News Media Reporting On Medication Treatment For Opioid Use Disorder Amid The Opioid Epidemic

The US is facing an opioid-driven drug overdose crisis that has grown increasingly lethal over the past two decades.¹ Only about 20 percent of people with opioid use disorder (OUD)—the clinical term for a spectrum of problematic opioid use—are estimated to receive any type of treatment in a given year.^2,3 The level of need far outweighs the treatment infrastructure’s capacity, particularly with respect to evidence-based medications approved by the Food and Drug Administration (FDA) to treat OUD.⁴ The proportion of specialty substance use treatment providers offering medications for OUD increased from 20 percent in 2007 to 36 percent in 2016.⁵ In 2016 only 6 percent of these providers offered all three FDA-approved medications—methadone, buprenorphine, and naltrexone—in part because of the distinct regulations that govern the prescribing and dispensing of each type of medication.

Medication treatment can alleviate the symptoms of withdrawal and craving associated with OUD. Extensive research on methadone and buprenorphine demonstrates that these medications promote improved retention in treatment, reduced use of other opioids (for example, heroin and prescription opioids), improved social outcomes (such as interpersonal relationships and workforce participation), and lowered risk of relapse and overdose, compared to treatment not involving medication.^6–9 While methadone and buprenorphine are opioid agonists that activate opioid receptors in the brain, the third FDA-approved medication, naltrexone, is an opioid antagonist that blocks opioid receptors. Naltrexone has a less extensive evidence base than methadone and buprenorphine do and requires complete withdrawal from other opioids before initiation of treatment.^10,11 These medications are delivered in a maintenance context analogous to treating diabetes with insulin. Often, medication is paired with psychosocial interventions such as counseling.

In the context of an opioid crisis that has escalated in lethality in recent years,¹ it is possible that the public discourse on OUD medication may be evolving as well. The surgeon general¹² and the National Academy of Medicine¹³ have encouraged the expanded use of OUD medications. Some large addiction treatment providers, such as Hazelden, that had previously provided only nonmedication approaches have recently shifted course and begun offering medication treatment.¹⁴

While addiction experts view the scaling up of medication treatment as crucial to stemming the morbidity and mortality associated with OUD,^15–17 it is not clear that this perspective permeates public discourse more broadly. An analysis of news media coverage can provide important insights on the information the public is receiving from the news and the environment in which various health policies are being considered, including policies determining access to medication treatment. News media coverage both reflects and influences public attitudes on policy issues. Public sentiment, in turn, is an important factor that contributes to policy adoption.¹⁸

Two mechanisms by which news media are theorized to influence public attitudes are agenda setting and issue framing.¹⁹ Communication literature suggests that the news media constitute one of the drivers of the public salience of issues (that is, agenda setting) by devoting greater coverage to certain topics.^19,20 With respect to opioid-related issues, Emma McGinty and colleagues found that news coverage of the opioid crisis increased from 1998 to 2012.²¹ While public opinion surveys did not measure changes over this period in the level of public concern about opioid-related problems, subsequent surveys suggest that the public’s rating of the opioid epidemic’s importance as a public health problem has increased in recent years.²² Most relevant to the present study, however, was the finding by McGinty and colleagues that while 36 percent of news stories about the opioid crisis included a depiction of a person receiving substance use treatment, fewer than 1 percent depicted a person receiving medication treatment for OUD.²¹ Half of Americans are unaware that effective treatment options exist for OUD,²² which aligns with skeptical attitudes about substance use treatment and prospects for recovery more broadly.²³

Issue framing is another mechanism by which news media are theorized to influence public attitudes and dialogue.^19,24 By emphasizing particular dimensions of an issue, news media can help shape what issues news consumers view as constituting social problems as well as how news consumers understand the causes and consequences of those problems, the potential solutions, and the actors responsible for addressing them.²⁴ With respect to OUD medications, it is unknown whether news media stories about them discuss underuse and barriers to access.

Addiction medicine doctors report frequently encountering misperceptions about medications that harm efforts to expand access and engage people affected by OUD.^25,26 One such misperception is that medication treatment for OUD simply replaces one addiction with another. While people engaged in medication treatment for OUD do become physically dependent on these medications, this is distinct from addiction—which is defined as compulsive use of a drug despite harm.²⁵ It is unclear to what extent these misperceptions are represented in the broader public dialogue. Understanding news media reporting on OUD medication can help elucidate the ways in which expert framing of this issue and dialogue in the public sphere align and diverge.

This study examined news media coverage of OUD medication over the ten-year period 2007–16. The study objectives were to assess changes over time in news media reporting on medication for treating OUD; the inclusion of accurate and inaccurate messages about OUD medication in news stories; and mentions of underuse, barriers to access, and policies to broaden or restrict access to OUD medication. We also examined whether the content of news coverage in states with high opioid overdose mortality rates differed from that of national coverage.

Study Data And Methods

Data And Analytic Sample

We identified US news stories about OUD medication during the ten-year period 2007–16. National sources included newspapers with high circulation (the New York Times, Wall Street Journal, Washington Post, and USA Today), television news shows airing on major networks (ABC, CBS, and NBC), and other television shows with high viewership (including CNN’s Situation Room, Fox News Channel’s Special Report, and the PBS NewsHour). To understand coverage of OUD medication in states in which the opioid crisis has been severe, we identified states with high opioid overdose mortality rates for most of the years during our study period, measured using CDC WONDER data.²⁷ These states included Kentucky, Nevada, New Hampshire, New Mexico, Ohio, Oklahoma, Tennessee, Utah, and West Virginia. We selected two newspapers in each of these states based on circulation and availability of full-text articles in news archives for all years of the study period. We also aimed for ideological diversity within states by including one right-leaning and one left-leaning newspaper when available, as determined by recent presidential endorsements—although newsrooms are typically less ideologically oriented than opinion desks are. The twenty-eight news sources included in our sample are listed in online appendix 1.²⁸

We queried the databases LexisNexis, ProQuest, and Newsbank/Access World News Research Collection for stories related to OUD medication using the following search terms: methadone or buprenorphine or Suboxone or Subutex or naltrexone or Vivitrol or medication-assisted treatment or opioid agonist therapy or opioid maintenance therapy or opioid maintenance treatment or opioid treatment program. This search returned 3,278 news articles and television transcripts. Two members of the study team (Jonathan Levin and Eleanore Alexander) reviewed all stories to determine whether they met study inclusion criteria. We excluded the 51 stories that were shorter than a hundred words, the 220 duplicate articles, and the 81 articles categorized as something other than a news story, editorial, or op-ed. We also excluded the 2,364 stories that made no more than a passing reference to a specific OUD medication or to one of our other search terms, such as medication-assisted treatment, because there was no additional content to code beyond that brief mention. Examples of the types of stories excluded based on this criterion were profiles of people who had used a medication for OUD treatment with no additional context; mentions of a new medication product with no additional context; mentions of proposals to increase funding to combat the opioid epidemic, including medication treatments, but with no additional information on those medications; and stories about methadone in the context of pain treatment rather than OUD treatment. After the exclusions, 23 television transcripts and 539 newspaper articles remained for coding. We retained the full census of these television transcripts and national newspaper articles in our analytic sample, and we selected a random sample of local newspaper articles from states with high opioid overdose mortality rates. The final analytic sample included 300 news stories: 106 national newspaper articles, 171 local newspaper articles in states with high opioid overdose death rates, and 23 television transcripts.

Coding The Content Of News Media Coverage

The authors collaboratively developed a fifty-one-item structured coding instrument to capture information on the following dimensions of OUD medication: mention of specific types of OUD medications (methadone, buprenorphine, or naltrexone) and nonmedication OUD treatments (such as counseling), the positive and negative consequences of OUD medication use (for example, reduced harms to health), underuse of medication treatment and barriers to access (such as provider availability), and policies designed to broaden (for example, expand insurance coverage) or restrict (such as dosage limits in insurance benefits) access to OUD medication. We also examined the accuracy of statements about medication treatment for OUD by coding five accurate messages and five corresponding inaccurate messages. We identified these messages by examining misperceptions about these medications reported in the literature^25,26 and based on our expertise. The messages included the following: OUD medication is an effective/ineffective treatment (for example, it works/doesn’t work), people can/should not be on OUD medication for a long time (such as months, years, or an indefinite period of time), people on OUD medication are/are not high or experiencing euphoria; OUD medication is/is not another form of addiction or is/is not substituting one addiction for another (excluding statements that referred to physical dependence), and OUD medications can/do not help people function (for example, fulfill personal obligations). We pilot-tested the instrument on twenty-five articles and refined it based on item coding difficulty and frequency of appearance of the items in the articles.

Two authors (Levin and Elizabeth Stone) coded a random sample of ninety (30 percent) of the articles. Items with poor interrater reliability (defined as having kappa statistics below 0.65) were dropped from the coding instrument. We retained one of the inaccurate messages (“OUD medication is not effective”) with a kappa statistic of 0.55 to ensure that we were capturing parallel information (this is the inaccurate counterpart of the message “OUD medication is effective”). Kappa statistics for all items and characteristics of the news stories included in the analytic sample (for example, word counts) are in appendices 2 and 3.²⁸

Analysis

We calculated the proportion of news stories that mentioned each item among all of the news stories in our analytic sample. Differences over time were estimated with Pearson chi-square tests, with time treated as a binary variable (2007–14 versus 2015–16)—given the notable change in quantity of coverage in the last two years of the study period. Differences between stories appearing in national versus local news sources in states with high opioid overdose mortality rates were estimated using Pearson chi-square tests.

The study was approved as not human subjects research by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Limitations

Findings from this study should be interpreted in the context of its limitations. First, news consumers obtain health information from a variety of sources, among them local television, online-only news media, and social media,²⁹ which were not included in the study sample. Our sample included national print and television and local print news from sources with high circulation/viewership.

Second, we did not include data from local newspapers in states with low overdose mortality rates. Therefore, analyses of differences in coverage between national and local news in states with high overdose mortality rates may reflect patterns in national or local coverage more generally.

Third, although we aimed to include an ideologically diverse sample by selecting newspapers with recent histories of endorsing presidential candidates from different political parties, newsrooms may operate independently from their editorial offices. We included both news articles and editorials in our sample.

Fourth, as a quantitative content analysis, this study might not have captured the nuance or context that could be better elucidated through qualitative analysis.

Fifth, although prior research has found a relationship between news coverage and public attitudes,^30,31 assessing a connection was beyond the scope of this study. Nevertheless, these findings can inform future research that measures public attitudes on and policy attention paid to this topic.

Finally, our coding approach examined narrowly how the news media have reported on medication treatment for OUD and did not consider how other treatment (for example, counseling or residential treatment) has been framed in the news media.

Study Results

The volume of reporting remained fairly constant during the years 2007–14, apart from an uptick in coverage in 2012, before it rose substantially in 2015 and 2016 (exhibit 1). In the full study period, the most frequently mentioned OUD medication was buprenorphine (in 66 percent of stories), followed by methadone (59 percent) and naltrexone (14 percent) (exhibit 2). The proportion of articles that mentioned buprenorphine and naltrexone increased significantly in the last two years of the study period, while the proportion that mentioned methadone declined significantly—although, as exhibit 1 demonstrates, the number of articles mentioning each type of medication increased. The proportion of news stories describing OUD medications in the context of medication-assisted treatment was significantly higher in the last two years of the study period than in 2007–14 (46 percent versus 23 percent) (exhibit 2).

SOURCE Authors’ analysis of data generated from the authors’ query of online news archives for news articles or television news transcripts about medication treatment for OUD published or aired during the period 2007–16. NOTE Medication-assisted treatment is OUD medication in combination with another psychosocial treatment.

Forty-five percent of the news stories included at least one of five accurate messages about medication for OUD, and 16 percent included at least one of five inaccurate messages (see appendix 3).²⁸ The most frequently appearing accurate message was that OUD medication is an effective treatment for OUD (26 percent) (exhibit 3). Examples of text segments coded for this message included the following: “Suboxone effectively reduces withdrawal symptoms and cravings that often drive users back to heroin. Studies show the success rate for addicts kicking the habit using medication is twice as high as with other methods”³² and “evidence suggests that maintenance approaches with medication like the [buprenorphine] implant, plus behavioral therapy and other support, are more effective than short-term detox programs.”³³

SOURCE Authors’ analysis of data generated from the authors’ coding of content of news articles or television news transcripts about medication treatment for OUD published or aired during the period 2007–16. NOTES The kappa statistic for “OUD medication is not effective” was low (0.55), so this item should be interpreted with caution. We retained this item to maintain parallel structure with the corresponding accurate statement (“OUD medication is effective”).

The most frequently appearing inaccurate message, which appeared in 9 percent of stories, was that OUD medication was another form of addiction or was substituting one addiction for another (exhibit 3). Text segments coded for this item included the following: “Some say methadone maintenance is substituting one addiction for another,”³⁴ and “it is far better to become drug free than to trade one addiction for another.”³⁵ Few differences were detected in mentions of these accurate or inaccurate items over time or when we compared messages appearing in local news sources from hard-hit states to those in national news sources. (See appendix 4 for differences over time for all items coded and appendix 5 for differences in items coded between local and national news sources.)²⁸

Forty-six percent of news stories from states hard hit by the opioid crisis mentioned at least one positive consequence of using OUD medication, compared to 67 percent of news stories appearing in national news sources (exhibit 4). In contrast, a significantly larger proportion of local news sources mentioned at least one negative consequence of using OUD medication, compared to national news sources (51 percent versus 36 percent). (As shown in appendix 4, no differences over time were detected in the proportion of stories mentioning positive or negative consequences of medication treatment.)²⁸

About 36 percent of all news stories noted that OUD medications were underused or that people faced barriers to accessing these medications (exhibit 2). Having difficulty finding a provider to prescribe OUD medications was the most frequently mentioned barrier. The proportion of news stories that identified patient caps (that is, the number of patients a provider can prescribe to under buprenorphine waiver regulation) and inadequate insurance coverage of these medications as causes of underuse increased in the last two years of the study period. Forty percent of stories mentioned a policy or action to expand access to OUD medications. There was a significant increase in the last two years of the study period in the proportion of stories mentioning any approach to expanding access to OUD medication treatment (53.2 percent, compared to 26.1 percent in 2007–14).

Discussion

News media coverage of opioid use disorder medications increased substantially in 2015 and 2016. Part of this change in the amount of coverage may be due to the wider availability of these medications over the course of the study period.⁵ While methadone has been used as an OUD treatment in the US for decades, buprenorphine (approved by the FDA in 2002) and extended-release naltrexone (approved in 2010) entered the US market more recently.

Another explanation for the surge in coverage in 2015 and 2016 may have to do with the evolving epidemiology of the opioid epidemic. Much of the policy action in the opioid crisis has focused on safer prescribing of opioids.³⁶ However, it is possible that the contribution of opioids such as heroin and, particularly, fentanyl to escalating overdose deaths in recent years³⁷ is shifting the media’s focus to treatment and harm reduction solutions.^17,38

The extent to which increased news media coverage has heightened public awareness of OUD medications and changed notions about the role they can play in tackling the opioid epidemic is unknown. Public opinion research on attitudes toward OUD medication specifically has been limited,³⁹ and no trend data exist to assess whether these attitudes have changed over time. This limited our ability to determine whether the changes in news media attention to OUD medication that we documented in this study were associated with increased knowledge of OUD medication among the public, as communication theory on agenda setting would hypothesize.^19,20

Addiction experts should be reassured that more articles included accurate messages about OUD medication than inaccurate messages. Indeed, an inaccurate message of great concern among OUD treatment experts^25,26 (that OUD medication simply substitutes one addiction with another) appeared in a relatively small minority (9 percent) of the news stories in our sample—although it was the most frequently appearing inaccurate message. It should be noted, however, that we coded for a circumscribed set of five accurate and five inaccurate messages and that other accurate and inaccurate messages likely appeared in these news stories that our instrument did not capture. Furthermore, both accurate and inaccurate messages appeared in some of the same stories. A quarter of the news stories described OUD medications as effective, which suggests that treatment effectiveness is not a feature of most news reporting on these medications. We know little about public awareness of the efficacy of OUD medications specifically. Given the significant underuse of OUD medications, the public’s potential lack of knowledge about the effectiveness of these medications (particularly in comparison to abstinence-based approaches) may contribute to low levels of use of these medications—along with health system factors, such as insufficient provider availability. Levels of knowledge and public attitudes about these medications are important to understand, as efforts continue to engage more people with OUD in evidence-based treatment involving medication.

Slightly more than a third of the news stories mentioned that OUD medications were underused or that people with OUD faced barriers accessing medication treatment. This suggests that while poor access to OUD medications has not been constructed as a problem in most of the reporting on this topic, it is not absent from coverage, either. Although mentions of underuse did not change over the study period, coverage of policies to increase access to OUD medications did appear more frequently in 2015–16 than in 2007–14. This may signal growing recognition of the value of these medications and of the government’s role in expanding access to them.

National and local news media from states more severely affected by the opioid crisis placed differing levels of emphasis on the negative and positive consequences of OUD medications. News stories emphasizing the challenges posed by these medications more often than their benefits are not by default inaccurate. However, the emphasis on challenges is an example of the news media’s framing of OUD medication treatment.^19,24 Framing OUD medications in terms of negative consequences has the potential to generate negative perceptions of the medications among residents and policy makers in states with high overdose mortality rates. In such states, this framing is more prevalent in local news reporting than national news sources.

From a public health perspective, this type of framing could discourage engagement in medication treatment among people with OUD. From a policy perspective, news reporting that more heavily emphasizes the negative consequences of OUD medications could reduce the motivation to expand access to them. It could also heighten public opposition to locating new OUD medication treatment providers in these communities. These are theoretical concerns and not empirical questions that we answered in this study. However, given substantial geographic variation in the availability of providers that offer OUD medications⁴⁰ and differences across states in Medicaid coverage of medication treatment,⁴¹ future research on the factors driving geographic disparities in access to OUD treatment should consider the potential role of local news media coverage and its implications for local attitudes about medication treatment. Public health and addiction treatment advocates who seek to expand access to OUD medications in these communities might consider targeting their communication efforts to disseminate information on the medications’ benefits.

Conclusion

Findings from this analysis of news media coverage over a ten-year period suggest that coverage of opioid use disorder medications increased in 2015 and 2016 compared to the prior eight years. News stories about OUD medications tended to include more accurate than inaccurate messages about the medications, although information on the medications’ effectiveness as OUD treatment was not mentioned in most news stories on this topic. Communities in areas of the country that have been hard hit by the opioid crisis may be consuming news that emphasizes the negative consequences of OUD medications more than their benefits—a net imbalance in emphasis that conflicts with addiction experts’ assessment of the net positive effect of these medications.^15,17

Most news coverage of OUD medication has not noted the significant underuse of this type of treatment.

Most news coverage of OUD medication has not noted the significant underuse of this type of treatment, which may shape whether the public recognizes OUD medication underuse as a problem amid an overdose epidemic. Given that the opioid crisis has produced reversals in life expectancy trends, the public health and addiction communities need to develop more effective strategies to communicate with the news media and public about the value of medication treatment for reducing morbidity and mortality associated with OUD.

ACKNOWLEDGMENTS

The authors thank Eleanore Alexander for her contributions to the study.

NOTES

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