The opioid epidemic ranks as one of the most serious and tragic public health crises in US history. The cost in human lives, health care, and lost work productivity is staggering. While there are signs that the opioid epidemic may have begun to level off, tens of thousands of opioid deaths continue to occur every year.
The roots of the United States' opioid epidemic are generally well known. Beginning in the 1990s, physicians, pressured by aggressive and deceptive marketing by pharmaceutical companies, began prescribing opioids widely to reduce the suffering of acute and chronic pain, which had long been seen as neglected. Misuse of opioids and drug addiction (despite promises from drug companies that the risk of abuse was low) increased dramatically. In subsequent waves of the crisis, many opioid users began turning to illicit opioids including heroin and synthetic drugs like fentanyl. The crisis has devastated communities and millions of families across the United States. Many academic studies and government commission reports have focused on education, treatment, and other strategies to address the opioid epidemic. Progress is being made, but the crisis will continue for many years to come.
While the actions of pharmaceutical companies, drug distributors, and “pill mill” physicians are the proximate cause of the opioid epidemic, public policy is also implicated in the crisis. Government is charged with regulating the marketing of prescription drugs, enforcing laws against the consumption and sale of illegal drugs, and promoting public health. The failure of policy makers to recognize the severity of the crisis as it was emerging and to act in a timely and appropriate manner by providing treatment services to at-risk populations and other necessary interventions must be considered in any effort to understand the scale of the epidemic's toll. The articles in this special issue fill that gap, and offer a broader perspective on the role of health politics and policy in the opioid crisis. The contributors explore the political, cultural, and institutional context in which the epidemic grew into the nation's most serious public health threat and in which ongoing responses are being designed and implemented. The issue offers many lessons for scholars interested in the intersection of population health, law, politics, and governance.
One of the most striking characteristics of these essays is the multidimensional nature of the issue. There is no single opioid crisis but rather multiple distinct causes as well as many different problematizations and interpretations of the impact of the introduction of these new compounds into the health care system. The contributors explore the role of different actors, including the public, the states, the media, Congress, and the bureaucracy (as well as their interactions) to understand how good intentions to reduce pain-related suffering, financial incentives, and policy breakdowns coincide. Three core themes emerge from the essays. The first is the powerful role of narratives and framing in shaping understandings of the opioid epidemic. The second is the opioid epidemic as a test of healthcare system governance. The third theme is the role of partisanship in mediating responses to the crisis.
The Role of Framing in the Opioid Epidemic
There is no one correct or natural way to understand the opioid epidemic. How people understand it—and how they apprise the benefits and costs of different ways to address it—are shaped by the political context in which discussions about the epidemic take place. It is clear that in such discussions words matter, and that it is impossible to even conceive of the politics or policy response without considering the narrative and framing, or how we describe it (pain management, drug abuse, public health epidemic). At the same time, unlike some policy phenomena, there is the undisputed fact of large-scale mortality and morbidity. The opioid epidemic for many years was under- rather than overstated, and the opposite of what Goode and Ben-Yehuda (1994) describe as a moral panic. Given that, it seems justifiable to agree with the nature of this as a bona fide crisis.
Several of the essays in this issue build on the rich traditions from different fields regarding the influence of framing on how we think about problems (leading scholars in this tradition include Peter L. Berger and Thomas Luckmann , Anne Schneider and Helen Ingram , and Deborah Stone , to name just a few). That intellectual tradition demands that the opioid crisis be seen as a policy or political phenomenon with a social construction. Only by disaggregating the phenomenon, and by recognizing the hidden assumptions that anchor its conceptualization, can we truly understand how a problem even comes to be seen as such.
In their essay comparing media representations of the crack cocaine and opioid epidemics, Carmel Shachar, Tess Wise, Gail Katznelson, and Andrea Louise Campbell point out that “the model used to frame a substance abuse epidemic is crucial because it not only shapes public perception of the epidemic but also the public policy responses.” The authors show that newspaper articles on the opioid epidemic are more likely to use medical terminology (such as health, treatment, and overdose) and that articles on the crack cocaine epidemic are more likely to use the language of social control and criminal justice (such as police, enforcement, and arrest). The differential framing of the two epidemics shows that race may play a contributing role in media framing. This is consistent with past research recognizing how some issues, such as welfare, have been racialized and closely identified with African American populations (Gilens 1999). However, the authors' finding that coverage of the methamphetamine epidemic also involved a criminal justice narrative suggests that the different framing of opioids and crack cocaine does not merely result from the different racial group predominately affected. The authors further show that while coverage of heroin shifted toward a medical frame over time, the tone and content of coverage of heroin still differed from coverage of opioids. This disparity suggests that another dimension that affects the framing of coverage is whether or not the drug in question is illegal. The authors make a strong case that in order for a media narrative to shift, two factors must come together: “an overall reframing of substance use as a public health issue” and “a perception that most users of the particular substance are white.” Taken together, the findings of the article offer new insights into how racial factors interact with other elements of the political and policy context to shape issue framing.
The essay by Jin Woo Kim, Evan Morgan, and Brendan Nyhan provides further evidence that perceptions of the racial identity of victims mediates political responses to public health epidemics. Examining sponsorship of drug-related bills in the US House of Representatives and drug-related mortality data at the district level, the authors find that legislators were more likely to introduce punitive legislation during the crack epidemic, whereas they are more likely to introduce treatment-oriented legislation during the opioid epidemic. Further, the authors show that legislators respond to drug deaths in their districts by sponsoring more treatment-oriented legislation, but “this relationship is only observed for opioid deaths and white victims.” Once again, we see how words are not just about words; framing likely reflects—and amplifies—preexisting racial inequity in society.
The essays in this issue not only explore how race mediates policy responses but also shed light on how issues like the opioid crisis come to be racialized in the first place, particularly when the victims are predominately white. Although the opioid epidemic is commonly described by public health experts as a major cause of the white “deaths of despair” hypothesis (Case and Deaton 2015), it is not obvious that opioids would necessarily be seen as a white issue—perhaps like the tendency of whites to not describe themselves in racial terms, thinking as they do, as the default rather than the exception in categories. Conversely, “people of color are almost always seen as ‘having a race’ . . . whereas whites are rarely defined by race” (DiAngelo 2012: 175). Indeed, the lack of initial racialization of the crisis raises questions that scholars may debate for a number of years into the future, but, at least for now, scholars in this issue provide some guideposts for exploration.
In their essay, Sarah E. Gollust and Joanne M. Miller examine whether the perception that whites are faring comparatively poorly in the opioid epidemic shapes white views on how to address it. Using a survey experiment, the authors show that white subjects who saw a news article framed to emphasize the higher rate of opioid mortality among whites increased whites' perception that they are on the losing side in the health policy domain. This loser perception, in turn, makes whites less supportive of government policies that are empathetic to opioid users, such as prevention programs and efforts to reduce stigma. In short, social identity is a key mediator of public opinion, and whites' willingness to support policies that would arguably help their own health and well-being depends on how whites view their position in society relative to nonwhites. These findings should encourage further scholarship into the ways (both intended and unintended) that elite messaging can create a perception that one group is winning and another is losing, even when public health policies would benefit the population as a whole.
The Opioid Epidemic and Healthcare Governance
Both policy makers and scholars may describe phenomena such as the opioid crisis as an aberration, as an unforeseen and novel governance challenge, perhaps as a way to explain flat-footed responses. In fact, crises such as the opioid crisis are a test of the resilience or “stress tests” for governance. Natural disasters like hurricanes and earthquakes are such tests. They reveal the adequacy of infrastructure investment and the quality and level of compliance with building codes, for example. Similarly, a health care system must have the capacity to meet new epidemics and other challenges, sometimes much more quickly than expected.
The scale of the opioid crisis in the United States—the fact that so many people have been caught in its grip for so many years—is taken by some as prima facie evidence of indicator of poor performance of American government. Yet many questions remain about just why government's response to the opioid epidemic has been so sluggish and inadequate. Governance failures can arise from multiple and reinforcing causes, including institutional fragmentation that prevents policy coordination, inadequate spending on vital public services, special-interest influence that diverts policy goals away from the common good, the short time horizons of reelection-minded officials, and implementation breakdowns of various kinds.
No doubt these and other factors have been at play in the opioid case. As Patricia Strach, Katie Zuber, and Elizabeth Peréz-Chiqués show in their article on treatment policies in New York State, however, government's actions can make a public health crisis worse, even when policies are well crafted and do what they are intended to do, because they are based on a faulty definition of the underlying problem. The authors' decision to study New York State is interesting because it offers a best-case scenario—a jurisdiction with the political will to address the opioid crisis and a higher level of institutional and administrative capacity than is found in many less-affluent states. Their findings are based on extensive interviews with the street-level bureaucrats—a research approach that generates powerful insights into how policies actually work on the ground.
The authors find a mix of macro and micro factors that cause what they call an illusion of services—the simultaneous availability of open treatment beds together with obstacles that prevent people from obtaining services when they show up and ask for them. These factors include admission criteria and the framing of opioids under a medical model of care, which causes hospitals to turn away patients who are not displaying outward signs of physical drug withdrawal. Larger, macro policy failures drive these micro issues of scarcity, including federal workforce policies, the lack of physicians eligible to prescribe buprenorphine, and—even more prosaically—staff shortages that led community facilities to turn away people in need, brought about by inadequate pay for people working in underserved areas. In short, the authors identify what the public management literature has long recognized to be bureaucratic goal displacement. Here we return to the disconnect between what policy makers believe is the problem is and how to address it, relative to the problems in actuality. Better use of the tools of policy analysis (define the problem, tailor the solution appropriately, confront the trade-offs) is critical to making tangible and sustainable progress on the opioid and substance abuse problem, yet the role of policy analysis is often neglected in a political process that places a premium on immediate action and symbolic solutions.
The Mediating Role of Partisanship and Information in the Opioid Epidemic
If ever there was a problem begging for officeholders to put partisan needs aside and focus on the public interest, it is the opioid epidemic. The test should be what solutions work—not on which party formulated them. However, the opioid epidemic has unfolded in the United States during an era of rising political polarization in which the two parties have battled over many health policy issues, most notably the enactment of the Affordable Care Act. Competition for power encourages Democrats and Republicans to differentiate themselves from their partisan opponents, even on issues where liberals and conservatives essentially agree (Lee 2009). How much difference has partisanship made in shaping responses to the crisis? To shed light on this important question, Colleen M. Grogan, Clifford S. Bersamira, Phillip M. Singer, Bikki Tran Smith, Harold A. Pollack, Christina M. Andrews, and Amanda J. Abraham investigate whether Democrat-led and Republican-led states have had different or similar responses to the opioid epidemic. Based on a legislative analysis across all 50 states, an online survey of state Medicaid agencies, and in-depth case studies with policy stakeholders, they find that Democratic and Republican states alike have passed legislation to address the opioid crisis, but that the level of fiscal commitment to address the opioid epidemic has been much higher in (predominantly) Democrat-led states that expanded their Medicaid program under the ACA. In Republican-led states that have declined to expand Medicaid, many people suffering from opioid use disorder (OUD) have found themselves without access to treatment.
The opioid crisis does not respect partisan boundaries, of course, and many of the individuals suffering from OUD are part of the GOP's party base. This raises a genuine puzzle. How have Republican officeholders in non-Medicaid-expansion states managed to pursue a policy that denies access to treatment without suffering electorally? Overall, the authors find that state-level Republicans have strategically distanced themselves from Republicans at the federal level. They have also pursued conservative policy options in their existing Medicaid programs, including copays and work requirements, tightened access over opioid prescribing, and adopted targeted expansions for “deserving” populations such as pregnant women. Taken together, these findings help explain how Republican officeholders have managed to claim credit for addressing the opioid crisis without endorsing major new investments in public health spending.
A key intervening variable in this partisan outcome was likely the role of information, a topic to which the study of Paul F. Testa, Susan L. Moffitt, and Marie Schenk contributes key insights. One of the challenges in understanding the influence of information is that people vary in their information exposure and the degree to which they actively seek out information. To capture these complexities, the authors performed an experiment in which some subjects were randomized to receive informational facts about the opioid epidemic and others were given the option of whether to receive the information. The study included three main outcome measures: respondents' objective knowledge about the opioid crisis, beliefs about the primary cause of this crisis, and support for general policy measures to address this issue.
The authors' findings are quite intriguing. They found that people who were interested in receiving more information about the crisis were more likely to have higher levels of education and income, less likely to be racial minorities, and more likely to identify as Democrats and liberals. Those people who would opt to receive information have different views regarding who or what is to blame for the opioid epidemic, with those more interested in finding out about the epidemic more likely to attribute blame to health care providers and less likely to attribute blame to illicit drug use. Finally, the authors show that among people likely to receive this information, information about the crisis “has a large positive effect on increasing support for treatment-oriented policies to address the opioid epidemic but no effect on support for more punitive approaches,” whereas the policy preferences of those who would not seek out the information were unchanged. Overall, the study results suggest that the effects of information about the opioid crisis will vary a great deal across the US population, based on the likelihood that a given person will encounter it. A better understanding of these issues could help policy makers design more effective information campaigns that would be better tailored to particular audiences or subgroups.
An overarching question of this special issue is whether and to what extent politics and policy bear a measure of responsibility for the opioid epidemic's severity and duration. Rather than come together against a common threat, policy makers often retreated to their partisan and ideological corners, allowing the epidemic to diffuse across larger and larger segments of the US population. Not only were the perceptions of the causes and solutions to the crisis deeply divided along political lines, the policy investments and administrative capacity building seemed to default on average to a policy response that was too late and too limited. In the global health arena, policy makers and researchers are moving to a more sophisticated and multifaceted understanding of the factors that contribute to effective health systems. They are increasingly recognizing the important role of health system governance. In US health policy, leaders and researchers seem less likely to use political and legal analysis to explain mortality and morbidity outcomes. The essays in this special issue clearly point to the need for public health practitioners and scholars to put political institutions and politics front and center.
Miriam Laugesen acknowledges the support of the Tow Foundation.