i.e., comparing themselves to members of their own group, rather than comparing themselves to individuals from advantaged groups.

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Focusing on multiple identities is a way that stigmatized individuals can draw on one of their alternative social identities33 (e.g., emphasize their professional workplace identity rather than their addict identity).

While it is worthwhile to try to remove the stigma attached to persons with addictions, it should be recognized that this may be a slow process, as changing social attitudes is an ambitious endeavour. In the meantime, stigmatized persons with addictions must find a way to live productive lives within this stigmatized condition, and the above three strategies represent methods by which this can be accomplished.34 The stigma associated with admitting addiction often leads those with addictions to put off seeking treatment.35 Understanding that addiction is a treatable illness can contribute to a greater understanding of addictive disorders, and reduce the stigma attached to diagnosis and treatment of addiction.36 Routine screening questions should be administered during doctors’ encounters with patients, to help doctors identify addiction issues and make appropriate referrals.37 Training about addictions should begin early in the medical student’s career.38

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5. Stigma and the Disease Models of Addiction Alcohol Dependence as Disease The roots of the disease concept of alcoholism go back more than 200 years in the United States, to when it was first articulated by a physician, Benjamin Rush.39 The American temperance movement positioned alcoholism as a disease during the 1800s. After Prohibition in the United States, the concept of alcoholism as a disease was re-emphasized by organizations such as the National Council on Alcoholism and Alcoholics Anonymous. Finally, in 1956 the American Medical Association Committee on Alcoholism encouraged physicians to view alcoholism as an “illness” to be “regarded as within the purview of medical practice.”40 In 1987, the American Medical Association officially embraced the disease model of addiction.41

Stigma and Alcohol Nomenclature Some research has shown that different labels can elicit different levels of stigma. One study compared labelling an individual either as an alcoholic or as a drunk resulted in somewhat different perceptions. The individual labelled as an alcoholic was rated as less reliable, more dishonest, and more ‘sick’ than the individual labelled as a drunk.42 The words alcoholic and alcoholism continue to carry considerable stigma, and the term alcohol dependence is generally more acceptable today. Changing nomenclature, however, has not changed the fact that those suffering from alcohol dependence are often reluctant to admit their addiction problem and seek treatment, due to fear of the stigma that such an admission would impose.43 44 A study of persons who had resolved their alcohol problem without treatment found that 40% said they had not sought treatment because of the stigma of being labelled an alcoholic.45 Another study found that some patients delay seeking treatment because they do not want to identify with the stereotype of an alcoholic.46 It is not only those who suffer from addictions who are reluctant to bring it out into the open. Family, friends, and employers are often similarly reluctant to discuss the issue, or to recognize that addictions exist.47 Even after recovery, recovered alcoholics or addicts may not be fully socially accepted in the workplace.48 The stigma attached to addiction remains a significant barrier to seeking treatment. The disease model can help to alleviate persons with addictions of debilitating feelings of guilt or shame regarding their condition.49

Drug Addiction as Disease Much of the scientific evidence of the last 25 years has shown that drug addiction is a “chronic, relapsing disease that results from the prolonged effects of drugs on the brain.”50 Research has revealed major differences between the brain images of addicted persons and non-addicted persons, indicating that addiction is a medical problem. Prolonged drug use 11

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causes extensive changes in brain function at the molecular, cellular, structural, and functional levels, and these changes persist long after the individual stops taking drugs.51 Drugs of abuse directly or indirectly affect the ‘reward pathway’ in the brain. While drug use may initially begin as a voluntary behaviour, when an individual moves into the state of addiction they become involved in compulsive drug seeking and use, even in the face of negative health and social consequences. Addiction occurs after chronic abuse of a drug, when the brain of the drug user, and the way that the drug user’s brain experiences pleasure and reward, has been changed by chronic use of the drug.52 This disease model does not mean that addicts cannot stop using drugs – only that doing so is very difficult and often requires treatment and major lifestyle changes. Although addiction is a disease that causes changes in the brain, which then drives a compulsion to take the drug, addicts can learn to change the behaviour through treatment.53 Over time, addicts may be able to recover by using other parts of their brain that weren’t affected by the drugs.54 Viewing addiction as a medical issue has implications for how society treats persons with addictions. Even if addiction is the result of an initial voluntary behaviour (recreational drug use), society must recognize that the brain of a person with an addiction is different from a non-addict’s brain. Society has learned to deal with people in different brain states in the case of schizophrenia or Alzheimer’s disease, and less stigma is attached to these brain diseases because they are considered uncontrollable. Treating persons with addictions requires the same level of sympathy and concern as treating other brain diseases.55

Women, Addiction, and Stigma Women who suffer from addictions seem to encounter a greater degree of stigma than men.56 Some of this stigma is related to perceptions of sexual promiscuity, and may result in the physical and/or sexual victimization of women who suffer from alcohol or drug addiction.57 Also, some research has shown that compared to men, women may be less likely to perceive alcohol dependence or drug addiction as a disease, and are more likely to attribute their alcohol dependence or drug addiction to stress or other factors.58 Women may also be more likely to perceive negative consequences attached to receiving treatment for addictions, such as losing their job, losing friends, or disrupting family.59

Addiction as Disease: Socioeconomic and Policy Aspects There has been some suggestion that our society finds it easier to accept addiction as a disease for some types of people, notably those with higher socioeconomic status. Acker (1993, p. 193) asks an important question regarding under what socioeconomic circumstances addiction is classified as a disease: “When, and for whom, is addiction a disease? For a White, middle-class addict working in a company with a skilfully administered employee assistance program (EAP) and liberal health care benefits, addiction is surely a disease. Is it also a disease for an African-American whose only

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employment consists of illicit trafficking in drugs or sex, who is arrested for possession or sale of drugs, who goes to prison upon conviction, and who is never exposed to treatment? Or is it a disease for an addict who stops drug use and maintains abstinence without ever seeking treatment?”60 Accepting addiction as a disease has important public policy implications. For example, if a convicted criminal is drug addicted, it is not a reasonable option to simply incarcerate that person without treatment. The model of addiction as a disease demands that addiction treatment is provided to those who commit crimes to support their addictions.

Critics of the Disease Model Some people charge that the disease model discourages drug users from taking responsibility for their actions. There are a minority of researchers who suggest that it is unhelpful to take away the stigma associated with drug abuse.61 They feel that addiction is a behavioural condition, rather than a brain disease.62 This minority believes that giving the message that addiction is chronic and relapse is inevitable is demoralizing to patients. They also feel that it also gives the treatment system an excuse if it doesn’t serve patients well.

Comparing the Stigma Associated with Cigarette Smoking Cigarette smoking is also stigmatized in our society.63 64 65 66 The stigma arises partly because of the second-hand smoke created by smoking, and partly because of the known risk of death and disease associated with smoking. Even lung cancer sufferers are stigmatized, due to the close association between smoking and lung cancer.67 Because of the nature of cigarette addiction (i.e., need to smoke 15+ cigarettes per day, tell-tale odour of smoke clinging to clothing and breath), smokers are less able to hide their addiction. However, approximately 20% of the Canadian population still smokes, so in spite of its increasing stigmatization, smoking is still a fairly widespread addiction. This tends to make smoking a more socially acceptable addiction (and less stigmatized) than alcohol dependence or drug addiction. Smoking is currently being banned in more and more indoor public spaces in an effort to protect workers and the general public from second-hand smoke; this creates a social denormalization of smoking, which results in further stigmatizing smokers (e.g., stigma attached to smokers huddled outside in the cold). As the smoking prevalence rate falls further, it is likely that the stigma associated with cigarette smoking will grow.

Will Acceptance of the Disease Model Result in De-Stigmatization? A 1984 study of college students in the U.S. assessed their impressions of the term “drug addict” and found that “the overwhelming image was of a disoriented, unhealthy, thin, lowclass, male ‘hippie’ with behavioural and skin problems who suffered from a disease.”68 Within this sample, 73% of the respondents described the drug addict as a hippie, while 32% of the respondents labelled drug addiction as a disease. A similar question about alcoholism

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showed that 76% of respondents described the alcoholic as a skid row habitué, while 58% of the respondents labelled alcoholism as a disease.69 In another study that compared attitudes toward alcohol abuse, cocaine abuse, and cigarette smoking, the disease concept of addiction was most strongly endorsed for alcohol abuse, and least strongly endorsed for cigarette smoking.70 In spite of a relatively large percentage of respondents recognizing alcoholism or drug addiction as a disease, there was still a tendency to attribute negative social aspects to persons suffering from alcoholism or drug addiction (i.e., attributions of being a hippie or a skid row habitué). This suggests that there is a wide gap between the science of addiction and public perceptions about drug abuse and addiction. Given this set of beliefs, it is possible that increasing the prevalence of the disease view of alcoholism or addictions may not necessarily result in de-stigmatization.71 72 73 As Crawford and Heather (1987, p. 1136) have remarked, “accepting or rejecting the disease view would appear to play little part in determining whether the public believes alcoholics are entitled to sympathy or should be offered help that involves public funding.”74 Some research examining mental disorders has found that regarding the mentally disordered as sick or diseased (i.e., the disease view) does not necessarily promote greater acceptance or more favourable treatment.75 Viewing those with mental disorders as diseased sets them apart from others in an unfavourable way, and it is possible that this view may result in a patronizing attitude toward those with mental disorders. One study found that stigma has enduring effects and continues to complicate the lives of the stigmatized, even after substance-related treatment has improved their symptoms and functioning.76

Summary of Benefits and Criticisms of the Disease Model To summarize, some of the key benefits of the disease model of addictions are as follows:77 The disease model conveys the seriousness of alcoholism/addiction to those suffering from it, and to the public at large. The disease model provides an organizing construct through which the addicted client, the care providers, and the family and social environment can better understand the nature of the addiction problem. The disease model designates public health authorities as the agents responsible for the prevention and treatment of the condition, and encourages the development of local facilities for treatment of addiction. The disease model replaces moral censure and criminal punishment of the alcoholic/addict with unprejudiced and open access to health care. The disease model relieves guilt and increases help-seeking behaviour. Some of the key criticisms of the disease model of addictions are as follows:78 The disease model fails to provide an adequate framework for prevention (i.e., at what stage does substance abuse become a disease?) The disease model strips the alcoholic/addict of responsibility.

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Labelling alcohol/drug problems as diseases is stigmatizing and dissuades heavy drinkers from seeking help. By focusing on alcohol problems as a disease, the disease concept allows the alcohol and drug industries to escape culpability for their product and promotional practices.

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6. Existing Efforts to Raise Public Awareness About Addictions Numerous calls for campaigns to destigmatize addiction have been made,79 and it appears that some action has been occurring in this area over the last several years. For example, in the U.K., an anti-stigma campaign aims to get rid of SPAM, an acronym for stigma, prejudice, anger, and misunderstanding.80 Four other major efforts are detailed below:

SAMHSA – Changing the Conversation - 2000 The Substance Abuse and Mental Health Services Administration (SAMHSA) in the United States sponsors National Alcohol and Drug Addiction Recovery Month in September, in order to bring attention to addictions and improve access to addiction treatment.81 The purpose is to destigmatize addiction, to promote the medical model of addiction, and to reverse the criminalization of addiction. The key objective is to create “a society in which people with a history of alcohol or drug problems, people in recovery, and people at risk for these problems are valued and treated with dignity, and where stigma, accompanying attitudes, discrimination, and other barriers to recovery are eliminated.”82 SAMHSA also published a report in 2000, entitled Changing the Conversation: The National Treatment Plan Initiative to Improve Substance Abuse Treatment. The purpose of the report was to stress that addiction is a treatable disease: “Changing the Conversation envisions a society in which people with a history of alcohol or drug problems, people in recovery, and people at risk for these problems are valued and treated with dignity, and where stigma, accompanying attitudes, discrimination, and other barriers to recovery are eliminated. We envision a society in which substance abuse/dependence is recognized as a public health issue, a treatable illness for which individuals deserve treatment. We envision a society in which high-quality services for alcohol and drug problems are widely available and where treatment is recognized as a specialized field of expertise.”83 The Changing the Conversation program has targeted its outreach efforts to educators, schools, public officials, civic leaders, employers, community-based organizations, faith/spiritual communities, health and wellness professionals, health insurers, individuals in the recovery community, individuals employed in the criminal justice system, and labour unions/trade associations.84 It is highlighted during National Alcohol and Drug Addiction Recovery Month in September.

Central East ATTC – Addiction Stigma Reduction Toolkit – 2000 The Central East Addiction Technology Transfer Center (ATTC), funded by a cooperative agreement from the Center for Substance Abuse Treatment (CSAT) at SAMHSA, has developed an Addiction Stigma Reduction Toolkit, which includes an implementation guide and 30-minute video.85 The video presents highlights from the Stigma Reduction Forum held September 28, 2000. The implementation guide, A Guide to Reducing Addiction-Related Stigma, provides useful information about a variety of approaches to prevent addiction16

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related stigma, including using stigma-free language, writing letters to the editor, developing a community action group, and implementing a community-based media advocacy campaign. In 2002, Join Together (a project of Boston University School of Public Health) convened a national policy panel to address discrimination and stigma against people seeking treatment or recovery from alcohol or other drugs. The results of a national survey had shown that a quarter of people in recovery had been denied a job or promotion, and 40% had experienced shame or social embarrassment because they were in recovery.86 The guiding principles for the panel’s report were that:87 • Addiction to alcohol or other drugs is a treatable chronic disease that should be viewed and addressed as a public health issue. • People seeking treatment or recovery from alcohol or other drug disease should not be subject to legally imposed bans or other barriers based solely on their addiction. Such bans should be identified and removed.

CAMH – Community-Based Anti-Stigma Campaign – 2000 The Centre for Addiction and Mental Health (CAMH) worked with community partners in 2000 to learn more about the stigma related to problem substance use.88 The goal was to develop an effective community-based anti-stigma campaign. Focus groups and interviews were conducted across Ontario with 87 people who had experience using drugs, 18 family members, and 36 service providers. Findings from this research showed that:89

People who have problems with substance use are judged and labelled in a negative way by society, and often come to think of themselves in the same way.

The substance users who are stigmatized the most are: o Those who use illegal drugs (especially those who inject drugs, use crack or heroin, or take methadone), or those who use any drug a lot; o Women (especially if they are pregnant and/or are mothers already); o People of lower socio-economic status; o Younger people and older adults; o Aboriginal people.

The main ways in which stigma affects people with experience using drugs are: o Violations of human rights; o Lack of employment; o Development of negative feelings about themselves; o Adoption of certain behaviours (avoiding needed services, becoming secretive, continued substance use).

Those who have the most contact with substance users were mentioned as being either the most stigmatizing and/or the most supportive: o The groups mentioned as stigmatizing substance users most are: People in the helping professions (physicians, psychiatrists, pharmacists, emergency room staff)

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Family and friends The legal system (police, lawyers, probation and parole officers) Government agencies (social services, Children’s Aid, provincial government) o On the other hand, many participants mentioned that counsellors, therapists, and treatment agencies have given them a lot of support. Some also cited family and friends, people in helping professions (e.g., family physical, psychiatrist, emergency department) and the legal system (e.g., police) as being supportive.

The most effective ways to reduce stigma are through: o Educational initiatives which: Highlight the reasons people develop problems with substance use; Seek to promote understanding; Address media biases and inaccuracies; Portray people with addictions as human beings. o Personalizing the issue by: Having people who have experienced substance use and stigma speak about it; Using well-known people as spokespeople to raise awareness that addiction can affect anyone; Showing the face of substance use on a variety of people in society. o Positive stories which: Show people who have experienced problems with substance use contributing to society.

The Providence Summit – 2004 In 2004, 58 advocates and experts from across the United States met in Providence, Rhode Island to refine ideas around a national campaign to change attitudes and actions about drug and alcohol addiction.90 The focus was on developing approaches to get Americans, political leaders, and policymakers to view addiction as one of the key health priorities. The development of a national campaign was expected to involve a series of steps, including: identifying shared campaign goals; defining target audiences, testing messages that would have wide acceptance beyond traditional supporters; developing a public policy agenda to ensure changes in the social and political system; and setting up a variety of communication channels to disseminate messages. The campaign’s goal would be to change attitudes and behaviour of Americans, as well as policies and laws. The campaign would start by targeting the general public and health professionals. Three of the six messages tested seemed to resonate strongly with the public:91 1. Addiction to alcohol and drugs is a disease that affects one in 10 Americans. As many as one in four American children are affected by parents or family members with an addiction.

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2. Recovery from addiction to alcohol and other drugs takes time, patience, and support. There are many ways that people can get the help they need, and we can never give up on helping family members and friends reclaim their lives. 3. Breaking the cycle of addiction is critical to a healthy society. It’s easier and less costly to treat abuse before it becomes an addiction, and to treat addiction in its early stages. A fourth message did not resonate as strongly with the public, but was a favourite of people in recovery: 4. Millions of Americans are in long-term recovery from alcohol and other drug addiction, and tens of thousands more get well every year. They are living proof that recovery is happening, and that there is a real solution to the problem of drug and alcohol addiction. The fifth and sixth messages were considered to be less convincing for the general public: 5. Helping people to achieve long-term recovery saves in health care costs, crime, and the toll on families. 6. Discrimination against people in recovery is unfair and makes their ability to achieve recovery more difficult.

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7. Parallels with Mental Health Anti-Stigma Campaigns The field of mental health offers the closest parallels to the field of addictions, in terms of successful anti-stigma campaigns. Several examples are detailed here.

WPA – Open the Doors – 1999 A recent initiative introduced by the World Psychiatric Association (WPA) has been aimed at reducing psychiatric stigma. The “Open the Doors” campaign was created as part of the Global Program to Reduce Stigma and Discrimination Associated with Schizophrenia, which has been developing since 1999 in Australia, Austria, Canada, China, Egypt, Germany, Greece, India, Italy, New Zealand, Spain, Sweden, and the UK.92 The 1996 Declaration of Madrid called for broader social action within the psychiatric field, and the “Open the Doors” campaign is intended to bring this goal to fruition. So far, a step-by-step guide to developing an anti-stigma program has been created, as well as a compendium of the latest information available on the diagnosis and treatment of schizophrenia. In Canada, a pilot program in Calgary has been undertaken in order to improve knowledge and attitudes about schizophrenia among high school students. This was accompanied by a public radio campaign in the Calgary area. Other initiatives have been undertaken in other countries, and reports on these various country initiatives are planned. For example, an evaluation of one initiative, a lecture on mental illness, showed that attitudes toward mental illness improved significantly among those who heard the educational lecture.93

USDHHS CMHS – Resource Centre to Address Discrimination and Stigma The U.S. Department of Health and Human Services – Center for Mental Health Services operates the Resource Center to Address Discrimination and Stigma (ADS Center; http://www.adscenter.org/ ). The information on this web site describes the stigma and discrimination associated with mental illnesses, and offers ideas and resources to counter this stigma. These include articles, fact sheets, brochures, books, and research.

Australia – Anti-Stigma Program Reports of an anti-stigma program intended to increase awareness of mental illness in Australia indicate that attitude change is slow to happen. However, evaluation of the campaign suggests that those who recalled the campaign were generally more tolerant and accepting of people with mental illness.94 The campaign was also useful in increasing awareness of various help services for persons with mental illness. Unfortunately, this campaign, like many of its type, suffered from under-funding, which both limits the effectiveness of the campaign as well as the ability to effectively measure its results.

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New Zealand - StigmaWatch In New Zealand, a “StigmaWatch” program was launched, which encouraged the community to participate in media monitoring.95 Through a website, the public was encouraged to report inaccurate or inappropriate references to mental illness in the media, and also to acknowledge accurate and appropriate reporting. As well, a popular New Zealand television soap opera was encouraged to include a story line about one of its young characters developing schizophrenia, in order to bring attention to the issue of mental illness. A free telephone help-line and an online help-line were tools within the New Zealand efforts that allowed the public to find out more about treatment for mental illness.96

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8. Where To From Here? There are a variety of levels at which an anti-stigmatization campaign could be developed. These include: • The cognitive level, using an educational intervention or social marketing intervention; • The affective (emotional) level, gaining the sympathy of the public; • The discrimination level, by using legislation and public policy to mandate fair treatment for persons with addictions; • The linguistic level, in which the syndrome might be renamed in order to gain greater respect (although such re-naming is usually only successful for a period of time, e.g., renaming alcoholism as alcohol dependence).97 Successful anti-stigma programs, as discussed in the previous sections, share a number of elements in common: • Clear-cut goals and objectives • Aimed at multiple target audiences, with appropriate messaging for each target audience • Use of a multi-faceted approach, including public relations and paid media • Inclusion of advocacy campaigns and media monitoring • Development of handbooks or guides to assist communities in getting involved • Inclusion of mass media campaigns • Use of a telephone help-line or information line • Inclusion of an evaluation framework to determine whether goals have been met. It should be recognized that successful anti-stigma campaigns have the potential to create a spike in demand for services, which the system must be prepared to meet. For example, reducing stigma associated with addictions might result in a spike in requests for treatment services, as the stigma associated with addictions becomes reduced. Agencies need to be prepared to deal with this as a side effect of a de-stigmatization campaign. As well, there are often significant difficulties in attributing attitude or behaviour change to multi-faceted public education or social marketing campaigns. Because there are a variety of forces contributing to changes in attitude or behaviour, it is not always clear exactly which elements were most responsible for the change. Furthermore, attitude and behaviour change is often fairly slow, and may be relatively difficult to measure unless large-scale longitudinal studies are undertaken. However, developing an anti-stigma campaign can contribute significantly toward achieving an environment in which persons with addictions feel comfortable in admitting their addictions and seeking treatment.

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87

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