Hi, and thanks for joining. It's my pleasure to introduce you to Michael Botticelli. Michael is the former director of the Office of National Drug Control Policy in the White House in the Obama administration. He's also the former director of Substance Use Services in the state of Massachusetts. He is the senior policy scholar this year at the School of Public Health in the Department of Health Policy and Management. But more importantly in all those things and particularly with the Obama administration, Michael really redefine the role of drugs are in this country and was an inspiration to really hundreds of thousands if not millions of people in the work and the incredible efforts that he lead to focus attention on the opioid crisis. So we're so thrilled that you're here with us at the school, Michael and thanks so much for joining for this course. It's good to be here, it's always fun to talk with you. So Michael will be part of a couple, you'll be part of a couple of classes, a couple of sessions, but this one we're going to talk about stigma, which has been a major focus of yours, both when you're at the national level and on the state. I wonder just to start, when you think of stigma related to opioid addiction, what do you think about? What does that mean to you? So as I think of both what is meant personally, but also as a person in long-term recovery has been a personal issue for me too. I'll just personalize it by talking about my own experience and what it meant for me is. As my substance use disorder was developing, it reached a point where I clearly knew that I needed help, but I was really afraid to ask for it. I thought because I had some level of education that people would think that I was stupid, that I was weak willed. It really prevented me from asking for help, and particularly asking for help in probably the earlier stages when I didn't have to have more significant consequences as relate to it. But like many people, my addiction, one of the consequences I had it wasn't major, but I had drunk driving accident. It's often those intersection with a legal system where we first identify people or be able to get care. My personal experience gets born out time and time again at various different levels. So as I think of stigma, it has an impact on the individual level. Right. One, we know that it results in people delaying seeking care often to when their condition is much more acute, and we know it creates a situation where people avoid seeking care. So when you look at national data, only about 10 percent of people who have a diagnosable substance use disorder get care and treatment. This for our national survey in drug use and health. When you look at for people who are even know they have a problem and who don't seek care, when they're asked the reason why they don't see care, one of the top factors is stigma, they're afraid that their employers are going to find out about it, they're afraid that their neighbors are going to find out about it. Well, one thing that is really striking about your answer and I've also come to appreciate, is that you went right to stigma as experienced by the individual and how it's affecting their own actions in a way the internalized stigma. Most people when they think of sigma, they think of well, it's just discrimination, somebody sees someone who's using drugs for example and just feels like there are moral failure or something like that. That it's externally imposed. But the primary issue that you just expressed is that, it keeps you from getting the treatment that they need it. Exactly. It was really what you felt as much as internally. Yes. Compared to what other people were saying as well. Obviously, how does those things interact? No. But I think it's both. So you do experience at the individual level, but that also gets translated to the public policy level as well. Actually, there's folks here, did some interesting survey information when you ask people about what they think about people who have a substance use disorder, and the kinds of things that are afforded to all the other folks like treatment, housing, employment opportunities, you find that people generally think that people with substance use disorders are less deserving of things like a treatment benefit. That has gotten reflected in public policy, in insurance discrimination quite honestly, around there under treatment of substance use disorder. So it gets magnified from the individual level up until the public policy level and quite honestly, the over criminalization and incarceration of people with a substance use disorder. What do you think is the root of the sigma? Where does it come from? So I think it is this long standing notion. There is a scientific work around addiction really has, I don't know if you could probably compare about the past 50 years, we've really come to a better scientific understanding of addiction. I think for a very long time, it was seen as an issue of a character flaw or a moral weakness, that people were weak willed. So the solution to that was people just needed a buck up and to be able to do it. So it wasn't a really a medical condition, so the genesis for addiction was not as a medical condition was really more of a social movement that we saw this. So I think our scientific understanding of addiction as a disease has really only been fairly recent. Even some of the treatments that we have, some have been around for a long time, but we're still in the development phase for a lot of treatment protocol. So I also think quite honestly, you can't diminish the racial component of people who've been affected by this, particularly when you look at who is in our jails and prisons particularly just in general, but particularly with substance use disorder, it's overwhelmingly people of course. So I think there's this nexus between race and a lack of scientific understanding of addiction as a disease. Even now, I think our rhetoric around addiction as a disease, I think we're far ahead on the rhetoric and really lag on the public health and health side stepping up in a more dramatic way. Well, let's talk a little bit about rhetoric and particularly about language. You've written and incredibly persuasive that we need to change the language around addiction. Can you go through that a little bit like in terms second hand in some ways? Yeah. We don't realize that language reflects some of these historic misunderstanding. They do. So one of the things that we have really come to understand with other diseases, that our use of language, as you said, is really reflected of what we think about people who have those disorders. I think of like the terminology that we used to use for people with mental illness, that we don't use anymore and because it's highly judgmental, highly stigmatizing. But yet, the language that we use around issues of addiction, calling people addicts and junkies, even use of the word abuse, triggers in people's minds a much more punitive view of people who have the disease. The American Medical Association, the American Society of Addiction Medicine and others have called for a change in the language of addiction. Dr. John Kelly, Dr. Yvette Olson and a number of other people have, I think, really exposed the dynamics of what happens when you use highly stigmatized language. So it extends to lab tests. Right. I mean, people have focused on, you don't say the urine test specimen was negative, people will say that was a clean urine specimen. Yeah. Or even people in recovery. So you'll hear people say in some of this, as a person in recovery, like some of this is also perpetuated, I mean coming from the recovery community itself and so we, I think have a double responsibility to change our own language. But not only urine toxicology screens clean and dirty, but we often say that about people's recovery status. So the opposite of that is clearly dirty, right? So it's really highly judgmental. Even the word abuse implies volition, I think it really underscores this notion that people are willingly addicted. So what we and a lot of other people have called for is the use of non-stigmatizing clinically appropriate language. So rather than talk about a substance abuse, we talk about a person with a substance use disorder, to your point clean and dirty, either in recovery or having a relapse or a remission if you're not calling the results of urine tox screen clean and dirty, positive and negative like you do other diseases. Refraining from using words like addict and junkie. Now, some people take the position that, well, when you do that you make it seem like people have no ability to change, that they're not actors at all in this and so you have like some people who are out there saying, "Well, people who want to change the language want to say is that it's really just not up to the patient at all." But the response to that is that these concepts can co-exist and maybe that if you use more clinically appropriate language, it actually can help individuals realize that everybody has a role in the recovery regardless of what your disorder is. Yeah. You don't have to use stigmatizing language for someone with diabetes to eat healthier for example. So how do you respond when you read something that says or they are trying to make it seem like people have no role with language like this? So I think there is this false dichotomy sometimes that if we say it's a disease and we have language that reflects that it's a disease, that somehow that obviates issues of personal choice and accountability. As someone in recovery, I think the whole point of recovery is that you own it, you're responsible for your actions and part of your recovery process is becoming accountable and making up for those actions. Also, I thoroughly understand that I have a significant role to play in terms of the choices that I make about my own recovery. But I think for a very long time, the pendulum was entirely on the person with the disorder to change their behavior. So think about the language of hitting bottom for instance that somehow that the medical community and other people didn't have a role in motivating people and diagnosing people and motivating people to seek care, we do it with other diseases all the time. I'm a former smoker but every time I went to the doctor, he or she would ask me about my smoking. There's evidence that that actually helps people. It does, it moves people and motivates them. Motivational interviewing is a evidence-based practice that you have about moving people. So I think that both our practice and our language really need to match our understanding of the dimensions of this disease. I also think it's part of our challenge around stigma as well. So part of the symptomatology of addiction is that sometimes people do things, they are not particularly attractive, they're not nice sometimes. But it's the same for me as like blaming the Alzheimer patient for forgetting. I'm not saying that that behavior needs to be excused or people are not accountable for it. But we need to put it in context of that is part of this terminology of the disease. It may to a certain extent, help people take responsibility and take actions if they realize what they're coping with is something that is in part biological, and if you just say that that person have to take, that can actually perpetuate the downward spiral. So I agree with you, I don't think they are averse to each other but it's interesting as I see that various, even just successful trying to change the language that you're giving some perspective. Here we are. Yeah, I think it's true but again, we know as a health community, even as a legal community, that we and they can be powerfully motivating in terms of getting people to acknowledge that they have an issue and getting them to seek care. Certainly, some of that motivation needs to be developed intrinsically on the part of the person to do that. But it's an obligation I think of the health community and others within the community to help support that and help celebrate that. We have often seem that not to be the case either, right. Even in the health community there is huge amount of stigma. Even in the health stigma, huge amount of stigma. I mean in some respects people have been very silent about their own recovery for the same reason. So we as a community, as a society really need to celebrate people in recovery and embrace them. Part of our work at the federal level was to really celebrate that and create the visibility that treatment works and recovery is possible because that's also really important for people to see, is that they need to understand that their life can change dramatically. Well, there really aren't for a long time the idea that people in treatment were doing great and it was something to be celebrated which is now part of the dialogue about this. So the only image people had in their mind is people are just at their worst point.
