Where the Fault Lies: Representations of Addiction in Audience Reactions to Media Coverage of the Opioid Epidemic

Abstract

The unprecedented number of deaths in the U.S. attributed to opioids has been referred to as an “epidemic of addiction.” Media coverage of the epidemic has stoked public discussion of addiction on social media platforms. This article describes how addiction is represented in comments on media coverage of the “opioid epidemic” and examines the relationship between media framing and audience representations of addiction. Content analysis methods were applied to data obtained from news posts (n = 397) and comments (n = 2,836) on the Facebook pages of 42 newspapers in Ohio, where overdose deaths are among the highest in the U.S. Eleven percent of comments were identified as referencing addiction (n = 319). These comments were classified into two overarching categories: (1) support, disease, and contributing factors expressed support for persons affected by the epidemic, represented addiction as a disease requiring treatment, and highlighted social and structural factors seen as contributing to the epidemic (61.1% of comments referencing addiction); and (2) misdirected attention and individual blame questioned the media focus on addiction and overdose deaths, highlighted individual choices to misuse opioids, and suggested that media coverage of the epidemic diverts attention away from other social problems viewed as being more worthy of public attention (38.9% of comments). Representations of addiction in comments were found to be independent of (not associated with) frames in media coverage (p = .945). Together, these results suggest that while a majority of commenters represent addiction as a legitimate social problem that warrants intervention and support, a substantial minority are dismissive of the epidemic, express anger and disdain for persons who use opioids, and seek to counter popular narratives of social and structural factors contributing to addiction.

Keywords

addiction social media mass media opioid epidemic U.S.

Introduction

Nearly 400,000 lives in the U.S. have been claimed by opioid-related overdoses during the period between 1999 and 2017 (Centers for Disease Control and Prevention, 2018; U.S. Department of Health & Human Services, 2019). The unprecedented level of morbidity and mortality associated with both prescription and illicit opioids has been referred to as an “epidemic of addiction” (Kolodny et al., 2015). In 2015, an estimated 11.5 million adults in the U.S. misused prescription opioids and 1.9 million were diagnosed with an opioid use disorder (Han et al., 2017). Use of heroin among U.S. adults has also increased significantly during this period (Martins et al., 2017). In her 2014 testimony to the Senate Caucus on International Narcotics Control, Nora D. Volkow, Director of the National Institute on Drug Abuse, declared opioid addiction a serious global problem affecting the health and social welfare of all societies (Volkow, 2014).

Media organizations have responded with expanded coverage of the opioid epidemic (McGinty et al., 2015; Webster et al., 2019; Willis & Painter, 2019). This coverage has swelled alongside increasing mortality associated with opioids (Dasgupta et al., 2009) and plays an important role in framing and defining the opioid epidemic as a social problem. Frames in news coverage serve to organize our experiences, render certain events meaningful, and guide collective action (Snow et al., 1986). Along these lines, media coverage of the opioid epidemic has aimed to raise awareness of affected populations, emphasize the responsibility of public officials to identify solutions, highlight conflicts between involved parties, and stress the challenges of opioid addiction through individual narratives (Russell et al., 2019). Popular media topics have included a presidential address to raise awareness of the opioid epidemic, news emphasizing the responsibility of drug companies and foreign governments in fueling the rise in opioid use, and debates about alternative treatments and opioid substitutes (Glowacki et al., 2018). Drug addiction tends to be presented within media coverage in a negative light, emphasizing individual culpability and stigmatizing language to refer to persons experiencing addiction (McGinty, Kennedy-Hendricks et al., 2019; Webster et al., 2019).

Although a growing body of research describes how media organizations frame their news coverage of the opioid epidemic, or provides a critical analysis of media stances toward addiction, to our knowledge, there are no studies that have examined the ways in which audiences represent opioid addiction in their reactions to this coverage. The present study was designed to identify prominent categories in representations of opioid addiction in Facebook comments on media coverage of the opioid epidemic in Ohio, where drug overdose deaths are among the highest in the nation and continue to worsen year-over-year (Scholl et al., 2019). Social media, including Twitter and Facebook, are frequent platforms for users to gather news information, voice concerns, and share calls for action (Glowacki et al., 2018). Comments on news coverage shared on these platforms may elucidate the reasoning by which Ohioans recognize (or not) opioid addiction as a social problem worthy of public attention and response. Together with the proliferation of opioid-related news content shared on social media, reactions by audiences on these platforms work to shape a collective definition of addiction as a social problem (Blumer, 1971). Understanding how Ohioans perceive the spread of opioid addiction within their local communities may help to clarify beliefs and attitudes that represent facilitators or barriers to the implementation of public health interventions and other related policies.

Literature Review

Societal Attitudes Toward Drug Addiction and Media Coverage of Drug Epidemics

U.S. attitudes toward drug addiction have historically been dominated by themes of fear, morality, and criminalization (Cohen, 1972). As early as the late 19th century, drug users were framed as dangerous and blamed for a wide array of social problems, for which punishment was often presented as the most appropriate and effective policy solution (Daniels et al., 2018; Reinarman, 1994). The anti-opium den ordinance, enacted by San Francisco in 1875, marked the first of what became an increasingly punitive series of U.S. drug policies in response to drug scares. Together, these policies solidified the criminal stigma associated with drug addiction (Reinarman, 1994). The stigmatization of addiction and the justification for criminal punishment were also fueled by mass media that emphasized the public’s vulnerability to violent crimes perpetrated by out-of-control drug users (Brownstein, 1991; Reinarman & Levine, 2004). Media organizations exert a powerful claims-making role in defining and legitimating social problems, including the social construction of drug epidemics and drug scares (Hartman & Golub, 1999; Vasterman, 2005). News media may act to sensationalize the scale and impact of drug epidemics or encourage myths about drugs and the people who use them through their choices of stories and sources (Hartman & Golub, 1999; Orcutt & Turner, 1993). Media can also shape discourse about drug dealing and trafficking, activities that are frequently represented as sinister and foreign threats to communities and U.S. interests as a whole (Boyd, 2002). Prior research has found that frames in national news coverage of heroin and cocaine have primarily emphasized conflict between drug enforcement and traffickers, violence, and risks associated with drug use (Orsini, 2017). Alongside the stigma of criminalization is a belief that addiction represents a moral failure or defect in decision making (Harding, 1986). Media coverage of the crack cocaine crisis during the 1980s fueled a narrative of moral failings on the part of inner-city African Americans (Reinarman & Levine, 1997). Framing addiction as a moral failure promotes drug use as a vice that is inherently wrong and represents people who use drugs as irresponsible, self-destructive, and risk-taking outsiders (Becker, 1963; Harding, 1986).

Over the past two decades, media and public discourse has moved toward an understanding of addiction as a chronic relapsing brain disease requiring treatment and surveillance (Tiger, 2013b, 2015; Volkow & Fowler, 2000). News narratives during this period have increasingly emphasized a disease model of addiction and introduced notions of a heroin epidemic in American suburbs, one that has been instigated by profiteering drug dealers and corrupt doctors (McLean, 2017; Orsini, 2017; Quinones, 2015). Frames in media coverage of the opioid epidemic by the Cincinnati Enquirer have served to raise awareness about issues related to treatment availability and public safety efforts to combat the crisis (Willis & Painter, 2019).

Mainstream representations of opioid addiction have also shifted alongside changing user demographics (McLean, 2017). Portrayals of addiction are often framed in terms of race and gender, with addictions in predominantly white and suburban communities frequently described as surprising and challenging the stereotype of what addiction is (Daniels et al., 2018; Netherland & Hansen, 2016). Further, badness is more likely to be invoked among racial minorities compared to white users, who are more often portrayed as sick and in need of care (Daniels et al., 2018; Tiger, 2013a). In response to this shift, the criminal justice system has instituted gentler drug policies, including drug courts and diversion programs, which are viewed as more forgiving of persons diagnosed with addiction than the severe punishments handed down in past decades such as imprisonment (Seelye, 2015; Tiger, 2013b). While this extant research provides a critical analysis of how addiction is represented in media coverage of the opioid epidemic, it does not illuminate how addiction is viewed among news audiences. People who live in areas directly affected by the opioid epidemic, including those who have overdosed themselves or witnessed another’s overdose, may offer additional structural explanations for the rise in drug-related problems in their communities, including economic deprivation (i.e., low income, unemployment) and an absence of normative deterrents to drug use, factors that have been underemphasized in media coverage (McLean, 2016, 2017). Community members may also take a more critical stance toward the criminalization of people who use drugs and persons diagnosed with addiction by noting policy failures associated with the War on Drugs and harsh mandatory minimum sentences for drug use (Reinarman & Levine, 1997, 2004).

Social Media and the Construction of Addiction as a Social Problem

Social media represents a prominent platform for information sharing and discourse about social problems (Fuchs, 2017). Social media platforms facilitate conversations about news in an interactive and largely unregulated way, allowing for beliefs and narratives of addiction to be constructed and reinforced (Tiger, 2015). Social media platforms may also allow for narratives and representations of addiction to be challenged by news audiences. Content shared on social media platforms can be used to illustrate the many ways that addiction is articulated within contemporary society, including its enactment as a problem requiring professional treatment, a pathology of disordered consumption, or as a metaphor for valued objects and activities (Dwyer & Fraser, 2016). The perceived anonymity of social media may also facilitate more candid discussions about one’s sentiments toward, or personal experiences with, opioid use, as well as comments about misuse by others (Chan et al., 2015). Reactions among social media audiences to news coverage of the opioid epidemic is an important source of data for understanding how the public views and understands addiction. Closely examining audience reactions may facilitate a more nuanced understanding of community-level responses to the opioid epidemic, including public health interventions enacted at the state and local levels. Indeed, previous research has described how the collective definition of an epidemic as a social problem requiring medical treatment and public health interventions—as opposed to an issue stemming from individual lifestyle choices—can impact the speed with which those interventions are developed and implemented (Kaplan, 1990).

Facebook, an online social network with 1.45 billion daily active users, represents a dominant platform for gathering and reacting to news content (Facebook, 2018). Facebook has publicized its efforts to show high quality, trusted news stories to users in their local town or city (Zuckerberg, 2018). In 2018, 68% of U.S. adults reported getting news on social media, among which 43% received it from Facebook (Matsa & Shearer, 2018). Comments by Facebook users on news coverage about the epidemic may provide a window into representations of opioid addiction. This discourse provides an opportunity to view the collective definitional process as it is happening. Through an analysis of Facebook comments to media coverage of the opioid epidemic in Ohio, this study seeks to examine the extent to which media audiences view addiction as a social problem and describe how addiction is represented within this discourse. We also examine the relationship between framing in news coverage and representations of addiction observed in Facebook comments. Our findings shine light on a substantial division between Facebook commenters in their representations of addiction. We found that a majority of comments represent addiction as a legitimate social problem warranting intervention and support. However, a sizable minority of comments were dismissive of the “opioid epidemic,” expressed anger and disdain for persons who use opioids, and sought to counter popular narratives of social and structural factors contributing to the rise in drug-related problems. These representations of addiction are found to be largely independent of news framing.

Method

Data Collection

Data for this study included posts and comments on the Facebook pages of 42 Ohio newspapers. These newspapers served communities across Ohio and varied in their circulation sizes and number of Facebook page followers (Appendix Table A1). The R statistical computing environment was used to retrieve 452 posts in January 2018 that were filtered for opioid-related key words like “opioid,” “heroin,” and “fentanyl” (Barbera et al., 2017). Posts included messages with links to content (e.g., articles on the newspaper website) and comments by Facebook users. We sought to extract all published news stories over a 5-year period between 2013 and 2017. However, limits placed on the Facebook Application Programming Interface restricted the number of posts that could be extracted from pages with larger volumes of news coverage. This restriction had the effect of limiting our analytic sample to more recent news coverage. Thus, the majority of posted news stories and associated comments examined in this study were published in 2016 and 2017. Posts were reviewed and flagged for exclusion if they were unrelated to the opioid epidemic or contained multiple stories within the message (e.g., a listing of the newspaper’s daily headlines); 55 of the 452 flagged posts (12%) were marked for exclusion, resulting in an analytic sample of 397 posts and 2,836 associated comments. This study did not require institutional review board’s review as it used public information obtained from news websites and comments by Facebook users posted directly to their public-facing platforms.

Data Analysis

Content analysis methods were used to code Facebook comments in two phases. The first phase involved the authors reviewing each of the 2,836 Facebook comments line-by-line and assigning a numerical code (=1) to those comments that referenced addiction. Comments were coded as referencing addiction if they explicitly referenced “addiction” or used similar language to describe addiction such as “habit,” “hooked,” or “addicted,” described people either individually (“addict”) or collectively (“junkies”), or wrote about the “addictive” qualities of drugs and other substances. A total of 319 comments (11% of all comments) were coded as referencing addiction across 98 posted stories. The second phase of analysis was limited to these 319 comments and used conventional content analysis methods to inductively develop a set of codes and categories for how addiction was referenced by Facebook users in response to media coverage of the opioid epidemic. All of the authors reviewed these comments line-by-line and made notes about the various ideas and concepts discussed in the text. These preliminary codes formed the basis of a codebook that was applied to the entire analytic sample. These codes were discussed among the research team and sorted into larger categories based on their relationships and linkages. Following additional discussion, the authors reached agreement on a smaller number of emergent categories and subcategories, into which each of the comments referencing addiction was coded. Intercoder reliability was established through extensive dialogue among the research team about the focus and boundaries of categories and subcategories, as well as about ambiguities and inconsistencies of individual comments that were coded within them. These collaborative discussions helped to refine the definitions and descriptions of categories and subcategories presented in the results.

Additional analyses were performed in R to examine the association between framing of media coverage and representations of addiction in posted comments. Four media frames in posted news stories were coded based on our prior work (Russell et al., 2019). These frames included: (1) awareness of the opioid epidemic and affected populations, which communicated the spread of opioid addiction and overdose deaths across communities; (2) programs, policies, and interventions, which emphasized the responsibility of public officials to identify solutions to the epidemic through declarations, legislation, and informal meetings with community leaders; (3) crime, punishment, legal cases, and law enforcement, which highlighted conflicts between parties to the opioid epidemic including local residents, law enforcement, and the judicial system; and (4) narratives of addiction and the long road to recovery, which provided a human face to the epidemic through personal stories of opioid addiction, withdrawal, and recovery. Pearson’s χ² test was used to examine the joint distribution of comments by addiction category and media frame. A p value of .05 was used to determine statistical significance.

Results

Facebook comments representing addiction fell into two overarching categories: (1) support, disease, and contributing factors and (2) misdirected attention and individual blame. These categories each represented distinct ways of thinking about addiction and its causes and consequences.

Category 1: Support, Disease, and Contributing Factors

Support, disease, and contributing factors included comments that emphasized support for persons with addiction, recognized the risks of using opioids, viewed addiction as a disease requiring medical treatment, and provided firsthand testimonials of addiction and its impact on affected persons and families. Comments within this category also acknowledged a range of social and structural factors that were viewed as contributing to addiction and the epidemic at large, including pharmaceutical marketing practices and drug trafficking. Support, disease, and contributing factors represented 61.1% of all comments referencing addiction (n = 195) and included four subcategories: (1) support and encouragement, (2) disease and risk, (3) contributors to addiction, and (4) witnesses to addiction. A unifying feature among comments categorized within support, disease, and contributing factors was their attempt to represent the opioid epidemic as a legitimate social problem that warrants intervention and support for persons with addiction, their families, and affected communities. These comments promoted a disease model of addiction that emphasized the risks of opioid use, encouraged people diagnosed with addiction to seek out pharmaceutical and other treatments, provided hope and prayers to those experiencing addiction for an eventual recovery, and consoled families with loved ones lost to overdose. Also importantly, comments within support, disease, and contributing factors attempted to de-emphasize the role of individual choice in opioid addiction and expand consideration to social and structural factors.

Support and encouragement

Commenters expressed support for persons with opioid addiction and encouragement for their efforts to follow a path to recovery (20.1%; n = 64). This included empathy (e.g., “My heart breaks for each and everyone dealing with addiction”) and hope for persons with addiction (e.g., “There is hope! Drug addicts can recover!”). Commenters expressed support through encouraging words and prayers, offered condolences to those who experienced an overdose death within their family, and urged others in the community to “somehow find a way to reach out for those who need help.” Comments categorized within support and encouragement promoted an understanding of addiction as a disease, encouraged people with addiction to seek treatment, and provided hope to those experiencing addiction for an eventual recovery. Indeed, Facebook users expressing support and encouragement argued that the success or failure of treatment and interventions was dependent on the willingness of community members and the larger society to “take action.” Commenters implored others in their communities to “step up and do the right thing,” which included efforts to increase awareness, identify solutions, and make effective treatments available to every person living with addiction. Commenters expressing support and encouragement tended to be critical of Facebook users whose comments they saw as “judgmental” or as “making hateful remarks” about persons living with addiction and their families. In response to a story posted by the Sandusky Register (“Taken from us”) that featured the photos and biographies of local community members who had died from opioid overdose, one Facebook user pointed to the potential harm done to persons living with addiction by stigmatizing language in comments:

I do believe that awareness is key to fighting this disease that is taking so many lives. We need not to worry about our reputations but saving our children. Until you have experienced the heart break of this disease I respectfully tell everyone that comments you make far more hurt the families than admitting you are dealing with addiction. If you cannot help an addict than please do them no harm by your words or actions.

Facebook commenters also questioned whether others’ critical stance toward addiction might change if their own family members were impacted by the opioid epidemic. Indeed, commenters noted that “every addict is someone’s child.” Comments within this category also advocated for treatment over criminal punishment (e.g., “punishing the addicted does not help the addicted”). Responding to a story posted by the Troy Daily News on the institution of more severe criminal charges for persons who overdose from opioids (“Overdose in Troy, face stiffer penalty”), one Facebook user commented that:

When it is your son, daughter, brother, sister, mom, dad, niece, or nephew that needs help, let’s see how quick you are to say let them die or waste of space in jail…Think of these peoples’ [sic] families, I had a nephew that just couldn’t get away from it and now he’s passed on, still doesn’t hurt any less losing them to drugs! [So] just put yourself in others[’] shoes and walk a mile!

Disease and risk

Comments categorized as disease and risk underscored the addictive properties of opioids, expressed concern about the spread of the epidemic, endorsed a disease model of addiction, and advocated for access to treatment for those living with addiction (18.5%; n = 59). Addiction was frequently referred to as a “disease,” “sickness,” or “terrible illness.” Facebook users highlighted the “spread” of deaths and devastation caused by opioid addiction throughout Ohio communities and emphasized the seriousness of the epidemic as a public health and social problem. Facebook commenters referenced how opioids were highly addictive (e.g., “once you start using that needle it pulls you right in”) and dangerous (e.g., “doses of death”). One commenter noted how the “fear of death isn’t nearly as strong as the grip of this drug and their addiction.” Another Facebook user attempted to distinguish the initial choice to try opioids from the “physical addiction” that results from continued use: “We may choose to try a drug, but nobody chooses to be an addict.” Responding to a post by the Springfield News-Sun (“Reason to hope: Clark rehab center sees impact of heroin-fighting drug”), one commenter compared the addictive qualities of opioids to those of nicotine and alcohol and viewed treatment as the only feasible solution to opioid addiction:

Addicts start out thinking it can’t happen to them, just like smokers and drinkers think they won’t get hooked. But the chemicals in heroin and crack, coke, crank are far, far more addictive than nicotine or even alcohol (though some may disagree here). Bottom line is that only rehab can break the cycle and even that may not work at first.

Another commenter responding to the Sandusky Register story described earlier (“Taken from us”) endorsed a medicalized understanding of addiction by imploring others to educate themselves about opioid prescriptions and help persons living with addiction to seek treatment:

I believe this article is meant to put a human face on the epidemic. This is not about people who choose to become addicted. This is not about worthless souls. They are not numbers. They are people with a terrible disease. A disease you pray your loved ones never develop. Educate yourselves on the safety of opioid prescriptions. Talk to your children. If you know someone with a drug or alcohol abuse disorder, help them seek treatment. Recovery is real. Treatment works.

Opioid addiction was described as a condition that “does not discriminate” and “involves people from all walks of life from the poor to the rich.” Facebook users spoke to the diversity of opioid users, pointing to the presence of addiction in such varied populations as older adults and people “brought up in a great family.” A post by the Journal-News (“Girl, 11, revived with Narcan after suspected overdose”) described reporters interviewing a neighbor who expressed “shock” over an 11-year-old girl’s suspected heroin overdose, stating that “She’s not that kind of kid. That’s not that kind of family.” In response, a Facebook user noted that:

I can’t help but wonder why everyone says “They aren’t that type of family” or that “the person is not that type.” Well, addiction is not specifically a certain, type of anything.

Contributors to addiction

Comments categorized as contributors to addiction urged others to be “looking at the why, not the what” and attempted to draw attention to larger social, political, and economic forces shaping addiction and the opioid epidemic at large (17.9%; n = 57). These forces ranged from poverty and the stigmatization of opioid use to ineffective drug policies and a lack of regulatory oversight on pharmaceutical companies and drug manufacturers. Facebook users seized opportunities to promote their beliefs about the various contributors to addiction by commenting on news content that sought to increase awareness of the opioid epidemic. Consistent with popular media narratives of the opioid epidemic, the financial interests of pharmaceutical companies were highlighted by many Facebook users as a significant contributor to opioid addiction and the recent spike in deaths due to drug overdose (Quinones, 2015). The marketing campaigns of pharmaceutical companies were seen as a driving force in Americans’ overuse of prescription drugs and resulting addictions. For instance, one commenter responded to a story in the Troy Daily News (“Miami County reports 10 ODs in 24 hours”) about a string of local overdoses by urging doctors and pharmaceutical companies to be more cautious with prescribing and marketing medications:

Doctors need to stop treating so many ailments with high powered narcotics and try alternative treatments. Pharmaceutical companies need to STOP advertising their drugs on television and print and let doctors go back to prescribing, not having patients demand certain drugs because they saw it on TV. We’ve become brainwashed that drugs cure everything…Stop introducing drugs to our kids at young ages because they have “learning and behavior” problems and we reeducate our society to have parenting skills again and control our kids. Pop pills in a 6 year old’s mouth and then wonder why they’re hooked on heroin at 16? Is it really rocket science?

Comments like the one above illustrated a belief among commenters that Americans are accustomed to drug use at a young age through prescribed medications for many common conditions.

Commenters also described how pharmaceutical companies profited from the manufacture of medications used to treat opiate addiction (e.g., Suboxone) and overdose (e.g., Narcan), despite their role in fostering addictions. One commenter responded to a post by the Springfield News-Sun about the over-the-counter availability of the overdose antidote Narcan by drawing attention to the financial interests of drug companies:

The truth is addiction is just another way to make money now. The pharmaceutical companies and government are partially to blame for addicting people to opiates and they make money on treatment centers and replacement drugs. It’s all about making money.

Commenters also drew attention to what they saw as ineffective policies designed to stem the spread of opioid addiction and prevent overdose deaths. For instance, Facebook users commented on how the U.S. War on Drugs was responsible for increased violence and wasteful government spending. Commenters also pointed to political corruption at multiple levels of public office (e.g., “Much corruption on many levels. Judges, lawyers, state reps, congress members.”) and saw negative views toward persons with addiction among elected officials as slowing the government response to the opioid epidemic. One commenter, responding to a story by the Chillicothe Gazette (“Where’s justice in overdose fatalities?”), alluded to the stigma of drug addiction among prosecutors and public officials as underlying the lack of traction in pursuit of criminal charges brought against drug dealers who were viewed as responsible for overdoses among persons who purchased their products:

If there was an ironclad case handed over to the prosecutors, it still wouldn’t be pursued. Ask them their personal feelings about drug addicts. There you will find why there is no prosecution. Remember, these positions are elected.

Witnesses to addiction

The widespread impact of the opioid epidemic on Ohioans was visible through the many commenters who shared personal or family experiences with opioid addiction. Witnesses to addiction (4.7%; n = 15) provided a window into understanding addiction for those without direct experience. Witnesses to addiction actively challenged the representation of addiction as a personal choice and moral failing. In its place, they offered firsthand testimonials about their own experiences with addiction and trials in recovery. Witnesses to addiction recognized the persistent social stigma of addiction and sought to provide counternarratives that emphasized the many factors that shape addiction. Witnesses to addiction included comments posted by persons who had recovered from addiction themselves, family members of persons with addiction, and people who lived in communities that were directly affected by the epidemic. Perhaps most illustrative of comments in this subcategory were the personal narratives of persons who had recovered from opioid addiction and offered to share their experiences. One commenter categorized within witnesses to addiction, who had experienced addiction and since recovered, challenged its characterization as an individual choice, and shared an online video that emphasized how social and structural forces shape the spread of addictions within communities:

Only if half of you truly knew what addiction is. It’s not a fukking [sic] choice. Some day you people will understand. I’m a recovering addict going on two and a half years clean. There are so many different factors that play into being an addict. I’m sure half of you can’t go without coffee or something you do or use daily…even though it’s not a illegal drug [it] is still the same concept. But some people like drama or they like judging people they have met let alone know what it’s like. [This comment included a link to a TED Talks video by Johann Hari titled “Everything you think you know about addiction is wrong”]

Another woman who had recovered from addiction commented on a post by The Cincinnati Enquirer about a video documentary detailing the opioid epidemic (“Seven days of heroin: This is what an epidemic looks like”). She wrote:

I thank God I am off Heroin. I am in recovery and have such a long way to go but I am now a mother which I never thought was even possible. I always said I would quit using if I got pregnant. It took a one night stand (we now have a 1 year old and going on 3 years together) January 2015 2 days before my birthday I found out I was pregnant. I quit using. I miscarried 10 days later on my [significant other’s] birthday. Our daughter was conceived December 2015. The end of 2014 after I died and came back went to detox got out started using again ended an abusive 10 year relationship and was running the streets when I met my daughter’s daddy. It’s been hard. Very hard. I am [hepatitis C positive] something I never thought would happen to me. Looking forward treatment and a new chapter being clean and raising our daughter together. We do recover. Baby steps still move mountains. My story isn’t over.

Another commenter on the same post, a parent of someone with opioid addiction, stated that:

Every person who does heroin is in pain, whether it [is] physical, emotional, or mental. I can’t imagine what they go through as an addict. I only know what I go through as a parent.

Witnesses to addiction were not limited to family members and persons recovering from addiction. There were also commenters who spoke of witnessing addiction in their communities, including teachers, health care workers, and staff at treatment centers. These commenters expressed concern about the epidemic and its consequences and offered their insights, advice, and recommendations about proper courses of treatment for opioid addiction. One commenter, an employee at an opioid addiction treatment center, responded to an article in the Sandusky Register (“Medication can help addicts deal with withdrawal”) that profiled different medications and interviewed people receiving those treatments:

Vivitrol is great for treatment but instead of Suboxone they should use Belbuca. We treat people Monday through Friday for addiction and Belbuca is the better way to go. Suboxone is simply a replacement that they get hooked on and the resale value is too risky.

Also illustrative were comments to a news post by the Lancaster Eagle-Gazette about “the opioid epidemic’s smallest victims: Infants born to drug-addicted mothers, essentially suffering withdrawal from the drugs their mother used.” While the framing of this post emphasizes the responsibility of the mother for her child’s suffering from opioid withdrawal symptoms, one registered nurse used Facebook as a platform to comment on her own similar work experiences and argued for educational initiatives to raise awareness about the consequences of opioid use during pregnancy:

It’s a sad reality that most people are unaware of. I’ve witnessed firsthand the suffering of these little ones in my role as a NICU [newborn intensive care unit] nurse. We have to extend compassion to these babies AND their mothers. Maybe the more we educate and open everyone’s eyes to the consequences of opiate use during pregnancy the closer we’ll come to helping the problem. Some moms are faithfully taking their suboxone and methadone without realizing that babies can withdrawal from those prescribed meds just as badly as they do heroin. Maybe if we can educate and make birth control easily accessible to those suffering the disease of addiction, even those in recovery, we begin to decrease the problem.

Category 2: Misdirected Attention and Individual Blame

Comments categorized within the second category, labeled misdirected attention and individual blame, take a more dismissive stance toward the social construction of the opioid epidemic as a significant problem worthy of public health response by news writers and other Facebook commenters. Comments categorized within misdirected attention and individual blame are characterized by expressions of anger and disdain for persons who use opioids, frequently include stigmatizing language to refer to persons with addiction, seek to counter popular narratives of social and structural factors as contributing to the spread of addiction, and disagree with the framing of addiction as a disease requiring treatment. Comments within misdirected attention and individual blame emphasized the choices made by persons with addiction to opioids. Comments coded within this category also questioned the media focus on addiction and overdose deaths, suggesting that such coverage diverts attention away from other conditions and social problems more worthy of public attention. Misdirected attention and individual blame represented 38.9% of all Facebook comments referencing addiction (n = 124) and included two subcategories: (1) unworthiness of attention and (2) addiction is a choice.

Unworthiness of attention

Unworthiness of attention challenged the prevailing definition of the opioid epidemic as a significant social problem deserving of public attention (20.7%; n = 66). In stark contrast to Facebook users who expressed support and encouragement for persons with opioid addiction, comments within this subcategory instead questioned their value and worth. Persons with addiction were labeled as “junkie losers” or as “leeching off society.” Facebook users viewed the problems associated with opioid addiction as drawing attention away from the societal burden of other drugs, diseases, and even other types of addiction. Commenters argued that the amount of attention devoted to the opioid epidemic by media and government officials was disproportionate to that paid to other conditions they saw as more deserving of public resources. Responding to a post by the Springfield News-Sun about a local treatment program (“Reason to Hope: Clark rehab center sees impact of heroin-fighting drug”), one commenter compared the experiences of those who are reliant upon expensive pharmaceutical treatment to persons with opioid addiction who receive medication-assisted treatment from public- and grant-funded programs:

Sure, give junkies a free pass but charge bank breaking amounts to someone who is having an allergic reaction for an epi pen. Let the junkies die, worthless scum.

Others highlighted the barriers that persons with diabetes face in obtaining needed medications. In response to a Dayton Daily News story about a woman who was revived with Narcan after overdosing on heroin (“Pharmacist helps save mother overdosing on heroin in grocery store bathroom, police say”), one Facebook commenter posted “No free Narcan for junkies[,] free insulin for diabetics.”

Commenters made references to the limited resources available to address other societal problems, diseases, and addictions to argue that opioid addiction should not be singled out and treated differently or devoted any special attention. Commenters also noted that people succumb to addiction to a range of behaviors and that addiction is ubiquitous in American society (e.g., “We’re all junkies”). These commenters pointed to other substances and addictive behaviors such as alcohol (drinking), tobacco (smoking), caffeine, and overeating. One news story that provoked the ire of commenters was posted by the Akron Beacon Journal (“‘It’s raining needles’: Drug crisis creates pollution threat”). This article aimed to raise awareness about the threat of syringes left behind by drug users that were “turning up everywhere,” including on rivers, beaches, parks, and the grounds of an elementary school. In response to this article, one commenter questioned the framing of opioid addiction as a disease and expressed a lack of concern for persons with opioid addiction:

It will be nice when this “population control” is over. I’m tired of hearing about it and care less each day. Put alcohol in your system and you’re a drunk. Weed and you’re a stoner. Some Crack…you’re a crackhead. Now put Heroin in your system and poof you have a disease?? They encourage you to do it by providing Narcan. Dumb.

Facebook commenters spoke of groups that have been indirectly affected by the opioid epidemic. People with chronic pain (e.g., “REAL pain”) were viewed by Facebook commenters as unintended casualties in the societal crackdown on opioid prescribing. In their view, the considerable attention devoted to opioid addiction has directed the collective focus away from the plight of chronic pain sufferers. Those who became medically dependent on pain medications were seen as more worthy of attention compared to those with addiction stemming from illicit opioid use; persons with opioid addiction were seen as diverting needed treatment away from those with legitimate pain. Facebook users voiced criticisms that “the fault lies in the seat of the people who are willing to FAKE pain just to get high.”

Another group deemed unworthy of attention, mothers and pregnant women with opioid addiction, were also blamed for their addiction and support for them was criticized as diverting attention from their children. Facebook users felt the parents “should not be allowed to have children…or be allowed anywhere around children.” In response to one article in the Morning Journal, which described court proceedings for a woman with opioid addiction charged with child endangerment (“Ohio woman gets 6 years in prison after infant grandson drowns in bathtub after she overdosed on heroin”), a commenter criticized what they saw as a lenient jail sentence and directed others to consider her grandson:

Another example of “aww…poor heroin addict” judge giving a CRIMINAL a pass on a sentence. But she’s an addict…But you don’t understand…She started on pain meds…She had such a bad life…Before you say anything to me…. get up off your drug taking enabler a$$es and go visit that baby’s grave.

Addiction is a choice

A notable subcategory within misdirected attention and individual blame included commenters who represented addiction as a condition that “starts with a choice.” Comments within this subcategory (18.2%; n = 58) represented opioid addiction as a consequence of poor decision making and failure of responsibility to oneself and others. These commenters believed knowledge of the danger and risks associated with opioid use is universal (e.g., “Everyone knows opioids are addictive”) and that people with addiction make a conscious decision to use opioids despite these known risks. This assumed knowledge was viewed as being enough in itself to prevent people from making what were seen by commenters as misinformed decisions to use opioids. Facebook users who promoted the view of addiction as a choice often remarked that persons with addiction need to accept personal responsibility and not be enabled by others who sympathize with their addiction (i.e., those with “bleeding hearts”). Addiction was viewed by these Facebook users as a failure of personal responsibility and that “people need to be responsible for themselves and get off that stuff.” Indeed, news content or other commenters who directed blame for the epidemic toward people and places other than the persons with addiction were seen by those with this viewpoint as making “excuses” for their poor choices. Emphasizing individual choices and morality, one commenter responded to a story in the Piqua Daily Call (“Aldi robber sentenced to four years in jail”), about a man with heroin addiction who was sentenced to jail for robbery, in the following way:

So sick of the heroin excuse…I’m glad the judge gave him jailtime…all heroin users are lowlifes in my book…Don’t try it[,] you don’t get addicted…period…end of story.

Another commenter, responding to a story by the Herald-Star (“Jefferson County could file opioid lawsuit”) about a lawsuit against manufacturers of prescription painkillers, rejected the popular narrative of blaming drug manufacturers and questioned the framing of addiction as a disease. Illustrative of this point was a Facebook commenter who viewed people who use drugs as being directly responsible for their addiction, and their excuses to stop using were seen as exacerbating the epidemic:

Ain’t that nice[,] let’s blame the Drug Companies for people that are too stupid to follow directions & take their pain meds as instructed. 1 pill 4 times per day does not mean take 4 pills 8 times a day. Drug addiction is not a disease. It’s a choice. Those pills did not force themselves down your throat. Cancer, diabetes, Alzheimer’s, those are diseases. Drug addiction is not a disease and until people start making better life choices & get their heads out of their Azz, drug addiction will continue to be a problem. All of the excuses in the world and blaming others will not fix the problem. Until people stop enabling the problem by using excuses, the problem will continue to grow.

Narcan was a frequent topic of discussion among commenters, including in articles reporting on efforts to make the overdose antidote more widely available. Facebook users categorized under addiction is a choice viewed the availability of Narcan as encouraging abuse or as deterring people from treatment (e.g., “Stop giving Narcan! It’s enabling the junkies!”). Views of addiction as a choice also framed how Facebook users saw the relative effectiveness of treatments. One commenter to a post by the Sandusky Register (“Medication can help addicts deal with withdrawal”) explaining different forms of medication assisted therapy for opioid addiction questioned whether persons with addiction would use the prescribed medication in the way they were intended:

ROTFL [rolling on the floor laughing]…yep…addicts get these medications and use them wisely???? Don’t kid yourself.

Association of Media Framing and Addiction Categories in Facebook Comments

We examined the distribution of comments according to the framing of news stories and categories in representations of addiction (Appendix Table A2). These analyses suggested that there is no association between media framing and representations of addiction in Facebook comments on posted news stories (p = .945). Audience representations of addiction were observed to be largely independent of the frames identified in media coverage of the opioid epidemic.

Discussion

The opioid epidemic has received substantial media attention. This increased attention is especially visible in Ohio, where deaths due to opioid overdose are among the highest in the U.S. The recent proliferation of news content related to the opioid epidemic, including posts shared on social media, has drawn audiences to the topic of addiction. Our study of comments on news content posted on Facebook by Ohio newspapers indicated that 11% of these comments referenced addiction. Facebook users were not passive consumers of media content but rather reacted with attempts to define and shape the significance (or insignificance) of opioid addiction as a social problem. They offered a range of perspectives on the causes and consequences of opioid addiction in U.S. society. We identified a notable divide between Facebook users whose representations were categorized as either: (1) support, disease, and contributing factors, which included comments that emphasized a medicalized understanding of addiction, considered social and structural contributors to addiction risk, supported treatment for persons with addiction in their path toward recovery, and provided firsthand testimonials of experiences with addiction and trials in recovery; and (2) misdirected attention and individual blame, which focused on the choices by persons to use opioids that led to addiction, their responsibility to stop using opioids, and the perceived diversion of attention by the opioid epidemic from other pressing social problems. Notably, comments within the misdirected attention and individual blame category viewed individual choices to use (or misuse) opioids as outweighing the role(s) of social and structural contributors to addiction highlighted by support, disease, and contributing factors comments, including the increased availability of prescription opioids or efforts by drug companies to market opioids and promote their use. Together, these comments inform our understanding of how the public is responding to the rise in drug-related problems within their communities, as well as factors that affect their support for policies and programs intended to prevent overdose and facilitate recovery from opioid addiction. The distribution of comments across these two categories representing addiction was found to be largely independent of frames used within posted media coverage.

Comments within the support, disease, and contributing factors category tended to situate addiction in a medical perspective—as a progressive brain disease that compromises an individual’s decision making and will to resist urges to use drugs (Volkow et al., 2016). Further, commenters within this category viewed addiction, and the opioid epidemic more broadly, as significant social problems shaped by forces ranging from pharmaceutical manufacturing and drug policies to drug trafficking and law enforcement. Facebook comments within the subcategory contributors to addiction reacted to media content with an intent to inform others about social forces they saw as contributing to the opioid epidemic, especially in response to news stories that in their eyes failed to provide sufficient context for understanding the problem or lacked investigative reporting. These comments engaged with larger discussions about the social, cultural, and economic roots of the opioid epidemic, including its ties to the supply of opioids in American marketplaces and anxieties caused by economic vulnerability and downward mobility in distressed areas (Botelho et al., 2017; Goodwin et al., 2018; Monnat, 2016). Additionally, some commenters were witnesses to addiction—persons with addiction themselves or family members of those with addiction—who offered firsthand narratives of the struggles of addiction that have been found to be underemphasized in media coverage of the opioid epidemic (Russell et al., 2019).

While comments categorized as support, disease, and contributing factors tended to endorse a disease model of addiction that focused on medical and structural explanations for the opioid epidemic, comments within the misdirected attention and individual blame category were more consistent with historical representations that blame people who use drugs for social problems and their own addictions. Negative attitudes toward persons with drug addiction are common among Americans—exceeding the stigmatization and discrimination associated with other conditions such as mental illness (Barry et al., 2014). Rather than favoring social and structural explanations for the spread of opioid addiction, comments within the misdirected attention and individual blame category conflated persons with addiction with the social problem itself. Addiction stigmas extended to the overdose antidote naloxone (Narcan®), the ready availability of which was viewed by commenters within the misdirected attention and individual blame category as enabling persons with addiction by providing a “safety net” against the negative consequences of drug use. These comments echo findings from other studies highlighting beliefs among community members and health care workers that naloxone availability serves to enable or encourage opioid use (Gatewood et al., 2016; Smith et al., 2019).

Comments within the misdirected attention and individual blame category, including those expressing beliefs that addiction is a choice, contrasted sharply with the calls of others to increase community and public health efforts to prevent deaths due to drug overdose and increase access to counseling and medication-assisted treatment for persons with addiction. Comments coded within the unworthiness of attention subcategory also placed blame for the epidemic directly upon individuals with addiction and questioned the attention directed toward the opioid epidemic. The increased attention devoted to opioid addiction was viewed by these commenters as taking the collective focus away from other populations and problems that were perceived as being more deserving of public discussion and resources, be it the high cost of medications for chronic illness or the adverse health consequences of other substances including alcohol and tobacco. The dismissive stance toward opioid addiction was also visible through comments in the unworthiness of attention subcategory about how the opioid epidemic has impacted chronic pain sufferers, who were viewed as being “really and truly in pain” as opposed to persons with addiction who were seen as “willing to fake pain just to get high.” When viewing the epidemic through this frame, patients with “real” chronic pain are unwitting casualties of providers’ efforts to limit opioid prescribing (R. Rubin, 2019). Physicians may be more vigilant against attempts by patients to obtain opiates as well as eager to transition patients with chronic pain off those medications (S. Rubin et al., 2018).

Commenters within the misdirected attention and individual blame category referred to themes of individual choice and personal responsibility to bolster their arguments against the allocation of public resources toward programs and policies meant to prevent opioid addiction and its consequences. Together, these comments suggest that public understandings of addiction have not altogether shifted from the themes of fear, morality, and criminalization that have characterized drug users and persons with addiction in previous drug epidemics. They also illustrate that stigmatizing language, including terms such as “junkie” or “addict,” are often used by commenters to refer to persons with addiction. Media coverage may contribute to public stigma toward addiction by using these terms when reporting on the opioid epidemic. One study found that nearly half of all media coverage of the epidemic during a 10-year period included stigmatizing terms, while only 2% of stories used less-stigmatizing language such as “person with an opioid use disorder” (McGinty, Stone et al., 2019). It is important to consider that public endorsements of a disease model of addiction may not be sufficient to reduce the stigma associated with persons who use opioids. Instead, it may contribute to stigmatization and amplify the challenges of recovery from addiction. Research on attitudes toward other stigmatized conditions, including schizophrenia and depression, has found that the perceived dangerousness of people diagnosed with these problems was greater when the conditions were understood as biological illnesses intrinsic to the affected individuals (Angermeyer et al., 2011; Kvaale et al., 2013; Read et al., 2006). Understandings of these disorders as biological in origin may induce a pessimistic outlook toward recovery (Haslam, 2011; Phelan, 2005). Research is needed to unpack the extent to which neuroscientific and biomedical understandings of addiction affect perceptions of persons who use opioids. Findings from one study of U.S. adults suggest a “double-edged sword” in which genetic (biomedical) explanations of addiction were associated with lower ratings of blame and increased confidence in the effectiveness of pharmacotherapy, while also being associated with reduced ascriptions of agency and self-control (Lebowitz & Appelbaum, 2017). Research among addiction treatment providers finds that addiction is represented by “deranged” or diseased brains, and that in the process of treating patients for addiction, neurobiological enactments run the risk of stigmatizing patients as “disordered” and “sick” (Barnett et al., 2018). Scholars have advocated instead that public health and legislative efforts devote greater attention to the varied “social, psychological, cultural, political, legal and environmental contexts” that impact upon “addictive behaviors” (Heim et al., 2014, p. 40).

There are some limitations to our study which lead us to be cautious in generalizing our results. First, our sample of media content was limited to posted media content and comments on a single social network platform (Facebook) within a single U.S. state (Ohio). Future research should examine the extent to which our findings extend to coverage and commentary in other areas affected (or less affected) by the opioid epidemic. Second, the views of addiction shared by commenters in response to news coverage of the opioid epidemic may be different from the views of Facebook users who read the news stories but choose not to comment upon them, and we are unable to examine differences in representations of addiction between active and passive consumers of news content on social media platforms. Despite these limitations, our findings are illustrative of how news audiences are actively engaged in discussions of addiction, including in shaping the collective definition of addiction as an individual issue or as a larger social problem.

The incomplete evolution of societal representations of addiction away from those focused on misdirected attention and individual blame toward those which emphasize support, disease, and contributing factors is particularly significant for increasing the traction of community and public health efforts to reduce drug-related problems and prevent overdose deaths. Research on the AIDS epidemic found that the individualistic social philosophy that characterized the public health crisis was a significant obstacle to developing effective policies (Kaplan, 1990). The association of the AIDS epidemic with lifestyle behaviors, decision making, and stigmatized or marginalized groups directly impeded much-needed public health responses to the crisis (Kaplan, 1990). Similarly, public health responses to the opioid epidemic may be slowed or halted by an individualistic social philosophy that associates drug use with disadvantaged populations and criminality. Indeed, an individualistic social philosophy of addiction emphasizes choices by persons to continue to use drugs and their perceived irresponsibility. Perhaps aware of this challenge, some Facebook commenters noted that the absence of policy interventions and continued growth of the epidemic could be attributed to the stigmatizing beliefs held by persons representing law enforcement, legal, and political organizations. Facebook commenters questioned the lack of political support for policies that could benefit those struggling with addiction and reminded others that public officials occupy elected positions. These findings might also help to explain the seemingly paradoxical findings that while a majority of the public view drug addiction and opioid use as major problems, less than one quarter of Americans view taking increased action to reduce deaths from opioid use as a top national priority (Blendon & Benson, 2018; Hartig & Doherty, 2018). The success of future efforts to address opioid addiction through policy reform and increased funding for treatment and prevention interventions will likely hinge on the extent to which popular representations of addiction both favor its collective definition as a social problem worthy of public attention and response and minimize the emphasis on individual choices and moral culpability.

Footnotes

Appendix A

Table A2.

Distribution of Comments by Media Framing and Addiction Categories.

Addiction Category	Total Sample	Framing Category in Posted News Coverage
Addiction Category	Total Sample	Awareness of the Opioid Epidemic and Affected Populations	Programs, Policies, and Interventions	Crime, Punishment, Legal Cases, and Law Enforcement	Narratives of Addiction and the Long Road to Recovery
Support, disease, and contributing factors	61.1% (195)	59.9% (91)	64.0% (48)	61.2% (41)	60.0% (15)
Misdirected attention and individual blame	38.9% (124)	40.1% (61)	36.0% (27)	38.8% (26)	40.0% (10)

Note. Pearson’s χ² test statistic = .375.

Two-tailed p value = .945.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

David Russell

References

Angermeyer

M. C.

Holzinger

Carta

M. G.

Schomerus

(2011). Biogenetic explanations and public acceptance of mental illness: Systematic review of population studies. The British Journal of Psychiatry, 199(5), 367–372.

Barbera

Piccirilli

Barbera

M. P.

(2017). Package “rfacebook” (R Package Version 0.6.15). https://cran.r-project.org/web/packages/Rfacebook/Rfacebook.pdf

Barnett

Dilkes-Frayne

Savic

Carter

(2018). When the brain leaves the scanner and enters the clinic: The role of neuroscientific discourses in producing the problem of “addiction.” Contemporary Drug Problems, 45(3), 227–243.

Barry

C. L.

McGinty

E. E.

Pescosolido

B. A.

Goldman

H. H.

(2014). Stigma, discrimination, treatment effectiveness, and policy: Public views about drug addiction and mental illness. Psychiatric Services, 65(10), 1269–1272.

Becker

H. S.

(1963). Outsiders. Free Press.

Blendon

R. J.

Benson

J. M.

(2018). The public and the opioid-abuse epidemic. New England Journal of Medicine, 378(5), 407–411.

Blumer

(1971). Social problems as collective behavior. Social Problems, 18(3), 298–306.

Botelho

Lemos

Souza

Clark

(2017). The drug overdose epidemic: Deaths of despair or deaths of addiction? Sociology Between the Gaps: Forgotten and Neglected Topics, 3(1), 4.

Boyd

(2002). Media constructions of illegal drugs, users, and sellers: A closer look at traffic. International Journal of Drug Policy, 13(5), 397–407.

10.

Brownstein

H. H.

(1991). The media and the construction of random drug violence. Social Justice, 18(4 (46)), 85–103.

11.

Centers for Disease Control and Prevention. (2018). Understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html

12.

Chan

Lopez

Sarkar

(2015). The canary in the coal mine tweets: Social media reveals public perceptions of non-medical use of opioids. PLoS One, 10(8), e0135072.

13.

Cohen

(1972). Folk devils and moral panics. Routledge.

14.

Daniels

Netherland

J. C.

Lyons

A. P.

(2018). White women, US popular culture, and narratives of addiction. Contemporary Drug Problems, 45(3), 329–346.

15.

Dasgupta

Mandl

K. D.

Brownstein

J. S.

(2009). Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality. PLoS One, 4(11), e7758.

16.

Dwyer

Fraser

(2016). Addicting via hashtags: How is Twitter making addiction? Contemporary Drug Problems, 43(1), 79–97.

17.

Facebook. (2018). Statistics. https://newsroom.fb.com/company-info/

18.

Fuchs

(2017). Social media: A critical introduction. Sage.

19.

Gatewood

A. K.

Van Wert

M. J.

Andrada

A. P.

Surkan

P. J.

(2016). Academic physicians’ and medical students’ perceived barriers toward bystander administered naloxone as an overdose prevention strategy. Addictive Behaviors, 61, 40–46.

20.

Glowacki

E. M.

Glowacki

J. B.

Wilcox

G. B.

(2018). A text-mining analysis of the public’s reactions to the opioid crisis. Substance Abuse, 39(2), 129–133.

21.

Goodwin

J. S.

Kuo

Y. F.

Brown

Juurlink

Raji

(2018). Association of chronic opioid use with presidential voting patterns in US counties in 2016. JAMA Network Open, 1(2), e180450–e180450.

22.

Han

Compton

W. M.

Blanco

Crane

Lee

Jones

C. M.

(2017). Prescription opioid use, misuse, and use disorders in US adults: 2015 National survey on drug use and health. Annals of Internal Medicine, 167(5), 293–301.

23.

Harding

(1986). Constructing addiction as a moral failing. Sociology of Health & Illness, 8(1), 75–85.

24.

Hartig

Doherty

(2018). More in U.S. see drug addiction, college affordability and sexism as “very big” national problems. Pew Research Center.

25.

Hartman

D. M.

Golub

(1999). The social construction of the crack epidemic in the print media. Journal of Psychoactive Drugs, 31(4), 423–433.

26.

Haslam

(2011). Genetic essentialism, neuroessentialism, and stigma: Commentary on Dar-Nimrod and Heine (2011). Psychological Bulletin, 137(5), 819–824.

27.

Heim

Blomqvist

Edman

Room

Storbjörk

(2014). Addiction: Not just brain malfunction. Nature, 507, 40. https://www-nature-com-s.web.bisu.edu.cn/articles/507040e.pdf

28.

Kaplan

M. S.

(1990). AIDS: Individualizing a social problem. Society, 27(2), 4–7.

29.

Kolodny

Courtwright

D. T.

Hwang

C. S.

Kreiner

Eadie

J. L.

Clark

T. W.

Alexander

G. C.

(2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annual Review of Public Health, 36, 559–574.

30.

Kvaale

E. P.

Haslam

Gottdiener

W. H.

(2013). The “side effects” of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33(6), 782–794.

31.

Lebowitz

M. S.

Appelbaum

P. S.

(2017). Beneficial and detrimental effects of genetic explanations for addiction. International Journal of Social Psychiatry, 63(8), 717–723.

32.

Martins

S. S.

Sarvet

Santaella-Tenorio

Saha

Grant

B. F.

Hasin

D. S.

(2017). Changes in US lifetime heroin use and heroin use disorder: Prevalence from the 2001–2002 to 2012–2013 national epidemiologic survey on alcohol and related conditions. JAMA Psychiatry, 74(5), 445–455.

33.

Matsa

K. E.

Shearer

(2018). News use across social media platforms 2018. https://www.journalism.org/2018/09/10/news-use-across-social-media-platforms-2018/

34.

McGinty

E. E.

Kennedy-Hendricks

Baller

Niederdeppe

Gollust

Barry

C. L.

(2015). Criminal activity or treatable health condition? News media framing of opioid analgesic abuse in the United States, 1998–2012. Psychiatric Services, 67(4), 405–411.

35.

McGinty

E. E.

Kennedy-Hendricks

Barry

C. L.

(2019). Stigma of addiction in the media. In: Avery

Jonathan D.

Avery

Joseph J.

(Eds.), The stigma of addiction (pp. 201–214). Springer. https://www.springer.com/gp/book/9783030025793

36.

McGinty

E. E.

Stone

E. M.

Kennedy-Hendricks

Barry

C. L.

(2019). Stigmatizing language in news media coverage of the opioid epidemic: Implications for public health. Preventive Medicine, 124, 110–114.

37.

McLean

(2016). “There’s nothing here”: Deindustrialization as risk environment for overdose. International Journal of Drug Policy, 29, 19–26.

38.

McLean

(2017). From “junkies” to “soccer moms”: Newspaper representations of overdose, 1988–2014. Critical Criminology, 25(3), 411–432.

39.

Monnat

S. M.

(2016). Deaths of despair and support for Trump in the 2016 presidential election. Pennsylvania State University Department of Agricultural Economics Research Brief, 5, 1–9. https://aese.psu.edu/directory/smm67/Election16.pdf

40.

Netherland

Hansen

H. B.

(2016). The war on drugs that wasn’t: Wasted whiteness, “dirty doctors,” and race in media coverage of prescription opioid misuse. Culture, Medicine, and Psychiatry, 40(4), 664–686.

41.

Orcutt

J. D.

Turner

J. B.

(1993). Shocking numbers and graphic accounts: Quantified images of drug problems in the print media. Social Problems, 40(2), 190–206.

42.

Orsini

M. M.

(2017). Frame analysis of drug narratives in network news coverage. Contemporary Drug Problems, 44(3), 189–211.

43.

Phelan

J. C.

(2005). Geneticization of deviant behavior and consequences for stigma: The case of mental illness. Journal of Health and Social Behavior, 46(4), 307–322.

44.

Quinones

(2015). Dreamland: The true tale of America’s opiate epidemic. Bloomsbury.

45.

Read

Haslam

Sayce

Davies

(2006). Prejudice and schizophrenia: A review of the “mental illness is an illness like any other” approach. Acta Psychiatrica Scandinavica, 114(5), 303–318.

46.

Reinarman

(1994). The social construction of drug scares. Constructions of Deviance: Social Power, Context, and Interaction, 92–105. Wadsworth Publishing. https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=151015

47.

Reinarman

Levine

H. G.

(1997). Crack in America: Demon drugs and social justice. University of California Press.

48.

Reinarman

Levine

H. G.

(2004). Crack in the rearview mirror: Deconstructing drug war mythology. Social Justice, 31(1/2) (95–96), 182–199.

49.

Rubin

(2019). Limits on opioid prescribing leave patients with chronic pain vulnerable. JAMA, 321(21), 2059–2062.

50.

Rubin

Burke

Van Natta

Yen

Shim

J. K.

(2018). Like a fish out of water: Managing chronic pain in the urban safety net. Journal of Health and Social Behavior, 59(4), 487–500.

51.

Russell

Spence

N. J.

Thames

K. M.

(2019). “It’s so scary how common this is now”: Frames in media coverage of the opioid epidemic by Ohio newspapers and themes in Facebook user reactions. Information, Communication and Society, 22(5), 702–708.

52.

Scholl

Seth

Kariisa

Wilson

Baldwin

(2019). Drug and opioid-involved overdose deaths—United States, 2013–2017. Morbidity and Mortality Weekly Report, 67(5152), 1419.

53.

Seelye

K. Q.

(2015, October 30). In heroin crisis, white families seek gentler war on drugs. The New York Times. https://www.nytimes.com/2015/10/31/us/heroin-war-on-drugs-parents.html

54.

Smith

J. O.

Malinowski

S. S.

Ballou

J. M.

(2019). Public perceptions of naloxone use in the outpatient setting. Mental Health Clinician, 9(4), 275–279.

55.

Snow

D. A.

Rochford

E. B.

Jr Worden

S. K.

Benford

R. D.

(1986). Frame alignment processes, micromobilization, and movement participation. American Sociological Review, 51(4), 464–481.

56.

Tiger

(2013a). Celebrity drug scandals, media double standards. Contexts, 12(4), 36–41.

57.

Tiger

(2013b). Judging addicts: Drug courts and coercion in the justice system. NYU Press.

58.

Tiger

(2015). Celebrity gossip blogs and the interactive construction of addiction. New Media & Society, 17(3), 340–355.

59.

U.S. Department of Health & Human Services. (2019). What is the U.S. opioid epidemic? https://www.hhs.gov/opioids/about-the-epidemic/index.html

60.

Vasterman

P. L.

(2005). Media-hype: Self-reinforcing news waves, journalistic standards and the construction of social problems. European Journal of Communication, 20(4), 508–530.

61.

Volkow

N. D.

(2014). America’s addiction to opioids: Heroin and prescription drug abuse. Senate Caucus on International Narcotics Control, 14, 1–16. https://www.drugcaucus.senate.gov/sites/default/files/Volkow%20Testimony.pdf

62.

Volkow

N. D.

Fowler

J. S.

(2000). Addiction, a disease of compulsion and drive: Involvement of the orbitofrontal cortex. Cerebral Cortex, 10(3), 318–325.

63.

Volkow

N. D.

Koob

G. F.

McLellan

A. T.

(2016). Neurobiologic advances from the brain disease model of addiction. New England Journal of Medicine, 374(4), 363–371.

64.

Webster

Rice

Sud

(2019). A critical content analysis of media reporting on opioids: The social construction of an epidemic. Social Science & Medicine. https://doi.org/10.1016/j.socscimed.2019.112642

65.

Willis

Painter

(2019). The needle and the damage done: Framing the heroin epidemic in the Cincinnati enquirer. Health Communication, 34(6), 661–671.

66.

Zuckerberg

(2018). Our next update on our 2018 focus to make sure Facebook isn’t just fun but also good for your well-being and for society. https://www.facebook.com/zuck/posts/10104493997365051