Despite significant strides in drug policy in recent decades, and changing attitudes about some substances, stigmatization of people who use drugs remains a pervasive challenge—one that puts our health, wellbeing and lives at serious risk. Why is the temptation to judge and shame certain people who use drugs such a tough habit to break?
Sociologist Erving Goffman’s 1963 book, Stigma: Notes on the Management of Spoiled Identity, was considered groundbreaking work for its time, and continues to be relevant today. The English word “stigma” stems from the Greek stizein, meaning “to tattoo.” Goffman describes how stigma, for the ancient Greeks, was explicit and visual. A stigma was a bodily evident sign to indicate someone was of low status, disgraced, or for whatever reason best for respectable people to avoid. For instance, a person might be physically branded as a slave.
By establishing their distance from the stigmatized group, dominant groups benefit from an elevated sense of self and status. As with the ancient Greeks, the more visible and obvious the stigma, the more powerful and inescapable it becomes. Throughout human history, physical markers have enabled conquest and subjugation. These can be imposed on the stigmatized group, such as forcing Jewish people to wear the yellow star of David in Nazi Germany. Other people are born stigmatized, such as with systemic racism, which degrades people’s humanity based on phenotype or skin pigmentation.
The physical effects of certain drug use can also be used to reinforce stigma. As one harm reduction outreach worker described to Filter, “It was really hard for me to re-enter the workforce, even with the nicest clothing, still having track marks and all this other baggage that you can see.”
Like prestige symbols, stigma symbols offer a shortcut for establishing hierarchical position. A flashy car, impressive job title and expensive clothes suggest success and worth. On the other hand, being branded a drug user provokes fear, shame, judgment and the threat of prison. As Sarah Wakeman, medical director for Substance Use Disorder at Mass General Brigham in Boston, told Filter, much of it boils down to “The very fact that we criminalize certain types of drug use. The whole point of criminalizing something is to increase the stigma of that action.”
The imposition of stigma inherently devalues a person’s humanity. The “drug user” label suggests that they can be routinely subjected to a multitude of discriminations. As Goffman explains, “By definition, of course, we believe the person with a stigma is not quite human … On this assumption we exercise varieties of discrimination, through which we effectively, if often unthinkingly, reduce his life chances.”
“We have bars which are perfectly socially acceptable … then criminalize people who need a safe space to use other types of substances.”
Stigmatization of drug use is used as grounds to deny people’s rights to housing, employment, education, health care and more. Societal shaming promotes riskier, isolated drug use while diminishing access to critical harm reduction resources and treatment—literally costing lives.
Drug use stigma is contextual. Moral judgement of drug users is often hypocritical, as well as discriminatory. People often make ethical allowances to justify their own methods for getting buzzed.
“I think there’s still this intense othering of people who use certain types of drugs and this notion of a distinct us versus them,” Dr. Wakeman said. “You know, there are those people who inject drugs, for example, or those people are different than us who use alcohol. Just think about the conversation around overdose prevention sites or supervised consumption spaces. We have bars which are perfectly socially acceptable for the people who are making the laws and policies that then criminalize people who need a safe space to use other types of substances.”
More privileged people can confine their drug use to private spaces, while maintaining conventional lifestyles and careers. They are more likely to avoid the risks of poverty, criminalization, and limited access to safe supplies that result in physical markers of poor health, lack of nutrition and subsequent damage to their appearance. “We don’t have the same degree of stigma, or even outright hatred that you can see towards certain communities of people who use drugs. That is connected to a long history of racism in the United States and how that has driven a lot of decisions around drug policy,” Dr. Wakeman said.
Jarringly, the more disadvantaged the person—living in public housing, perhaps, or on the streets—the more likely they are to be placed in a position where their drug use is made visible and subjected to the most stigma. Terrell Jones, the outreach and advocacy program manager at New York Harm Reduction Educators and a long-time harm reduction leader, told Filter that the hardships of the COVID pandemic have exacerbated the problem. “Stigma is at an all-time high because of the increase of drug use due to social and economic factors, where people have started using more and it’s more and more public drug use that people are experiencing,” Jones said. “People are walking around with their kids and seeing injection drug use and it hurts.”
“People disrespected me, dehumanized me, mocked me, and put me into a deeper hole of my drug use.”
For the most vulnerable, their drug use is transformed into the defining aspect of who they are. They are subjected to dehumanizing labels. Unlike stigmas placed on people who are, for instance, disabled or suffering from an illness, drug-use stigmas—in common with those around sex work, weight or gender non-conformity—often result from perceptions of a moral failing, indulgent behavior or depravity.
“People disrespected me, dehumanized me, mocked me, and put me into a deeper hole of my drug use,” Jones said. “The community needs to understand how much of a part they play. Instead of putting people down, give them some kind of resource. That goes a long way. This person is a human being. People act like drug users come from another world, like aliens, outcasts … people where something went wrong.”
Stigma damages trust and access to effective care for people who use drugs in medical settings, creating further risk. “Doctors and nurses are humans and members of society,” Dr. Wakeman said. “They’ve been influenced by the same societal stigma that laypeople have, particularly because learning about drug use and addiction and harm reduction is generally not a part of our medical training or hasn’t been to date … I think there sometimes is cognitive dissonance for health care providers in that they’ve been taught that drug use is bad. Often it’s actually the policies around drug use that cause the most harm. But I think in people’s minds, there’s this notion that drug use is harmful to your health, so if someone is engaging in that behavior, they must not value their health.”
“Reframing that narrative,” she continued, “is, ‘Actually people who use drugs have not forfeited their human rights, including their right to the best possible health care.’”
Stigmas even follow people into treatment and recovery programs, where expectation of total abstinence dominates and people who “relapse”—or even who use certain medications, like methadone—are judged harshly or deliberately excluded from services and support. “The narrative was so strong that if you’re not abstinent, and not abstinent in this way with this kind of program model, you are still perceived as less than,” one former participant told Filter.
Harm reduction at its core is a strategy against stigma. Giving people the space and freedom to manage their own health without judgment or coercion is a core component. Harm reduction is not just a strategy to minimize the risks of drug use, but a philosophy for self-care and community care that promotes compassion, openness and practical knowledge that can improve and save lives.
But harm reduction is also dismissed by abstinence-only believers who label its practices as permissive or “enabling.” Before we can shift the general population’s stigmatization of drug use, perhaps we need to dismantle the exclusion and shaming within the drug treatment and recovery community, which pushes people out of the services and support that could help them stabilize or save their lives.
After a year of reporting on the overdose crisis for Vox, journalist German Lopez declared that stigma against drug use is “the single biggest reason America is failing in its response to the opioid epidemic.” Overdose claimed over 100,0000 lives in the US in 2021. These were deaths that could have been prevented, by naloxone, methadone, buprenorphine, drug checking services and safe consumption sites, among other resources.
Stephen Hamill is vice president for policy advocacy and communication at Vital Strategies, a public health nonprofit. Earlier this year, Vital Strategies launched the first national advertising campaign to raise awareness about harm reduction as a remedy for the US overdose crisis (full disclosure: I served as a communications advisor for the campaign). “As long as people see this issue as something that doesn’t affect them, it will never gain political priority,” Hamill told Filter. “You will continue to see NIMBYism around putting services in every community because they feel like, People like me don’t need a needle exchange. We don’t need safe supplies or drug testing kits. It’s those bad people who are going to benefit.”
Humanizing those “other” people was a core strategy of the Vital Strategies campaign to subvert the stigmas that create obstacles for harm reduction programs. It featured the stories of people who use or have used drugs, presenting them as human beings who are loved, and who are contributing to their communities as harm reduction workers.
Dr. Wakeman also described a program to challenge stigma in hospital settings, whereby patients who use drugs volunteer to return to the hospital and visit with the staff where they were hospitalized. “I think that can be incredibly humanizing because people who work in hospitals and emergency rooms in particular often only encounter folks in a moment of crisis,” she said. “They may see someone when they’re in the throes of active withdrawal or after an overdose … it can be really powerful to just connect with the person outside of that to see them in their normal clothes and see them as a sister or a father or just a human being, essentially.”
“We do need more non-stigmatized people with courage enough to acknowledge our own drug use.”
Another approach, most prominently advocated by Dr. Carl Hart, a neuroscientist, noted author and psychology professor at Columbia University, calls for privileged drug users to put skin in the game by publicly outing their own drug use.
Admittedly, the ability to keep one’s drug use private is a benefit of privilege. It’s a tough ask to let go of that benefit and risk the curse of stigma. Yet we do need more non-stigmatized people with courage enough to acknowledge our own drug use. Whether it’s caffeine, nicotine, alcohol, mushrooms, marijuana or opioids, just about all of us have consumed substances that alter our consciousness. Being open and honest with ourselves might not only make us better, more compassionate and less judgmental people, it could also improve our own health.
If we look to comparable campaigns to end stigma—for instance, around HIV, mental health and sexual orientation—the template we need looks like a web of all of the above. We need to draw attention to the human cost of stigma, the people whose lives were cut short and their grieving loved ones. We need the statistics that demonstrate what compassionate and non-judgmental care can accomplish. We also need the stories of people living fulfilling lives, after using drugs or while still using them, that transcend stigma. We need to challenge the use of dehumanizing language and labels that reinforce discrimination—such as the word “clean,” which suggests that people who use drugs are “dirty.” We need to hold the media accountable for their role in perpetuating drug-use myths and stereotypes.
As Hamill said, “Stigma can be a way of disassociating yourself from the risk. It’s like that’s something that wouldn’t happen to someone like me, that happens to these other people who have bad behaviors, or they’re bad types of people.”
To change this, we need to be willing to let go of the hollow sense of status that labeling and judging others may give us. Perhaps if we can learn to acknowledge that our own shit indeed does stink, we can avoid constantly stepping in it.
Screenshot of Terrell Jones in Vital Strategies’ “Harm Reduction Saves Lives” advertising campaign