Substance Use and Autonomy in Word and Deed
It’s like a series of riddles. What experience has universal meaning but no agreed-upon name? What “deadly disease” do some people not mind having – or might not even exist? What service is out of reach for many who desperately want it, while pushed on others with grave consequences if they refuse?
Archetypal imagery can help free our thinking from cliches and stereotypes.
Image description: The 9 of Wands from the Rider-Waite-Smith tarot deck. A person with a bandaged head and a wary expression holds one upright wand, with eight more wands standing in a line behind them.
I am a “normie” according to my colleagues in twelve-step recovery. This label means that unlike them, I can use substances “like a normal person” – again, their language. I think of myself as a counselor of “addiction” because people tell me this term best describes their experience. It is subjective, not clinical. But even in explaining this positionality I am using terms loaded with assumptions, to which many professionals, advocates, and people with lived experience might object. One might suggest I stick to neutral language. I have found there is no such thing.
Substance use work is ridden with contradictions, beginning with how we talk about it. And these contradictions highlight how differently providers approach substance use compared to most other areas of physical and mental health. Progressive discourse aims to “destigmatize” substance use. But in practice, interventions remain patronizing at best and violent at worst. As revealed in our contested language, we are nowhere near shared understanding on the matters of choice and free will.
This essay begins with an exploration of language, then examines violations of autonomy in substance use services. Guided by the ethic to honor all people’s autonomy without conditions, I close by presenting four key areas for advocacy toward person-centered care for all who want it.
Tropes in Substance Use Discourse
“Language guides” on the topic of substance use present certain language as correct or current. Such pronouncements are deceptively flattening, however, because people with lived experience use and identify with a huge variety of different terms. The rest of us, too often, avoid the topic altogether rather than risk saying the wrong thing. Rather than giving instruction on language, then, I aim to equip readers to think more critically about it.
Below I present three tropes in discussion of substance use—including among people who intend to challenge stigma or are speaking from lived experience. I call these tropes “Essentialism,” “Pity,” and “Respectability.” Addiction essentialism is the belief that all people with addictions share a common set of innate, immutable traits. Pity toward people with addictions casts them as victims, while respectability arguments insist they are law-abiding and productive.
The left-hand side of the table below compares examples of how each discourse presents people’s state of mind, motivations, and place in society. Note these are merely examples; this summary is not comprehensive, and narratives may draw from multiple tropes or perspectives not represented here.
| Essentialism | Pity | Respectability | |
|---|---|---|---|
| Sample language and standard narrative | “Alcoholics and addicts” can improve their lives by getting sober | People “suffering from substance use disorders” would quit if they could | “People who use substances” still have homes, jobs and families |
| Capacity for decision-making | Rationally seeking pleasure and money to support habit | Total loss of control, unable to make rational decisions | Rationally choosing to control use and avoid any harm to others |
| Motivations for substance use | For pleasure, escape | To deal with problems (personal or systemic) | Dependence on medications prescribed for a medical issue |
| Suggested community response | Punishment, segregation | Paternalism, charity | Tokenism, promotion as spokesmodels |
Any language may be valid for a particular individual, but as applied to a whole population, it leaves many people out. For example, much advocacy against stigma relies on the respectability framework, which reinforces distinctions between deserving and undeserving. Respectability politics suggests that people who use illicitly and for pleasure, or who are unhoused or unemployed, do not deserve the same rights and access as respectable drug users.
Likewise arguments for substance use treatment often draw on the pity framework, promising rescue from “the degradation of a life ruled by drugs.” Proponents may call this narrative “compassionate” or “humane,” but tellingly, it remains the same whether used to advocate increasing access to voluntary treatment, or forcing people into mandated treatment. The very concept of treatment carries a judgment that something is wrong and requires a professional fix designated by expert authorities–making it essential that people choose freely to engage.
The language I usually hear from people with lived experience–in describing themselves–tracks with essentialism and uses the terms considered most judgmental. For example, no one has told me they haplessly fell into their “drug dependence” or “substance use disorder.” Instead they tend to say they have an “addiction,” an “issue” or a “problem,” and describe escalating use toward pleasure or avoidance.
Why would people choose to describe their identities and experiences in the most stigmatizing terms? We are familiar with politically reclaimed language, as in “queer,” “fat,” or “mad.” A common example from substance use is calling oneself a “drunk.” But in addition to subverting derogatory labels, I believe addiction essentialism appeals to people with lived experience because of its model of autonomy. In essentialism, people with addictions are in fact credited with rational decision-making and pursuit of pleasure. Many seem to find this more respectful and more accurate to their experience, whether they judge themselves or not.
We have no perfect language. Thus the goal should not be one uniform manner of speaking, but rather understanding the compromises in any terms we use. We now move from language considerations to a look at autonomy, and violations thereof, in substance use services.
Treatment As It Is Today
Currently, people are forced into substance use treatment by numerous legal and extralegal means. Pathways into mandated treatment in any state run through its criminal courts, jail diversion programs, probation or parole officers, and “child protective services.” People may also be pushed into treatment by employers or medication prescribers. There is no meaningful choice when refusing treatment carries such vital stakes: potentially losing one’s freedom, children, job, or medications. The July 2025 executive order titled “Ending Crime and Disorder on America’s Streets” suggests many more potential routes to forced treatment, including indefinite detention, for substance use.
No therapeutic experience can bypass consent; forced care is an oxymoron. Thus substance use counselors are expected to serve as enforcers and informants: keeping patients in line and reporting on their activities to the authorities who referred them. (I use the term “patient” in this context because alternatives like “client” or “participant” suggest a level of agency they do not have.)
Treatment organizations, for their part, rely on a steady stream of mandated patients for revenue, and accordingly shape services toward the demands of referring entities rather than patients’ wishes or needs. Treatment itself is typically standardized, “one size fits all,” and occurs mostly or entirely in groups. Every group patient receives exactly the same interventions, at the same time intervals, in the same order. Individual therapy is considered too expensive and inefficient for substance use agencies, no matter how many patients want it.
Most treatment programs are “drug-free,” meaning they do not offer or allow maintenance medications to prevent withdrawal. (In prescribing for substance dependence, maintenance medications contain the drug on which the person is dependent, thus “maintaining” them by preventing withdrawal symptoms.) Maintenance medications are considered “evidence-based,” but programs that do provide them sometimes push prescriptions on people who do not want them. All along, patients are denied their autonomy, treated as units subject to an administrative process rather than people entitled to care.
Four Choices Everyone Should Have in Substance Use Services (But Few Do)
With the goal of inclusion for all people with substance use histories, and with respect for the autonomy of each, I propose the following choices for all to freely make.
Choice 1: Whether to enter treatment
For purposes of this essay, “treatment” refers to any paid service aimed at changing a person’s relationship to substances. All treatment must be fully voluntary, targeting self-identified goals. Those not seeking treatment or who identify no problem should have access to peer support and liberatory harm reduction: peer-led practices toward safety, autonomy, and political empowerment.
Peer support and harm reduction can be integrated into any voluntary service, and there is no inherent conflict between these practices and formal treatment. People may find any of these models helpful at different times, or even use them concurrently. Professionalized systems, however, tend to co-opt peer support and harm reduction toward institutional priorities. These concepts’ most liberatory forms have always taken place outside professional settings—sometimes outside the law as well—and their experts are peers, never people like me. I provide examples of peer-led, nontreatment options in the resource list below.
Choice 2: What type of treatment to engage in
People interested in treatment should have a wide variety of options based on how they understand their problem and what they believe would be helpful. Individual counseling, as one basic example, is completely inaccessible to many people due to cost and insurance barriers. And beyond medical and psychosocial models, people may want body work, immersion in nature, creative activities, or other forms of healing or self-development.
Standardized group substance use programs do benefit some people, by their own testimonies. One size fits some. But for everyone else who is interested in treatment but frustrated and failed by the current model, there must be real alternatives.
Choice 3: Acceptance or refusal of medications
For simplicity, this section specifically discusses maintenance medications. These medications are controversial because some people see them as “trading one addiction for another.” This derogatory framing ignores the many safety benefits of taking a quality-controlled prescription as opposed to street drugs. Maintenance medications should be accessible to all who want them.
While we are far from that goal, however, we still must respect that maintenance medications are not for everyone. Some people want independence from all substances, illicit or prescribed. This approach carries risks, but so too do medications. People must be able to weigh and choose risks for themselves. As it stands now, maintenance prescribers often dismiss patients’ concerns about these medications and desires to be drug-free. Patients may even be mandated to take particular medications. True autonomy in medicating for substance use means honoring every individual decision to opt in, or opt out.
Choice 4: Creating an advance directive
An advance directive is a document indicating a person’s wishes, to be put into action or reviewed for guidance under circumstances of concern as specified by them. Medical advance directives are already commonplace, and mental health advance directives are also valid in all fifty states, though used less often. Mental health advance directives have been shown to reduce coercive crisis interventions, yet I find no research or guidelines specific to substance use.
An informal variation on this practice is “mad mapping.” Mad mapping is holistic and highly personalized, emphasizing creativity even in the process of contingency planning. A mad map might be thought of as a sophisticated set of notes to self and to trusted others, to be consulted in a crisis.
Many of my patients have wanted to constrain their own future choices, but lacked any mechanism to do so. As with other long-term mental health challenges, people with self-identified substance use problems learn their own patterns over time. They can often recognize signs that they need more support, and of what kind. If this knowledge informed a detailed advance directive or mad map, their best insights would already be on hand when the need arose. That said, in implementation it is crucial that substance use advance directives be honored as “real” without ever resorting to the coercive interventions they are intended to prevent.
Conclusion
There is no single right way to work with substance use, or even to talk about it. This essay is a call to center personal autonomy in substance use discussion and services, rather than what is considered up-to-date or evidence-based. When people can freely choose to engage with support and services–or not–we have no need for universal standards in discourse or practice. The right approach is whatever language or form of care honors a person’s autonomy.
Resources and References
Examples of Peer-Led and Nontreatment Options
Drug User Liberation Front (Canada)
Additional Resources
Additional twelve-step groups for specific drugs are available in many communities and online. For more information on liberatory harm reduction, see Shira Hassan’s work:
To find local in-person, peer-led harm reduction and advocacy for drug users, search online for your location plus “user’s union.”
Rosalie Genova (she/her) is a clinical counselor on Wabanaki land in Portland, Maine. She quit community addiction treatment in 2022 to build a solo practice around freely chosen, quality care. Rosalie writes the newsletter A Cure For Addiction. CE webinars, recommended resources, and more information on Rosalie’s work can be found here.
IDHA’s blog is home to diversity of perspectives and opinions about mental health and healing. These posts seek to magnify a wide range of perspectives on different topics. The opinions expressed are the writers’ own.