This article provides a present-day reflection, focusing mainly on Brazil, of terms used by society at large (and frequently by health workers) to refer to people who use drugs. The greater part of the scientific literature is published in English and, therefore, Brazilian literature does not yet contain standardizations of adequate terms in the area of alcohol and other drugs. This results in a series of doubts and (uncritical) reproduction of terms that have not been used in the scientific literature for more than 10 years.¹1. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy [Internet]. 2010 May [cited 2020 Dec 3];21(3):202-7. Available from: https://doi.org/10.1016/j.drugpo.2009.10.010
https://doi.org/10.1016/j.drugpo.2009.10... The intention is to provide references rather than to rigidly standardize these terms, since language – whether used in clinical practice or in scientific literature – is dynamic. A panorama will be presented of current discussion and alternatives on which researchers, health workers, the press and the population can base themselves in order to reduce stigma in the area of alcohol and other drugs.

Science has evolved in diverse domains, ranging from new discoveries that make previous findings obsolete, to modification of terms that become inappropriate at a given moment in history. In the area of mental health, for instance, “exceptional” children are now called “children with intellectual disability”, and “schizophrenics” are now called “people with schizophrenia”.²2. American Psychiatric Association. DSM-5: Manual diagnóstico e estatístico de transtornos mentais [Internet]. 5. ed. Porto Alegre: Artmed Editora; 2014 [citado 2020 dez 3]. Disponível em: http://www.niip.com.br/wp-content/uploads/2018/06/Manual-Diagnosico-e-Estatistico-de-Transtornos-Mentais-DSM-5-1-pdf.pdf
http://www.niip.com.br/wp-content/upload... Adequacy of language in the area of mental health is not merely a question of being politically correct, as this expression relates to words that are used in social contexts just to conceal prejudice rather than to combat it.

Adequate use of terms in the area of alcohol and other drugs is not a recent movement. Since the 1960s, the World Health Organization (WHO) has been discussing and changing several nomenclatures; for example, the term “alcoholic” has been replaced by “alcohol dependence”.³3. Edwards G, Arif A, Hadgson R. Nomenclature and classification of drug-and alcohol-related problems: a WHO memorandum. Bull World Health Organ [Internet]. 1981 [cited 2020 Dec 3];59(2):225-42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2396054/pdf/bullwho00419-0057.pdf
https://www.ncbi.nlm.nih.gov/pmc/article... The American Psychiatric Association removed the term “abuse” from the new version of its Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5).²2. American Psychiatric Association. DSM-5: Manual diagnóstico e estatístico de transtornos mentais [Internet]. 5. ed. Porto Alegre: Artmed Editora; 2014 [citado 2020 dez 3]. Disponível em: http://www.niip.com.br/wp-content/uploads/2018/06/Manual-Diagnosico-e-Estatistico-de-Transtornos-Mentais-DSM-5-1-pdf.pdf
http://www.niip.com.br/wp-content/upload... In Brazil terminologies contained in laws and decrees have been changed, replacing terms such as “addicted offenders”,⁴4. Brasil. Presidência da República. Casa Civil. Lei n. 5.726, de 29 de outubro de 1971. Dispõe sobre medidas preventivas e repressivas ao tráfico e uso de substâncias entorpecentes ou que determinem dependência física ou psíquica e dá outras providências [Internet]. Diário Oficial da União, Brasília (DF), 1971 nov 1 [citado 2020 dez 3];Seção 2:12. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/1970-1979/L5726.htm
http://www.planalto.gov.br/ccivil_03/lei... “drug addict sanatorium”,⁵5. Brasil. Império do Brasil. Decreto n. 847, de 11 de outubro de 1890. Promulga o Código Penal [Internet]. Coleções de Leis do Império do Brasil, Rio de Janeiro (RJ); 1890 dez 13 [citado 2020 dez 3]. Disponível em: http://www.planalto.gov.br/ccivil_03/decreto/1851-1899/d847.htm
http://www.planalto.gov.br/ccivil_03/dec... “National Anti-Drug Council” with other more adequate terms, such as “dependent”,⁶6. Brasil. Presidência da República. Casa Civil. Lei 10.409, de 11 de janeiro de 2002. Dispõe sobre a prevenção, o tratamento, a fiscalização, o controle e a repressão à produção, ao uso e ao tráfico ilícitos de produtos, substâncias ou drogas ilícitas que causem dependência física ou psíquica, assim elencados pelo Ministério da Saúde, e dá outras providências [Internet]. Diário Oficial da União, Brasília (DF), 2002 jan 14 [citado 2020 dez 3]. Disponível em: http://www.planalto.gov.br/ccivil_03/LEIS/2002/L10409.htm
http://www.planalto.gov.br/ccivil_03/LEI... “access to care”,⁷7. Brasil. Presidência da República. Casa Civil. Lei n. 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental [Internet]. Diário Oficial da União, Brasília (DF), 2001 maio 9 [citado 2020 dez 3]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10216.htm
http://www.planalto.gov.br/ccivil_03/lei... “National Policy on Drugs”, respectively. Jointly with other organizations, in 2017 the Brazilian Platform on Drug Policies launched a Journalist’s Guide to Drugs, with the aim of providing guidance to press professionals so as to reduce stigma in Brazilian media reports and stories.⁸8. Araujo T. Guia sobre drogas para jornalistas [Internet]. São Paulo: IBCCRIM-PBPD-Catalize-SSRC; 2017 [citado 2020 dez 3]. Disponível em: http://pbpd.org.br/glossario/guia-sobre-drogas-para-jornalistas/
http://pbpd.org.br/glossario/guia-sobre-... Efforts like these contribute to the adequacy, coherence and propagation of scientific findings among society.

A study conducted in 2010 with health workers tested the influence of the expressions “drug abuse” and “substance use disorder” and found that when the term “abuse” was used, health workers were more inclined to indicate actions of punishment and blame.¹1. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy [Internet]. 2010 May [cited 2020 Dec 3];21(3):202-7. Available from: https://doi.org/10.1016/j.drugpo.2009.10.010
https://doi.org/10.1016/j.drugpo.2009.10... Use of inadequate terms, including by highly qualified professionals, can be prejudicial to access, seeking treatment and adherence to it by people who use drugs.⁹9. Botticelli M P, Koh H K. Changing the language of addiction. Jama [Internet]. 2016 October [cited 2020 Dec 3]; 316(13): 1361-1362. Available from: https://doi.org/10.1001/jama.2016.11874
https://doi.org/10.1001/jama.2016.11874...

10. Fadus MC. Rethinking the language of substance abuse. Curr Psychiatry [Internet]. 2020 Jul [cited 2020 Dec 3];19(7):e9-10. Available from: https://www.mdedge.com/psychiatry/article/224467/addiction-medicine/rethinking-language-substance-abuse
https://www.mdedge.com/psychiatry/articl... ^-1111. Ashford RD, Brown AM, Curtis B. The language of substance use and recovery: Novel use of the go/no–go association task to measure implicit bias. Health Commun [Internet]. 2019 Oct [cited 2020 Dec 3];34(11):1296-302. Available from: https://doi.org/10.1080/10410236.2018.1481709
https://doi.org/10.1080/10410236.2018.14...

It is recommended that unspecific terms or terms with unclear meanings be avoided, such as “moderate use”, “healthy use”, “unhealthy use”, “responsible use”, “problematic use”, “misuse” and “compulsive use”,¹¹11. Ashford RD, Brown AM, Curtis B. The language of substance use and recovery: Novel use of the go/no–go association task to measure implicit bias. Health Commun [Internet]. 2019 Oct [cited 2020 Dec 3];34(11):1296-302. Available from: https://doi.org/10.1080/10410236.2018.1481709
https://doi.org/10.1080/10410236.2018.14... ^,1212. Saitz R. Things that work, things that don’t work, and things that matter—including words. J Addiction Med [Internet]. 2015 Nov-Dec [cited 2020 Dec 3];9(6):429-30. Available from: https://doi.org/10.1097/adm.0000000000000160
https://doi.org/10.1097/adm.000000000000... as well as common everyday terms (Figure 1).¹¹11. Ashford RD, Brown AM, Curtis B. The language of substance use and recovery: Novel use of the go/no–go association task to measure implicit bias. Health Commun [Internet]. 2019 Oct [cited 2020 Dec 3];34(11):1296-302. Available from: https://doi.org/10.1080/10410236.2018.1481709
https://doi.org/10.1080/10410236.2018.14...

12. Saitz R. Things that work, things that don’t work, and things that matter—including words. J Addiction Med [Internet]. 2015 Nov-Dec [cited 2020 Dec 3];9(6):429-30. Available from: https://doi.org/10.1097/adm.0000000000000160
https://doi.org/10.1097/adm.000000000000...

13. Kelly JF, Saitz R, Wakeman S. Language, substance use disorders, and policy: the need to reach consensus on an “addiction-ary”. Alcohol Treat Q [Internet]. 2016 Jan [cited 2020 Dec 3];34(1):116-23. Available from: https://doi.org/10.1080/07347324.2016.1113103
https://doi.org/10.1080/07347324.2016.11...

14. Broyles LM, Binswanger IA, Jenkins JA, Finnell DS, Faseru B, Cavaiola A, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus [Internet]. 2014 [cited 2020 Dec 3];35(3):217-21. Available from: https://doi.org/10.1080/08897077.2014.930372
https://doi.org/10.1080/08897077.2014.93... ^-1515. Pivovarova E, Stein MD. In their own words: language preferences of individuals who use heroin. Addiction [Internet]. 2019 Oct [cited 2020 Dec 3];114(10):1785-90. Available from: https://doi.org/10.1111/add.14699
https://doi.org/10.1111/add.14699... It is also proposed that terms such as “alcohol user” be avoided, even though this term has been proposed to replace another inappropriate term such as “alcoholic” (“alcoólatra” in Portuguese), which denotes “idolatry”.¹¹11. Ashford RD, Brown AM, Curtis B. The language of substance use and recovery: Novel use of the go/no–go association task to measure implicit bias. Health Commun [Internet]. 2019 Oct [cited 2020 Dec 3];34(11):1296-302. Available from: https://doi.org/10.1080/10410236.2018.1481709
https://doi.org/10.1080/10410236.2018.14... ^,1616. Wakeman SE. Language and addiction: choosing words wisely. Am J Public Health [Internet]. 2013 Apr [cited 2020 Dec 3];103(4):e1-2. Available from: https://dx.doi.org/10.2105%2FAJPH.2012.301191
https://dx.doi.org/10.2105%2FAJPH.2012.3... The word “alcoolista” has been used more in the Brazilian context, and denotes “someone who has a preference for something”; however, as it is a question of a disorder due to alcohol use, the person does not prefer to use alcohol, but rather does so because of their current clinical picture, which involves genetic, psychological and social factors.¹⁷17. Volkow ND. Stigma and the toll of addiction. N Engl J Med [Internet]. 2020 Apr [cited 2020 Dec 3];382(14):1289-90. Available from: https://doi.org/10.1056/nejmp1917360
https://doi.org/10.1056/nejmp1917360... The expression “chemical dependence” has also been discussed as being unspecific, since it does not cover psychological and social factors, and reduces a multifactorial dimension into just one of its facets – the “chemical” part.¹⁸18. Wakeman SE. The language of stigma and addiction. In: Avery JD, Avery JJ, editors. The stigma of addiction. New York: Springer; 2019. 71-80 p.

In the social imaginary, the term “abuse” is associated with violent behaviors directed towards other people, such as rape and domestic violence.¹²12. Saitz R. Things that work, things that don’t work, and things that matter—including words. J Addiction Med [Internet]. 2015 Nov-Dec [cited 2020 Dec 3];9(6):429-30. Available from: https://doi.org/10.1097/adm.0000000000000160
https://doi.org/10.1097/adm.000000000000... The term is used in the area of alcohol and other drugs and can perpetuate the idea that a person who uses drugs is guilty and deserves punitive measures and exclusion.¹²12. Saitz R. Things that work, things that don’t work, and things that matter—including words. J Addiction Med [Internet]. 2015 Nov-Dec [cited 2020 Dec 3];9(6):429-30. Available from: https://doi.org/10.1097/adm.0000000000000160
https://doi.org/10.1097/adm.000000000000... ^,1414. Broyles LM, Binswanger IA, Jenkins JA, Finnell DS, Faseru B, Cavaiola A, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus [Internet]. 2014 [cited 2020 Dec 3];35(3):217-21. Available from: https://doi.org/10.1080/08897077.2014.930372
https://doi.org/10.1080/08897077.2014.93...

15. Pivovarova E, Stein MD. In their own words: language preferences of individuals who use heroin. Addiction [Internet]. 2019 Oct [cited 2020 Dec 3];114(10):1785-90. Available from: https://doi.org/10.1111/add.14699
https://doi.org/10.1111/add.14699...

16. Wakeman SE. Language and addiction: choosing words wisely. Am J Public Health [Internet]. 2013 Apr [cited 2020 Dec 3];103(4):e1-2. Available from: https://dx.doi.org/10.2105%2FAJPH.2012.301191
https://dx.doi.org/10.2105%2FAJPH.2012.3...

17. Volkow ND. Stigma and the toll of addiction. N Engl J Med [Internet]. 2020 Apr [cited 2020 Dec 3];382(14):1289-90. Available from: https://doi.org/10.1056/nejmp1917360
https://doi.org/10.1056/nejmp1917360... ^-1818. Wakeman SE. The language of stigma and addiction. In: Avery JD, Avery JJ, editors. The stigma of addiction. New York: Springer; 2019. 71-80 p. Other terms commonly used when giving the results of toxicology tests, or at places where substance use disorder treatment is provided, are “clean” or “dirty”.¹⁸18. Wakeman SE. The language of stigma and addiction. In: Avery JD, Avery JJ, editors. The stigma of addiction. New York: Springer; 2019. 71-80 p. Such words, apart from evoking implicit punitive prejudice, reduce the sensation of self-efficacy, and are a barrier to changing paradigms in the field of health.¹²12. Saitz R. Things that work, things that don’t work, and things that matter—including words. J Addiction Med [Internet]. 2015 Nov-Dec [cited 2020 Dec 3];9(6):429-30. Available from: https://doi.org/10.1097/adm.0000000000000160
https://doi.org/10.1097/adm.000000000000... In the case of toxicology tests, use of the expressions “positive” and “negative” is recommended.⁹9. Botticelli M P, Koh H K. Changing the language of addiction. Jama [Internet]. 2016 October [cited 2020 Dec 3]; 316(13): 1361-1362. Available from: https://doi.org/10.1001/jama.2016.11874
https://doi.org/10.1001/jama.2016.11874... ^,1717. Volkow ND. Stigma and the toll of addiction. N Engl J Med [Internet]. 2020 Apr [cited 2020 Dec 3];382(14):1289-90. Available from: https://doi.org/10.1056/nejmp1917360
https://doi.org/10.1056/nejmp1917360...

Another aspect to be considered is the encouragement of language aimed at changing the perception of a person from their “being” a problem, to their “having” a problem. ¹⁵15. Pivovarova E, Stein MD. In their own words: language preferences of individuals who use heroin. Addiction [Internet]. 2019 Oct [cited 2020 Dec 3];114(10):1785-90. Available from: https://doi.org/10.1111/add.14699
https://doi.org/10.1111/add.14699... For example, terms like “users” and “dependents” group people together and depersonalize them; for this reason, the expressions “person who uses drugs”, “person with a substance use disorder” or “person dependent on alcohol” are preferable.¹⁵15. Pivovarova E, Stein MD. In their own words: language preferences of individuals who use heroin. Addiction [Internet]. 2019 Oct [cited 2020 Dec 3];114(10):1785-90. Available from: https://doi.org/10.1111/add.14699
https://doi.org/10.1111/add.14699... Other current terms have been adopted, such as those that denote degrees of risk, like “at-risky “, “low-risk” or “high-risk”.⁹9. Botticelli M P, Koh H K. Changing the language of addiction. Jama [Internet]. 2016 October [cited 2020 Dec 3]; 316(13): 1361-1362. Available from: https://doi.org/10.1001/jama.2016.11874
https://doi.org/10.1001/jama.2016.11874... With regard to “drug dependence”, which is currently referred to as “substance use disorder”, the findings show that both expressions are appropriate for health settings.¹²12. Saitz R. Things that work, things that don’t work, and things that matter—including words. J Addiction Med [Internet]. 2015 Nov-Dec [cited 2020 Dec 3];9(6):429-30. Available from: https://doi.org/10.1097/adm.0000000000000160
https://doi.org/10.1097/adm.000000000000... ^,1313. Kelly JF, Saitz R, Wakeman S. Language, substance use disorders, and policy: the need to reach consensus on an “addiction-ary”. Alcohol Treat Q [Internet]. 2016 Jan [cited 2020 Dec 3];34(1):116-23. Available from: https://doi.org/10.1080/07347324.2016.1113103
https://doi.org/10.1080/07347324.2016.11... ^,1616. Wakeman SE. Language and addiction: choosing words wisely. Am J Public Health [Internet]. 2013 Apr [cited 2020 Dec 3];103(4):e1-2. Available from: https://dx.doi.org/10.2105%2FAJPH.2012.301191
https://dx.doi.org/10.2105%2FAJPH.2012.3... ^,1919. Goodyear K, Haass-koffler CL, Chavanne D. Opioid use and stigma: the role of gender, language and precipitating events. Drug Alcohol Depend [Internet]. 2018 Apr [cited 2020 Dec 3];185:339-46. Available from: https://dx.doi.org/10.1016%2Fj.drugalcdep.2017.12.037
https://dx.doi.org/10.1016%2Fj.drugalcde... Even expressions frequently used in health and research contexts, such as “demotivated”, “resistant”, “non-adherent”, can individualize responsibility for treatment. Alternatives to these expressions are “not in agreement with the treatment plan”, “opted not to”, “has not begun treatment”.¹⁴14. Broyles LM, Binswanger IA, Jenkins JA, Finnell DS, Faseru B, Cavaiola A, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abus [Internet]. 2014 [cited 2020 Dec 3];35(3):217-21. Available from: https://doi.org/10.1080/08897077.2014.930372
https://doi.org/10.1080/08897077.2014.93...

In view of the countless barriers and difficulties found in the area of alcohol and other drugs in Brazil (where over 43.1% of the population used alcohol; 17.3% used tobacco; and 3.4% used an illegal substance in the last 12 months), ²⁰20. Bastos FIPM, Vasconcellos MTLD, De Boni RB, Reis NBD, Coutinho CFDS. III levantamento nacional sobre o uso de drogas pela população brasileira [Internet]. Rio de Janeiro: Fiocruz; 2017 [citado 2020 dez 3]. Disponível em: https://www.arca.fiocruz.br/handle/icict/34614
https://www.arca.fiocruz.br/handle/icict... an initial way forward would be to adopt language that is appropriate from the scientific and health point of view, and which transmits the same dignity and respect offered to people with other health conditions. The negative consequences of drug use go beyond substance use disorder, and also involve increased occurrence of chronic diseases, early death, and disabilities.²¹21. Burton R, Sheron N. No level of alcohol consumption improves health. Lancet [Internet]. 2018 Sep [cited 2020 Dec 3];392(10152):987-8. Available from: https://doi.org/10.1016/s0140-6736(18)31571-x
https://doi.org/10.1016/s0140-6736(18)31... In the meantime, efforts to change terminologies need to take place systematically and consistently, taking current scientific findings into consideration.

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