The Language of Substance Use and Recovery: Novel Use of the Go/No-Go Association Task to Measure Implicit Bias

Substance use stigma: A systematic review of measures and their psychometric properties

Background

Instruments to measure substance use stigma are emerging, however little is known regarding their psychometric properties. While research has evolved to view substance use stigma as a context sensitive international phenomenon that is embedded within cultures, validated self-report measures are lacking and comprehensive reviews of the existing measures are extremely limited. In this systematic review of substance use stigma and shame measures, we aim to contextualize results from existing research, lay the groundwork for future measurement development research, and provide a thorough resource for research scientists currently designing studies to measure substance use stigma.

Methods

We searched three databases using Boolean search terms for psychometric evaluations of measures of substance use stigma and shame and evaluated the quality/psychometric properties using an adaptation of the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) systematic review guidelines.

Results

We identified 18 measures of substance use stigma. Overall, most measures had minimal psychometric assessments and none of the measures met all domains of the COSMIN measure quality criteria. However, most studies reported satisfactory factor analyses and internal consistency scores.

Conclusions

Most measures of substance use stigma and shame had psychometric assessment across a limited range of criteria and no measures of structural substance use stigma were found. The most reported psychometric properties were structural validity and convergent validity. We suggest future researchers investigate test-retest reliability and cross-cultural validity for existing substance use stigma measures, as well as develop and evaluate novel measures assessing structural stigma of substance use.

Stigma Communication Surrounding Nonmedical Opioid Use Among Affected Family Members

A growing body of research demonstrates the role of language in stigma toward nonmedical opioid use (NMOU). Terms like "substance abuser" perpetuate stereotypes and evoke punitive judgments. This study examines how affected family members (AFMs) communicate stigma when discussing their loved one's NMOU. Semi-structured interviews were conducted with 34 adults with a close family member with a history of NMOU. An iterative approach was used to analyze instances when stigmatizing terms or messages were used. AFMs described people engaged in NMOU as underweight, "dirty," or "nodding off," and often labeled these individuals "addicts" or opioid "abusers." Responsibility for the NMOU was attributed to both internal (e.g. choice) and external (e.g. brain disease) factors. People engaged in NMOU were linked to physical danger, resource threats, and threats to the family members' reputation and relationships. While most stigma messages related to the person engaged in NMOU, stigmatizing messages directed toward AFMs also emerged; family members labeled "enablers" were judged, blamed, and described as a threat to the person engaged in NMOU. Although AFMs expressed care and desire to support their loved ones, they often conveyed stigma in their language choices. This language among AFMs may reflect internalized stigma. Increased efforts are needed to help AFMs cope with the challenges of a loved one's NMOU and identify effective ways to support their loved one. One way AFMs can support their loved one is by using more inclusive, person-first language.

A qualitative examination of social identity and stigma among adolescents recovering from alcohol or drug use

Introduction

Alcohol and other drug (AOD) use disorders are stigmatized conditions, but little is known about youth's experience of this stigma, which may threaten their developing social identity and recovery process. This study investigates youth's perceptions of AOD use-related stigma in the context of their social identity.

Methods

This study uses data from 12 youth (ages 17-19) who were in recovery from problematic AOD use. Participants completed a Social Identity Mapping in Addiction Recovery (SIM-AR) exercise, in which they created a visual map of their social groups, and semi-structured interview, in which participants were asked about their experience creating their SIM-AR and reflections on their social network. SIM-AR data were descriptively analyzed, and interviews were thematically analyzed for instances of stigma.

Results

Using stigmatizing terminology, participants expressed some stigmatizing attitudes towards themselves and others in their network who used substances and perceived both positive and negative reactions from those who knew about their disorder. Findings suggest that youth may experience some internalized stigma and perceive stigma from others in their social networks, which may be a barrier to the development of a healthy social identity and engagement in recovery supports.

Conclusions

These findings should be considered when seeking to engage youth in treatment and recovery programming. Despite the small sample, the findings suggest the importance of considering how stigma may influence adolescents' treatment and recovery experience in the context of their social environment.

Starting the Discussion: A Call to Enhance Care for People With Stimulant Use Disorder

Stimulant use disorder (StUD) significantly contributes to substance-related morbidity and mortality in the United States. Overshadowed by the country's focus on opioid-related overdose deaths, stimulant and stimulant/opioid overdose deaths have increased dramatically over the last decade. Many individuals who use stimulants illicitly or have StUD have multiple, intersecting stigmatized characteristics which exacerbate existing barriers and create new obstacles to attaining addiction treatment. Illicit stimulant use, StUD, and stimulant-related overdose disproportionately impact minoritized racial and gender, and sexuality diverse groups. Historically, people who use illicit stimulants and those with StUD have been highly stigmatized, criminalized, and overly ignored by health care providers, policymakers, and the public compared to people who use other drugs and alcohol. As a result, most people needing treatment for StUD do not receive it. This is partly due to the lack of evidence-based treatment for StUD, which has resulted in few programs specializing in the care of people with StUD. The lack of available treatment is compounded by high rates of StUD in marginalized groups already reluctant to engage with the health care system. As health care professionals, we can improve outcomes for people with StUD by changing how we talk about, document, and respond to illicit stimulant use, related characteristics, behaviors, and social and structural determinants of health. To do this, we must seek to understand the lived realities of people with StUD and illicit stimulant use and use this knowledge to amend existing models of care.

The State of the Science of Nurses' Implicit Bias: A Call to Go Beyond the Face of the Other and Revisit the Ethics of Belonging and Power

This article summarizes the current state of nurses' implicit bias and discusses the phenomenon from Levinas' face of the Other and ethics of belonging, Watson's human caring and unitary caring science, and Chinn's peace and power theory. Nurses' implicit bias is a global issue; the primary sources of nurses' implicit bias include race/ethnicity, sexuality, health conditions, age, mental health status, and substance use disorders. The current research stays at the descriptive level and addresses implicit bias at the individual level. This article invites nurses to go beyond "the face of the Other" and revisit the ethics of belonging and power.

Exploring the intersectionality of stigma and substance use help-seeking behaviours among lesbian, gay, bisexual, transgender, queer, questioning or otherwise gender or sexuality minority (LGBTQ+) individuals in the United States: A scoping review

Problematic substance use (SU) is a significant issue among LGBTQ+ individuals, but rates of treatment/help-seeking in this population remain low. This review aimed to investigate literature about intersectional stigma of SU and LGBTQ+ identity and its impact on SU help-seeking behaviours in the U.S. Eligible studies from eight-database were included if peer-reviewed, in English, from the U.S., published between 2000 and 2022, focused on SU, stigma, SU help-seeking behaviours, among LGBTQ+ adults. Of 458 search results, 50 underwent full-text review, 12 were included in the final sample. Minority Stress Theory emerged as a relevant theoretical framework. Findings revealed that increased SU as a coping strategy was associated with minority stress. Intersectional stigma negatively impacted SU treatment experience among LGBTQ+ individuals, leading to avoidance of help-seeking or poor treatment outcomes. Patterns of SU and impact of stigma among LGBTQ+ individuals differ, wherein bisexual and transgender individuals reported significantly more treatment barriers and unique stressors. LGBTQ+ individuals reported earlier age of SU onset and were more likely to encounter opportunities for SU. This review highlights the impact of intersectional stigma on SU help-seeking behaviour among LGBTQ+ individuals in the U.S. Recommendations are provided for future clinical practice, research, and policy to better support LGBTQ+ individuals.

How to Reduce Stigma and Bias in Clinical Communication: a Narrative Review

A growing body of literature demonstrates that healthcare providers use stigmatizing language when speaking and writing about patients. In April 2021, the 21st Century Cures Act compelled clinicians to make medical records open to patients. We believe that this is a unique moment to provide clinicians with guidance on how to avoid stigma and bias in our language as part of larger efforts to promote health equity. We performed an exhaustive scoping review of the gray and academic literature on stigmatizing medical language. We used thematic analysis and concept mapping to organize the findings into core principles for use in clinical practice. We compiled a list of terms to avoid and seven strategies to promote non-judgmental health record keeping: (1) use person-first language, (2) eliminate pejorative terms, (3) make communication inclusive, (4) avoid labels, (5) stop weaponizing quotes, (6) avoid blaming patients, and (7) abandon the practice of leading with social identifiers. While we offer guidance clinicians can use to promote equity through language on an individual level, health inequities are structural and demand simultaneous systems and policy change. By improving our language, we can disrupt the harmful narratives that allow health disparities to persist.

Why language matters in alcohol research: Reducing stigma

BACKGROUND

The use of pejorative or stigmatizing language to describe individuals with alcohol and drug use disorders adversely affects treatment seeking, quality of care, and treatment outcomes. In 2015, the International Society of Addiction Journal Editors released terminology guidelines that recommended against the use of words that contribute to stigma against individuals with an addictive disorder. This study examined the use of stigmatizing language in National Institutes of Health (NIH)-funded research and reviews published by the journal, Alcoholism: Clinical and Experimental Research (ACER) from 2010 to 2020, with the goal of sharing the results with the alcohol research community to enhance awareness.

METHODS

The search for stigmatizing language in ACER was limited to NIH-funded articles made publicly available on PubMed Central (PMC). Though ACER is not an open-access journal, original research and reviews directly funded by NIH are published to PMC for open access to the public as required by the conditions of NIH funding. ACER articles published on PMC were searched from 2010 to 2020 with specific queries for individual terms of interest including those considered pejorative ("alcoholic," "addict," and "abuser") and outdated ("alcohol dependent," "alcohol abuse," and "alcoholism"). The number of articles containing a term of interest for a given year was divided by the total number of articles published in that year to determine the percent use of each term per year.

RESULTS

Our search of research and reviews (n = 1903) published in ACER on PMC determined that although the use of pejorative and outdated terminology has decreased over time, there is continued use of the term "alcoholic" over the last decade. Specifically, in 2020, over 40% of articles searched for in PMC still included "alcoholic." The results of a separate manual search (n = 110) on the Wiley Online Database showed that approximately 30% of articles used the term "alcoholic" in a stigmatizing manner.

CONCLUSIONS

Stigmatizing language can perpetuate negative biases against people with alcohol use disorder. We encourage researchers to shift away from language that maintains discriminatory conceptions of alcohol use disorder. Reducing stigma has the potential to increase rates of treatment seeking and improve treatment outcomes for individuals with alcohol use disorder.

Effect of Exposure to Visual Campaigns and Narrative Vignettes on Addiction Stigma Among Health Care Professionals: A Randomized Clinical Trial

IMPORTANCE

Stigma toward people with opioid use disorder (OUD) is pervasive in clinical settings, impeding delivery of high-quality care. To date, no study has evaluated the effect of different stigma-reduction messages or messengers among health care professionals.

OBJECTIVE

To evaluate the effect of OUD-related messages delivered by different messengers on stigma and attitudes toward people with OUD among health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial examined the effects of OUD-related messages delivered by a visual campaign alone or in combination with a written narrative vignette from the perspective of 1 of 3 messengers. Health care professionals in the US were recruited from 2 national online survey panels (Ipsos KnowledgePanel and SurveyHealthcareGlobus). A total of 1842 participants completed a web-based survey measuring stigma toward people with OUD from November 13 to 30, 2020.

INTERVENTIONS

Eight groups were exposed to 1 of 2 message frames. One frame (Words Matter) emphasized the harm of stigmatizing language, and the other (Medication Treatment Works) focused on the effectiveness of medications approved by the US Food and Drug Administration for the treatment of OUD. Message frames were communicated through either a visual campaign alone or a visual campaign in combination with a written narrative vignette from the perspective of a simulated patient with OUD, a clinician, or a health care system administrator.

MAIN OUTCOMES AND MEASURES

Dimensions of stigma toward people with OUD were measured on 5-point Likert scales that included items about desire for social distance from people with OUD, perception of individual blame for OUD, perspective of OUD as a medical condition, and support for increased governmental spending on OUD treatment. The level of warmth felt toward people with OUD was measured by a feeling thermometer (range, 0-100 points).

RESULTS

Among 1842 participants, the mean (SD) age was 47 (13) years; 1324 participants (71.9%) were female, 145 (7.9%) were Hispanic, 140 (7.6%) were non-Hispanic Black, 1344 (73.0%) were non-Hispanic White, and 213 (11.6%) were of other non-Hispanic race (ie, individuals who did not self-report race as Black or White and did not self-report ethnicity as Hispanic). Compared with nonexposure, exposure to the combination of visual campaign and narrative vignette communicating the importance of nonstigmatizing language from the perspective of a patient with OUD was associated with a lower probability (difference, -16.8 percentage points, 95% CI, -26.1 to -7.4; P < .001) of unwillingness to have a person with OUD marry into the family (a measure of social distance preference) and a 7.2-point (95% CI, 3.2-11.1; P < .001) higher warmth rating. Participants exposed to the combined visual campaign and patient vignette about the value of medication treatment for OUD also had significantly lower levels of stigma compared with those in the nonexposed control group (eg, unwillingness to have a person with OUD as a neighbor: difference, -15.3 percentage points; 95% CI, -24.6 to -6.0; P = .001).

CONCLUSIONS AND RELEVANCE

In this study, messages about nonstigmatizing language and effective medication for OUD reduced stigma among health care professionals. Stigma-reduction efforts targeting health care professionals may improve health care system capacity to serve people with OUD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05127707.

Investigating Healthcare Provider Bias Toward Patients Who Use Drugs Using a Survey-based Implicit Association Test: Pilot Study

OBJECTIVES

Negative bias against people who use illicit drugs adversely affects the care that they receive throughout the hospital. We hypothesized that emergency providers would display stronger negative bias toward these patients due to life-threatening contexts in which they treat this population. We also hypothesized that negative implicit bias would be associated with negative explicit bias.

METHODS

Faculty, nurses, and trainees at a midwestern tertiary care academic hospital were invited (June 26, 2019-September 5, 2019) to complete an online implicit association test and explicit bias survey.

RESULTS

Mean implicit association test results did not vary across demographics (n = 79). There were significant differences in explicit bias scores between departments regarding whether patients who use drugs deserve quality healthcare access (P = 0.017). We saw no significant associations between implicit and explicit bias scores.

CONCLUSION

Though limited by sample size, the results indicate that emergency and obstetrics/gynecology providers display more negative explicit bias toward this patient population than other providers.

Assessing Stigma Towards Substance Use in Pregnancy: A Randomized Study Testing the Impact of Stigmatizing Language and Type of Opioid Use on Attitudes Toward Mothers With Opioid Use Disorder

OBJECTIVE

To examine the extent to which colloquial phrases used to describe opioid-exposed mother-infant dyads affects attitudes toward mothers with opioid use disorder (OUD) to assess the role stigmatizing language may have on the care of mothers with OUD.

METHODS

We employed a randomized, cross-sectional, case vignette of an opioid-exposed dyad, varying on 2 factors: (1) language to describe newborn ("substance-exposed newborn" vs "addicted baby") and (2) type of maternal opioid use (injection heroin vs nonmedical use of prescription opioids). Participants were recruited using an online survey platform. Substance-related stigma, punitive-blaming, and supportive scales were constructed to assess attitudes. Two-way analyses of variance were conducted to determine mean scale differences by vignette. Posthoc analyses assessed individual item-level differences.

RESULTS

Among 1227 respondents, we found a small statistical difference between language and opioid type factors for the supportive scale only (F = 4.31, η2 = .004, P = 0.038), with greater agreement with supportive statements when describing injection heroin use, compared to prescription opioid use, for the "substance-exposed newborn" vignette only. In posthoc analyses, greater than 85% of respondents agreed the mother was "responsible for her opioid use," her "addiction was caused by poor choices," and that she "put her baby in danger."

CONCLUSIONS

We found no major differences in attitudes regardless of vignette received. Overall, respondents supported opportunities for maternal recovery yet blamed women, describing mothers as culpable for causing harm to their newborn, showcasing internally conflicting views. These views could contribute to ongoing stigma and avoidance of care among pregnant women with OUD.

Addressing Bias and Stigma in the Language We Use With Persons With Opioid Use Disorder: A Narrative Review

BACKGROUND: Despite an increase in access to medications for opioid use disorder, less than 20% of individuals with opioid use disorder (OUD) receive treatment. Stigmatizing language has been identified as a potential trigger for explicit and implicit biases that may adversely affect treatment enrollment and quality of care for persons with OUD. AIMS: To conduct a narrative review of the literature on stigmatizing language and OUD, examine how treatment outcomes are affected, and present strategies to reduce bias and promote OUD treatment. METHOD: A narrative review of the literature between 2010 and 2019 was conducted using CINAHL, PubMed, and PsycINFO. Key search terms were opioid use disorder (or substance use disorder), stigma, and language. Fifty-two articles were screened for inclusion, and 17 articles were included in this review. RESULTS: The articles reviewed provide consensus that stigmatizing language toward persons with OUD fosters explicit and implicit bias and impedes engagement in treatment. Four themes emerged: (1) stigma and language, (2) stigma and language used by health care professionals, (3) stigma and language used by the general public, and (4) stigma and language used by people with OUD. CONCLUSIONS: Stigmatizing language is dehumanizing and plays a pivotal role in bias and discrimination that may contribute to unsatisfactory treatment outcomes among persons with OUD. Health care professionals, nursing in particular, must assume an intentional stance against stigma perpetuated toward persons with OUD through advocacy in education, practice, policy, and the media.

Development of an unannounced standardized patient protocol to evaluate opioid use disorder treatment in pregnancy for American Indian and rural communities

BACKGROUND

Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited.

METHODS

We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians.

DISCUSSION

The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

Dynamic labeling discernment: Contextual importance of self-identifiers for individuals in recovery

Recent studies associate identifiers, such as "alcoholic/addict", with stigma, discrimination, and service deficits. Yet, little is known about why and how self-identifiers are chosen. This study analyzed qualitative responses from individuals (N = 42) in recovery from substance use disorders (SUDs) concerning their use of "alcoholic/addict" or "person with a SUD". Evaluative structure and generative theories were developed via latent content analysis and grounded theory. Secondary analysis evidenced four thematic constructs: contextual significance, flexibility/rigidity, leveraging identity to counteract stigma, and indications of identity integration/disintegration. Some individuals indicated the contextual utility of certain identifiers, regardless of associated stigma and bias.

Recovery dialects: A pilot study of stigmatizing and nonstigmatizing label use by individuals in recovery from substance use disorders

Previous research has found language used to describe individuals with a substance use disorder (SUD; e.g., "addict," "substance abuser") contributes to and elicits negative bias among the general public and health care professionals. However, the prevalence in which recovering individuals use these labels to self-identify and the impact of such labels are unknown. The current pilot study, a cross-sectional design, examined the usage of two labels ("addict," "person with a SUD") as well as the differences in recovery outcomes among individuals in recovery. Participants (n = 54) used both labels at high rates ("addict": 66.67%; "person with a SUD": 38.89%), though mutually exclusive use was lower ("addict" only: 35.19%, "person with a SUD" only: 7.5%). Common label use settings included mutual-aid recovery meetings, with friends and family, and on social media. Analysis of variance tests found no statistically significant differences between label groups for recovery capital, self-esteem, internalized stigma and shame, flourishing, or length in recovery. Descriptively, participants using only "person with a SUD" had more positive outcomes, although these individuals also had higher levels of internalized shame. Results suggest that language may have only a marginal impact on individuals in recovery, although professionals and the general public should continue to avoid using stigmatizing labels. Additionally, many individuals in recovery have the ability to discern context and setting, switching between positive and negative labels as appropriate. Future research is warranted given these pilot findings and should focus on long-term impacts of self-labeling and internalized stereotypes among individuals in recovery. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

In their own words: language preferences of individuals who use heroin

BACKGROUND AND AIMS

Use of non-judgmental, respectful and uniform language to describe individuals with substance use disorders (SUD) is recommended to reduce stigma. However, existing research concerning the use of labels for substance use has largely focused on perspectives of treatment providers and the general public, and to a lesser degree of those in long-term recovery. This study aimed to examine and compare labels that individuals who use heroin and are initiating SUD treatment (1) use to describe themselves and when speaking with others who use drugs, with family and with treatment providers, and (2) prefer to be called and never want to be called. Design and Setting This was a cross-sectional survey study using a convenience sample of individuals initiating an in-patient managed withdrawal program in Massachusetts, USA.

PARTICIPANTS

Between October 2017 and May 2018, 263 participants were enrolled.

MEASURES

Participants completed a survey about (1) what labels they used to refer to self and when talking with others who use drugs, with providers, families and at 12-Step meetings and (2) to identify which label they preferred least and most for others to use when referring to them.

FINDINGS

More than 70% of participants used the term 'addict' to describe themselves and when speaking with others. However, use of 'addict' varied by context, and was most common at 12-Step programs. Fewer than 15% reported using 'user' or slang terms, most commonly 'junkie', in any communications. The most-preferred label for others to call them was 'person who uses drugs', while the most common label that participants never wanted to be called was 'heroin misuser' or 'heroin-dependent'.

CONCLUSION

Label preferences by individuals who use heroin and are in early recovery are consistent with general guidelines about use of first-person language and suggest avoidance of language indicative of drug misuse or dependence.

Biased labels: An experimental study of language and stigma among individuals in recovery and health professionals

BACKGROUND

Labels such as "addict" and "substance abuser" have been found to elicit implicit and explicit stigma among the general public previously. The difference in the levels of this bias among individuals in recovery and those employed in the health profession has not yet been identified, however. The current study seeks to answer this question using measures of implicit bias.

METHODS

A subset sample (n = 299) from a previously completed study (n = 1288) was selected for analysis. Mixed-model ANOVA tests were completed to identify variance between d-prime automatic association scores with the terms "addict" and "substance abuser" among individuals in recovery and those identified as working in the health professions.

RESULTS

Individuals in recovery did not have lower negative associations with either term, whereas individuals employed as health professionals had greater negative associations with the term "substance abuser" but did not have greater negative associations with the term "addict."

CONCLUSIONS

Results provide further evidence that previously identified stigmatizing labels have the potential to influence medical care and medical practitioner perceptions of individuals with substance use disorders and should be avoided. Further exploration into the role negative associations derived from commonly used labels have in the individual recovery process is needed to draw appropriate recommendations.

Substance use, recovery, and linguistics: The impact of word choice on explicit and implicit bias

BACKGROUND

The general public, treatment professionals, and healthcare professionals have been found to exhibit an explicit negative bias towards substance use and individuals with a substance use disorder (SUD). Terms such as "substance abuser" and "opioid addict" have shown to elicit greater negative explicit bias. However, other common terms have yet to be empirically studied.

METHODS

1,288 participants were recruited from ResearchMatch. Participants were assigned into one of seven groups with different hypothesized stigmatizing and non-stigmatizing terms. Participants completed a Go/No Association Task (GNAT) and vignette-based social distance scale. Repeated-measures ANOVAs were used to analyze the GNAT results, and one-way ANOVAs were used to analyze vignette results.

RESULTS

The terms "substance abuser", "addict", "alcoholic", and "opioid addict", were strongly associated with the negative and significantly different from the positive counterterms. "Relapse" and "Recurrence of Use" were strongly associated with the negative; however, the strength of the "recurrence of use" positive association was higher and significantly different from the "relapse" positive association. "Pharmacotherapy" was strongly associated with the positive and significantly different than "medication-assisted treatment". Both "medication-assisted recovery" and "long-term recovery" were strongly associated with the positive, and significantly different from the negative association.

CONCLUSIONS

Results support calls to cease use of the terms "addict", "alcoholic", "opioid addict", and "substance abuser". Additionally, it is suggested that "recurrence of use" and "pharmacotherapy" be used for their overall positive benefits. Both "medication-assisted recovery" and "long-term recovery" are positive terms and can be used when applicable without promoting stigma.