American stigma: A brief history  

Recent reporting from NPR’s Brian Mann explored how some doctors are unwilling to treat addiction. They don’t think medications will help the patients. They don’t want those patients in their offices. And they don’t feel prepared to treat them.  

In 2025, 80 percent of people who had an SUD did not get treatment. And this in a moment, when, for example, restrictions have eased on opioid use disorder-treating buprenorphine. 

In one dramatic moment from Mann’s reporting, a man who seemed to be struggling with substance use is sent back to the streets by hospital staff. They said there was nothing they could do to help him. The police officers handling the situation are uncomfortable with the response and say as much on a recording of the incident. The man died of an overdose shortly thereafter. 

Mann reported that ‘“for decades, addiction was seen as a moral or criminal issue.”  I would suggest that has been an issue for much longer than that. Stigma against people with a substance use disorder is as American as apple pie. 

Of course that stigma would affect medical professionals. In 2025, researchers in the journal Addiction reported that stigma is “widespread within the primary care and emergency medicine workforces – the workforces called to the forefront to combat the overdose epidemic.” 

I don’t think these findings would be especially surprising to anyone who has sought treatment for an SUD. While many health care professionals are doing important work, they are subject to the same education from popular culture as the rest of us. American culture is replete with stigma revealed in stereotypes and jokes about people with substance use disorders. It runs deep. 

In Washington Irving’s 1819 short story, “Rip Van Winkle,” Rip gets drunk in a forest and wakes up 20 years later. He drinks, it would seem, to escape something – responsibility, work, relationships – but readers are supposed to view Rip as a slacker. And Irving’s stories became American myths taught to schoolchildren for centuries. 

Some late 19th century temperance advocates used the tale to teach about the horrors of drinking. One contemporary treatment center writes on its website that RIp should have trusted his gut. His story, they write, is “reminiscent of the story many alcoholics and addicts face when they finally ‘wake’ up, and realize how much time has passed them by, thanks to their drinking and/or using.”

The message is clear: Make better choices because your addiction is a moral issue.

Rip’s not alone in turning to substance use in order to deal with stress or mental illness: In Melville’s short story “Bartleby the Scrivener,” Turkey drinks in order to survive his dull and monotonous work. The narrator in Poe’s “Ligeia” uses laudanum to deal with the loss of his wife. These are characters dealing with trauma, grief, and loss, or escaping a world that is moving too fast for them. And they are making poor choices. 

By the late 19th century and into the 20th century, stigma against substance use and addiction gathered with the growing strands of racism and xenophobia. Opium use is tied to Chinese Americans despite the many white women prescribed the medicine and white men addicted to it after the war. Fear of Black men using crack cocaine is amplified in newspapers around the country. And in the Midwest, advocates called for the prohibition of alcohol for reasons not least of which was the influx of Eastern European immigrants who drank beer. 

The response took shape with a war on drug users that began with the Exclusion Act of 1909, led to the Controlled Substances Act of 1970, and persists through this moment in the actions of a government that seeks to control fentanyl by blowing up boats off the coast of Venezuela. 

I occasionally get private questions from parents or friends seeking treatment for a loved one. In hushed tones they ask how and where they can get help. Their discretion tells me we have so far to go before they and their loved one know that they are loved and cared for and that there is help available.

In the wake of the overdose catastrophe, more Americans should be aware that addiction is not a moral failing, and that the overdose crisis was generated by policy failures.

It’s not just the interpersonal things. It’s the way that stigma is baked into the system. How structures, such as the ridiculous barriers for dispensing methadone, prevent people from practicing research-based medicine. Most recently, consider the cuts to SAMHSA, the virtual erasure of the term “harm reduction” from the CDC, RFK Jr’s apparent belief that “wellness farms” are gold-standard, and our continued war on drugs.

In recent months, there has been excitement about a new fentanyl vaccine. The vaccine works by training the immune system to recognize and attack fentanyl and fentanyl analogues. 

But a vaccine can’t address the underlying causes of addiction. It is a solution that has its roots in the demon drug myth – if we can just stamp out this one drug all will be well. It’s a solution that is rooted in stigma. A quick fix, maybe, but not a long-term solution. We don’t have to think about the drivers of addiction. We don’t have to solve the bigger issues.

In some ways, we’re all like Rip Van Winkle, asleep since the turn of the century as more than 1.25 million Americans have died of an overdose, only to awaken, confused, and disoriented. 

And somehow we just take up right where we left off.