Media framings of the role of genomics in “addiction” in the United States from 2015 to 2019: Individualized risk, biomedical expertise, and the limits of destigmatization

Abstract

News coverage of the opioid epidemic is a useful site for examining genomic framings of addiction. Qualitative analysis of 139 articles published in the United States from 2015 to 2019 discussing genomics, addiction, and the opioid epidemic found an emphasis on both a postgenomic framing in which genetics operates in relation to social and environmental factors, and a molecularized understanding of addiction which highlighted the role of neurobiology and individual-level genetic risk. Discussions of genetics were often intertwined with calls for a biomedicalized approach that frames addiction as a chronic disease in need of medication, and thus under the purview of medical experts. Finally, while genomic discourses were invoked to reduce stigma, genomics was at times used to describe addicts as biologically distinct from other people, reflecting the possibility that genetics—even in the postgenomic context—can be used to promote a biologically essentialized understanding of people with addiction.

The opioid epidemic presents a new context to examine how genetics, treatment, and stigma are currently related in discourses around substance use disorders. The epidemic is a significant topic of public concern in the United States, prompting the passage of multiple pieces of legislation (21st Century Cures Act, 2016; Comprehensive Addiction and Recovery Act, 2016; SUPPORT for Patients and Communities Act, 2018), which have significantly expanded public funding of both treatment and research. Genomic science is at the forefront of much of this research—shaping both research into the etiology of substance use disorders and response to treatments and prescription opioids. While early twin studies have supported the hypothesis that substance use disorder is a heritable trait for a variety of substances (Kendler et al., 1994, 2000, 2003; Li et al., 2003; Tsuang et al., 1998), more recent research, using whole genome sequencing and large data sets, has shifted toward examining substance use disorder as a complex trait involving several hundred genes whose expression are shaped by a number of environmental factors (Kendler et al., 2012).

Drawing from both critical addiction studies and ethical, legal, and social implications (ELSI) of genomics, this study examines how discussions of genomics of addiction¹ during media coverage of the opioid crisis have been used to frame the status of substance use disorder, treatment, and stigma. Following the work of Erving Goffman, scholars have used the concept of “frames” to examine how events and issues are socially constructed in the media. Frames can define a social problem, as well as suggest solutions or interventions, and are thus a critical part of agenda setting (Entman, 1993, 2007; Gitlin, 1980). In this sense, the media is neither a simple reflection of public opinion nor a unilateral tool that shapes it, but a dynamic social institution that is both shaped by and shapes public discourse (Conrad, 1997; Entman, 1991; Eyck and Ten, 2005; Gamson and Modigliani, 1989). Thus, the frames encountered should be taken as both reflective of and potentially shaping public opinion on the role of genomics in addiction.

Thematic analysis of 139 articles published between 2015 and 2019 found three key themes. First, there was an emphasis on a postgenomic framing which emphasize how genetics operates in relation to social, psychological, and environmental factors (Keller, 2015). While postgenomic framings have the potential to expand discussions of the role of social and environmental factors in substance use disorders, this study also found genomics was also used to promote an molecularized understanding of substance use disorder which highlighted the role of neurobiology and individual-level genetic risk (Darling et al., 2016; Rose, 2007). Second, discussions of genetics dovetailed with the support of medical expertise around treatment, particularly through support of the use of medication-assisted therapy (MAT). Given that medication-assisted therapies such as methadone and buprenorphine remain controversial in the United States, this indicates that genomic discourses might be a part of boundary work around substance use disorder therapy and expertise (Gieryn, 1983). Finally, while genomic discourses were invoked to reduce stigma, genomics was also used to describe people with substance use disorders as biologically distinct from other people—reflecting the possibility that genetics—even in the postgenomic contexts—can be used to promote a biologically essentialized understanding of people with substance use disorder. Collectively, these themes illustrate that genetics is part of a biological, but also an individualizedrisk-focused model of that is also potentially divergent from the abstinence-based model of treatment, and which carries its own concerns for stigma.

Critical addiction studies and the history stigma and substance use disorders in the United States

Substance use disorders—from alcoholism to drug addiction—have a long history of stigmatization in the United States. People with substance use disorders in the United States have been viewed as criminals and as “weak willed” individuals since the 1800s. Scholars have argued that these moralizations of substance use disorders and addiction reflect larger Western and industrialized concerns with self-control, productivity, and autonomy (Campbell, 2007; Courtwright et al., 2013; Levine, 1978; Valverde, 1998). These moralizing and criminalizing discourses have not existed outside of science and medicine, but have instead been intertwined with claims from medicine, pharmacology, genetics, neuroscience, and psychology.

The medicalization of drunkenness and substance use disorders in the United States dates back to the nineteenth century when inebriate asylums were first established (Tracy, 2007 [2005]; White, 1998). Physicians advanced what historian Sarah Tracy (2007 [2005]) calls a medico-moral framing of alcoholism that asserted medical authority over a disease while continuing to draw from contemporary discourses which moralized drunkenness. This medical model operated in tandem with eugenicist’s calls for the prevention of transmission of the disease to further generations (Tracy, 2007 [2005]). Eugenic scientists argued that alcoholism was not only a heritable trait, but one indicating evolutionary “unfitness” and weakening the national stock (Kevles, 1995). In the early twentieth century, the Harrison Narcotic Act in 1914 ushered in the Classic Era of Narcotic Control, during which substance use was criminalized and treatment was rare outside of institutionalized settings (Courtwright, 2001; Musto, 1999). However, these policies did not come solely from law enforcement, but were supported by both psychologists and pharmacology researchers, who promoted the view that people with substance use disorders were morally derelict (Acker, 2002). And while the federal approval of methadone treatment at midcentury marked the ascendancy of a medicalized model of therapy, the federal government supported methadone clinics not out of a concern with public health, but as a way to reduce crime (Musto, 1999).

In the 1990s, the National Institute of Drug Abuse began to focus on research into the neurobiological basis of substance use disorder. One of the goals of this research agenda was to reduce the stigma by using neurobiology to counter moralizing arguments that people with substance use disorder had a lack of willpower (Leshner, 1997). There is some evidence that public opinion is increasingly adopting this view amid the opioid epidemic—with a majority of people surveyed believing that addiction is a disease rather than a personal weakness (PBS NewsHour/Marist Poll, 2017). However, critical addiction studies scholars² have also pointed out that neuroscientific framings of substance use disorder continue to be paired with moralizing discourses by stigmatizing relapse and justifying increased policing of people with substance use disorder (Campbell, 2010; Reinarman, 2005). Scholars have argued that the brain disease paradigm not only “lacks diagnostic robustness and epidemiologic utility,” but decontextualizes the brain in ways that render all brains the same and render social influences invisible and reinstates racialized narratives and drug use and therapy (Choudhury and Slaby, 2016; Hammer et al., 2013; Hansen et al., 2020). Collectively, this scholarship calls attention to the ways that biological and medicalized approaches around substance use disorders continue to contribute to stigma.

The ELSI of genomics and substance use disorders

ELSI of genomics scholarship has examined how genomic explanations of substance use disorder impact concepts such as social distancing, treatment efficacy, agency, and responsibility. While genetic narratives might counter moralizing discourses, scholars have asked whether they also lead to an essentialized understandings of substance use disorder as a immutable, biological trait that cannot be treated (Condit et al., 1998). Findings on the impact of genetic explanations of substance use disorder and alcoholism through both experimental and survey designs have been complex and evade either optimistic or essentialized frameworks. Surveys have found that while the public is increasingly endorsing genetic explanations for all alcoholism, genetics has not increased social acceptance (Pescosolido et al., 2021; Schnittker, 2008). Experimental studies comparing the affective response to genetic and non-genetic explanations of substance use disorder found that these models had conflicting effects. Genetic explanations were a “doubled-edged sword” that decreased feelings of blame but also decreased feelings of agency. In addition, and in keeping with the findings presented in this article, genomic explanations of substance use disorder increased participants’ beliefs in the efficacy of pharmacotherapy and decreased their perceived effectiveness of psychotherapy (Lebowitz and Appelbaum, 2017, 2019). However, qualitative studies have also found that the biological models relying on genomics are flexibly integrated into individual’s understanding of their disease, which indicates that genomic narratives might act in complex ways outside of experimental settings (Dingel et al., 2017, 2019).

Media analysis has been a critical arena for scholars interested in studying public discourse about genomics writ large (Condit, 2001). Scholars interested in how the media has framed biotechnology and genetics have found that the media tends to emphasize optimistic frames as well as scientific “hype,” which focuses on benefits over risks and leads to an overemphasis on individualized interventions (Caulfield, 2018; Conrad, 2001; Ostergren et al., 2015). Studies specifically on genomics of alcoholism and substance use disorder have noted an emphasis on bio-reductionist, individualized understandings of substance use disorder, which marginalizes social and environmental factors (Conrad, 1997; Dingel et al., 2015; Ostergren et al., 2015).

However, there has not been any research on genomics and addicition in the context of reporting on the opioid epidemic. Studies of media reporting on scientific research during the epidemic found that while discussions of scientific studies were included in reporting, there was very little direct reporting on scientific research related to opioids (Matthias et al., 2020). These studies found there has been a shift away from criminal justice–focused solutions toward public health interventions—though medication–assisted therapies remain controversial and stigmatized (Chenworth et al., 2021; Kepner et al., 2022; McGinty et al., 2015, 2019; Willis and Painter, 2019). However, public opinion may diverge from public health–focused media frames (Russell et al., 2019). Finally, researchers have also noted that the trend toward public health and medical framings also correlates with a racialized framing of the opioid epidemic as primarily impacting rural-White communities (Shachar et al., 2020).

Methods

Data collection

Articles were identified via a keyword search in the ProQuest database for news articles and transcripts published in the United States from 2015 to 2019 containing variants on the terms opioid,³ addiction,⁴ and genetic.⁵ These terms overlap with other studies about genomic discourses around substance use disorders (Dingel et al., 2015). While the term substance use disorder is preferred in many circles, the term addiction is the most common term used in public discussions of substance use disorders and thus more reflective of public discourse (McGinty et al., 2019). The ProQuest database includes a wide selection of both national and smaller, local periodicals. As the opioid epidemic has been both a local and national issue, the goal was to ensure that articles were included from both major news publications with broad audiences and smaller publications focusing on the impact of the opioid epidemic in local communities.

The years 2015 to 2019 were selected because of a substantial increase in news coverage of the opioid epidemic starting in 2015 (Kennedy-Hendricks et al., 2019), and data collection was conducted at the start of 2020. The initial search generated a pool of 894 articles, which was screened for duplicates and against the following criteria:

1. The opioid epidemic was either the focus of the article or discussed substantially. Articles that mentioned the term opioid without a discussion of the epidemic were eliminated.

2. The discussion of genetics was informative. Articles that simply mentioned terms related to genetics were eliminated.

3. Letters to the editor were eliminated, but editorials and opinion articles were included.

Screening generated a final pool of 139 articles.

Scientific reporting on genomics of addiction comprised a small amount of the sample (n = 17). The majority of articles were opinion editorials (n = 48), human interest stories (n = 44), or news reports (n = 31). The sample of articles is biased toward local periodicals: 26 articles were from outlets with national distribution⁶ and 113 were from news outlets with local distribution. This distribution reflects the choice of database—ProQuest—which carries a wide variety of small news outlets with local distribution and was an intentional part of the study design (Table 1). Findings should be interpreted as indicative of reporting by local periodicals. For most themes, prevalence in the local sample drove the findings for the entire study with one exception. However, the theme, “12-Step/Big Book: Critical/Qualified,” which captured discussions that were either critical or qualified in their support of abstinence models of treatment, appeared in 23% (n = 6) of the national articles, but only 7% (n = 8) of local. This issue is addressed during the discussion of themes.

Table 1.

Description and prevalence of key themes.

Theme	Description	Total articles (N = 139)	Local articles (n = 113)	National articles (n = 26)
Genetics: Multifactorial Framework	Any discussion that lists genetics as one of a set of causes of addiction	58% (n = 81)	60% (n = 68)	50% (n = 13)
Addiction as Chronic Relapsing Brain Disease	Any discussion of chronic relapsing brain disease or the neurobiology of addiction	53% (n = 74)	54% (n = 61)	50% (n = 13)
Stigma and Addiction	Any discussion of the stigma associated with addiction	49% (n = 68)	46% (n = 52)	58% (n = 15)
Medicalized Languages of Risk	Any reference to risk, predisposition, or related language (potential, susceptibility, vulnerability, tendency, likelihood) to describe the role of genetics in addiction	48% (n = 67)	52% (n = 59)	31% (n = 8)
Addiction: Counter willpower or choice	Any discussion of addiction that counters the narrative that it is the result of a lack of willpower, poor choices, or moral failing	42% (n = 58)	42% (n = 47)	38% (n = 10)
MAT	Any discussion of MAT for addiction	34% (n = 47)	33% (n = 37)	38% (n = 10)
MAT: Supportive	Any discussion of MAT that is positive or supportive	27% (n = 38)	27% (n = 31)	27% (n = 7)
MAT: Critical/Qualified	Any discussion of MAT that is critical or offered qualified support	6% (n = 8)	5% (n = 6)	8% (n = 2)
Genetics and Destigmatization of Addiction	Any discussion that referenced genetics to de-stigmatize addiction	25% (n = 35)	27% (n = 30)	19% (n = 5)
Genetics: Single factor Framework	Any discussion that focuses on genetics by itself	24% (n = 34)	27 (n = 31)	12% (n = 3)
Genetics and choice/willpower: undermines	And discussion that describes genetics as taking away or undermining the choice or willpower of an individual	23% (n = 32)	24% (n = 27)	19% (n = 5)
Genetics and choice/willpower: doesn’t undermine	Any discussion that describes genetics as not taking away an addict’s willpower or choice	1% (n = 1)	1% (n = 1)	0% (n = 0)
Addiction and Diabetes	Any discussion making a parallel between addiction and diabetes	19% (n = 26)	20% (n = 23)	12% (n = 3)
Genetics Comparison	Using genetics to compare people with substance use disorders to people without	18% (n = 25)	19% (n = 22)	12% (n = 3)
12-Step/Big Book: Critical/Qualified	Any discussion of 12-step or Big Book program that is critical or qualified	10% (n = 14)	7% (n = 8)	23% (n = 6)
12-Step/Big Book: Supportive	Any discussion of 12-step or Big Book program that is positive or supportive	7% (n = 10)	8% (n = 9)	4% (n = 1)
Addiction and Heredity	Any reference to heredity or heritability to describe the role of genetics in addiction	7% (n = 10)	9% (n = 10)	0% (n = 0)

MAT: medication-assisted therapy.

Data analysis

Codes were generated following a modified grounded theory approach applied to an initial close analysis of 40 articles utilizing inductive coding and memo-ing (Clarke and Clarke, 2005). Coding was conducted by the author, who is highly trained in qualitative analysis. The themes which were chosen for close analysis—stigma, biological models of addiction, MAT—emerged from analysis, but also reflect the larger conversations about genomics and substance use disorder that this study emerged from. Once a coding framework (Table 1) had been generated, it was then applied to the entire pool of articles. Individual codes were reviewed at the end of coding for internal consistency and grouped into broader themes for discussion.

Discussion of results

Postgenomic risk and neurobiology of substance use

Early media studies of the portrayal of genetics of alcoholism found that alcoholism was framed as a distinct trait that could be inherited through a single gene (Conrad, 2001). In contrast, my study found that the genomics of addiction is typically discussed through a postgenomic narrative in which many genes confer risk in relationship to other social, psychological, and environmental factors (Keller, 2015). Scholars have proposed the term postgenomic to characterize the period following the Human Genome Project and the one gene-one disease model (Conrad, 1999). For some, postgenomic signals the end of the gene-centrism and genetic determinism that seemed to haunt earlier eras of genomics, and to bring attention to the many social and environmental factors shaping gene expression (Richardson and Stevens, 2015).

However, this study also found genomics was used to promote an individualized framing of addiction which highlighted the role of neurobiology and individual-level genetic risk. Nikolas Rose argues that while medicine has long focused on the body as the site of health and illness, during the twentieth century it has taken a turn toward the “molecular.” This “style of thought” is illustrated through medicine’s focus not on the body, but on the molecular processes underlying the biological functioning of the body: the work of neurotransmitters, proteins, DNA, and RNA. Scholars have argued that while contemporary genomic models make space for nuanced understandings of social and environmental factors, they are often collapsed back into these molecularized understandings of addiction through the focus on both neurobiology and genetic risk (Darling et al., 2016; Rose, 2007).

The theme “multifactorial narrative” captured discussions in which genetics was discussed as operating in relation to other social, psychological, and environmental factors. This theme appeared in 58% of articles (n = 81). The following quotation is from an article covering drug education program, Rise Above, being used in schools in Colorado:

He asked the students why teens use drugs in the first place; responses included peer pressure, depression, boredom and curiosity. Judge also shared some of the risk factors that may lead people to get addicted: genetics; environmental issues such as access and acceptability and stress and trauma.

(Jones. Journal-Advocate. 8 May 2015)

Genetics is not presented as the sole cause of addiction, but as a risk factor that operates in relationship to a range of other factors, including environment, social acceptability, and mental illness. It is important to note that the short discussion illustrated here is typical of how this “multifactorial narrative” was typically presented with little exposition or discussion of the relationship between the contributing factors.

In addition, this study found a strong overlap between genetic and neurobiological discussions of addiction. Over half of the articles discussed addiction as a chronic disease located in the brain (53%, n = 74). In 45% of the total articles analyzed (n = 62), there was an overlap at the quotation level between a discussion of addiction as a brain disease and a discussion of the role of genetics in addiction. The following quotation, from a human-interest story focused on a family struggling with heroin addiction, illustrates how these discussions complemented one and other:

Scientists who have studied why some people become addicts say up to 60 percent of the risk can be linked to genetic factors.

“The search for the genetic bomb has been going on for decades,” says Dr. Yngvild Olsen, a Baltimore-based addiction medicine specialist. “Part of the problem is it looks like it’s not just one gene or genetic mutation, but close to 100 that have been discovered.”

Olsen says those predisposed to addiction have differences in their brains’ reward system, as well as greater sensitivity to stress and pain. Other risk factors include mental illness, living in an environment where drugs are accepted or available, childhood trauma and the age at which someone tries the drug—the younger drug use starts, the more dangerous to the still-developing brain.

(Marbella, The Baltimore Sun, 22 March 2015)

The article first draws upon the risk estimate that was established using early twin studies, which operated under the early hypothesis that there was a gene for addiction. However, the scientist quoted then shifts to the more contemporary understanding of substance use as the function of many genes. The quotation then shifts again to a discussion of neurobiology which implies a connection between genetics and the brain. While the quotation ends with a discussion of social and environmental factors (e.g. postgenomic framing), the focus of the quote is still on the individual biology of the person with substance use disorder and on the role of genetics—and not social factors—in determining risk.

The molecularization of addiction is also evident in the way that genetics was used to discuss risk. As Rose (2007) argues, genetic understandings of risk also call upon individuals to manage their own risk. Forty-eight percent of the articles (n = 67) discussed genetics in relationship to risk through terms like predisposition, risk factor, susceptibility, vulnerability, tendency, potential, and likelihood. While these medicalized languages of risk emphasize the contingent relationship of genomics to illness—and avoid a deterministic frame—they also focused on addiction as an individualized-biological phenomena rather than an environmental or social phenomena. The following quotation is from an article covering a community forum discussing the opioid epidemic in Arlington Heights, Illinois:

Lott said half of the risk of developing an addiction to heroin or any substance is genetic, but the other half comes from the environment. He said environmental factors the community can change include parent and societal attitudes about drug use and low self-esteem in teens. People also can remove unnecessary prescription drugs from their homes and be cautious when accepting prescriptions for opiates such as Vicodin, Jorgensen said. But Worden said some more basic actions—following the “parental gut” feeling that says something is wrong, listening, being patient and ending permissive attitudes about teens using alcohol and marijuana—are other important steps people can take.

(Wilson. Daily Herald. January 28, 2015)

While the article discusses a variety of social and environmental factors such as availability, mental health, and social attitudes, it also calls upon the reader to manage these risks by controlling their own environment. Social and environmental factors are invoked in order to draw attention to the ways that risk can be acted up and self-managed. These molecularized understandings of genetic risk also establish biomedicine as the appropriate site of expertise, addressed in the next section.

Medical expertise, genomics, and support for MAT

In 2000, a group of addiction treatment doctors published a special communication in the Journal of the American Medical Association arguing that drug dependence was a chronic disease similar to diabetes, asthma, and hypertension (McLellan et al., 2000). Their argument was that drug dependence was not an acute, but a chronic state in need of ongoing medical care—specifically medication management. Genomics was a key part of their argument. Citing twin studies for each disease, they argued that the significant heritability of addiction made it similar to diabetes, hypertension, and asthma. More importantly, the parallels between these chronic diseases meant that addiction should be treated with both medical care and medication.

This study found that genomics was used to support these same calls for medical expertise around addition treatment both through a continued parallel to chronic disease—in particular diabetes—and through significant support for the use of MAT. This indicates that genomic narratives of addiction may be a key site of a boundary work around expertise and treatment for addiction (Gieryn, 1983). The concept of boundary work was originally used to explain an ideological process of demarcation by which scientists define what is and is not science in order to maintain their access to resources. However, the concept is also helpful when examining the practices and discourses through which experts maintain their authority.

Nineteen percent of the articles (n = 26) specifically discussed diabetes as a parallel disease. The following illustrative quotation is taken from an article profiling a local addiction counselor in the Kennebec Journal in Augusta, Maine:

Through all his years of experience, Creamer has come to the conclusion that addiction is a disease – that it should be viewed as a medical issue and people who are addicted are not the problem, nor is the substance they are using.

The problem is the disease, and it should be treated as any other disease such as diabetes or cancer, he says. He acknowledges that his views may not be popular with some people, but he is set in his belief that genetics plays a very large part in predisposing people to addiction.

“I think the majority of people now believe that there’s a genetic basis to it. I think the evidence points to maybe a 60/40, with the 40 due to environmental and social causes.”

(Calder, Kennebec Journal, 30 March 2015)

Genetics is not the subject of the discussion but a tool to provide support for a larger argument that addiction is a disease like diabetes or cancer. The subject of the article, Bob Creamer, first makes the case that not only is addiction a disease, but that it is a disease in need of medical treatment. The discussion of genetics immediately follows, thus providing implicit support for the argument that addiction is a biological problem. Even when Creamer mentions environmental and social causes like trauma, it is tied to describing how risk exists at an individual level.

One of the most striking themes to emerge in the analysis was the positive support for the use of MAT, which remains controversial within addiction treatment circles. The Big Book model of therapy popularized by Alcoholics Anonymous has generally eschewed the use of substitution therapies arguing that those with addiction need to abstain from all addictive substances. Researchers have long identified an ideological split between abstinence-based treatment programs and the use of MAT (Knudsen et al., 2011), which is a continuing barrier to access (Beetham et al., 2020). Media analysis of posts to Twitter and Reddit has shown that MAT remain controversial and stigmatized (Chenworth et al., 2021; Dekeseredy et al., 2021), and other studies of reporting on the opioid epidemic found more negative than positive reporting on MAT (Kennedy-Hendricks et al., 2019). However, my study found the opposite. The use of MAT was discussed in 34% (n = 47) of the articles, and in 27% of the total sample of articles (n = 38), the discussions were positive. In contrast, critical discussions of MAT occurred in only 6% of the articles (n = 8). The following quotation is from an article discussing the increasing support for medialized approach to addiction across the political spectrum:

Officials have described addiction as a chronic brain disease and have said it can be managed with medication and lifestyle changes, similar to diabetes. Earley said studies showing half of addiction cases could be tied to genetics also contributed to the new understanding. The other half of cases are caused by environmental factors, access to substances, trauma or psychiatric conditions, he added.

Experts recommend doctors prescribe medications, such as buprenorphine, to help people with addictions stave off painful withdrawal symptoms.

“That fact also tends to make people say, ‘OK, so my high blood pressure is treated with a pill, and you can actually treat this with a pill, so maybe it is a disease,’” Earley said.

(Leonard. The Examiner. 1 May 2018)

The expert quoted in the article is Dr. Paul Earley, then president-elect of the American Society of Addiction Medicine. Genetics—albeit operating in conjunction with the environment—provides an important link in this quotation between the necessity of MAT and the disease status of addiction. In fact, the effectiveness of medication itself is used to buttress the support of the larger argument that addiction is a disease. Intertwined in the framing of addiction as a disease in need of medication is also an argument that addiction treatment should be overseen by medical experts.

There were articles that presented both genomic narratives of addiction and supportive discussions of abstinence-based programs (7%; n = 10); however, they were far fewer in number than the number supportive of MAT and fewer than the number of articles critical of abstinence-based treatment (10%; n = 14). The following is an example of one such criticism of abstinence-based programming from the Hartford Courant on insurance coverage of addiction treatment:

The jump in claims has led, in part, to closer scrutiny by insurers of treatment methods and outcomes.

“The current approach to substance-use disorder treatment is based largely on the Alcoholics Anonymous 12-step model, which doesn’t take into account that 40 percent to 60 percent of substance abuse is attributable to a person’s genetic makeup,” Cigna CEO David Cordani wrote recently in an online essay when he called for comprehensive treatment, including medication, therapy and family support.

(Lee. Hartford Courant. 11 July 2016)

Genetics is invoked to both criticize abstinence-based programs and make the case for programs that offer medication. What is at stake in this quotation is who the addiction experts are. Are they the programs based in abstinence or are they medicalized programs that combine medication with therapy? While it is important to note that abstinence models of addiction treatment can incorporate discussions of genomics, the dominance of the supportive discussion of MAT in articles discussing genomics of addiction indicates an alliance of expertise between genomic and pharmaceutical discourses. Critical discussions of abstinence-based therapy were more typical in the national than the local periodicals. This issue requires further study, but it suggests that this position reflects national reporting.

Experimental studies have found that genomic narratives of addiction lead individuals to support the use of pharmaceutical treatments over psychotherapy (Lebowitz and Appelbaum, 2017). However, when this alliance is placed in the context of an ideological split between abstinence and medication-based treatment, it raises questions about how genomic narratives might also be employed to do boundary work. MAT places expertise in the realm of biomedicine and under the supervision of medical clinicians, who are licensed to administer these therapies. Scholars have argued that the lack of educational requirements for substance abuse counselors—which differs from other mental health professionals—is also one of the barriers to implementing evidence programs like MAT (Dawson, 2019; Kerwin et al., 2006). However, as discussed in the conclusion, further research is needed to better examine how genomic discourses might be used differently among different treatment practitioners.

Uncertain destigmatization

Stigma around addiction featured prominently in the news articles analyzed: 49% of the articles (n = 68). Significantly, genetics was discussed as destigmatizing addiction in 25% (n = 35) of the articles. In both personal stories of addiction and in discussion with medical and scientific experts, articles addressed the stigmatizing stereotypes of people with substance use disorder as deviants, criminals, or other kinds of “weak-willed” individuals. Stigma was sometimes discussed as a barrier to treatments and sometimes as a stereotype that people with substance use disorder themselves struggle with. The following quotation is from opinion editorial by parents whose son overdosed on heroin:

We feel it is important to have compassion for addicts who often feel shame and guilt as they see the harm they are doing to themselves and others. However, this is not easy, because the disease frequently changes a person into someone with few redeeming qualities. Addiction is not a weakness or moral failing but a complicated disease with many facets, including brain chemistry, genetics, environmental factors and trauma. It is difficult for those of us not addicted to understand the compulsion that drives addicts to use. Their need for drugs has been likened to the need for air.

(Maack and Rambo. The Press Democrat. 30 September 2017)

In this quotation, genomics is invoked to frame addiction as a disease with a biological basis. In fact, addiction is so biological that the authors make a parallel to the very process of breathing. However, the quote also illustrates the tensions that exist around de-stigmatizing through a biological narrative. While genomics is used to displace the moralizing framing of addiction as a character failing, it did not necessarily counter the stereotype that people with substance use disorders act in amoral or asocial ways. Biology, and not structural issues such as the continued criminalization of drug use, becomes the explanation for problematic behavior.

Another theme that emerged in analysis points to how genomics narratives may have uncertain effects on stigma: genetic comparison. This theme encompassed any use of genetics to compare people with and without substance use disorders and it appeared in 18% (n = 25) of the articles. In these quotations, genetics was used to underscore a fundamental difference or otherness between people with and without substance use disorders. This first illustrative quotation is from a doctor discussing addiction in an article published in the Philadelphia Inquirer on the role of pain medication in the opioid epidemic:

“Physical dependence is a normal adaptation; you take a drug and your body adapts to it and changes. When the drug stops, your body reacts to that change,” O’Brien said. “Addiction is getting a high, doctor-shopping, doing all those things. It’s pathological.” Genetic differences, he added, influence who goes from the first to the second.

(Sapatkin. Philadelphia Inquirer. 20 March 2016)

The doctor quoted makes a distinction that has been critiqued by science studies scholars: the difference between physical dependence and addiction (Keane et al., 2011). In this doctor’s narration, people with substance use disorder can be compared to those who only experience physiological dependence based on not only their behavior and experience of the drugs, but also because of their genetics. Becoming physically dependent on opioids is described as a normal effect of using these substances, but addiction is described as a pathological state characterized both by a phenomenological experience of a drug (getting high) and by a set of behaviors (doctor shopping). Genetics is key to the comparison between the people whose biology follows a normal path toward dependency and those whose biology leads to a pathological state of addiction.

This comparative theme was also found in non-expert discourses on addiction. The following is from a human-interest story about a pastor who lost his son to a heroin overdose:

If love and concern could have stopped Matt from his addiction, Jim said he would not be at the church preaching his son’s funeral. He talked a little about how some people have a genetic disposition to addiction. While some people can experiment with drugs and alcohol and walk away from it, Matt could not. His addiction led to time in jail, and it led to him trying to battle that addiction every day.

(Warren. The Daily Record. 12 March 2017)

In this narration, there are people with a genetic disposition to addiction that will struggle to walk away after trying a drug experimentally. And then there is the rest of the world, who can experiment but not become addicted. The use of genetics to compare or to articulate the difference between people with and without substance use disorders is a small but striking theme from this study, which reflects the ingrained notion that people with substance use disorder are a biologically distinct class of individuals. Rather than genetics being invoked to discuss the distributed risk that might exist across a population—some people have a lower or higher genetic burden—genomics becomes the site of difference or otherness between people with addiction and the rest of the population. Even in postgenomic narratives, where genetic risk operates alongside social and environmental factors, genetics can still be used to argue for a fundamental, biological difference between those who have substance use disorders and those who do not.

Conclusion: Questions for future research

This study has several limitations which should be considered in interpreting findings. First, this study examined a 5-year period and thus cannot consider historical change in themes that might have occurred over the entirety of the opioid epidemic. Second, the analysis did not consider regional or other differences in reporting on the opioid epidemic. Further analysis and a larger sample of articles would be required to see whether these themes varied in distribution by the impact of the opioid epidemic in a state, political lean of the state, or region (e.g. midwest, east coast, and south).

Within these limitations, this study did find that genetics plays a supporting role in broader discussions of risk, stigma, and treatment. More specifically, genomics is entangled with a particular conceptualization of addiction that is aligned with both molecularized understandings of risk and biomedical expertise. Genomics itself was rarely a focus of any of the articles. Scientific reporting on addiction was a small part of the sample (n = 17). While this might reflect the choice of database, other studies have found that science is generally discussed in the context of reporting on the opioid epidemic rather than a focus in and of itself (Matthias et al., 2020).

While expert discourse around the role of social and environmental factors has trickled into discussions of addiction, the brevity of these discussions reflects both the fact that actual dynamics are rarely of interest; rather, genomics was used to support broader discourses about individual risk, the use of MAT, and medical expertise. However, further research is needed to compare how genomic narratives function in the contexts of discussions of comparative treatment contexts—that is, abstinence-based and medication-based. Is genomics predominantly used in conjunction with discussion of MAT, or does a different kind of discussion around the heritable basis of addiction emerge in discussions of abstinence-based therapy? In other words, is the discussion absent or are different languages used to describe the addiction as either a family disease or a heritable trait that are different from the more scientific languages tracked in this study? Studies of these kinds would be key to understanding how scientific discourse around addiction shapes the discussions of both therapeutic interventions and stigma.

While the postgenomic moment has been heralded as enlarging the engagement between biology and the social, this study found that the role of the social and the environment was largely collapsed back into an individualized and molecularized understanding of genomic risk. While contemporary genomics has the potential to open up new understandings of genomic malleability (Lappé and Landecker, 2015), as genomics is translated into clinical settings the emphasis on quantification continues to transform social and environmental factors into stabilized, individualized understandings of risk (Ackerman et al., 2016; Kerr et al., 2019; Novas and Rose, 2000). Rather than genomics opening up a space for discussions of addiction as a societal issue, genomics was utilized to refocus on the individual and strategies for self-managing that risk, which also stabilized biology. While genetics is certainly not destiny in these discussions, it is still rendered as distinct from social and environmental factors.

Biography

Katherine Hendy is a medical anthropologist and science studies scholar who uses qualitative and ethnographic methods to investigate the production and circulation of biomedical knowledge.