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A lesson in language: vocabulary becomes the legacy issue of the outgoing drug czar.

As director of the Office of National Drug Control Policy (ONDCP) under President Barack 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'?"


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."

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.

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.


Botticelli 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.

Gary A. Enos is Editor of Addiction Professional.

Language Recovery


Treatment is the goal                Treatment is an opportunity for
Treatment is the only way into       initiation into recovery (one of
recovery                             multiple pathways into recovery)

Untreated addict/alcoholic           Individual not yet in recovery

Substance abuse                      Substance use disorder/addiction/
                                     substance misuse

Drug of choice/abuse                 Drug of use

Denial                               Ambivalence

Relapse prevention                   Recovery management

Pathology-based assessment           Strength/asset-based assessment

Focus is on total abstinence from    Focus is on the drug the client
all illicit and non-prescribed       feels is creating the problems
substances the clinician

A drug is a drug is a drug           Each illicit substance has unique
                                     interactions with the brain;
                                     medication, if available, is

Relapse                              Recurrence/return to use

Relapse is part of recovery          Recurrence/return to use may occur
                                     as part of the disease

Clean/sober                          Drug-free/free from illicit and
                                     non-prescribed medications

Self-help group                      Mutual aid group

Drug overdose                        Drug poisoning

Graduate from treatment              Commence recovery

Source: Office of National Drug Control Policy
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Author:Enos, Gary A.
Publication:Addiction Professional
Article Type:Cover story
Date:Mar 22, 2017
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