Criminal Activity or Treatable Health Condition? News Media Framing of Opioid Analgesic Abuse in the United States, 1998–2012
Abstract
Objective:
Opioid analgesic abuse is a complex and relatively new public health problem, and to date little is known about how the news media frame the issue.
Methods:
To better understand how this issue has been framed in public discourse, an analysis was conducted of the volume and content of news media coverage of opioid analgesic abuse over a 15-year period from 1998 to 2012 (N=673 news stories). A 70-item structured coding instrument was used to measure items in four domains that prior research suggests can influence public attitudes about health and social issues: causes, solutions, and consequences of the problem and individual depictions of persons who abuse opioid analgesics.
Results:
Although experts have deemed opioid analgesic abuse a public health crisis, results of our study suggest that the news media more often frame the problem as a criminal justice issue. The most frequently mentioned cause of the problem was illegal drug dealing, and the most frequently mentioned solutions were law enforcement solutions designed to arrest and prosecute the individuals responsible for diverting opioid analgesics onto the illegal market. Prevention-oriented approaches, such as prescription drug–monitoring programs, were mentioned more frequently in the latter years of the study period, but less than 5% of news stories overall mentioned expanding substance abuse treatment, and even fewer mentioned expanding access to evidence-based medication-assisted treatments, such as buprenorphine.
Conclusions:
Findings underscore the need for a concerted effort to reframe opioid analgesic abuse as a treatable condition addressable via well-established public and behavioral health approaches.
Rates of opioid analgesic abuse, addiction, and overdose have risen steeply in the United States over the past two decades (1). In 2013, an estimated 4.5 million Americans used prescription pain relievers (the majority of which are opioid analgesics) for nonmedical purposes, and 1.9 million nonmedical users were dependent on these drugs (2). Overdose deaths involving opioid analgesics have quadrupled since 1999 and now total about 16,000 a year, more than deaths caused by heroin and cocaine combined (1,3,4). Unlike other addictive substances, such as heroin, alcohol, and tobacco, opioid analgesics have a legitimate use that benefits the public’s health: treatment of pain (5–7). For most of the 20th century, physicians limited their use of morphine and other opioids to the treatment of short-term acute or cancer-related pain (5,8). Beginning in the late 1990s, however, doctors began to prescribe opioid analgesics with increasing frequency (1), likely due to a confluence of factors, including the medical community’s heightened awareness of the widespread problem of undertreated pain coupled with the development of a new generation of extended-release opioid analgesics (5,6,9–11).
Opioid analgesic abuse is a complex and relatively new public health problem, and to date little is known about how the news media have framed the issue. Analyzing the content of mainstream news coverage is an established method for examining the public discourse surrounding health and social issues, and news media coverage can influence public and policy makers’ attitudes in important ways (12–16). Large bodies of research have demonstrated the agenda-setting (13,16,17) and issue-framing functions of the news media (14,18,19). By focusing news coverage on some topics rather than on others, the news media can influence which issues audiences deem important and in need of response (agenda setting) (13,16,17). By highlighting certain aspects of issues, the news media can influence how the public and policy makers perceive the causes of and appropriate responses to a given issue (issue framing) (14,19).
Several types of frames can influence public attitudes, including causal, solution, and consequence frames, as well as individual depictions. Causal frames can influence the public’s attributions of responsibility for and desired solutions to a problem (20–23). Given the multiple actors involved in the opioid analgesic abuse epidemic, causal framing could affect who the public holds responsible. News coverage of proposed policy solutions focused on specific groups may imply responsibility for the problem and influence public attitudes toward the policy’s target population (24). Prior research has shown that emphasizing specific consequences of a given issue can influence public perceptions of the seriousness of the problem (25), endorsement of societal versus individual responsibility for causing and solving the problem (26), and support for government intervention (27,28). Reporters often use depictions of specific individuals affected by the issue at hand to engage readers, and—even if the individual is atypical—such depictions can influence how the public views the entire affected population (29). News media depictions of persons abusing opioid analgesics are important in the context of already high levels of stigma toward persons with substance use conditions in the United States (30,31), which could be further exacerbated by negative depictions (32–35).
Prior studies have examined news media coverage of other drug issues (36–39), but to our knowledge, no previous research has examined news media framing of the broad opioid analgesic abuse epidemic in the United States. To better understand how this issue has been presented in the public discourse, we analyzed the volume and content of U.S. news media coverage of opioid analgesic abuse over a 15-year period from 1998 to 2012. Given the prior research showing that public attitudes about health issues are influenced by news media coverage (15,16,21,40,41), our findings could have important implications for beginning to understand how the American public and policy makers perceive the problem and its potential solutions.
Methods
Approach
Although some news media content analyses employ qualitative methods to gain in-depth understanding of the discourse around an issue by using a small sample of news stories, our goal was to assess the content of news coverage in a large sample of high-circulation print and high-viewership television news sources that reach large segments of the American public. Using quantitative methodology, we analyzed national and regional news sources to assess news media content in four domains that prior research has shown to influence public attitudes: news media messages about the causes of (22,26,42), solutions to (24), and consequences of opioid analgesic abuse (43), as well as depictions of individuals who abuse opioid analgesics (20,29).
We analyzed print and television news stories focused on the topic of opioid analgesic abuse from 1998 to 2012. News sources included four of the highest-circulation national newspapers in the United States in 2012, one of the highest-circulation newspapers in each of the four U.S. census regions (Northeast, South, Midwest, and West), and the morning and evening news programs for the three largest broadcast television networks. We used the Audit Bureau of Circulation (44) to identify newspaper circulation rates in 2012 and used Nielsen Media Research (45) to identify television viewership in the same year. [A complete list of the news sources used is included in an online supplement to this article.]
News Coverage Selection
We used a set of terms designed to capture content about opioid analgesic abuse and addiction to search Lexis-Nexis, ProQuest, and NewsBank online archives to collects news stories. Search terms included terms commonly used to describe opioid analgesics (for example, “painkiller,” “pain medication,” and “opioid”), 11 names of commonly used brand name and generic opioid analgesics (for example, “OxyContin” and “hydrocodone”), and “abuse,” “addict,” “misuse,” and “overdose.” [A full list of search terms is included in the online supplement .] The search yielded 4,625 newspaper stories and 654 television stories. Because the number of newspaper stories was high, we took a 40% random sample of them (N=1,850). We included a complete census of television transcripts (N=654). We reviewed each story and excluded those that were not focused on opioid analgesic abuse. News stories and editorials with 100 or more words were included. The final analytic sample included 673 total news stories and editorials (437 newspaper stories and 236 television transcripts).
Content Analysis
We developed a 70-item structured coding instrument to analyze the content of news coverage of opioid analgesic abuse [see online supplement ]. In addition to the measures of interest described below, the instrument captured information about the characteristics of the news stories, for example, word count, publication, and placement within the publication. Two authors (AKH and JB) piloted the instrument on a small subset of articles and refined instrument content based on pilot results. A random sample of 30% of the news stories (N=194) was double-coded by the same two authors to assess interrater reliability for each dichotomous yes-no item. The remaining 70% of articles were coded by a single coder (either AKH or JB). All items met conventional standards for adequate reliability with kappa values of .69 or higher; the majority of items had kappa statistics of .80 or higher [see online supplement ]. Data were collected in 2013 and analyzed in 2014.
Measures
Measure domains were chosen on the basis of previously summarized literature showing that causal, solution, and consequence frames, as well as individual depictions, can influence public attitudes about social issues. We developed an initial list of individual measures within each domain. During piloting, additional measures that emerged from the data were added to the coding instrument. [For a complete list of measures, see the online supplement .]
Characteristics of opioid analgesics.
We measured whether news stories mentioned that opioid analgesics are narcotics or controlled substances and effective at treating pain and also whether stories mentioned specific types of opioid analgesics (for example, OxyContin).
Causes of opioid analgesic abuse.
We assessed whether news stories mentioned 15 potential causes of opioid analgesic abuse identified from the prior literature. We included causes attributable to individual abusers, clinicians, individuals who engage in illegal sale or diversion of opioid analgesics, and pharmaceutical companies.
Solutions to opioid analgesic abuse.
We measured whether news stories mentioned 13 solutions to opioid analgesic abuse, including but not limited to, policies proposed in Prescription Drug Abuse: Strategies to Stop the Epidemic, a 2013 report issued by Trust for America’s Health (TFAH). Because the TFAH recommendations were published after our study period (1998–2012) concluded, we did not expect to capture explicit mention of TFAH’s policy guidelines in news stories. However, the recommendations set forth in the TFAH report had been proposed, discussed, and in some cases (for example, prescription drug–monitoring programs) enacted and implemented in many U.S. jurisdictions prior to publication of the report (46,47). We also measured other proposed and enacted solutions identified in the scholarly literature and news media coverage of opioid analgesic abuse. We measured news media mentions of law enforcement solutions (for example, prosecuting drug dealers), prevention-oriented solutions (for example, improving prescription warning labels), treatment solutions (for example, expanding addiction treatment), and harm reduction solutions, including passing laws to increase use of naloxone, a rescue medication that can reverse the course of opioid overdose.
Consequences of opioid analgesic abuse.
We assessed whether news stories mentioned six potential consequences of opioid analgesic abuse, including health-related consequences, trouble with the law, medical care costs, employment-related consequences, damaged relationships with family and friends, and transitioning to other drug (for example, heroin) use.
Individuals depicted.
We documented the characteristics of individual abusers of opioid analgesics depicted in the news stories. For example, we measured whether news stories depicted abusers as involved in illegal activity, such as buying or selling opioid analgesics on the illicit market or engaging in other crime. We also measured whether news stories depicted celebrities abusing opioid analgesics or individuals receiving treatment for opioid analgesic abuse. Because youths and active duty military personnel and veterans are disproportionately affected by opioid analgesic abuse, we measured the frequency with which these categories of individuals were depicted in the news media.
Data Analysis
We calculated the proportion of stories mentioning each measure to assess the content of news stories focused on opioid analgesic abuse during the study period. To assess whether news coverage of this evolving issue changed over time, we used chi square tests to assess differences in news media mentions of the causes of and solutions to opioid analgesic abuse across five three-year intervals (1998–2000, 2001–2003, 2004–2006, 2007–2009, and 2010–2012). Prior research suggests that print and television news coverage differs in the use of individual depictions (21,40,48). Therefore, we used logistic regression to compare the presence of individual depictions in print versus television news stories. Models controlled for news story word count and clustered standard errors by news source in order to account for lack of independence within news sources.
Results
Of the 673 included news stories, 437 (65%) were newspaper stories and 236 (35%) were television stories. The volume of news coverage of opioid analgesic abuse in our study sample increased over time, with 13 stories in 1998 and 63 in 2012. Thirty-nine percent of stories mentioned that opioid analgesics are controlled substances, and 44% mentioned that these medications are effective at treating pain (Table 1). The opioid analgesics most frequently mentioned by name were OxyContin (43% of news stories) and Vicodin (25% of news stories).
| Characteristic mentioned by news story | N | % |
|---|---|---|
| Opioid analgesics are narcotics or controlled substances | 262 | 39 |
| Opioid analgesics are effective at treating pain (either generally or for one of the conditions below) | 296 | 44 |
| Acute injuries | 135 | 20 |
| Chronic pain | 121 | 18 |
| Cancer | 67 | 10 |
| Back pain | 61 | 9 |
| Headaches or migraine | 13 | 2 |
| Arthritis | 13 | 2 |
| Fibromyalgia | 3 | <1 |
| Mentions a brand namea | 524 | 78 |
| OxyContin | 292 | 43 |
| Vicodin | 166 | 25 |
| Fentanyl | 50 | 7 |
| Percocet | 43 | 6 |
| Demerol | 33 | 5 |
| Suboxone | 6 | <1 |
| Duragesic | 2 | <1 |
| Mentions a generica | ||
| Oxycodone | 119 | 18 |
| Hydrocodone | 89 | 13 |
| Morphine | 80 | 12 |
| Codeine | 24 | 4 |
| Methadone | 15 | 2 |
a
The list is inclusive of all opioid analgesics mentioned in news stories. No other brand name or generic medications were mentioned.
The most frequently mentioned causes and the direction and statistical significance of changes in news media coverage of the causes of analgesic abuse across the study period are shown in Table 2 [see the online supplement for the frequency and rate of all cause measures by year]. Seventy-seven percent of news stories mentioned any cause of opioid analgesic abuse (Table 2), and news media descriptions of the causes of opioid analgesic abuse fluctuated over time. Among stories mentioning any cause, illicit drug dealing was mentioned most frequently (57% of news stories). Physician-related causes were also frequently mentioned: 45% of news stories that noted any cause mentioned that it was easy to get a prescription for an opioid analgesic from a doctor, and 28% mentioned that doctors prescribe painkillers at inappropriately high doses or prescribe more pills than necessary. Although experts agree that pharmaceutical companies’ failure to disclose the risks of opioid analgesics has contributed significantly to the current epidemic of abuse, only 8% of news stories mentioned this as a cause.
| Cause or solution | Stories | Change 1998–2012 | ||
|---|---|---|---|---|
| N | %a | Direction of trendb | p | |
| Any cause of opioid analgesic abuse mentioned | 518 | 77 | Mixed | <.001 |
| Illicit drug dealing by doctors, patients, or others | 297 | 57 | Mixed | <.001 |
| Any physician-related cause | 245 | 47 | Mixed | <.001 |
| Easy to get a prescription for pain medication from doctors | 234 | 45 | Increasing | <.001 |
| Doctors prescribe painkillers at inappropriately high doses or prescribe more pills than necessary | 146 | 28 | Increasing | <.001 |
| Any patient-related cause | 164 | 32 | Mixed | .013 |
| Having friends or family members who use or abuse opioid analgesics | 122 | 24 | No change | |
| Easy to get prescriptions from different doctors (doctor shopping) | 89 | 17 | Mixed | .049 |
| People don’t know that opioid analgesics can be addictive or cause overdose | 61 | 12 | Mixed | .002 |
| Pharmacy, pain clinic, and pharmaceutical company causes | 175 | 34 | No change | .223 |
| Easy to get opioid analgesics from pharmacies | 99 | 19 | Mixed | .002 |
| Easy to get opioid analgesics from pain clinics | 56 | 11 | Increasing | .003 |
| Pharmaceutical companies fail to disclose risks of prescription painkillers to patients and doctors | 42 | 8 | Mixed | .033 |
| Any solution to opioid analgesic abuse mentioned | 343 | 51 | Mixed | .001 |
| Any law enforcement solution | 219 | 64 | Decreasing | .003 |
| Arrests and prosecutions of individuals who illegally buy or sell opioid analgesics | 126 | 37 | Decreasing | .015 |
| Arrests and prosecutions of physicians who illegally prescribe or sell | 102 | 30 | No change | .502 |
| Any prevention-oriented solution | 141 | 41 | Increasing | .002 |
| Educating individuals about the dangers, proper use, and storage of opioid analgesics | 67 | 20 | Increasing | .129 |
| Prescription drug–monitoring programs | 50 | 15 | Increasing | <.001 |
| Expanding substance use treatment | 11 | 3 | No change | .402 |
| Any harm reduction solution | 1 | <1 | No change | .418 |
| Law to protect people from criminal charges for drug crimes if they seek medical help for someone experiencing overdose | 1 | <1 | No change | .418 |
| Law to support use of rescue medication that reverses the effects of opioid analgesic overdose (naloxone) | 0 | — | No change | — |
a
For mentions of any cause and any solution, proportions were calculated for the total number of news stories (N=673). For mentions of specific causes and solutions, proportions were calculated for the subset of news stories that mentioned any cause (N=518) or any solution (N=343).
b
Trends in mentions of specific causes or solutions were examined by comparing the proportion of news stories mentioning a given cause or solution across five periods: 1998–2000, 2001–2003, 2004–2006, 2007–2009, and 2010–2012. “Mixed” indicates that the proportion fluctuated but with no clear increasing or decreasing trend. Chi square tests were used to assess differences across the five periods.
The most frequently mentioned solutions and the direction and statistical significance of changes in news media coverage of solutions to opioid analgesic abuse across the study period are shown in Table 2 [see the online supplement for the frequency and rate of all solution measures by year]. Slightly more than half (51%) of news stories mentioned any solution to opioid analgesic abuse (Table 2), and news media mentions of solutions varied significantly over the study period. Among news stories mentioning any solution, law enforcement efforts to arrest and prosecute drug dealers were mentioned most frequently (64% of news stories). Only 3% and less than 1% of news stories mentioned expanding substance use treatment and harm-reduction policies, respectively, as potential solutions. The proportion of news stories mentioning law enforcement solutions decreased over the study period, from 70% in 1998–2000 to 57% in 2010–2012 (p<.05), and the proportion of stories mentioning prevention-oriented solutions increased from 10% in 1998–2000 to 55% in 2010–2012 (p<.05).
Ninety-four percent of news stories mentioned a health-related consequence of opioid analgesic addiction (Table 3). Addiction or dependence was mentioned most frequently (75%), followed by death (53%) and overdose (41%). One-third of news stories (35%) mentioned trouble with the law, and 13% mentioned an employment-related consequence.
| Adverse consequence | N | %a |
|---|---|---|
| Any | 638 | 95 |
| Specific | ||
| Health-related consequence | 598 | 94 |
| Addiction or dependence | 481 | 75 |
| Death | 335 | 53 |
| Overdose | 260 | 41 |
| Trouble with the law (for example, arrest or revocation of medical license) | 224 | 35 |
| Employment-related consequence (for example, fired) | 81 | 13 |
| Damaged relationships (for example, marital difficulties or losing custody of children) | 60 | 9 |
| Transitioning to other drug use (for example, heroin or cocaine) | 21 | 3 |
| High health care costs to individuals, families, or society | 13 | 2 |
a
For mentions of any consequence, proportions were calculated for the total number of news stories (N=673). For mentions of specific consequences, proportions were calculated for the subset of stories that mentioned any adverse consequence (N=638).
Over 80% (N=552) of news stories depicted a specific individual abuser of opioid analgesics (Table 4). Among these, 66% depicted persons actively involved in criminal activity, such as buying or selling drugs illegally or robbery, and 12% depicted persons abusing other illicit drugs in addition to opioid analgesics. Few depictions were of teens (12%) or active duty military personnel or veterans (2%). Consistent with prior research, television news stories were more likely than print news stories to include individual depictions of opioid analgesic abusers (p<.05).
| Variable | All stories (N=673) | Television (N=236) | Print (N=437) | |||
|---|---|---|---|---|---|---|
| N | %b | N | %b | N | %b | |
| Any depiction of a person who abuses opioid analgesics | 552 | 82 | 219 | 93 | 333 | 76** |
| Characteristics of individuals depicted | ||||||
| Criminal depiction | ||||||
| Any illegal activity by person depictedc | 365 | 66 | 114 | 52 | 251 | 75*** |
| Use of other illicit drugs (for example, heroin or cocaine) | 64 | 12 | 10 | 5 | 54 | 16* |
| Celebrity depiction | ||||||
| Nonathlete | 226 | 41 | 122 | 56 | 104 | 31*** |
| Athlete | 33 | 6 | 2 | <1 | 31 | 9*** |
| Treated substance use depiction | ||||||
| Receiving any type of drug abuse treatmentd | 200 | 36 | 85 | 39 | 115 | 35 |
| Receiving medication-assisted treatment for opioid addiction (for example, buprenorphine or methadone) | 2 | <1 | 1 | <1 | 1 | <1 |
| Teen depiction | 65 | 12 | 43 | 20 | 22 | 7*** |
| Active duty U.S. military or veteran | 9 | 2 | 3 | 1 | 6 | 2 |
a
Print news stories were compared with television news stories by using logistic regression. Models controlled for news story word count and adjusted standard errors to account for lack of independence within news sources.
b
For mentions of any depiction, proportions were calculated for the total number of news stories (N=673). For mentions of specific depictions, proportions were calculated for the subset of news stories that included any depiction (N=552).
c
Buying or selling prescription or other drugs illegally or involvement in other criminal activity, such as robbery or assault
d
For example, counseling or nonclinical support, such as Narcotics Anonymous
*
p<.05, **p<.01, ***p<.001
Discussion
Like other substance use problems, opioid analgesic abuse is treatable. However, the results of our study show that from 1998 to 2012, the news media were more likely to frame opioid analgesic abuse as a criminal justice issue than as a treatable health condition. The criminal justice frame may have important implications for the American public’s and policy makers’ preferred solutions to the problem. In addition to highlighting illegal drug dealing as the principal cause of opioid analgesic abuse, our study found that the news media focused on law enforcement solutions targeting illicit drug dealing as opposed to upstream approaches designed to prevent abuse and deter diversion of legitimate pain medications to the illegal market or evidence-based addiction treatment and harm reduction approaches.
Of note, although prior to 2007 news stories were much more likely to mention law enforcement solutions rather than prevention-oriented solutions, the gap began to narrow in 2007–2009, and by 2010–2012 news stories mentioned the two categories of solutions with near-equal frequency. This shift in news content may both reflect and cause changes in attitudes (12). On the one hand, the shift may reflect a change in thinking and potentially growing consensus, among the experts and opinion leaders who often serve as sources for news coverage (12,49). Although certain implications are outside the scope of our study to assess, prior research suggests that the shift in news coverage away from law enforcement and toward prevention-oriented solutions may also influence attributions of responsibility for solving the problem and policy preferences among the American public and nonexpert policy makers who mainly serve as consumers, rather than sources, of news coverage on this topic (21,24,42).
Although the majority of news stories mentioned health-related consequences of opioid analgesic abuse, abusers were more often depicted as engaging in criminal activity than seeking or obtaining treatment. Results of a recent experimental study suggest that portrayals of successful treatment of opioid analgesic abuse can improve public attitudes toward and reduce willingness to discriminate against individuals experiencing the condition (50), but only slightly over a third of news stories depicted an individual engaging in treatment. Demonizing users of drugs, alcohol, and tobacco has a long history in the United States and is associated with social stigma and punitive policies directed at these groups (24,30,51,52).
Public health–oriented policies, including those recommended by TFAH in 2013, were rarely mentioned in news coverage from 1998 to 2012. For example, during this period expanding substance abuse treatment was mentioned in only 3% of news stories. Laws to protect people from criminal charges for drug crimes if they seek medical help for themselves or other experiencing overdose and laws to support use of the rescue medication naloxone were mentioned in less than 1% of news stories. TFAH’s introduction of treatment, prevention, and harm reduction recommendations in 2013 may have led to greater inclusion of these important approaches in the public discourse surrounding opioid analgesic abuse in subsequent years, but our study was unable to assess such a shift.
These findings should be interpreted in the context of several limitations. Our sample did not include the local television and Internet-only news sources through which many Americans access at least some of their news (53). Although we used high-circulation and high-viewership national and regional news sources, it is unclear whether our findings are generalizable to other news sources. Although prior studies have shown direct links between news media coverage and public attitudes (20,26,32,54), content analysis of news stories did not allow us to assess how exposure to news coverage of opioid analgesic abuse influences public opinion about the issue. Our analysis did not permit us to explain the trends in news coverage, which may be driven by competing issues in the news cycle or the changing landscape of news media coverage in the Internet age.
Conclusions
From 1998 to 2012, U.S. news coverage primarily framed opioid analgesic abuse as a criminal justice issue rather than as a treatable health condition. This is concerning given that evidence-based treatments for this condition exist and portrayals of individuals with opioid analgesic addiction who recover can reduce public stigma and discrimination toward this group (50). Although study findings suggest a possible shift toward public health–oriented solutions in recent years, few stories mentioned substance abuse treatment across the study period and no news stories mentioned the rescue medication naloxone. The findings underscore the need to continue efforts to reframe opioid analgesic abuse as a treatable condition addressable via well-established public health and behavioral health approaches.
Footnote
The authors gratefully acknowledge funding support for this study from AIG, Inc.
Supplementary Material
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Information & Authors
Information
Published In
Cover: Fame Weathervane, by E.G. Washburne and Company, circa 1890. Copper and zinc with gold leaf. American Folk Art Museum, Long Island City, New York. Gift of Ralph Esmerian, accession number 2005.8.62. Photo credit: Gavin Ashworth.
History
Received: 11 February 2015
Revision received: 8 May 2015
Revision received: 8 June 2015
Accepted: 31 July 2015
Published online: 1 December 2015
Published in print: April 01, 2016
Authors
Competing Interests
Other than receipt of support from AIG, Inc., the authors report no financial relationships with commercial interests.
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