A Comprehensive Approach:
Preventing Blood-Borne Infections Among Injection Drug Users

Chapter 2, Section 1: Negative Attitudes and Stigma Toward IDUs Persist Despite a New Understanding of Addiction

Negative attitudes and biases about addiction and drug users are pervasive and derive from experience and deeply felt moral and philosophical beliefs. These attitudes, widespread among the general public and many policy makers, are prevalent even among service providers and health professionals (Cole and Slocumb, 1993; McGrory et al., 1990; Wallack, 1991; Yedidia et al., 1993; Yedidia et al., 1996). IDUs are stigmatized, seen as less valuable citizens than others in the population. Many IDUs are marginalized, without full participation in the economic, social, or cultural life of their community. For those IDUs who are infected with HIV or other blood-borne illnesses or who have associated mental illness or other conditions, the stigmatization and marginalization are further increased (Des Jarlais et al., 1993).

In the eyes of many, IDUs, at best, are seen as victims of their addiction. At worst, they are viewed as criminals or as weak and bad people whose chaotic lives and inability to overcome addiction result from moral failure rather than from a legitimate medical condition or a lack of access to adequate, comprehensive treatment (Des Jarlais et al., 1993; Leshner, 1997). They are regarded somehow as alien figures, as one of "them," not one of "us." Their addiction or resulting infection with HIV or hepatitis is "their fault." IDUs are incorrectly perceived to be unwilling to change their behaviors or unable to respond to education, outreach, or treatment interventions (Jones and Anderson, 1999). These negative and dehumanizing attitudes toward IDUs even extend to the providers and programs that work with them. These professionals and organizations are also seen as having lower social value than those working with mainstream populations and are often stigmatized for serving IDUs (AED, 1999; Friedman, 1998).

"Junkiephobia" is a term that has been used to encapsulate this complex of stereotypes, stigma, and negative attitudes toward IDUs (Jones and Anderson, 1999). Like "racism" and "homophobia," "junkiephobia" covers a number of social and individual factors underlying these attitudes. For example, a lack of knowledge about addiction and ignorance of the lives and cultures of IDUs is a factor leading to stereotyping and stigmatization. Fear of the addictive capacity of drugs and of addicts themselves is another factor. Reluctance to support policies that might appear to promote or condone drug use, such as syringe exchange, is a third powerful factor. Lack of specific provider training and education also hamper those in service agencies from providing empathetic, responsive, and appropriate services and education to IDUs.

These attitudes persist among the public, policy makers, and service providers despite advances in the neurosciences and the behavioral sciences that have transformed the understanding of drug abuse and addiction. It is now known that the roots of addiction lie in a series of complex biochemical changes that occur in the brain over time, causing alterations in brain function. The result is a chronic and relapsing, but treatable, disease with intertwined biological, behavioral, and social components.

Studies over the last 20 years have revealed that all drugs have the same effects on a single pathway deep inside the brain, the mesolimbic dopamine system (Childress et al., 1999; Koob, 1996; Koob, 1992; NIDA/Hospital Practice, 1997; Volkow et al., 1993). When activated in response to natural rewards, such as food, water, sex, and nurturing, this pathway provides pleasurable feelings. These pleasurable feelings cause the individual to repeat the behavior to reactivate the reward pathway. All addictive drugs, and nicotine, also activate this reward system by causing an extra release of dopamine into the pathway. Initially, an individual uses a drug because of the pleasurable effects on mood, perception, and psychological state. Prolonged drug use, however, causes fundamental and long-lasting changes in the brain. At some point, these changes throw a metaphorical "switch" in the brain. Once the switch is thrown, the individual moves from a state of voluntary drug use to a state of addiction in which drug seeking and use are uncontrollable and compulsive. In the addicted state, the pleasurable effects of the drug may be minimized or absent altogether.

  The compulsion to use some drugs, like heroin, is partly driven by the need toward off the withdrawal syndrome, which occurs when use is stopped or reduced. This syndrome is characterized by nausea and vomiting, muscle cramps, sweating, agitation, and depression. Because these symptoms can be managed with medications and because not all addictive drugs result in this syndrome (cocaine, for example, does not), addiction is no longer defined so much by the element of physical dependence, but is increasingly described as compulsive drug seeking and use that come to dominate a drug addict's life, even in the face of terrible physical and social consequences (Leshner, 1997; NIH, 1997).

Another concept that is key to the current understanding of drug addiction is that it is not an acute illness, but rather a chronic, relapsing condition that is treatable. Like other chronic illnesses, such as diabetes, asthma, or hypertension, appropriate treatment must be focused more on effective management over the long term rather than on a permanent cure (Leshner, 1997). Treatment compliance and relapse rates in drug addiction are about the same as in these other chronic medical conditions (O'Brien and McLellan, 1996).

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