As Republicans debate alternatives to the Affordable Care Act, support for addiction treatment has been notably absent from their policy prescriptions.
This stands in stark contrast with the GOP’s campaign trail rhetoric. Throughout 2016, Republican presidential hopefuls shared a sympathetic view of the opioid addiction crisis. Jeb Bush called his daughter’s struggle with addiction a journey “through hell,” while Carly Fiorina related the “haunting” memory of her stepdaughter’s eyes transforming into a “dull, flat void” in the period before her fatal overdose in 2009.
While less passionate about the issue, Donald Trump launched his presidency with a pledge to stop the “American carnage” caused by rising drug use and overdose deaths.
At first glance, these descriptions of the damage wrought by the opioid epidemic appear compassionate. When viewed in light of the devastating cuts to Medicaid services for mental health and addictive disorders proposed in the Senate’s Better Care Reconciliation Act, they appear contradictory and even hypocritical.
In reality, these narratives are not antidotes to the policy problem, but a piece of it. Since the nation’s first opiate epidemic peaked in the mid-1890s, stories designed to create a visceral emotional response have generated attention, but ultimately undermined effective solutions. In calling attention to the problem of addiction, these sensational stories reinforced stereotypes that people who used substances, regardless of their backgrounds, were subhuman, unworthy and probably incurable. As an unintended consequence, support for treatment was often short-lived.
From the asylums of the late 1800s to the federal narcotics penitentiaries of the mid-1900s to the nationwide treatment system of today, treatment advocates dwelled on the negative consequences of substance use in an attempt to evoke pity, fear or alarm that would inspire immediate public support.
Now, even the most sympathetic Republican proposals for more generous treatment funds extend a crisis-driven mentality that has been part of the larger problem in treating drug addiction since the 19th century. This approach has caused support for treatment to evaporate almost as quickly as it materializes and has thwarted every attempt to build a sustainable treatment infrastructure. By preserving an outdated and counterproductive view of addiction, GOP policymakers’ sensationalism inhibits their ability to solve the crisis they love to lament.
Sensationalism as a literary form debuted in the 1860s and 1870s. Exposing the details of lurid private acts — sex, violence, drug use — the form soon infected other genres: Newspaper publishers justified its use by arguing that manufactured shock and outrage raised awareness about important social problems.
They sensationalized one of the most pressing problems of the age — drug addiction. Then as now, panicked coverage raised public awareness about the previously submerged problem. The medicinal use of opiates took off in the 1800s, becoming an epidemic after midcentury and peaking in the mid-1890s.
Muckraking journalists played a key role in exposing the source of the epidemic: the doctors who endorsed opium and morphine, and the drug companies who peddled patent medicines with undisclosed narcotic ingredients. The stories also entailed breaching the privacy of the main drug abusers, “neurasthenic” upper-class white women who nursed their habits in secret.
Sensational portraits in everything from novels to medical literature painted the addict as a pathetic domestic figure who was flirting with death. The novelist Wilkie Collins depicted this figure drinking laudanum to welcome “the blessing of oblivion,” while neurologist George M. Beard deemed her destined to be “weeded out” as “the tendency for debility leads to its own elimination.”
For a time, designated asylums offered treatment to address the growing addiction problem. But the sympathy elicited by the sensational coverage quickly dwindled when treatment providers’ promises to permanently transform patients failed to materialize. At the height of the 19th-century opiate epidemic, treatment was already on the decline; only 30 of the first 50 organizations founded to treat addiction remained open in 1893.
Public perceptions about asylums’ incorrigible upscale client population contributed to their downfall. The public began to view treatment as a luxury of idle, ill-behaved wealthy people who offered little social value to the wider community. Treatment virtually disappeared as the stigma associated with it increased. Patients’ demand for private residential treatment dropped, and the limited funding for publicly supported asylums dried up.
The situation worsened in the early decades of the 20th century as the demographics of drug use shifted from middle- and upper-class women to lower-class urban males. For this new population, heroin and morphine use was “recreational,” and reformers began to reframe drug use as a symptom of lawlessness rather than nervousness. The press cast people who used drugs as villains rather than victims. Anti-drug policies hardened in response.
But sensational tropes continued to shape conversations about treatment, even as treatment took more limited and punitive forms. In 1928, William Randolph Hearst helped journalist Winifred Black publish “Dope: The Story of the Living Dead,” a book intended to drum up support for two centralized federal penitentiaries designed to corral and treat people with narcotic addiction. The campaign was successful. The facilities became the therapeutic concession to a federal drug policy that was otherwise committed to punishing users of illicit narcotics.
By the 1950s, writers presented the high relapse rates — as high as 90 percent in some accounts — of the residents discharged from the federal penitentiaries as a sensational failure of treatment. The stories of relapse once again supported the notion that the available forms of treatment were a poor public investment and addiction to hard drugs a hopeless cause.
Ironically, when former penitentiary residents challenged this treatment system by creating their own alternative treatment model, their protests reinforced negative stereotypes about people who used substances by recounting “hitting bottom” with their addictive behaviors and their close brushes with death. One influential group of “ex-addict” reformers organized a response to rising heroin use in the 1960s by contesting the effectiveness of existing treatment institutions, not the perception that their addictions had stripped them of their humanity.
Inspired in part by the advocacy of ex-addict reformers, government officials invested in community-based treatment in the 1960s and early 1970s. They laid the groundwork for today’s nationwide treatment system, which, thanks to drug-war policies that invested in prisons and urged treatment privatization, emerged from the Reagan era with gaps in the continuum of care and vulnerable to government cutbacks.
Today, the sensationalist narrative remains, and so does the crisis-driven mentality it promotes.
Support for addiction treatment requires empathy for the lifelong process of recovery, not the invasive details of the pain of active addiction. Recent research suggests that interpersonal contact that normalizes, rather than sensationalizes, the lived experience of recovery can encourage treatment-seeking among people with substance use disorders and help address the social discrimination that impedes treatment and recovery efforts. We now have eras of evidence that describing people with addictive disorders in horrifying terms is a problematic form of advocacy. The search for counter-narratives will be essential to progress.
Although support for addiction treatment has ebbed and flowed for more than a century, the stigma against people who use drugs has been a historical constant. Today’s sensationalistic coverage of addiction — gruesome scenes of parents overdosing in front of children, babies born with neonatal abstinence syndrome, families fracturing as drugs enter their homes and communities, or drug-dependent women being driven into prostitution — exploit the private suffering of an already vulnerable population and contribute to stigma rather than countering it.
Stigma, in turn, contributes to apathy, and time-limited funding disappears when the public no longer feels a sense of urgency. Future attempts to build a sustainable treatment infrastructure will be undermined as long as treatment advocates continue to depict people who struggle with addiction as already dead.