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To neither target, capture, surveille nor wage war: On-going need for attention to

metaphor theory in care and prevention for people who use drugs

David C Perlman, MD1, 2,*,+, Ashly E Jordan, MPH3, 4,+

1
Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, 120 East 16th St, 12th Floor

New York, NY 10003 USA

2
Center for Drug Use and HIV Research, 120 East 16th St, 12th Floor New York, NY 10003 USA
3
Department of Epidemiology, City University of New York, School of Public Health, 365 Fifth

Avenue, New York, NY 10016 USA

4
Center for Drug Use and HIV Research, 433 First Avenue, 7 th Floor, New York, NY 10010

USA
+
Authors contributed equally to the manuscript
*
Corresponding author, David C Perlman, MD, Chief of Infectious Disease, Professor of

Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, 120 East 16th St,

12th Floor, New York, NY 10003 USA, Email: Dperlman@chpnet.org

Keywords

Metaphor theory, people who use drugs, health promotion

The authors have no conflicts of interest to declare.

This work was supported by the Center for Drug Use and HIV Research, an NIH P30 Center

(P30 DA011041).

Abstract

Metaphors and the frames they evoke potently influence how people understand issues. These

concepts of discourse, metaphor and framing have been productively used in a range of studies

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including in the field of addiction. In public health and clinical discourse on people who use

drugs, use of terms such as “targeting,” “surveilling,” and “capturing,” along with “war on

drugs” frames and referring to drug treatment as “substitution” may reinforce negative

perceptions of people who use drugs. Avoiding military metaphors and explicitly leveraging

metaphors that emphasize humanity, social cohesion, and agency have the potential to improve

public health for people who use drugs.

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Words matter not only in the literal content of their meaning, but also in the metaphorical and

culturally relevant frames, affect, and references they evoke. Linguists have shown that metaphor

is an integral unavoidable aspect of discourse, and of how language communicates; metaphors

allow an “understanding and experiencing of one kind of thing in terms of another.”1,2 The

specific choice of words and metaphor potently influences how people understand issues.

Metaphors and evoked frames do more than allow comparisons and understandings: they create

specific understanding by making or highlighting specific connections and by deemphasizing or

obscuring others.1,3,4

Metaphors and evoked frames establish some ideas or objects as self-evident, and others

as unexplained or inexplicable. As formulated by philosophers and linguists, it is through

metaphors and the frames they evoke that language constructs understanding and shapes the

social world, and often constructs understandings that reflect or reinforce (consciously or

unconsciously) existing power structures and dominant ideologies.1,5-8

These concepts of discourse, metaphor and framing have been effectively used in studies

of a range of health conditions including drug use6,9,10 and in communicating health information

to patients.11,12 Metaphor theory has been potently used in political discourse to influence public

perception and is commonly used in advertising and various forms of propaganda. 7,8,13 Lakoff

has drawn attention to the effective use of metaphor theory in political discourse, and to the

importance of developing similarly sophisticated use of metaphor theory and framing for any

effective policy.1,8 Health communication would benefit from enhanced and on-going attention

to the implications and uses of metaphor theory.

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The importance of metaphors and framing has been recognized in studies of drug use,

drug treatment and drug policy.10,14 An important example of their practical application has been

the very intentional shift from referring to “drug addicts,” “intravenous drug abusers” or even

“injection drug users,” to use of the term “people who use drugs” (PWUD). The importance of

this reframing lies in removing both mental associations to all forms of abuse, and to the

dehumanization inherent in externally ascribing a primacy of identity to an activity an individual

may engage or have engaged in, and instead in reaffirming the fundamental humanity of the

people in question. Also critical to this shift are implications of sameness or difference, that is,

whether the frames evoked establish or reinforce notions of social exclusion, or instead situate

drug use as an activity engaged in by people in a community.10 Advances in treatment and

systems for substance misuse prompts the need for ongoing re-assessments of the language used

to refer these care systems.

Terminology used to refer to methadone, buprenorphine, and other pharmacologic agents

in the management of opioid dependence is evolving. The term “drug abuse treatment” has

obvious negative connotations. Hence the superficially more neutral term “opioid substitution

treatment” is commonly used and even preferred by many outstanding scholars and policy

advocates in the field. However, in popular discourse the frame of “opioid substitution” may lend

itself to and reinforce notions of continued dependence and to perceptions that individuals are

merely substituting one stigmatized “bad behavior” for another. Further, the term “substitution”

also evokes frames of a lack of progress or improvement; within deeply resonating metaphors of

“life as a journey” in which moral, purposeful behaviors are commonly conceptualized as

directional and as forward moving (e.g., “a straight and narrow path”,) the term “substitution”

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casts the intervention as non-forward moving and potentially immoral.8 Some have suggested

use of the alternate term “opioid agonist treatment.”15 This term has the advantage of avoiding

the notions of substitution. However, the term “agonist” refers only to a subset of evidence-based

treatment options (e.g., methadone, buprenorphine) and not to opioid antagonist treatments (e.g.,

naltrexone). Further, this medical and pharmacologic term may not be well-understood by

patients and lay audiences.

The terms “medication” and “treatment” instead frame the intervention as helpful,

evoking frames of things that can and will improve through its use. It is broad in that it includes

reference to both agonist and antagonist treatments without the use of medical jargon. The term

“assisted” gives agency to the person using it, evoking frames of an individual seeking self-

improvement. Further, the verb “assist” simultaneously frames the provider as one who offers

evidence-based help, reinforces perceptions of drug treatment as a moral experience, and evokes

frames of social cohesion.8,16,17 Nonetheless, use of the term “medication assisted treatment”

itself might be critiqued on the grounds that it privileges medical discourse, which itself may

produce a range of understandings, but this likely to be preferable to the more marginalizing and

devaluing frames evoked by the term “substitution” and to the narrow and more technical term

“agonist”.10

Similar issues arise in the use of other terms commonly employed by well-intended

providers and researchers. This includes the term “target” to refer to the focused or directed

delivery of services. To say, for example, that efforts are needed to “target a vulnerable

population” makes use of what had been referred to as “military metaphors.”7,18,19 Some have

argued that the use of military metaphors in medical settings is part of a more macro-

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normalization of the militarization of society. 7,20 More specifically, in popular discourse, to

“target” any group, may evoke subconscious images of people being, and perhaps even

deserving to be, shot. The term may also evoke images embedded in recent historical memory,

e.g., of then-Alaskan Governor Sarah Palin‟s superimposed images on a web-site of then-

Congresswoman Gabrielle Giffords on an actual target; Giffords was subsequently shot in the

head during a meeting with constituents. Use of the term “target” evokes concepts of difference

and of devaluation, distinguishing a valued “we” with whom one “ought” to identify, from a

deviant, immoral or at best vulnerable “other.”

Commonly employed terminology such as “target,” or references to systems which are

designed to “capture” individuals or information, or which refer to ongoing “surveillance” or

“monitoring,” may, by evoking deep cognitive frames, 7 unintentionally reinforce the

marginalization of such populations, may reinforce mistrust among potential patients and

communities, and may undercut efforts to improve engagement in services. Use of conscious

vernacular which avoids invoking such potentially marginalizing frames, e.g., by using the terms

“focusing” or “directing” (rather than “targeting”) services, “case finding” or “identifying” rather

than “capturing” data or individuals, and “supporting” or “maintaining communication with”

individuals rather than “surveilling,” “tracking” or “monitoring” may be better terminology

choices. 1,2,19

A key use of military metaphor is, of course, the term, “war on drugs.” This particular

military metaphor does correctly reflect highly militarized aspects of the global drug trade and of

the use of armed forces to curtail such trade. However, while the “war on drugs” has not reduced

the global drug trade or the adverse health consequences of illicit drug use (and may have

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increased them), 21 it may be as relevant that the term “war on drugs” shifts the frame away from

considering social supportive and public health responses and instead towards facilitating

acceptance of militarized responses as both normative and appropriate. Further, the term

obscures that in many settings the “war on drugs” may in fact be a “war on people,” that is, on

PWUD, frames them as appropriate enemies in that war, or at best, as collateral damage victims,

rather than as people who engage in specific behaviors and may benefit from engagement in

effective interventions.20

An additional point is that metaphors and evoked frames may be chosen, which

advertently or inadvertently, remove PWUD from consideration, or from discourse. A critical

discourse analysis found that the recent HCV screening public health policy shift in emphasis

from a focus on risk factor based screening (i.e., injection drug use) to age-based screening,

essentially removes injection drug use from the discourse. 22

Drug use and care for PWUD remain highly stigmatized phenomena. Addiction and drug

use, and metaphors and frames, are both deeply embedded in both brain and social

phenomena.23,24,25 Metaphor and framing have a powerful impact on how people perceive things

and are potent aspects of approaches to care, research and policy. Studies have shown that even

single metaphors have been found to instantiate interpretations consistent with and bounded by

evoked frames, to do so covertly, and to influence opinions about how to address issues. 25,26

Impressions evoked by such frames profoundly affect views of PWUD by others, and may create

and reinforce negative self-images among PWUD. 27 Avoiding frames and metaphors which

inadvertently dehumanize and marginalize PWUD and instead choosing language which

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emphasizes their humanity and depict care systems as inclusive and accepting of PWUD may

yield public health benefits.

The use of the term “medication assisted treatment” rather than “opioid substitution

therapy,” or even “opioid agonist therapy” and use of terms such as “direct” and “focus” rather

than “target,” “identifying” rather than “capturing,” when referring to services for PWUD may

have valuable clinical and policy benefits. The more effective and consistent application of

metaphor theory by scientists, public health officials, journals, service organizations and

providers, and specifically the deliberate use of language that through metaphor and evoked

frames reinforces concepts of humanity, social cohesion, improvement and agency have the

potential to be a vital part of provider and system effectiveness, and efforts to improve the health

of PWUD.

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References

1. Lakoff G, Mark J. Metaphors We Live By. Chicago, IL: The University of Chicago Press;

1980.

2. Thibodeau PH, Boroditsky L. Metaphors we think with: the role of metaphor in

reasoning. PLoS One. 2011;6(2):e16782.

3. Reisfield GM, Wilson GR. Use of metaphor in the discourse on cancer. J Clin Oncology

2004;22(19):4024-4027.

4. Tversky A, Kahneman D. The framing of decisions and the psychology of choice.

Science 1981;211(4481):453-458.

5. Derrida J. Structure, sign, and play in the discourse of the human sciences. A Postmodern

Reader 1993:223-242.

6. Foucault M. The Birth Of The Clinic. Abingdon, Oxon: Routledge; 2003.

7. Lakoff G. Metaphor and war: The metaphor system used to justify war in the Gulf. Peace

Research 1991:25-32.

8. Lakoff G. Moral Politics: How Liberals And Conservatives Think. Chicago, IL:

University of Chicago Press; 2010.

9. Sontag S. Illness As Metaphor And AIDS And Its Metaphors. New York: Doubleday,

1990.

10. Moore D, Fraser S, Törrönen J, Tinghög ME. Sameness and difference: Metaphor and

politics in the constitution of addiction, social exclusion and gender in Australian and

9
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Swedish drug policy. Intern J Drug Policy 2015;26(4):420-428. doi:

10.1016/j.drugpo.2015.01.011

11. Lanceley A, Clark JM. Cancer in other words? the role of metaphor in emotion disclosure

in cancer patients. Br J Psychother 2013;29(2):182-201.

12. Parrott R, Smith RA. Defining genes using “blueprint” versus “instruction” metaphors:

Effects for genetic determinism, response efficacy, and perceived control. Health Comm

2014;29(2):137-146.

13. Herman ES, Chomsky N. Manufacturing Consent: The Political Economy Of The Mass

Media. New York: Pantheon Books, 1988.

14. Gryczynski J, Johnson J, Coyhis D. The healing forest metaphor revisited: The seen and

“unseen world” of drug use. Subst Use Misuse 2007;42(2-3):475-484.

15. Samet JH, Fiellin DA. Opioid substitution therapy-time to replace the term. Lancet

2015;385(9977):1508-1509. doi: 10.1016/S0140-6736(15)60750-4.

16. Kleinman A. Caregiving as moral experience. Lancet 2012;380(9853):1550-1551.

17. Annas GJ. Reframing the debate on health care reform by replacing our metaphors. N

Engl J Med 1995;332(11):744-747.

18. Slobod D, Fuks A. Military metaphors and friendly fire. Canadian Med Assoc J

2012;184(1):144.

19. von Elm E, Diener MK. The language of war in biomedical journals. Lancet

2007;369(9558):274.

20. Paley D. Drug War Capitalism. Oakland CA: AK Press; 2014.

10
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21. Report of the Global Commission on Drug Policy 2011. Accessed on October 21 2016 at

http://www.globalcommissionondrugs.org/wp-

content/themes/gcdp_v1/pdf/Global_Commission_Report_English.pdf.

22. Jordan AE, Perlman DC. The Shift in Emphasis from Risk-Based to Age-Based Hepatitis

C Virus (HCV) Testing in the US Tends to Remove Injection Drug Use from Discourse

on HCV. Subst Use Misuse 2016. Ahead of print doi: 10.1080/10826084.2016.1225767.

23. Rhodes T. The „risk environment‟: a framework for understanding and reducing drug-

related harm. Intern J Drug Policy 2002;13(2):85-94. doi: 10.1016/S0955-

3959(02)00007-5

24. Wise RA. Addiction becomes a brain disease. Neuron 2000;26(1):27-33.

25. Lakoff G. Mapping the brain's metaphor circuitry: metaphorical thought in everyday

reason. Front Hum Neurosci 2014;8:958. doi: 10.3389/fnhum.2014.00958

26. Thibodeau PH, Boroditsky L. Natural language metaphors covertly influence reasoning.

PLoS One 2013;8(1):e52961. doi: 10.1371/journal.pone.0052961

27. Simmonds L, Coomber R. Injecting drug users: A stigmatised and stigmatising

population. Intern J Drug Policy 2009;20(2):121-130.

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