What the media gets wrong about opioids

https://www.cjr.org/covering_the_health_care_fight/what-the-media-gets-wrong-about-opioids.php

After Jillian Bauer-Reese created an online collection of opioid recovery stories, she began to get calls for help from reporters. But she was dismayed by the narrowness of the requests, which sought only one type of interviewee.

“They were looking for people who had started on a prescription from a doctor or a dentist,” says Bauer-Reese, an assistant professor of journalism at Temple University in Philadelphia. “They had essentially identified a story that they wanted to tell and were looking for a character who could tell that story.”

Although this profile doesn’t fit most people who become addicted, it is typical in reporting on opioids. Often, stories focus exclusively on people whose use started with a prescription; take this, from CNN (“It all started with pain killers after a dentist appointment.”), and this, from New York’s NBC affiliate (“He started taking Oxycontin after a crash.”)

Alternatively, reporters downplay their subjects’ earlier drug misuse to emphasize the role of the medical system, as seen in this piece from the Kansas City Star. The story, headlined “Prescription pills; addiction ‘hell,’” features a woman whose addiction supposedly started after surgery, but only later mentions that she’d previously used crystal meth for six months.

The “relatable” story journalists and editors tend to seek—of a good girl or guy (usually, in this crisis, white) gone bad because pharma greed led to overprescribing—does not accurately characterize the most common story of opioid addiction. Most opioid patients never get addicted and most people who do get addicted didn’t start their opioid addiction with a doctor’s prescription. The result of this skewed public conversation around opioids has been policies focused relentlessly on cutting prescriptions, without regard for providing alternative treatment for either pain or addiction.

While some people become addicted after getting an opioid prescription for reasons such as a sports injury or wisdom teeth removal, 80 percent start by using drugs not prescribed to them, typically obtained from a friend or family member, according to surveys conducted for the government’s National Household Survey on Drug Use and Health. Most of those who misuse opioids have also already gone far beyond experimentation with marijuana and alcohol when they begin: 70 percent have previously taken drugs such as cocaine or methamphetamine.

Conversely, a 2016 review published in the New England Journal of Medicine and co-authored by Dr. Nora Volkow, director of the National Institute on Drug Abuse, put the risk of new addiction at less than 8 percent for people prescribed opioids for chronic pain. Since 90 percent of all addictions begin in the teens or early 20s, the risk for the typical adult with chronic pain who is middle aged or older is actually even lower.  

This does not in any way absolve the pharmaceutical industry. Companies like Purdue Pharma, the maker of Oxycontin, profited egregiously by minimizing the risks of prescribing in general medicine. Purdue also lied about how Oxycontin’s effects last (a factor that affects addiction risk) and literally gave salespeople quotas to push doctors to push opioids.

The industry flooded the country with opioids and excellent journalism has exposed this part of the problem. But journalists need to become more familiar with who is most at risk of addiction and why—and to understand the utter disconnect between science and policy—if we are to accurately inform our audience.

The innocent victim narrative

The reporters who called Bauer-Reese were not ill-intentioned in seeking the most sympathetic addiction stories; it is genuinely altruistic to want to portray those who are suffering in a way that is most likely to move readers and viewers to act compassionately. But such cases can have an unintended side effect: highlighting “innocent” white people whose opioid addiction seems to have begun in a doctor’s office sets up a clear contrast with the “guilt” of people whose addiction starts on the streets.  

This is a result of racist drug policies that began decades ago. The war on drugs declared by Richard Nixon in 1971 was part of the Republican “Southern strategy,” which used code words like “drugs” “crime,” and “urban” to signal racist white voters that the party was on their side. When Ronald Reagan doubled down harsh law enforcement during the crack years, he merely intensified that strategy.

Rather than skeptically investigating, however, members of the media enlisted themselves as happy drug warriors throughout the 1980s and ’90s. Sensational stories focused on crack and its users as the cause of the problem, frequently ignoring that addiction hits hardest in communities facing high unemployment, de-industrialization, cuts in benefits, and loss of hope. In 1986, for example, promoting his documentary 48 Hours on Crack Street, CBS anchor Dan Rather intoned, “Tonight, CBS News takes you to the streets, to the war zone for an unusual two hours of hands-on horror.”  Or here’s The New York Times in 1991, “Crack Hits Chicago, Along with a Wave of Killing,” and in 1994, “Crack Means Power, and Death, to Soldiers in Street Wars.”

Now that the problem is seen as “white,” however, socioeconomic factors and other reasons that people turn to drugs are more commonly discussed. The result is that today’s white drug users are portrayed as inherently less culpable than the black people who were caught up in the crack epidemic of the ’80s and ’90s.

Craig Reinarman, professor of sociology emeritus at the University of California, Santa Cruz, has documented biased coverage of addiction since before the crack era. “Now that the iconic user is white and middle class, the answer is no longer a jail cell for every addict, it’s a treatment bed,” he says. The biased coverage ends up perpetuating a public perception that some drug use, usually by African Americans, is criminal while other drug use, usually by white people, is not.

Criminalization still deeply affects our sympathy for people with opioid addiction. This headline recently appeared in the Times: “Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?” Is that a question reporters would ask about people with diabetes who don’t follow their diet or those with heart disease who don’t exercise? In fact, the condition discussed in the Times article is not inherent to drug injecting, and the treatment of it doesn’t require limited resources like transplants do: it’s spread by unsterile syringes, which is a result of lack of access to clean ones, not addiction itself.

Often, stories focus exclusively on people whose use started with a prescription.

It’s important for journalists to understand that criminalization is not some sort of natural fact, and laws are not necessarily made for rational reasons. Our system does not reflect the relative risks of various drugs;legal ones are among the most harmful in terms of their pharmacological effects. With the exception of the legislation that resulted in the creation and maintenance of the FDA, our drug laws were actually born in a series of racist panics that had nothing to do with the relative harms of actual substances.  

In order to do better, journalists must recognize that addiction is not simply a result of exposure to a drug, and that “innocence” isn’t at issue.  The critical risk factors for addiction are child trauma, mental illness, and economic factors like unemployment and poverty. The “innocent victim” narrative focuses on individual choice and ignores these factors, along with the dysfunctional nature of the entire system that determines a drug’s legal status.

The difference between dependence and addiction

Widespread conflation of addiction and dependence further mars opioid coverage.

These days, experts from the National Institute on Drug Abuse and the authors of the Diagnostic and Statistical Manual, now DSM-5, agree that the core of addiction is compulsive drug use that continues regardless of bad outcomes. Unfortunately, from 1987 to 2013, the DSM termed its diagnosis “substance dependence.” This misnomer supported a widespread misconception of “real” addiction as the need for a substance in order to function and avoid getting physically ill, rather than a compulsion that drives behavior.

The critical difference between addiction and dependence becomes clear when you look at specific drugs. Crack cocaine, for example, doesn’t cause severe physical withdrawal symptoms, but it’s one of the most addictive drugs known. Antidepressants like Prozac, meanwhile, don’t produce compulsive craving the way cocaine can, but some have severe withdrawal syndromes.

Needing opioids for pain alone, then, doesn’t meet the criteria for addiction. If the consequences of drug use are positive and the benefits outweigh the harm from side effects, then that use is no different from taking any other daily medication. Dependence in and of itself isn’t a problem unless the drug isn’t working or is more harmful than it is helpful.

Unfortunately, while the scientific understanding has changed to reflect these facts, the press hasn’t caught up. The Washington Post conducted a poll of pain patients on opioids that labeled one third of them as addicted after they responded “yes” to a question that asked whether they were “addicted or dependent,” without defining either term. A CBS affiliate in Chicago talked about treating “opioid dependence” when they actually meant “addiction”; this CNN story has the same problem.  

Needing opioids for pain alone doesn’t meet the criteria for addiction.

This would be a mere semantic issue if it didn’t have such awful effects on policy. Conflating addiction and dependence results in harm to pain patients, children exposed to opioids in utero, and people who take medication to treat addiction.

Any pain patient who takes opioids daily for long enough will develop physical dependence and suffer withdrawal if the medication isn’t tapered slowly. But if either the doctor or the patient sees this dependence as addiction, then the patient is at risk of being cut off from medication that is actually helpful.

In some instances, hundreds or even thousands of patients have been forcibly tapered from opioids in an attempt to comply with federal guidelines and law enforcement pressures, without regard for individual medical circumstances or needs. For instance, Oregon has proposed rules which prohibit Medicaid patients from receiving more than 90 days worth of opioids, period, unless they are dying, and that all who are currently on opioids must stop. But there is no evidence to support cutting off chronic pain patients who are doing well on these medications, and at least one preliminary study associated such a drastic measure with increased risk of suicide while not reducing overdose risk.

To make matters worse, mistaking dependence for addiction also harms people who take treatment medications like methadone or buprenorphine, which are the only two therapies proven to cut the death rate by 50 percent or more.  These medications don’t produce any intoxication once an appropriate and regular dosing schedule is instituted. They relieve the compulsion and the consequences that are the hallmark of addiction.  However, they only work for as long as people stay on the meds—in other words, patients remain dependent.

Sadly, even if patients have gone from being homeless and unemployable to being productive workers, the fact that they are still on medication means that they are often stigmatized as being “not really” in recovery—indeed, if dependence is the same as addiction, they aren’t. This misconception leads many to prematurely stop, often resulting in overdose death.

It’s important for journalists to explain these distinctions—to ensure that both pain patients and people with addiction have access to appropriate medication.

Plus, there’s no such thing as an addicted baby

Perhaps the most insidious product of the media’s failure to distinguish between addiction and dependence is the myth of “addicted babies,” which leads to headlines like “The Tiniest Addicts.” Such a stigma that can do lasting harm to a child:  research from the crack years showed that infants labeled as “crack babies” were seen as having less potential and normal toddler behavior was labeled as pathological.

Infants certainly can experience physical dependence and painful withdrawal as a result; what’s known as “neonatal abstinence syndrome” is the result of withdrawal symptoms following opioid exposure in the womb. However, babies can’t be “born with addiction.” An infant doesn’t know why it feels uncomfortable or what could fix the problem—it has dependence, not addiction

How to change your language, and your coverage

How can journalists do better?  First, be aware of the importance of your language, and explain the differences between key terms to your readers and viewers.

Last year, the AP decided to update its stylebook to address these issues, which provides a useful guide. Journalists are advised to use the phrase “person with addiction” rather than the noun “addict.” “Person first” language is already used routinely for people with other mental illnesses such as schizophrenia and depression; failing to follow best practices for people with addiction suggests it’s not really a legitimate health problem.  

Similarly, just as we no longer use offensive terms like “maniac” to refer to people with bipolar disorder, words like “druggie” and “junkie” should be avoided. The AP urges its members not to conflate addiction and dependence for precisely the reasons listed above, and also warns against using the term “drug abuse”—which, like “dependence,” has been removed from the DSM. “Misuse” is more accurate and less moralistic.

Ask yourself if you are covering addiction the way you would any other medical disorder. Would you rely on police as sources to discuss patients’ behaviors or pharmacology? Would you accept claims about patients that frame them fundamentally dishonest by nature? Would you highlight only “innocent” victims of the disease?

Ask yourself if you are covering addiction the way you would any other medical disorder.

Don’t accept claims about what works in addiction treatment at face value. Ask for research supporting treatment outcomes. If it doesn’t exist, or if there is data on similar programs having poor outcomes, include these facts.

Be as skeptical of claims about work or spiritual cures as you would be for cancer care. The addiction treatment industry simply is not professionalized in the way other health care is. Many treatment providers have little training beyond their own experience with addiction and are not familiar with the research. Don’t give self-interested claims about treatment outcomes or the supposed superiority of self-help groups the same weight as peer-reviewed data—and make sure you include peer-reviewed research whenever you cover medication and behavioral treatment.

Ensure that your audience knows that our system of drug laws is not based on scientific information about drugs. Writing about drugs frequently contains implicit racism;stories framed around the idea that white people with addiction “are not typical” imply that people of color are.

Finally, if you think you know a fact about substance misuse, check it. Some of the best stories come from simply exploring the research that shows that most of what we think we know about drugs is completely wrong.

Filed under: General Problems