“He was riding away on a bicycle. The last thing he said was, ‘I love you.’”
So opens a gut-wrenching tale about a man with a heroin addiction who came close to death several times before finally losing his life to an opioid overdose. The piece concludes that those who abuse heroin face two outcomes: death or sobriety.
Such stories—which shape how we view the issue, the people it affects, and the solutions we see and support—frame addiction as a crisis of individual suffering and bad choices, where the only solution is to make better decisions and have a stronger will. But bad decisions do not explain the epidemic, and better decisions won’t end it. We must change policy and practice to support people with addiction, help others resist it, and expose fewer people to addictive substances in the first place. Specifically, we need evidence-based interventions to identify who is at risk for addiction and interrupt the “risk chain” as early as possible. We also need treatment programs that provide hope, care, and support.
Framing the opioid epidemic as an individual problem hides these solutions. As philosopher Brendan de Kenessey argues, our preoccupation with individuals’ decisions obscures the power of prevention and society’s role in promoting it.
Meanwhile, though framing the opioid issue as a crisis boosts our sense of urgency, it tanks our ability to see and engage with solutions. For example, a recent story in Vox is headlined: “America’s opioid crisis has become an ‘epidemic of epidemics.” The author of this article probably intended to educate readers and spur people to take action. Unfortunately, the crisis tone could very likely have the opposite effect, dampening hope and causing people to think the problem is too big and intractable to solve.
Instead, we need narratives that support the possibility of solutions. This issue is dire and deeply disturbing, but not irreversible. This is not the first opioid crisis in human history, nor the first in the United States. History teaches us that we cannot treat our way out of a health epidemic. The infamous “Broad Street” cholera outbreak in 1850s London, in which more than 600 people died, is one example. Many believed “bad air” was the cause of illness, but physician John Snowe identified the true source of infection: contaminated water. Public officials closed the nearby water pump and inspected other water sources, which contained the outbreak and prevented further illness and death. In this case, as with addiction, treatment was necessary, but if it had come at the expense of preventing the disease, the epidemic would have continued. In short, rather than narrowly focusing on treatment—always the more obvious and pressing demand—we need a balanced approach that emphasizes prevention.
Framing prevention is notoriously difficult. Building support for activities that, if successful, will result in, well, nothing, is not exactly a rallying cry. But with examples, explanation, and repetition, we can help people value and support prevention.
Reframing addiction
In research conducted by FrameWorks in 2015, we found that using metaphors—particularly ones that deal with the active and collaborative process of construction, or the idea that social services build wellbeing—to explain the need for human services across someone’s lifespan increased public support for prevention policies and programs. A survey testing the frame effects of the construction metaphor found that it boosts support for prevention policies by a significant margin. Thus, we need narratives that emphasize prevention, and connect it to treatment and perhaps ultimately a cure for substance use disorders.
Yet, news stories and advocacy communications materials often exclude this insight. In a 2016 analysis, FrameWorks found that the news media and advocacy groups rarely explain how to prevent adolescent substance abuse. Without this explanation, the public is left to its own assumptions: Experimentation with drugs is a rite of passage, and teens don’t understand or appreciate the risks.
The same analysis also found that, as we mentioned earlier, media tend to frame addiction as an individual affliction—in this case, one of impaired willpower. Individualism is apparent in organizational materials, too, which often cast substance use as a matter of choice. As the National Council on Alcoholism and Drug Dependence warns on its website: “If you are hanging out with a group in which the majority of kids are using drugs to get high, you may want to think about making some new friends. … You don’t have to go along to get along.”
As members of the public, we consume a steady diet of these individualistic messages. Each time we hear one, it activates a set of cognitive associations about addiction and opioids, will and morals. Each one strengthens some mental muscles (those associating addiction with choice) and leaves others to atrophy. Eventually, these stories seep into our conscience, and determine how we think about addiction and responsibility.
Even people dealing with addiction in their families think this way. One of us, a physician, listened as a patient talked about how long he had suffered before finding the will to seek treatment. Citing willpower as the crucial factor in his recovery, he then said: “I was seven when my mother’s boyfriend gave me a hydrocodone while they were partying together. I loved it.” This man’s grandparents were alcoholics. He was probably born dependent, as a result of alcohol consumption during pregnancy.
Does the frame of personal responsibility and moral failure really fit and explain stories like his?
Instead of focusing on individuals and their decisions, we need to explain addiction as a brain disorder, not a moral failure. People who suffer from addiction need care in the same way people with diabetes, heart disease, or cancer do. Whether the source of the disorder stems from opioids, alcohol, or nicotine, everyone needs support, encouragement, and healthy relationships to achieve wellbeing.
We also need to explain the neurobiological roots of the opioid problem, as well as the social policies, medical practices, and marketing practices that have contributed to it. We need to explain and show how addiction works. This doesn’t mean we should take people out of our stories, but it does mean that we should place them within contexts and larger systems. Though it’s focused on a different issue, activist Irene Robinson does this well in her film about school closures in Chicago. The story frames larger messages about educational equity and reform, making it clear that the problem with education is not about immoral people with deficient values, but about a system that constrains some options and makes other paths all too easy to follow. The opioid epidemic needs more stories like this—gripping and powerful accounts that show the systemic roots of the problem, and the changes to policy and medical practice required to solve it.
To change the frame, we must also avoid “othering” individuals with addiction. Instead, we need to help people relate to the problem by rooting its cause in a system we live in and a biology we all share. We need to readjust our frames and explain that substance use disorders are caused by the brain’s reward system reacting normally in an abnormal environment. It’s not “those people” who have a problem, it’s a problem that has them. “Us-and-them” framing is a dangerous trap. As long as addiction is seen as being about “them,” it’s too easy to say that it’s not about “us.” People may view addiction as a rural problem, a poor problem, a problem of people who have no control over their lives.
The opioid epidemic is a salient issue; the public understands it is an urgent social problem. To mobilize action, we need stories like these, which explain the neuroscience of addiction in plain language, lack stigmatizing imagery and crisis language, and affirm that treatment works. We need to frame addiction around "us"—our families, friends, and even ourselves—and not "them," or "addicts." We need to emphasize solutions, not just problems, and we need to prioritize prevention. Unless and until we do, the epidemic will continue.
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Read more stories by John Dreyzehner & Nat Kendall-Taylor.