Addiction is not a moral failure: Why harm reduction matters

During a rural posting in West Africa, I once saw people at a religious centre locked up, chained to poles and subjected to harsh conditions because they were “addicted to drugs,” brought by their family members who believed they were “demon possessed” or needed “spiritual deliverance.” I remember being shocked and moved to tears at these attempts to detoxify or rehabilitate – but without evidence-based care, compassion, dignity or an understanding of the illness itself.

We are all familiar with the word “addict.” It is used so casually that many people no longer hear the harm inside it. I am writing about people living with substance use disorder: people who continue using substances such as fentanyl, alcohol, cocaine, nicotine or other drugs despite harms to their health, relationships, work and safety.

The stigma is enormous. Society often labels them as weak, irresponsible, criminal or morally failed. We see them on the street, in the subway or outside hospital entrances, and we keep our distance. The smell, the unkempt hair, the tattered clothes, the poverty and sometimes the visible association with crime all reinforce our fear.

Even our language betrays us. When someone stops using drugs, we often ask, “How long have you been clean?” It sounds harmless, but it carries a hidden meaning: if you are using, you are dirty.

That language follows people into the health-care system. Many with substance use disorder face stigma from health-care providers who see them as difficult, non-compliant, drug-seeking or not worth the effort. This can delay pain control, withdrawal treatment and compassionate assessment. It also helps explain why some of them leave emergency departments or hospitals before their treatment is complete. Sometimes they leave not because they do not want care, but because the care they receive does not feel like care.

Stigma also drives people into hiding. People who might benefit from treatment may avoid seeking help because they fear being called a junkie, a crackhead, a criminal or a failure. And when people hide their substance use, they may use alone. In a toxic drug supply, using alone can be fatal.

Not everyone who uses drugs is living on the street. Many use substances behind closed doors, in homes, workplaces and families that appear stable from the outside. Addiction does not respect socioeconomic status. It can happen in a shelter, a mansion, a university residence or an office.

This is where I believe the comparison with cancer becomes useful – not because addiction and cancer are the same disease, but because both force us to ask what kind of suffering deserves compassion. When someone has cancer, we usually respond with empathy, dignity, love and urgency. We do not ask whether they deserve chemotherapy or ponder if it was of their own making.

Substance use disorder is also a chronic, treatable medical condition. It affects the brain, behaviour, decision-making, reward, memory and survival. In that sense, addiction can be thought of as a cancer of the mind: not a moral failure, but a process that grows inside a person, consumes more and more of life, and competes against the person’s own desire to live.

No one is born wanting to be addicted. Even babies born after exposure to substances in pregnancy may experience withdrawal after delivery, but they are not “addicts.” Addiction requires craving, loss of control and continued use despite harm. Genetics, trauma, mental illness, pain, poverty, peer exposure, family history and drug availability all play a role. Choice may be involved at some point, but addiction is what happens when choice becomes narrowed by biology and life circumstance.

Using a substance is not, by itself, addiction. Addiction is use despite harm. It is wanting to stop and not being able to. It is returning to something that is destroying you because, at that moment, your brain and body believe you need it to survive.

Withdrawal helps explain part of this. For someone not living with addiction, drugs are seen as dangerous. But for someone who is physically dependent, the experience can feel inverted: if I do not use, I will be harmed. My body may sweat, shake, vomit, ache, panic, cramp and feel tortured from the inside. With alcohol or benzodiazepines, withdrawal can even be medically dangerous without treatment.

Initially, a person may use a substance to feel high, numb pain or escape trauma. Over time, the brain adapts. The same amount no longer produces the same effect. More is needed. This is tolerance. Eventually, the drug is no longer only about pleasure. It becomes about feeling normal, avoiding withdrawal and quieting a craving that can overwhelm reason. Craving is not a simple appetite. It is more like suffocation, with the drug becoming oxygen.

This does not mean people with addiction lack values, dreams or love for their families. Many hate what the substance has done to their lives. Many have promised themselves and their loved ones that they will stop. Then they return to the same substance that has cost them jobs, homes, relationships, freedom and, sometimes, nearly their lives. That is not because they are evil. It is because the illness has invaded the part of the brain that helps them pause, reason, choose and hope.

This is why harm reduction matters. We must prevent people, especially young people, from being exposed to harmful substances in the first place. But we must also keep alive those who are already trapped. Naloxone, supervised consumption services, opioid agonist therapy, trauma-informed care, housing, counselling and respectful primary care are not signs of surrender. They are ways of saying: your life still matters, even before you are ready or able to stop.

If we want to address stigma, we must start with language. Say “person with substance use disorder,” not “addict.” Say “person who uses drugs,” not “junkie.” Say “in recovery,” not “clean,” because the opposite of clean is dirty. No human being should be made to feel dirty because they are sick.

We also need humility. Many of us are one trauma, one prescription, one accident, one bereavement, one childhood wound, one untreated depression or one toxic environment away from a different life. Our brains are shaped by exposure, learning, pain, our environments and relationships.

When we look at people living with addiction, we must resist the temptation to see only the substance. Behind the drug is a human being who was once somebody’s baby, classmate, sibling, friend or partner. A life may have been derailed, but it is not disposable.

The goal is not to romanticize addiction. Addiction can cause devastation. It can hurt families. It can be associated with crime, unbearable pain and untimely death. But stigma has never cured it. Shame has never reversed it.

Chains did not heal the people I saw in that West African centre. Fear did not give them recovery. What they needed then is what people need now: evidence-based care, dignity, compassion and a society willing to see the human before the drug.