(A position statement by NDPA, as at April 2026)
By Peter Stoker, C. Eng., M.I.C.E. (Retd) – Director – National Drug Prevention Alliance
At various times new suggestions are made for policy and practice in responding to drug misuse, addictions, treatment, education and prevention. Whilst these suggestions may derive from genuinely constructive attempts to improve the condition of drug misusers, and of society at large, they can sometimes be exploited by those who advocate liberalising policy and practice.
Two earlier such well-known examples where this kind of exploitation has been seen are known under the terms ‘human rights’ and ‘harm reduction’. Both these initiatives have a genuinely valid place in policy and practice, but both have also been called into quite different tactical ploys by liberalisation ‘influencers’. Another such example has been the attempts to replace the terms ‘misuse’ or ‘abuse’ by the more neutral term ‘use’ – this illustrates how the power of words as can be deployed to influence particular policy/practice attitudes and goals.
More recently, these same influencers have widened their approach to address the subject of ‘stigma’. Moves in this field have even developed so far as to include the establishment of an Anti-Stigma Institute, under the auspices of the Addiction Policy Forum, a Washington DC-based nonprofit organisation.
Drug addiction can be seen as the extremity of drug misuse, the possible end state of a progressive behaviour which started with curiosity, then experimentation, then occasional use, through regular use to what becomes, for some, a compulsion to use. This end state can be seen to affect literally millions of people worldwide. At some stage in this progression, a person may become victim to what has been defined as SUDs – Substance Use Disorders; these disorders may include not only health consequences but also eventual dissociation by the user’s friends, partners, relatives, employers, social service providers, child care agencies, housing agencies and more. Many people perceive SUDs as a moral failing, not just a bad decision, and their reaction may well be influenced by this judgement call.
In the context of perceived stigma, a harrowing account of how thing can go badly wrong for those experiencing SUDs was published in ‘Filtermag.org’ by Patricia A Roos, a sociologist whose son Alex died from a drug overdose in May 2015. Her article, dated September 2025, was entitled ‘Stigma from Medical Providers Contributed to My Son’s Overdose’. (Ref 1) Here are a few of the points made in her article, paraphrased for brevity:
Alex had many ‘protection privileges’ – white, middle-class, educated supportive parents and friendship circle, never abused, and yet he took a downward path of behaviour, firstly through anorexia, then in addiction … he resided in many ERs etc, sometimes encountering medical providers who helped him, but many times not – instead of empathic support he experienced chastisement for ‘bad choices’ and ‘lack of willpower ’… ‘drug-seeking behaviour’ … ‘lack of engagement’ and ‘denial’. Stigmatisation powered his downward spiral … he was labelled, blamed … in effect written off. Roos observes that while stigma is present in multiple institutions, it must be said that its presence in medical care is especially pronounced, insidious and devastating. Roos goes on to comment that it is ‘perhaps not surprising that medical providers stigmatise, making moral judgements when they should be making prognoses and decisions based on science, relying on culturally-induced assumptions of personal responsibility instead of their scientific knowledge’.
Roos applauds the work of Erving Goffman, a renowned sociologist, author of many publications which address, inter alia, the subject of stigmatisation. Perhaps most relevant here is his 1963 book ‘Stigma – Notes on the Management of Spoiled Identity’. (Ref 2)
It should also be noted that towards the end of her article, Roos expresses support for ‘decriminalising and regulating drugs’ and wider use of harm reduction initiatives. She also is scathing of the US Governments recent (2025) change of strategy and defunding, away from harm reduction, under the direction of Health and Human Services Secretary Robert F Kennedy Jr.
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National bodies may strive to introduce order into stigmas around substance use disorder; for example, America’s NIDA (National Institute on Drug Abuse) have produced several papers around this theme, one of which is entitled: ‘Addressing the Stigma that Surrounds Addiction’. (Ref 3)
On the other hand, critics of stigma can sometimes exhibit hastiness in dismissing all stigma as ‘bad’ – to go down this route would be to ignore that social stigma has always been a major factor in what controls and limits human behaviours, in the interest of society as a whole. As one observer put it “Stigmatisation is part of what makes humans social animals”.
In his 2025 book ‘What is it like to be an Addict?’ (Oxford University Press) (Ref 4), Owen Flanagan makes the key point that “… amongst the most important thing addicts say is that they are by no means blameless”.
As the review of Flanagan’s book concludes: “it is refreshing to read a book that refuses to dehumanise addicts by depriving them of responsibility or delegitimising the shame they feel for their actions”. In this context, it is worth reflecting on the fact that many drug misusers – including not a few addicts – achieve recovery and lasting sobriety without any help from anyone else – neither medical professionals nor AA groups play any part in the ability of these individuals to dig themselves out of the hole they were in.
In developing his thinking, Flanagan is sceptical of the tendency to medicalise all of life’s setbacks and sadnesses, and he goes on to make the constructive comment that dismissing the so-called ‘War on Drugs’ as a costly failure may be hasty – saying “… we can’t be sure that many addictions wouldn’t be worse in its absence”. Critics of prevention could do worse that contemplate on this observation.
And mention of prevention should remind us that addiction is only one part of the total experience of drug misuse – there are several phases of behaviour which come before addiction. It follows, therefore, that each of these phases may generate comments by those around the user – including what may seem to be just stigmatising comments – but are in fact a useful part of the self-recovering processes which enable individuals to recover.
Amongst those seeking to generate a more balanced view on stigma, an informal grouping of British specialists includes – amongst others – Professor Neil McKegany (Ref 5) – a prominent sociologist and leading researcher in the field of drug misuse, known for founding the Centre for Drug Misuse Research at the University of Glasgow in 1994; Deirdre Boyd, founder and head of DB Recovery Resources, which sustains ongoing working links with McLean Hospital, Massachusetts, and David Raynes, a Senior Adviser to the National Drug Prevention Alliance who was formerly a senior officer and drugs specialist with HM Customs and Excise (as it was known during his time).
Collating together some of the comments by these specialists on the subject of stigma …
McKeganey: “If one’s aim is to reduce prevalence of drug misuse, one needs to retain a view of drug use as a stigmatised activity” (by society as it stands) … “stigmatisation actually varies depending on the drug in question” – Cannabis, Cocaine, Heroin each attract different levels of stigma … “drug use can be stigmatised without the user being stigmatised i.e. moral judgement can stigmatise drug use but not the user”.
Boyd: “The greatest stigma is that which does not recognise addicts and their recovery … this takes recognition away from and is insulting to people who have altered their lives to stay that way and to give back to society.” … “Sadly, stigmatisation is often encountered with the medical profession itself”.(See later comments in this article, by Patricia S Roos) … “Stigma played a huge role in reducing tobacco use – adverts with children shaming parents who smoke, office workers expelled to smoke outdoors” … “stigma also pays a role in reducing alcohol use; images of drunken capering, of children abandoned, etc” (Recalling Hogarth’s 1751 image of ‘Beer Street’ and ‘Gin Lane’!)
Raynes: “Social stigma has for millennia been part of what controls and limits human behaviour.” … “This business of trying to remove social stigma from drug addiction and use, or from any antisocial behaviour, is in my view a trap, A very deliberate one … Don’t fall for it.”
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In conclusion (for now) herein offered is an extended ‘quote’ from a paper written by an American doctor, Sally Satel. (Ref 6) This was published by John Hopkins University Press of Baltimore, as part of a larger paper entitled ‘Addiction Treatment Science and Policy for the Twenty First Century’ – and in it she nailed her colours firmly to the mast by entitling it ‘In Praise of Stigma’. Satel spoke on the value of constructive stigma as part of improving treatment effectiveness, but was roundly condemned for doing so. As she put it: “Clearly, I had committed heresy”.
Despite her much-voiced support for accessible, respectful and competent treatment, her support for stigma remained ‘a bridge too far’ for some. She resolutely commented “Why try to destigmatise irresponsibility that leads to ruptured families, ruined careers, and crime … we don’t have to neutralise the moral valence (valence meaning ‘capacity to classify’ e.g. ‘good-bad’) of addiction-fuelled behaviour to destigmatise the treatment process”.
She goes on to challenge some of the alleged benefits of eliminating stigma, as set forth by the National Institute on Drug Abuse (Ref 7) – as shown here following, in italics – “… it will get more addicts into treatment/it will improve the availability of treatment/it will speed the development of medications” and “it will help addicts self-esteem”. A charitable evaluation of these allegations is that they seem to speak more from hope than from proven conviction.
Satel calls up McLean Hospital, Massachusetts, and in particular psychologist Gene Heyman, (Ref 8), who makes the powerful point that voluntary behaviour is mediated by the brain … motivation and self-control are acts of the brain. Recovery itself depends on willpower, and people have the capacity to transform themselves.
In the end, observes Satel, the de-stigmatisation campaign could be said to have its heart in the right place, but in her opinion its marksmanship is too sweeping, too uncontrolled, and thus tends to make things worse in its search for what could be better. As she says in closing her statement:
“Finally, even if we could somehow ‘untaint’ addiction, what would be the price? Stigmatisation is a normal part of human interaction, has a civilising effect on social life, and is often the basis of the antidrug messages we give our children … There is nothing unethical – and everything naturally and socially adaptive – about condemning the reckless and harmful behaviours that addicts commit. This need not negate our sympathy for them or our duty to provide care.”
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CONCLUSIONS:
This is a subject which will run and run, so it may be considered premature to attempt sweeping conclusions at this time. However, this writer offers the following as indicators of what might prove to be ‘route markers’ …
- Stigma, when encountered, can be and should be assessed as either ‘constructive’ or ‘obstructive’ to interventions with drug misuse.
- Stigma directed at the user is often obstructive to and unhelpful for progress.
- Stigma directed at drugs and their effects on individuals and on society at large can be constructive in the right context, if applied sensitively.
- Attempts by some to remove stigma in its entirety can often be identified as a tactic for unmerited liberalisation of drug strategy, policy and practice.
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REFERENCES:
- Roos, PA. ‘Stigma from Medical Providers Contributed to My Son’s Overdose’. Filtermag.org, 2015
- Goffman, E. ‘Stigma- Notes on the Management of Spoiled Identity’. Pelican, 1963
- NIDA – https://drugabuse.gov/about-nida/noras-blog/2020/04/addressing-stigma-surrounds-addiction)
- Flanagan, O. ‘What is it like to be an Addict?’. Oxford University Press, 2025
- McKeganey, N. ‘Controversies in Drugs Policy and Practice’. Palgrave Macmillan, 2011
- Satel, S. ‘In Praise of Stigma’. John Hopkins University Press, 2007.
- https://sallysatelmd.com/html/PraiseStigma2007.pdf – The text in this reference sets out the full statement by NIDA as to the benefits they saw at that time in ‘eliminating stigma’ – but in searching for the actual NIDA paper – entitled ‘www.drugabuse.gov/about/welcome/aboutdrugabuse/stigma/‘ it was not found possible to access it.
- Heyman, GM. ‘Consumption Dependent Changes in Reward Value, a Framework for Understanding Addiction’. Elsevier, 2003
(ENDS)