Turning the Focus from Opioid Addiction to Treatment and Recovery

These days, you’d be hard-pressed to open a news app, turn on the TV, or check your social media feeds without coming across a story about how the opioid epidemic is affecting families across the United States. From profiles of lives cut short by an overdose to features about the collateral damage inflicted on children to articles presenting grim statistics, there has been no shortage of stories documenting the toll of the epidemic.

It is much tougher to report on how the U.S. should address it. Or more specifically, how to best treat the 21 million Americans who struggle with addiction.

“Coverage of the opioid epidemic on a human level has been pretty good,” says Seth Mnookin, an author and director of the Graduate Program in Science Writing at the Massachusetts Institute of Technology. “There have been many fewer stories talking about the science behind any aspect of it—the science behind addiction, or the science behind treatment and recovery.”

One reason for that coverage imbalance, Mnookin says, is the lack of agreement among scientists, treatment providers, and people in long-term recovery about what approaches work best for different individuals. That can complicate reporters’ efforts to evaluate studies and be appropriately skeptical about recovery rates and treatment claims. “Another challenge for journalists,” Mnookin says, “has been finding ways to write about recovery and not just have it be anecdotally based.”

Mnookin has been open about his own recovery from heroin addiction many years ago, pointing out that there is not a widespread understanding about what constitutes recovery. Most clinicians agree that recovery is a process that typically takes years, not months, and that it isn’t just a matter of being drug-free.

But as media outlets shift from covering the problem of addiction to highlighting potential solutions, many reporters are finding that it’s easier to focus on what’s wrong with our treatment system rather than identifying how it can or should be fixed. There’s a lack of good data about basic questions like how recovery rates compare for addictions to different types of drugs, or rigorous evaluations of treatment approaches that take into account the characteristics of different clients—say, an older unemployed man with a decade-long heroin habit vs. a young woman using prescription opioids in college. Sources with impressive academic titles often disagree about what qualifies as “evidence-based treatment,” and even argue about whether addiction should be considered a disease.

Since addiction has mostly been treated outside the healthcare system, sometimes by unregulated for-profit providers, journalists must navigate the financial motives that can influence interviews with “experts,” as well as research funded by companies with a stake in the results. And as more people in recovery decide to share their stories, bucking the stigma that has long kept addiction in the shadows, media outlets must be careful about how these examples are framed. Just as there is more than one way to lose weight—and no easy fix for our obesity epidemic—there are many pathways to overcoming addiction. Yet one reason it’s important to cover these success stories is to balance the narrative of despair with a dose of hope.

William White, emeritus senior research consultant at the nonprofit Chestnut Health Systems who has worked in the addictions field for nearly 50 years as a clinician, educator, and research scientist, has written about the media’s disproportionate focus on the mayhem of addiction, urging a more balanced approach. In an essay titled, “Waiting for Breaking Good: The Media and Addiction Recovery,” White notes that coverage of recovery is “rare and tangential,” contributing to a popular perception that overcoming addiction is the exception rather than the norm. In fact, according to his analysis of 415 studies of recovery outcomes, about half of those individuals who once met diagnostic criteria for a substance use disorder did achieve remission—which some studies defined as abstinence and others as reducing use to non-problematic levels.

Yet just under half of them consider themselves to be “in recovery,” illustrating another challenge reporters writing about this topic face. Although there is a growing shift toward viewing addiction as a public health issue rather than a criminal one—including a 2016 Surgeon General’s Report, “Facing Addiction in America”—the fact that many of the drugs being used are illegal can make some people wary of speaking publicly about a past problem.

Journalists have highlighted a range of efforts to help people recover from addiction, such as a prison rehabilitation program in New Hampshire, a community-based approach in Ann Arbor, medication-assisted treatment in Kentucky, and an alternative to incarceration in Seattle. But what’s also needed is a longer view examining the success rates of various programs down the road. White is critical of the media’s tendency to profile people in early recovery, which he likens to “interviewing an infant about the meaning of life.” White says what is still missing from most media coverage is the perspective of people who have been drug-free for many years: “I don’t see any leading or local journalists telling the story of long-term (emphasis on long-term) recovery from opioid addiction and drawing lessons from the collective experience of these individuals and families.”

I have firsthand experience with many of the points White raises. After writing a joint memoir, “Chancers: Addiction, Prison, Recovery, Love,” with my husband, Graham MacIndoe, about how he became addicted to heroin and finally managed to quit in 2010, I was surprised by the media’s focus on the lurid details of his years of addiction rather than the prison rehabilitation program and other support that ultimately helped him succeed. Even more unsettling was the pessimism about Graham’s chances of remaining drug-free.

One person who interviewed us in 2016 commented, “I recently saw a documentary about dealing with drug addiction in Seattle,” presumably referring to the Frontline documentary, “Chasing Heroin,” which had aired earlier that year. “Most of the addicts said that it’s almost impossible to stay off forever.”

My husband challenged that assumption, pointing out that he knows a lot of people who have quit heroin and remained drug-free for many years. Yet the interviewer returned to that topic later, asking: “So you don’t fear relapsing? Is it something you have to be constantly vigilant about?”

It’s a common question—one we both get asked often—but if you think about someone whose cancer is in remission, I suspect most people wouldn’t pose a similar question in the context of inevitability or fear. That’s the issue my husband addressed when he replied: “To be honest with you … I try not to live with that fear or that past hanging over me. I enjoy every day.”

“Chasing Heroin” is about Seattle’s Law Enforcement Assisted Diversion (LEAD) program, which allows police officers to redirect people stopped for low-level drug crimes to community-based services instead of jail. Marcela Gaviria, who wrote, produced, and directed the documentary, says she was interested in exploring how communities were responding to the opioid epidemic, focusing on LEAD as an alternative to the drug war she has covered for many years. One of her goals was “to try to help people by asking the tough questions about why they’re not getting better treatment.” What “Chasing Heroin” illustrates best is that it it’s not enough to stop arresting people for drug crimes—there have to be quality programs to treat them and services that continue after they’ve been discharged from residential care.

“This is the thing about treatment: it’s not a magic bullet,” says one mother Gaviria filmed, who spent $40,000 to send her teenage daughter to rehab for 90 days. After getting into heroin, she went into a 30-day detox center. After doing well for a year and a half and graduating from high school, her daughter relapsed and died of a heroin overdose, demonstrating “how hard it is to crawl out of this,” Gaviria says.

She and her team interviewed an impressive group of people tackling this topic from many angles: researchers and academics, public policy makers, doctors, law enforcement officials, a judge, counselors, and social workers, ultimately focusing on two individuals going through the LEAD program, two who weren’t in the program, and a father desperate for advice on how to help his daughter. Their relationship is one of the most poignant aspects of the film, particularly the father’s conflict over what he could or should do for a 20-year-old shown shooting up on the streets.

It also highlights why reporting on treatment for addiction is so challenging. “There’s no Consumer Reports for where to send your child,” Gaviria says. “Nobody knows what works, what doesn’t, or where to go.”

The fact that the people she filmed were part of the LEAD program made it easier to decide to show them actively using drugs. “It would’ve been very difficult to film people breaking the law if they weren’t part of a program that didn’t criminalize them,” Gaviria says.

By choosing individuals caught up in the criminal justice system—often those with more severe addictions, less support, and more unstable lives—“Chasing Heroin” focuses on a population that has proven hardest to treat. But as Gaviria points out, the complex reasons why people aren’t getting good treatment is a story the press should be investigating more, especially since there are so many conflicting opinions about what actually works. “As journalists that’s what we do—identify problems—and one of the problems is that complete confusion,” she says. “But I think we’ve failed as journalists as well. A lot of the coverage is very ‘Look, how shocking—this is happening everywhere,’ but not really asking tougher questions.”

One of the tough questions for Gaviria is the economic model of the for-profit addiction treatment industry, which exists mostly outside the health care system with little oversight and plenty of opportunity for abuse. That is an issue reporters have been investigating more aggressively in Florida, which has become a top location for treatment centers and sober homes—but also a magnet for fraud and abuse. Local journalists have been at the forefront of exposing the dark side of the treatment business, a story national outlets have later followed.

For instance, The Palm Beach Post’s series, “Addiction Treatment: Inside the Gold Rush,” has been investigating corruption, patient brokering, and insurance fraud in the sober home industry since 2015. Also known as halfway houses, sober homes offer transitional housing for people who have completed in-patient rehabilitation, typically requiring drug testing and imposing other rules.

However, the Post has published articles about sober home residents openly using drugs, allegations that one owner was using clients as part of a prostitution business, and reports that some owners are cashing in on the chance to bill insurance companies for urine samples collected from residents for drug testing—earning $150 for each sample collected as many as five times per week.

Holly Baltz, senior editor of investigations for The Palm Beach Post, says about eight reporters and two editors have worked on the series—including Christine Stapleton, an investigative reporter at the Post and a recovered alcoholic who has been sober for almost 20 years. “Christine was a big driver in writing about this,” Baltz says. “She and other reporters in the recovery community spearheaded the project because they’d been hearing about patient brokering and other kinds of corruption in the industry.”

An unanticipated source of the “gold rush” in the treatment industry is money made available by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act, which expanded insurance coverage for addiction treatment. But as The Palm Beach Post, The New York Times, and STAT and its partner The Boston Globe have reported, some of the fraud that characterized Florida’s pill mills shifted to the practice of patient brokering, whereby middlemen collect fees to refer out-of-state clients to rehab centers in places like Florida. “It’s an inherently local problem that’s going national,” says Baltz, adding that she expects more scrutiny of the addiction treatment business as national media outlets shift their focus from the problem of the opioid epidemic to potential solutions. “Sadly, the great number of people who are dying is starting to rev up the issue.”

For The Palm Beach Post, taking on a topic that is a big business locally presents challenges the national outlets don’t necessarily face. Asked if the paper has had any pushback from local treatment providers objecting to the largely negative tone of the articles in the series, Baltz says, “Yes, we have.” Her team has tried to find positive news to highlight, such as articles about Palm Beach County’s Sober Homes Task Force and its efforts to tackle some of the problems in the industry, which has resulted in dozens of arrests—some prompted by the the Post’s reporting.

The paper also ran an op-ed by a task force member, who pointed out the challenge of reining in patient brokering in an era when deep-pocketed and sometimes unethical treatment providers can manipulate Google’s advertising program to attract clients. For instance, an online search for a rehab center could lead to a site with a toll-free phone number for a business selling patient referrals to the highest bidder. That is an issue The Verge covered extensively in September, revealing some of the deceptive practices used to lure desperate individuals to rehabs that often don’t deliver the services promised. Shortly afterward, Google announced a crackdown on rehab ads, a business Bloomberg reported may have added up to $1 billion a year in revenue for Google, which charged $100 or more in fees for clicks on ads linked to searches like “heroin rehab near me.”

Baltz says these problems in the largely unregulated treatment industry make it difficult to find inspiring stories to share. “We want to write about people doing it well,” she says. “But it feels like just about every time we start looking into people we hear about something negative—from tapping our sources or court records. It’s been a little bit difficult to find the good guys.”

Difficult, but not impossible, and reporters are discovering examples of treatment approaches that seem promising, even if it can be tough to assess their long-term results.

For instance, the Vice News documentary, “Cold Turkey: New Hampshire’s Prison Detox,” filmed inmates participating in a rehabilitation program offered at the state prison in Berlin. Nilo Tabrizy, who produced the documentary, says she was interested in exploring access to treatment after working on a documentary about the overdose reversal drug naloxone: “I was drawn to New Hampshire because it was among the top five states in terms of fatal overdoses, but it ranked second to last in terms of access to treatment.” After calling different treatment providers in New Hampshire, she decided to focus on the program at the prison because “it seemed like it was doing something more than the baseline cold turkey approach.”

Choosing to focus on rehabilitation in a prison setting can be controversial—courting criticism from those who think the government shouldn’t be spending money “treating criminals,” as well as those who believe that it perpetuates the criminalization of addiction. An op-ed by Sam Quinones in The New York Times, “Addicts Need Help. Jails Could Have the Answer,” about a similar program at a jail in Kentucky, sparked negative comments from both sets of critics, and letters arguing that “Jail Isn’t the Place to Treat Drug Addiction.”

But highlighting these programs reflects the reality that someone struggling with addiction is more likely to get treatment after getting caught up in the criminal justice system, either through a referral from drug court to a community facility or sometimes programs offered by prisons or jails. “For many people, the way they were able to get treatment was by going to prison,” Tabrizy says. “Most of the people who ended up in that wing were there because of a crime associated with their addiction.”

Before the shoot, Tabrizy had several conversations with the prison’s mental health administrator, who helped navigate which inmates were willing to be filmed—about half of the program’s participants. “I only wanted to talk to inmates who were comfortable speaking to me, and I wanted to make sure I wasn’t getting in the way of their treatment,” Tabrizy says.

She also had anyone who appeared on camera sign a release, which outlined how the footage would be used. Since the program participants had been off drugs for months, Tabrizy didn’t have to navigate the ethical issue that comes up when interviewing people who are still using: whether they have the cognitive capacity to consent to being interviewed, photographed, or filmed.

What is striking about the documentary is how open and articulate a few of the inmates are about how they became addicted to drugs and ended up in prison, knowing they’d be identified by their full names.

In addition to individual interviews with some of the program participants, Tabrizy filmed one of the group therapy sessions, capturing a candid discussion about relapse risks and how to manage them outside of prison—given that many people would be sent to halfway houses offering minimal support. “My goal has always been to represent people in addiction and people in recovery with humanity,” Tabrizy says. For instance, asked about how it feels to be off drugs, one young man admits, “I hate it but I love it”—explaining that he’s glad he can feel and express his emotions again, but that also means dealing with a lot of pain and regret.

Tabrizy says she kept in touch for a while with a couple of the people she filmed: one person was arrested for drug possession after getting released from prison and one seemed to be doing well the last time she heard any news. That mixed success rate illustrates why it’s tough for reporters to highlight examples of treatment programs that seem promising. There are a lot of factors that impact recovery, and even for researchers, it is not easy to gauge if a treatment program wasn’t effective—or if it couldn’t address all the factors someone in recovery may have to overcome, like finding a job or a place to live despite a criminal record.

Derek Wolfe, a recent graduate of the University of Michigan, wrote about how one community is trying to address those broader challenges in an eight-part series on Medium in 2016. “The Healing Forest Project” explores how Ann Arbor, Michigan has taken a community-based approach to recovery, the idea being to create a “healing forest” locally rather than sending people for treatment in another state.

The series presents a thorough overview of the factors necessary to create a community supportive of recovery, including access to treatment, affordable housing for people transitioning out of residential care, employers willing to hire staff members in recovery, educational programs that offer an alternative to campus drinking culture, and support groups that provide a sober social network, and role models who are in recovery themselves.

Wolfe’s take is influenced by knowing people in recovery and understanding what it takes to rebuild a life wrecked by addiction. He notes that when the media do address recovery, the stories sometimes suggest there’s a quick fix. For instance, articles that describe a celebrity who “completed” treatment after spending a few months in rehab can set an expectation that 90 days may be all it takes to get well. However, the lengthy timeline for recovery isn’t one that fits our current news cycle, when reporters rarely get to follow a story for months let alone years. “We’re talking about a disease that doesn’t operate on that cycle so it doesn’t make it easy to report and be patient,” Wolfe says. “But that’s what treating addiction is—it’s about being patient with people.”

Our cultural quick-fix mentality can sometimes infuse reports about new medications to treat opioid addiction, which often don’t delve into all the things a pill or a shot can’t address—like estranged children or a spouse who won’t give you another chance. “The thing that bothers me most about addiction coverage is that I don’t think it’s really honest about what happens to people when they’re addicted to drugs,” Wolfe says. “That’s not being covered enough—how much addiction ravages people’s lives in every way.”

For that reason, he emphasizes how important it is for reporters to spend time with people who have gone through the treatment process they’re writing about, to really understand all of the hurdles they face. “Once you realize how much work these people are putting into getting healthy again,” he says, “you might have a new appreciation for what it takes.”

For Laura Ungar, an investigative reporter for Courier Journal in Louisville, Kentucky and a member of USA Today’s investigative team, cultivating sources with that type of personal experience has been key to writing about addiction, which she started covering in depth in 2010. “Prescription for Tragedy,” a three-part series she worked on with Emily Hagedorn was published in January 2011—chronicling the toll of prescription drug abuse in Kentucky. Since then, she has written about the surge in heroin use as Kentucky cracked down on pain pills, the epidemic’s devastating effect on children, and the plight of babies born dependent on drugs, a project supported by a fellowship from the Center for Health Journalism at the University of Southern California.

As her focus shifted to treatment and she started reporting on medications like buprenorphine, which when combined with naloxone is sold under the brand name Suboxone and often touted as a leading treatment for opioid addiction, her sources tipped her off about some of the drug’s downsides that weren’t getting as much attention. “That’s how I started hearing, ‘You should look into buprenorphine. It can be misused, diverted, and sold on the street’—by talking to people who had that intimate knowledge,” Ungar says.

The headline of her June 2017 article, “Rogue Doctors Exploit Loopholes to Let a Powerful Drug ‘Devastate a Community,’” could just as easily sit atop one of her 2011 articles about painkillers. Instead, it describes how a medication intended to curb opioid cravings and ease withdrawal was being prescribed by doctors with disciplinary records, fueling misuse and the rise of rogue clinics that Kentucky’s attorney general called “the second coming of our pill mills.”

The Courier Journal published the full complaint records against 27 physicians, who were subject to disciplinary action by the state medical board for breaches, such as allowing a receptionist and maintenance man to see patients and call in prescriptions for Suboxone, writing prescriptions for themselves or family members, and conspiring to distribute controlled substances.

Ungar interviewed patients who had both positive and negative experiences with Suboxone, a researcher at the University of Kentucky who in a study of nearly 1,000 people who had taken the medication found that abuse and diversion were common, and doctors who followed responsible prescribing practices as well as doctors who were subject to disciplinary action. “I did get some backlash from people asking, ‘Why are you writing negatively about medication-assisted treatment when it’s the only way we can treat this epidemic?’” Ungar says. “But I think we have to put that skeptical eye toward everything, even when the medical community is saying medication-assisted treatment plus therapy is the best approach. That doesn’t mean we don’t look at all the different sides of things and investigate what could go wrong.”

Because addiction is such a big issue in the community, Ungar’s articles often generate a lot of emails and calls—some from people who want to share their story as well. “The reason they usually give is, ‘Maybe my story can help others,’” Ungar says. “They view it as something good that can come out of a terrible time in their lives.”

Even so, she cautions her sources about the potential repercussions of talking openly about a drug problem: “You have to really explain to your sources that they’re going to be in the paper and what they say could endanger their job.”

The Courier Journal includes a list of resources with many of these articles, offering advice on where readers can get help. The paper also hosted a speakers’ panel about the opioid epidemic in 2016, eliciting so many questions from audience members that the paper ran follow-up Q&As answering questions that required more research—like how many beds were available in local treatment centers.

Right now, one of her projects is editing a series of stories about recovery, looking at different ways people in the community have worked to break free of addiction. So far, the profiles range from a woman who had been off drugs for 87 days to a man in recovery for more than six years. One of the goals is to show multiple pathways out of addiction, resisting the urge to present one treatment or therapy as better than another.

That is perhaps the most important advice Ungar has for anyone newer to the beat: “Whenever anyone says, ‘This way is the best way,’ I’m skeptical of that. Having spent years covering addiction, I’ve seen people on all sides of the issue, so when I encounter someone who’s an evangelist for one type of treatment over another, I think as a reporter you have to step back and say, ‘This is not black and white.’ It’s a complicated issue with a lot of factors at play.”