Opioids' impacts in the United States over the past two decades have been vast, profound, and complex. High death rates, overdose rates, and addiction rates manifested across varied geographies, ages, and racial and ethnic groups (CDC n.d.; Scholl et al. 2019). Opioids impaired economic productivity, strained health care systems, created new demands on the criminal justice system, and burdened family and community networks (NIDA n.d.-a). Varied forms of opioids—prescription drugs, heroin, fentanyl—contributed to the epidemic, emerged from different distribution sources, and presented different implications for various parts of public health systems.
Medical scholarship has made considerable strides in learning about the mechanisms that underlie opioid addiction, the correlates for its incidence, and promising forms of medical interventions (Williams et al. 2013; Walley et al. 2013; Schwartz et al. 2013). Public health scholarship has revealed aspects of medical policy and practice that contributed to the opioid epidemic, including physicians' prescribing practices and weak regulatory oversight from the Food and Drug Administration (Hadlad et al. 2017, 2019; Zettler, Riley, and Kesselheim 2018). Yet, we know much less about the roles that politics and governments at all levels of the system have played in abetting the epidemic. What has US policy and practice done in response to the current predicament, and what are key lessons for policy and practice moving forward? The director of the National Institutes for Health and the director of the National Institute on Drug Abuse have called for “all scientific hands on deck” to effectively address opioid addiction and its impact (Volkow and Collins 2017a, 2017b). This special issue of the Journal of Health Politics, Policy and Law represents a political science “all hands on deck” approach to understand the complex governmental and political terrain in which the opioid epidemic has unfolded. Underlying medical problems reside in political representation problems, social and economic inequality problems, and bureaucratic adaptation problems. By bringing together scholars from different theoretical perspectives and by examining different levels of government engagement with opioids, this issue considers how addressing questions about opioids also provides new insights on enduring features of US politics and policy, including the power of race, the development of the conservative welfare state, and the challenge of crafting interventions that work on the frontlines.
The politics of race have figured prominently in national responses to opioids. Since death rates associated with opioid use have been higher among whites than other groups (CDC 2018; NIDA n.d.-b), have legislators been more likely to pursue less punitive, more public health–oriented policies in response to opioids in contrast to more punitive criminal justice policies pursued for other drug epidemics? To start this special issue, Jin Woo Kim, Evan Morgan, and Brendan Nyhan compare the opioid era with the crack cocaine era to test whether the policy response to opioids has been less punitive than the response to crack, and whether differences in policy responses are associated with race. Using original data on district-level drug-related deaths and (co)sponsorship of legislation in the House of Representatives on illegal drugs, they find policy makers were more likely to introduce punitive drug-related bills during the crack era and were more likely to introduce treatment-oriented bills in the opioid era. Their results also suggest the relationship between district-level drug deaths and subsequent sponsorship of treatment-oriented legislation is greater for opioid deaths than for cocaine-related deaths and for white victims than for black victims. Their results demonstrate the persistence of racial inequalities and double standards in US drug policy.
The next question this issue addresses is, Does this trend that emerges in Congress of less punitive, more public health approaches for opioids relative to other epidemics also extend to media coverage? Carmel Shachar, Tess Wise, Gali Katznelson, and Andrea Louise Campbell provide additional evidence on racial inequalities through differences in the ways that media have portrayed the opioid and crack epidemics. Drawing on newspapers from across the country and over time, they systematically evaluate how each epidemic was framed in public discourse. They find that articles on the opioid epidemic are more likely to use medical terminology while articles on the crack cocaine epidemic used criminal justice terms more frequently. The differences in how the media have framed the two epidemics reveal additional ways in which race may play a role in public policy responses and outreach.
Racial politics also emerge in public opinion on policy alternatives. By assessing individuals who perceive themselves to be health policy losers, Sarah E. Gollust and Joanne M. Miller depart from and extend conventional scholarship that focuses on perceptions of being a political loser. Gollust and Miller find that whites who perceive themselves to be on the losing side of public health had less empathetic responses to the opioid crisis. Perceiving oneself to be a political loser, however, was unrelated to attitudes about addressing opioids. Their findings suggest how perceptions that one's racial group has lost ground in the public health context could have down-stream political consequences.
How has partisanship played a role in responses to the opioid epidemic, and what do these responses reveal about the development of the conservative welfare state in America? Colleen M. Grogan, Clifford S. Bersamira, Phillip M. Singer, Bikki Tran Smith, Harold A. Pollack, Christina M. Andrews, and Amanda J. Abraham take up these questions and offer new insights on the conservative welfare state. Their analysis of the intersection of state Medicaid policies and opioid assistance reveals that actions in Republican-led state policy do not mirror Republican oppositional rhetoric and proposals at the federal level. Challenging conventional theories of welfare state retrenchment, their findings suggest conservatives rely on program fragmentation to both expand and retrench benefits, not only to retrench programs.
Given the scope and complexity of the opioid epidemic, where do we go from here? Information campaigns constitute a commonly used policy approach to public health problems. Yet, Paul F. Testa, Susan L. Moffitt, and Marie Schenk demonstrate how experimental approaches that assess the impact of information campaigns may misestimate their effects by failing to account for respondents' willingness to receive new information, policy, and research. Using a doubly randomized survey experiment, Testa and his colleagues examine how willingness to seek new information shapes the way members of the public update their preferences about policies related to the opioid epidemic. Among those respondents likely to receive information, treatment has a large positive effect on increasing support for policies to address the opioid epidemic. Among those who would avoid this information, preferences appear to be unmoved by treatment. These effects would be missed by standard experimental designs and highlight the importance of access to and receptiveness toward new information.
Yet, information campaigns constitute only one component of addressing complex policy problems, like the opioid epidemic. Patricia Strach, Katie Zuber, and Elizabeth Pérez-Chiqués develop the concept of an illusion of services, demonstrating the disconnect between what the state perceives as the problem (information) and what frontline service providers and constituents perceive as the problem (structural barriers). Policies may fail not because they are poorly designed or poorly implemented, but because the policies fail to address the actual underlying problem. In the case of opioids, misplaced solutions can hide evidence of the underlying problem and exacerbate the issue that policy makers strive to fix.
The evolving terrain of opioid drug abuse renders this epidemic complex for policy and practice. While much attention has focused on opioid use among young white men in rural areas, recent estimates suggest growth in the opioid death rate among black individuals, individuals over the age of 65, and individuals who live in mid-sized metropolitan areas (Scholl et al. 2019). The collision of an evolving terrain with enduring political, regulatory, and health care structures reveals ways in which the US political process operates to yield inequities, inefficiencies, and ineffectiveness. Lessons from opioids—about racial politics, about the complexities of service delivery, about manifestations of partisan politics—extend well beyond this epidemic and reveal fundamental structural challenges embedded in US politics and policy.
Initial drafts of the articles that appear in this special issue were presented at the Politics of the Opioid Epidemic conference convened at Brown University in February 2019. The conference was supported by the Watson Institute for International and Public Affairs, the Taubman Center for American Politics and Policy, and the Journal of Health Politics, Policy and Law. We are grateful to Jennifer Costanza for her work organizing and implementing the conference proceedings.