Agenda Setting and Framing of America’s Opioid Crisis and Its Actors: The Occurrence of Pharmaceutical Companies
Master’s Thesis
Graduate School of Communication Corporate Communication
Sophia Steinhäußer Student ID: 12748269
Thesis Supervisor: dhr. dr. G.L.A. (Toni) van der Meer Date of completion: 26-06-2020
Abstract
In order to provide an understanding of how media discourse evolves during a major crisis that affects numerous actors and different levels of society, the following study demonstrates an initial research examining first and second level agenda setting of America’s opioid crisis in the media. This study particularly focuses on the investigation of corporate actors and their appearance during the crisis, as they play an increasingly important role in societal issues and therefore become more visible in news coverage. A semantic network analysis was conducted to automatically identify implicit media frames used by five U.S. newspapers over five years (N = 4652). Applying first level agenda setting theory, results revealed that the media highlighted four actor groups in crisis news coverage, which were found to correspond to the media frames examined on the basis of second level agenda setting. Overall, news media predominantly framed the crisis in terms of normative solutions, by providing concepts on how to deal with the immense consequences of the crisis. Additionally, aggregated on a monthly level, frame development was found to be concurrent with certain events. Corporate actors were identified to be strongly related to the responsibility frame, although over time they occurred to be the actor group least mentioned by the media, which suggests that the opioid crisis is a rather socio-political than a corporate crisis. Differences in framing regarding the proximity of a source became apparent, with local newspapers using frames that might more represent affected people, while national newspapers reported more about
pharmaceutical companies, politics, and the aspect of responsibility. This study contributes to existing crisis literature by providing an understanding of how a large societal crisis is framed in news coverage over time, suggesting that media might play a role in solving the crisis by focusing on future-oriented humanistic care.
Keywords: crisis communication, framing, agenda setting, implicit media frames, crisis actors, corporate actors, opioid crisis, semantic network analysis
Introduction
Every year, thousands of lives are claimed by the opioid crisis, making it one of the largest and most devastating crises the United States has ever experienced. Although its beginnings date back 30 years, around 130 Americans still die from an opioid related overdose every day (National Institute on Drug Abuse (NIDA), 2020a). Even a regular or slightly increased use of opioids can quickly escalate to an addiction, or even lead to death (NIDA, 2020a). Despite these potent effects, painkiller opioids like OxyContin were highly promoted by pharmaceutical companies in the early 90s, emphasizing “safety, efficacy, and low potential for addiction” (DeWeerdt, 2019). The aggressive promotion of the pain relief medication, over-prescriptions, and their easy misuse led to an increasing number of opioid addicts seeking more drugs, even substitution drugs like Heroin or Fentanyl. Until today, the consequences are felt across the country, which led the White House to declare a national public health emergency in October 2017 (Hirschfeld Davis, 2017). Given the severity of this societal crisis, it is important to examine how society has understood this crisis and the role corporate actors may have played in its development.
Therefore, media and communication play a crucial role in the accurate dissemination of information. Not only does communication in crisis situations serve as a tool to inform the public, but it also shapes the understanding of social debates, can reduce uncertainties and may even contribute to the solution of the crisis itself (Liu & Kim, 2011; Reynolds & Seeger, 2005; Van der Meer, 2016). Crisis communication of issues and actors in media coverage can constitute the crisis (Kleinnijenhuis, Schultz, & Oegema, 2015a), and turn it into a dynamically complex discourse. News media can guide this process and thus represent an ultimate decision-making power on which and how topics are eventually communicated. In addition, media can also shape the responsibility of and association with the crisis (Coombs, 2007). Therefore, the corporations’ role depicted by the media is essential to understand, as these produced and promoted the crisis-causing opioids. The aim of this study is therefore to shed light on the opioid crisis from a communication point of view, examining the discourse
of issues and actors, and how the media presents them. As corporate actors seem to have a large share in this crisis, the focus will be particularly placed on the involved drug companies.
Furthermore, this study will focus on first and second level agenda setting - the latter being often referred to as framing (Weaver, McCombs, & Shaw, 2004). These concepts are applied as they represent valuable assets to communicate a crisis. Agenda setting can be understood as the selection of topics to be addressed, while framing is the assignment of interpretation schemes; together, they can influence the perception of issues and actors among the public and stakeholders (Carrol & McCombs, 2003; Entman, 1993). Especially in crises, when different sources publish countless pieces of information at once, frames can help process this information by providing structure and meaning (Hallahan, 1999; Schultz, Kleinnijenhuis, Oegema, Utz, & Van Atteveldt, 2013).
Recent research of agenda setting and framing in crisis situations often examined its effects on the public or an organization’s reputation (Coombs & Holladay, 2002, 2010), whereas others investigated more in terms of a PR & news media-centered view by examining how organizations get framed by the news media in comparison with their PR communication (Kleinnijenhuis, Schultz, Utz, & Oegema, 2015b; Van der Meer, Verhoeven, Beentjes, & Vliegenthart, 2014). According to Entman (1993), everybody who communicates uses frames, especially the media. Before examining the perception and impacts of frames, it is thus of great importance to study which frames were set by the media in the first place (An & Gower, 2009). Research on the opioid crisis has mainly been conducted in the medical field, whereas little research has been done from a societal perspective (Webster, Rice, & Sud, 2020). The evolving complex discourse on a societal level has led to a great amount of media attention, making this crisis a crucial case to shed more light on the role that framing plays in crisis communication.
Examining the opioid crisis in terms of media crisis communication can provide a variety of contributions: It can create a better understanding of the development of a major social crisis, while giving insights into how reporting and framing contribute to the
how they appear in news coverage allows to demonstrate what role they represent in the crisis discourse. Moreover, to get an idea of framing considering the opioid crisis in the country and its most affected states, national and local newspapers are studied. This relates to the proximity of affected people or sources to events, which can influence how a crisis is framed in the media (Lee, 2009). Furthermore, this thesis may serve as a scientific
foundation for future research on the impact of framing on several stakeholders, like the public or organizations. In order to make these contributions, the main research question guiding this study reads as follows: How is the opioid crisis framed by the media, and how do (corporate) actors occur in the news coverage?
To address this research question, the method of an automated semantic network analysis was conducted on the reporting of five newspapers to explore different media frames of the opioid crisis and the occurrence of corporate actors (Hellsten, Dawson, & Leydesdorff, 2010; Vlieger & Leydesdorff, 2011). In the following, the case of the opioid crisis will be explained before moving to the underlying theory of this study.
Theoretical Framework
The Case
The opioid crisis is one of the most devastating societal crises in the history of the United States. The crisis originated between 1980 and 1990, when the discussion about poor treatment of chronic pain began, questioning the use of opioids for cancer treatments or postoperative pain only (Jones, Viswanath, Peck, Kaye, Gill, & Simopoulos, 2018). In response, the Drug Enforcement Agency (DEA) declared that it would reduce the stringency of opioid prescription rules (Joranson, Gilson, Dahl, & Haddox, 2002), which resulted in opioids quickly becoming the primary method for the treatment of chronic non-cancer pain (Stein, 1997). Starting in 1997 with about 670,000 prescriptions, the number of prescriptions rose to 6.2 million in 2002, followed by a continuous increase in the years after (NIDA, 2020b; Van Zee, 2009). In 2012, the prescription rate reached its peak with more than 255 million prescriptions.
The increased use of opioids to combat pain was strongly supported by
pharmaceutical companies. In 1996, an opioid drug called OxyContin produced by the pharmaceutical company Purdue Pharma entered the market (Van Zee, 2009). In a promotional video for OxyContin in 1998, which specifically addressed doctors, Purdue Pharma explained a “low risk of addiction” and marketed it as the “best pain medication” (GoLocal, 2019). In contrast to how these painkillers were promoted, opioids can, in fact, cause addiction with the first dose. Many of those who had access to prescribed opioids quickly recognized the analgesic effect and the feeling of being high, which led them to misusing and – for an immediate instead of slow-acting effect – even injecting it (Gasparro, 2020). The common voice is that drug-companies have pushed doctors to prescribe more and more opioids, while some say that doctors often over-prescribe opioids as they "are used to prescribing multiples of 30" (Hirsch, 2017, p. 82).
When the media increasingly began to report on opioid over-prescriptions, the DEA started investigating and closing medical clinics, called “pill-mills”, which inappropriately prescribed the painkillers (Gasparro, 2020; Malbran, 2007). This, however, did not solve the problem: With many of the pain clinics closing, and due to lower prices, addicts began to buy synthetic drugs like Heroin or Fentanyl on the streets. Today, 80% of those who are addicted to Heroin, started with a legal medical prescription of an opioid painkiller (NIDA, 2020a).
Purdue Pharma was the largest but not the only drug company involved in the emerging crisis, and OxyContin was not the only prescribed opioid drug. The painkillers Percocet, Vicodin, Demerol, or Norco are made up of different active ingredients and substances, all belonging to the opioid category. Besides Purdue Pharma, pharmaceutical companies such as manufacturer Teva Pharmaceuticals, or Mallinckrodt, leading supplier Johnson & Johnson, and major distributor companies McKesson, Cardinal Health,
AmerisourceBergen, or CSV health, shared the resulting sales business (Horwitz, Higham, Bennett, & Kornfield, 2019; Pitzke, 2019).
The drug companies argued that their marketing never misrepresented the safety of narcotics, citing a letter, but not a representative study, from the most prestigious
peer-reviewed New England Journal of Medicine, which states that only 1% become addicted to prescribed narcotics (Horwitz et al., 2019). Over time, however, these corporations were denounced for playing a significant role in the opioid crisis and its aftermath. In October 2019, many of them agreed in a preliminary settlement of several million dollars, including McKesson, Cardinal Health, Amerisource Bergen and Teva, who agreed to pay $260 million, and Purdue Pharma, who agreed on a tentative payment of about $4.5 billion (Hoffman, 2019). In order to form the basis of empirical research and investigate the complexity of this social crisis and the occurrence of (corporate) actors in news reporting, the following theories will be considered.
Crisis Communication and News Media
In times of a societal crisis with an enormous gravity such as the opioid epidemic, news media play a decisive role not only in providing information to society but also in assessing the severity of the crisis (Nelkin,1988). Moreover, the dynamics of a crisis get often “constituted in the communicative interplay between several actors” (Kleinnijenhuis et al., 2015a, p.4), whose different perspectives can lead to consequences for society, politics, economy, and the media. This can cause unpredictable situations and insecurities among the audience (Van der Meer, 2016). Thus, media communication can provide collective understanding and knowledge for the public to reconstruct social order (Sorribes & Rovira, 2011). In particular, traditional news media have a high priority in communicating a crisis by acting as a third party. They are thus considered to be more reliable than social media, mostly represent the direct voice of many actors involved in the crisis (Schultz, Utz, & Göritz, 2011; Sung & Hwang, 2014). Therefore, news media may help to filter and structure
complexity of information by playing a key agent in deciding on what topics and actors are set to the agenda and how they and their connections should be perceived.
First Level Agenda Setting: Media Salience
To understand the role of the media in times of crisis, this research will look at first and second level agenda setting. In general, agenda setting theory describes the “power of the news media to set a nation’s agenda” (McCombs, 2002, p.1) and is made up of two levels. The core effect of the first level agenda setting theory lies in the attention given to certain topics and actors in the news media, which influences public perception towards the importance of these issues (Carrol & McCombs, 2003). Research on these phenomena has been mainly conducted in a political context (Iyengar & Simon, 1993; McCombs, Lopez-Escobar, & Llamas, 2000; Scheufele, 1999), starting with McCombs and Shaw in 1972, who conceptualized the foundation of agenda setting. According to Carrol and McCombs (2003), the effects of agenda setting can also be seen and studied in a business context. One of their principal statements on agenda setting at the first level describes that "the amount of coverage a company receives in the news media is positively correlated with the public's awareness of the company" (Carrol & McCombs, 2003, p. 39). In the complexity of
information, people require simplicity and guidance through the wide range of topics. This is also reflected in the coverage of substantial social crises such as the Persian Gulf crisis and war, which was examined by Iyengar and Simon (1993), where increased media coverage led the Gulf crisis to become more prominent in public awareness. Thus, if a particular issue is published more frequently and disseminated in several media, more value is attached. Consequently, to refer it back to the foundations of agenda-setting theory: The mass media “may not be successful … in telling people what to think, but it is stunningly successful in telling its readers what to think about” (Cohen, 1963, p.13; McCombs & Shaw, 1972).
In this study, agenda setting theory is used to portray how the crisis developed and what actors played a role in terms of communication and media coverage. Through their communicative interplay, they form the fundamental component of crisis development (Kleinnijenhuis et al., 2015a), since every actor involved in a crisis tries to assert their interests to avoid unwanted attention by the media. As corporate actors represent the origin
of the crisis causing drug addiction, the focus will be on the involved drug companies particularly. The research questions are therefore as follows:
RQ1: How has media attention changed concerning the opioid crisis?
RQ2: Which (corporate) actors were highlighted by the news coverage during the opioid crisis?
Second Level Agenda Setting: Framing
The next level of agenda setting theory deals with attributes assigned to the objects or issues named second level agenda setting. In 1997, McCombs, Llamas, Lopez-Escobar, and Rey, came up with this concept, referring to the salience of attributes to the objects, namely the influence news coverage has on public perception. Distinct attributes are
mentioned with a higher frequency than others, thus influencing the public’s interpretation of the objects (Carrol & McCombs, 2003). In that sense, first level agenda setting is about the importance of an issue, and second level agenda setting is about the framework it can be understood and evaluated in.
The majority of scientists often equate this process with framing, arguing that both theories are essentially the same (McCombs et al.,1997; Weaver et al., 2004). Entman (1993), described framing as “to select some aspects of a perceived reality and make them more salient in a communicating text, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described” (p. 52). Second level agenda setting, respectively framing, highlights specific attributes of particular objects, that is, they get assigned with characteristics or qualities that create an interpretative package around the issue.
According to Scheufele (1999), two concepts of framing are to be distinguished: media frames and audience frames. The difference lies in how framing is seen as a variable. Concerning the audience frames, framing is deemed as an independent variable, which can therefore influence the interpretation in society. Regarding media frames, framing is
considered a dependent variable, shaped by the source, authors, or other influencing factors. As such, media frames work as a tool for journalists who play a crucial role in frame building and thereby contribute to shaping the way information is published to the audience
(Brüggemann, 2014; Van der Meer, Verhoeven, Beentjes, & Vliegenthart, 2017). Media frames are defined as “a central organizing idea or storyline that provides meaning to an unfolding strip of events” (Gamson & Modigliani 1989, p. 143).
Since this study does not deal with the public and organization-centered effects, but rather how the media actually framed the crisis and its actors over time, framing can arguably be seen as the dependent variable (Scheufele, 1999). How issues and actors are ultimately perceived in society or emerge from the crisis depends - among others - on the frames in which the media communicate about them. Accordingly, Entman (1993) identified four functions of media frames by communicating a crisis, which (1) define problems, (2) diagnose causes, (3) make moral judgments, and (4) suggest remedies. He argues that where frames appear, they are determined by the “presence or absence of certain keywords, stock phrases, [or] stereotypical images [that] provide thematically reinforcing clusters of facts or judgments” (Entman, 1993, p. 52). Hence, which topic or actor attracts attention in the media and how it is communicated during a crisis can be deduced from the function of the frames (Van der Meer, 2016).
One frame that depicts an important element of crisis communication when it comes to diagnosing causes, is the responsibility frame. In fact, researchers have found that this frame is often the predominant frame in crisis communication (An & Gower, 2009; Semetko & Valkenburg, 2006). As a crisis develops, the question of who is held accountable
increases, bringing more and more information and actors to light (Iyengar 1991). Since pharmaceutical companies seem to have a major part in the opioid crisis, it can be assumed that responsibility might be predominantly attributed to them.
In order to examine media frames, this research particularly intends to discover implicit frames. Unlike explicit frames, which are applied with a more conscious decision by the author to use a particular perspective, implicit frames represent the latent meaning of
word occurrences and their correlations, which primarily appear in public debates (Hellsten et al., 2010). These so-called repertoires, concealed behind word co-occurrences, can be identified by conducting an automated semantic network analysis, further discussed in the methods section (Hellsten et al., 2010). Regarding the opioid crisis, there has been no study to date on how news media in general have framed this crisis and how frames and actors evolved, which leads to the next research questions:
RQ3: Which frames can be identified in the news coverage during the opioid crisis and is there a shift in framing over time?
RQ4: How do frames in the news coverage of the opioid crisis correspond to different (corporate) actors?
Crisis Proximity Factor
One factor that can impact how a crisis gets framed is the proximity of the source of framing to the events happening (Lee, 2009). This factor is closely related to the news media value of social significance (DeLung, Magee, DeLauder, & Maiorescu, 2012; Lee, 2009). People closer to an event or crisis are more likely to feel more affected than people in distant areas. When people or institutions are more affected, they also become more engaged. This may lead to a higher value and greater social significance being attached to a crisis. Social significance depicts a media value concerning events that seem to be significant among public (Lee, 2009). This was demonstrated by Buckman (1993), who studied how eight news magazines in six countries reported about elections in their own country and other countries. Geographic proximity played a crucial role as seven of the eight newspapers drew more attention to the national elections than any other election located in another country. In addition, Shoemaker and Cohen (2006) analyzed news worldwide and found that more news coverage of a particular topic was related to the media value of social significance.
Therefore, it can be assumed that social significance can construct media frames, depending among others on the proximity of events to the news organization (Vliegenthart & Van
Zoonen, 2011). News media sources that are closer to the current crisis could also frame the crisis differently from various aspects.
Although the opioid crisis affects the whole country, some states are more heavily affected by opioid victims and social consequences than others. Three of the most affected states are West Virginia, Ohio, and Maine, with the highest rates of opioid-involved overdose deaths and the highest number of opioid prescriptions in the country (NIDA, 2019). In 2017, West Virginia, the leading state in overdose deaths, recorded 49.6 overdose deaths per 100,000 people and 81.3 opioid prescriptions per 100 people. Ohio, in second place, counted 39.2 opioid-induced overdose deaths and 63.5 prescriptions. Maine, the third most affected state in terms of opioid prescription quantities, was affected with 29.9 deaths and 55.7 prescriptions of opioids (NIDA, 2019). The NIDA declares that opioid overdose deaths were calculated, including substances used as subsequent drugs of opioid prescriptions, such as Heroin, natural and semi-synthetic opioids, Methadone, and other synthetic narcotics. That again shows the immense far-reaching consequences of the crisis.
Since these states are more affected by the crisis than other states in the country, it can be expected that the local newspapers from these areas frame the crisis differently. For this reason and based on the previous theory concerning the proximity of a crisis, the following research question will be examined:
RQ5: Are certain frames used more often in local newspapers than in national newspapers?
Method
Data Collection
Given the complexity of the crisis and its far-reaching consequences, a large number of news reports, social media posts, and other crisis-related news have been published, making it challenging to analyze all existing data (van der Meer, 2016). In order to capture this complexity, the method of automated semantic network analysis is considered the most appropriate for this study.
The relevant data was found on the Nexis Uni database. Different versions of the search terms were combined, such as "opioid crisis" OR "opioid epidemic" AND drugs, AND/OR "pharmaceutical companies", AND/OR drugs, AND/OR overdose, AND/OR prescriptions, but resulted to be too specific and failing to represent the complexity of the crisis. In order to adequately cover the reporting of the crisis, the broader search string "opioid crisis" OR "opioid epidemic" was ultimately used to obtain the highest possible number of articles regarding two national U.S. newspapers, The New York Times and The Washington Post, as well as three local U.S. newspapers operating in the most affected states such as The Charleston Gazette-Mail (West Virginia), Dayton Daily News (Ohio), and Bangor Daily News (Maine). Based on the broad search term opioid crisis, Google Trends demonstrated that American’s interest in the crisis started to increase in July 2016 (Google Trends, 2020), when consequences of abusing opioids for years became apparent (NIDA, 2016), and the Obama administration signed a Recovery Act into law (The White House, 2016). These might also be reasons for a rise in news coverage. To see how media attention and frames have developed before 2016 and over time, the timeframe for this study was set from January 1st, 2015, until January 31st, 2020. The initial sample consisted of the whole population of 5265 newspaper articles. However, during data collection procedures, duplicates and some irrelevant articles were excluded. Subsequently, the units of analysis consisted of N = 4652 articles (The New York Times (NYT) N=1541, The Washington Post (WP) N=908, The Charleston Gazette Mail (CGM) N=1025, Dayton Daily News (DDN) N=877, Bangor Daily News (BDN) N=301).
Automated Semantic Network Analysis
In order to illustrate semantic relations between word occurrences, a semantic
network analysis was applied in this study. Digital communication makes it possible to detect not only information in articles but also the underlying meaning of the message, which contains background repertoires and meaning constructions of large amounts of data (Hellsten et al., 2010; Vlieger & Leydesdorff, 2011). Words appear in a polysemic context,
which, based on word co-occurrences and shared meaning, can be filtered out by the method of semantic network analysis. By applying an algorithm, the latent dimension of communication can then be investigated (Vlieger & Leydesdorff, 2011). These latent dimensions are then analyzed in a factor analysis where frames can be created based on their correlation. Many researchers have applied this form of automated content analysis to investigate underlying meanings of social discourses, such as analyzing debates, media frames, or crisis framing over time (e.g., Jonkman & Verhoeven, 2013; Leydesdorff & Hellsten, 2005; Van der Meer et al., 2014). In practice, the automated semantic network analysis for this study consists of several steps based on the manual of Vlieger and Leydesdorff (2011).
First of all, a list of 120 most frequently occurring words in the articles was created by the software FrequencyList. These words were filtered out by additionally applying a
standard list of stopwords. Second, after manually removing remaining, irrelevant words, a program called JFreq was applied. The converted articles demonstrating the units of analysis, as well as the standard list of stopwords, formed the input for the Jfreq software. This allowed to construct a word-document matrix based on co-occurrences between words, paragraphs, and articles. The occurrence matrix was then sorted from the highest to the lowest frequency of words. In a third step, to ensure that the most frequent words are included, the previously created list from FrequencyList was compared with the final matrix. In their manual, Vlieger and Leydesdorff (2011) advise that more than 255 words would be difficult to analyze. The frequency software created the matrix with word stems but counted words that had an 'apostrophe' as separate words. Accordingly, the same words were added to the actual word stems. Finally, the matrix consisting of 206 words was used as an input file for the software SPSS for further analysis.
In order to identify the underlying frames that emerged in the reporting of the opioid crisis, factor analysis was conducted. Hellsten et al. (2010) have previously used an automated semantic network analysis combined with factor analysis to investigate implicit frames. In contrast to traditional content analysis, automatic semantic network analysis has a
more explorative character, which allows determining implicit frames in the form of word clusters instead of using a predefined scheme, like a codebook (Van der Meer et al., 2014). Based on the actual clustered words, frames are labeled with personal interpretation. Thus, the risk regarding “fallacy of misplaced correctness” (Van der Meer et al. 2014, p. 756) needs to be considered.
Initially, the factorability of 206 items was examined. First of all, the assumptions of a factor analysis had to be met. Therefore, it is suggested that items should at least correlate at .3 with at least another item to provide factorability. Regarding this, 15 items were excluded. The Kaiser-Meyer-Olkin Measure of sampling adequacy was .89, which is above the recommended value of .6. Additionally, Bartlett’s test of sphericity was statistically significant X2 (2628) = 193933,64, p <.001.
A principal component analysis was used to identify and compute composite scores for the factors underlying the main frames that occurred in the reporting of the opioid crisis. Initial eigenvalues indicated 15 components above 1, of which the first six components showed 16%, 9%, 6%, 4%, 4% and 4% of the variance. The other components demonstrated eigenvalues just above one and a variance of less than 3%. Consequently, a varimax and oblimin rotation for the factor loading matrix was performed for a five and six factor solution. The five-factor solution, which explained 40% of the variance, was chosen for the following reasons: components stand in line with previous theory of frame functions (Entman, 1993), the similarity of the sixth factor with another factor, and the dissatisfying factor loadings of subsequent factors. There was almost no difference between the five factor varimax and oblimin solution. Additionally, another 109 items were excluded due to low factor loadings (below .3), and difficulty interpreting these items within specific factors. Finally, the word compositions of actor groups were excluded from the factor analysis to measure correlation. Following, 68 items that have primary loadings above the recommended absolute value of .3 and the best-defined factor loadings were performed with a varimax rotation as the final solution. The factor loading matrix is presented in Appendix A, Table 1.
Actors
In order to filter out the actors involved in the crisis, the focus was placed on the players known from the case. It was examined whether these appeared in the first 206 words of the frequency list. They were divided into political actors, corporate actors, distributor actors, and legal actors by an explicit name, profession, or institution. In detail, the political actors were based on the words trump, presid, congress, govern; distributor actors, on doctor and pharmaci; legal actors, on court and attorney, and corporate actors on the words
johnson, teva, mckesson, amerisourcebergen, cardinal' and purdu. Comparing this list with the corporations mentioned in the case, the pharmaceutical companies CSV health and Mallinckrodt did not appear among the most frequent words. Therefore, the companies to be examined in this study are Purdue Pharma, Teva Pharmaceuticals, McKesson, Johnson & Johnson, Cardinal Health, and AmerisourceBergen.
Data Analysis
After the factors have been determined, several analyses were conducted to answer the other research questions. To give an overview of the first-level agenda setting,
descriptive statistics, and visual graphs were used to present media attention over time. Additionally, linear regressions depict the development of actors and frames over time. To examine how the resulting frames correspond to different (corporate) actors, Pearson’s correlations were conducted. Beforehand, assumptions for significant Pearson’s correlation models were tested, including level of measurement, related pairs, absence of outliers, and linearity. Furthermore, to find out if there is a shift in framing over time, visual graphs present the frame development over the years. Lastly, chi square tests and independent t-tests were conducted to compare the effect of the newspaper’s proximity on the framing of corporate actors during the crisis.
Results
Media Attention
In order to answer RQ1 on how media attention has changed with regards to the opioid crisis, descriptive statistics will give an overview of the news coverage development (Figure 1). Media attention was highest in 2018, with an average of 135 articles per month (M = 134.67, SD = 25.54). Starting with a low share of news coverage in 2015 (M = 3.91, SD = 5.24), the average reporting increased permanently until early 2018. In 2019, media attention declined again slightly with an average of 102 articles per month (M = 102.25, SD = 19.86). Three striking peaks in mid-2017, early 2018, and mid-2019 should be taken into account here, as they might refer to specific events that will be elaborated in the discussion.
Figure 1. Number of articles of the opioid crisis by year.
Actors
In response to RQ2, which actors were highlighted by the media and particularly, which corporate actors appeared, a general overview will be presented, followed by a regression analysis to show how their occurrence changed over time. Of all articles, political actors appeared with 71.6%, legal actors with 51.6%, distributors with 39.5%, and corporate
0 20 40 60 80 100 120 140 160 180 200 Ja n 1 5 Mä r 15 Ma i 1 5 Ju l 1 5 Se p 15 No v 15 Ja n 1 6 Mä r 16 Ma i 1 6 Ju l 1 6 Se p 16 No v 16 Ja n 1 7 Mä r 17 Ma i 1 7 Ju l 1 7 Se p 17 No v 17 Ja n 1 8 Mä r 18 Ma i 1 8 Ju l 1 8 Se p 18 No v 18 Ja n 1 9 Mä r 19 Ma i 1 9 Ju l 1 9 Se p 19 No v 19 Ja n 2 0 Nu m be r of Ar tic le s Time Media Attention
actors with 32.3%. In particular, the following graph will illustrate the actor’s development on a monthly level.
Figure 2. Means of actor development in the news coverage by time aggregated on a monthly level.
Aggregated on a monthly level, the graphs show actor development over time (Figure 2), demonstrating that political actors are constantly protruding in the crisis reported by the media. The first peak in August 2016 indicates a link to the presidential election later in 2016 when both Hillary Clinton and Donald Trump addressed the opioid epidemic as part of their campaigns (Ronayne, 2016). Concerning means per articles with actor occurrences per month, the highest reporting on political actors can be registered in January 2018 (M = 11.01; SD = 16.72), when the government released a new policy to support the federal program in states (Pore, 2018). In July 2019, media attention was greatest among distributor actors (M = 6.97; SD = 13.58), as more data were published on the actual numbers of opioid-prescriptions and pill dispensing (Achenbach, Bernstein, O’Harroq, & Boburg, 2019). The question of who is actually accountable for the crisis increased, which also shifted the media to focus more towards corporate actors, who, on average, barely appeared until October 2018. In September 2019, corporate actors gained most media attention (M = 10.01; SD = 16.19), when most drug companies agreed on a settlement (Horwitz et al., 2019). Legal
0,00 2,00 4,00 6,00 8,00 10,00 12,00 Ja n 1 5 Ma r1 5 Au g 1 5 Oc t1 5 De c1 5 Fe b 1 6 Ap r1 6 Ju n 1 6 Au g 1 6 Oc t1 6 De c1 6 Fe b 1 7 Ap r1 7 Ju n 1 7 Au g 1 7 Oc t1 7 De c1 7 Fe b 1 8 Ap r1 8 Ju n 1 8 Au g 1 8 Oc t1 8 De c1 8 Fe b 1 9 Ap r1 9 Ju n 1 9 Au g 1 9 Oc t1 9 De c1 9 Ac to r De ve lo pm en t b y m ea n Time Actor Development
actors occurred mostly on a pretty low level, but also with a peak in September 2019 (M = 5.47; SD = 7.28), where courts were involved in the lawsuits. Regression analyses revealed, that time positively predicted all groups of actors that appear in the crisis news coverage: political actors (B = .059; p =.001); corporate actors (B = .085; p <.001); legal actors (B =.021, p < .001). This entails that they have been increasingly highlighted by the media in the course of the crisis. However, there was no statistical significance for the distributor actors, suggesting that they were consistently present (B = .012, p = .292); (see Appendix B, Table 2).
Frames
To investigate RQ3, which frames can be identified in the news coverage, the factor analysis was conducted. Overall, this factor analysis indicated five distinct factors that present the five principal frames in the news coverage of the opioid crisis (Table 3). The allocation of the labels to the five components is based on their word composition and on classifying them according to the aforementioned four functions of Entman (1993).
Table 3
Composition of frames
Frames Items
Socio-Economic Consequences Frame econom, power, creat, busi, chang, job, cost, increas, peopl, move, pay, educ, program, life, person, support, famili, help, legisl, system, high, commun
Problem-Definition Frame addict, overdos, opioid, heroin, treatment, drug, medic, death, treat, epidem, prescrib, fentanyl,
Political Consequences Frame politic, polit, democrat, polici, administr, campaign, american, washington, fight, republican, offic
Responsibility Frame distribut, investig, pharma, industri, enforc, pharmaceut, control, million, prescript, lawsuit, justic, agenc, office, depart, market
Regarding Entman (1993), it should be considered that he examined the four frame functions in a political context and that the definitions talk about a “causal agent” (p.52). In this study, it is argued that the causal agent of the crisis is defined as opioids or opioid addiction. It can be claimed that the problem definition frame (1) explains the crisis and the country’s actual addiction problem. The function of (2) diagnosing causes can be linked to the responsibility frame, as it is “the forces creating the problem” (p.52), questioning who was in control of the issues. Furthermore, (3) evaluating the problem and its effects can be linked to frames of socio-economic and political consequences since they describe the impacts more precisely. The normative solution frame represents the function of (4) suggesting remedies, such as working with the Medicaid health program and how to deal with the consequences.
In general, the opioid crisis was predominantly framed in terms of the normative solution frame, with 26.2% of all articles (Figure 3). Regarding the words in this component, it could refer to measures for insurance and health care systems, asking for more budget for health programs for states. The problem-definition frame is the second most common frame within the epidemic, accounting for 23%, as many articles describe the actual problem of how a medical drug can lead to so many deaths. Furthermore, the socio-economic consequences frame appears at 18.9%, telling stories of people affected, where they might need support,
Figure 3. Frequencies of occurrence according to frames
0 5 10 15 20 25 30
Socio-Econ. Cons. Problem-Def. Political Cons. Responsibility Normative
Solution Pe rc en ta ge o f f ra m e oc cu re nc e Frames Frame Occurence
and how the economy might deal with the crisis and suffering families and communities. The political consequences frame appears with 17.6%, describing processes in the political field and how they might try to fight the opioid crisis. Remarkably, the responsibility aspect, at only 14.3%, is the least considered frame in the news coverage of the opioid crisis. Given its composition, this includes industrial investigations, drug control, and the demand for justice.
Frame Development
The following Figure (4) demonstrates whether there have been changes in frame development over the years. A regression analysis was conducted to demonstrate the trend over time on a monthly basis. In 2015, the news coverage of the opioid crisis was mainly framed in terms of the problem definition frame (63.8%), as a core explanation of the crisis was still needed in the beginning. While media attention increased in 2016, other frames expanded, but reporting was still more framed in terms of problem definition (36.9%), followed by the normative solution frame (23.7%). In 2017, the opioid crisis was
predominantly reported within the normative solution frame, when more political and social action were taken. In 2018, the frames were almost evenly distributed, but with a clear increase in the responsibility frame, which stands out most clearly in 2019 with 24%. Time predicts that there is a positive trend for the socio-economic consequences frame (B = .006; p < .001), the responsibility frame (B = .006; p = .002), and the political consequences frame (B = .001; p = .450), but negative trends for the problem-definition frame (B = - .017; p < .001), and the normative solution frame (B = - .003; p = .155). This indicates that over time, frames with a positive trend were increasingly used by the media, whereas the problem-definition and normative solution frames were less present. It should be considered that the regression analysis did not show statistical significance for the normative solution frame (p =.155), and the political consequences frame (p =.425), which indicates that their presence is consistent during the entire crisis reporting period. Detailed results on the regression can be found in Appendix B, Table 4.
Figure 4. Means of frame development by time aggregated on a monthly level. Fr am e D eve lo pm en t b y F ac to r M ea n Time -0,30 0,3 0,6 0,9 1,2 Ja n1 5 Ma r1 5 Au g1 5 O ct 15 D ec1 5 Fe b1 6 Ap r1 6 Ju n1 6 Au g1 6 O ct 16 D ec1 6 Fe b1 7 Ap r1 7 Ju n1 7 Au g1 7 O ct 17 D ec1 7 Fe b1 8 Ap r1 8 Ju n1 8 Au g1 8 O ct 18 D ec1 8 Fe b 1 9 Ap r1 9 Ju n1 9 Au g1 9 O ct 19 D ec1 9 Problem-Definition -0,5 -0,25 0 0,25 0,5 Ja n1 5 Ma r1 5 Au g1 5 O ct 15 D ec1 5 Fe b1 6 Ap r1 6 Ju n1 6 Au g1 6 O ct 16 D ec1 6 Fe b1 7 Ap r1 7 Ju n1 7 Au g1 7 O ct 17 D ec1 7 Fe b1 8 Ap r1 8 Ju n1 8 Au g1 8 O ct 18 D ec1 8 Fe b 1 9 Ap r1 9 Ju n1 9 Au g1 9 O ct 19 D ec1 9 Socio-Economic Consequences -0,8 -0,4 0 0,4 0,8 Ja n1 5 Ma r1 5 Au g1 5 O ct 15 D ec1 5 Fe b1 6 Ap r1 6 Ju n1 6 Au g1 6 O ct 16 D ec1 6 Fe b1 7 Ap r1 7 Ju n1 7 Au g1 7 O ct 17 D ec1 7 Fe b1 8 Ap r1 8 Ju n1 8 Au g1 8 O ct 18 D ec1 8 Fe b 1 9 Ap r1 9 Ju n1 9 Au g1 9 O ct 19 D ec1 9 Political-Consequences -0,7 -0,35 0 0,35 0,7 Ja n 15 Ma r1 5 Au g1 5 O ct 15 D ec1 5 Fe b1 6 Ap r1 6 Ju n 16 Au g1 6 O ct 16 D ec1 6 Fe b1 7 Ap r1 7 Ju n 17 Au g1 7 O ct 17 D ec1 7 Fe b1 8 Ap r1 8 Ju n 18 Au g1 8 O ct 18 D ec1 8 Fe b 19 Ap r1 9 Ju n 19 Au g1 9 O ct 19 D ec1 9 Responsibility -0,6 -0,3 0 0,3 0,6 0,9 Ja n1 5 Ma r1 5 Au g1 5 O ct 15 D ec1 5 Fe b1 6 Ap r1 6 Ju n1 6 Au g1 6 O ct 16 D ec1 6 Fe b1 7 Ap r1 7 Ju n1 7 Au g1 7 O ct 17 D ec1 7 Fe b1 8 Ap r1 8 Ju n1 8 Au g1 8 O ct 18 D ec1 8 Fe b 1 9 Ap r1 9 Ju n1 9 Au g1 9 O ct 19 D ec1 9 Normative-Solution Frames
Relationship between Frames and Corporate Actors
To find out if and how actors relate to the examined frames (RQ4), specifically corporate actors, Pearson’s Correlations were conducted. Figure 5 shows significant correlations only.
Figure 5. Correlations between actors and frames.
Note: *Significance at p < .05, **Significance at p < .01
Overall, political actors were found to be positively correlated to the political consequences frame (r = .67 p < .01), and normative solution frame (r = .22 p < .01),
indicating that the more the media is reporting about political actors, the more they frame it in terms of political consequences or normative solutions, whereas when they frame the crisis regarding problem-definition, fewer political actors appear (r = -.16, p < .01). Distributor actors, corporate actors and legal actors were found to be positive related to the
responsibility frame r = .62, p < .01; r = .45, p < .01; r = .48, p < .01, signifying the actors Pol. A. Corp. A. Distr. A. Socio-econ. Cons. F. Problem-Def. F. Political-Consequ. F. Responsibility F. Norm. Solution. F. Legal A. .450** .624** .478** .670** .280** .218** .171** .214** .192** -.156** .114** .038** -.072** -.144** -.096* -.158** .146**
most strongly associated with this frame. A negative relationship was found between
distributor actors and the political frame r = -. 158, p < .01. Apart from that, there was a very weak, negative correlation between legal actors with the problem definition frame r = - .08, p < .01. Corporate actors were also found to have a negative relationship with the political consequences and the normative solution frame r = -.15, p <.001; r = - .10, p < .01. More details of the correlations can be seen in Appendix B, Table 5.
Corporate actors were found to be strongest related to the responsibility frame (see Table 6). In this context, the responsibility frame, the pharmaceutical company McKesson was found to have a moderately strong positive relation to this frame r = .38, p <.01, followed by Amerisource Bergen r = .31, p < .01, and Purdue Pharma r = .25, p < .01. Teva was weakly positively correlated r = .25, p < .01, as well as Cardinal Health r = .22, p < .01. Johnson & Johnson appeared to have a very weak relation with the responsibility frame r = .15, p < .01. Apart from that, almost all drug companies did not show any other associations to frames, except for a negative association with the political consequences frame.
Table 6
Pearson’s Correlations between Corporate Actors and Media Frames
Frames Corporate Actors
Variables S.-E. Consequ . Proble m- Def. Political Consequ . Responsib ility Normative
Solution Purdue Teva Johnson McKess. Cardinal Amer.B.
Purdue .073** -.032* -.138** .252** -.104** — Teva .016 .013 -.117** .235** -.026 -.614** — Johnson .028 .009 -.094** .150** -.015 -.031 -.022 — McKesson -.013 -.030* -.033* .381** -.011 .000 .000 .000 — Cardinal -.014 -.006 .030* .219** .012 .000 .000 .000 .000 — Amerisource.B. -.012 -.007 -.074** .307** -.013 .000 .000 .000 .000 .000 —
Proximity Factor
In order to answer RQ5 regarding whether there is a difference in reporting between national newspaper and local newspaper crosstabs and chi square tests for frame
differences, and an independent samples t-test to examine differences in reporting the actors, were conducted. The underlying five newspapers were computed to a new variable by grouping NYT and WP to national newspapers, and CGM (West Virginia), DDN (Ohio), and BDN (Maine) to local newspapers. A chi square test compared framing for the sort of newspaper and was found to be significant X2(4) = 171.81, p < .001 (Table 7). In particular, local newspapers frame more in terms of socio-economic consequences, problem-definition, and normative solutions than national newspapers. Regarding frames of political
consequences and responsibility, national newspapers use these frames slightly more than local newspapers.
Regarding the different actors involved in the crisis, independent t-tests (Appendix B, Table 8), showed significant differences in reporting between national and local newspapers regarding political actors t (4650) = 16.35, p < .001, and corporate actors t (4650) = 9.61, p < .001. National newspapers are reporting more on political actors (M = 8.44, SD = 13.57), than local newspapers do (M = 3.36, SD = 5.67). Corporate actors are slightly more
Table 7
Presence of media frames in national and local newspapers
Group National NP (%) Local NP (%)
S-E. Consequ. 18.7 % 19.2 % Problem-Def. 22.0 % 24.1 % Political Consequ. 23.6 % 10.9 % Responsibility 15.1 % 13.4 % Normative Solu. 20.6 % 32.4 % Total 100,0% 100,0% χ2 (4) = 171.85, p < .001
mentioned in national newspapers (M = 3.18, SD = 8.72) than in local newspapers (M = 1.22, SD = 4.13).
Discussion & Conclusion
This study aimed to examine the news coverage of the opioid crisis in local and national US newspapers in terms of agenda setting and framing. In particular, this research explored media salience regarding reporting of the opioid crisis in general and what kind of actors were highlighted. In addition, media frames and their development were studied and related to the actors, specifically corporate actors.
The results regarding the first level of agenda setting revealed that the crisis received most media attention from 2016 onwards. Some issues can receive more attention and therewith make the crisis more prominent in media coverage. For example, news media reported more about the opioid crisis in mid-2017, when some states began filing lawsuits against several drug-makers (Bischoff, 2017; Frolik, 2017). Even more media attention was given in early 2018 when the government outlined several measures to curb opioid abuse, and in mid-2019, when a study confirmed the first drop in overdosed-related deaths in 2018 (Tinker, Howard, & Gumbrecht 2019). Additionally, news media predominantly discussed four different actors when covering the crisis: political, corporate, distributor, and legal actors. This might already indicate the scope and communicative complexity of the crisis as these actors are operating in the impaired fields like criminal justice, health care, economic growth, and burdened communities (NIDA, 2020a). Political actors present the most frequently mentioned group, which is due to the election in 2016 when both Hillary Clinton and Donald Trump addressed the opioid epidemic as part of their campaigns (Ronayne, 2016).
Moreover, the White House called out a national health emergency in 2017 and released new policies to combat the opioid epidemic in the following years (Drash, 2017). Distributor actors appeared in the beginning when several doctors and pharmacists were arrested, and new guidelines appeared for prescribing opioids as well as in 2019 when it became clear how many prescriptions and pills were distributed (Achenbach et al., 2019; Dowell,
Haegerich, Chou, 2016). Legal actors appeared almost steady during the crisis, as they constantly tried to uncover the crime behind the opioid business (White, 2015), but most of all in 2019, when corporate actors were also increasingly highlighted by the media, as many pharmaceutical companies agreed on a settlement of opioid lawsuits (Hoffman, 2019). Overall, corporate actors were the least present group in crisis news coverage. Therefore, these findings indicate that the opioid crisis is presented by the media as a societal and political crisis rather than a corporate crisis.
Concerning the second level of agenda setting, the resulting five media frames - socio-economic consequences, problem-definition, political consequences, responsibility, and normative solution – were found to correspond to the existing frame functions of Entman (1993), like defining the problem, diagnosing causes, evaluating the problem, suggesting remedies. In particular, news media framed the crisis generally in terms of the normative solution frame, by suggesting how to deal with the immense consequences of the crisis. This is in line with previous studies, that suggest that media can help to solve a crisis (Liu & Kim, 2011; Van der Meer, 2016). However, this contradicts the research of An and Gower (2009), which states that the responsibility frame was often predominant in crisis communication. Initially, the problem-definition frame dominated the news coverage, as it was essential to explain the crisis. Its decline indicates that this frame has receded into the background, as the question of how to solve the consequences and who to hold accountable has become more critical. This is also reflected by the increasing trend of the responsibility frame, which became particularly evident in 2019 when corporations had to justify their actions publicly for the first time. Arguably, this could indicate that it took the media a long time to define the crisis and discuss moral or normative solutions, which then led to the debate on
responsibility, and thus also resulted in corporate actors being apparently pushed off the agenda until then.
Even though Purdue Pharma and Teva Pharmaceuticals were the most prominent corporate players in the opioid production, the distributor giants McKesson, Amerisource Bergen, and Cardinal Health were even more related to the responsibility frame, being
portrayed as openers of the floodgates by selling billions of oxycodone pills (Hakim, Rashbaum, & Rabin, 2019). Especially McKesson was heavily blamed by the media, as it turned out that they failed to report suspicious orders for opioids (Hakim et al., 2019). As a supplier of active ingredients, Johnson & Johnson was framed least in terms of responsibility, as the blame was attributed to the manufacturers and distributor companies serving the pharmacies. However, interestingly enough, distributor actors were also framed in terms of responsibility. Although they did not produce the crisis-causing substances, they gave out thousands of opioid orders and pills, and therefore, news media portrays them as co-responsible for the crisis and its consequences.
The socio-economic consequences frame increases in news reporting over time, as more data gave insight on the impact of the crisis on society, like jobs, families, and
communities (NIDA, 2020a). Legal and political actors were highlighted within this frame, as well as in the normative solution frame, which might serve as a prerequisite for
socio-economic consequences, because normative actions are crucial to provide comprehensive support, as the costs of health care and the economic consequences are often impossible to overcome for the people. Additionally, the political consequences frame and political actors were always represented by the media. Several peaks in the development of the political consequences frame signify that the occurrence is often related to aforementioned events like the presidential election, declaring the opioid crisis to a national health emergency, or the release of campaigns and programs to fight the crisis (Drash, 2017; Pore, 2018).
Regarding the proximity of a newspaper in framing a crisis, results showed that this factor plays an essential role in reporting on political or corporate actors and in framing in terms of socio-economic consequences, problem definition, and normative solution. These frames are more likely to be used by local newspapers, as they have in common that they all relate to issues that may be more socially significant and relevant to people, who have to deal with the crisis and its consequences on site (DeLung et al., 2012; Lee, 2009). Political actors and the large pharmaceutical companies appear more frequently in national
companies are the manufacturers and distributors for the whole country, probably making them appear more distanced to the most affected states, even though West Virginia and Ohio were among the first states to sue the big drug companies. This can also be supported by the fact that the frame of responsibility in which these actors mostly appear, and the political consequences frame, tend to be covered more by national newspapers than by local newspapers.
Concluding, this study demonstrates that the opioid crisis was predominantly framed in terms of normative solutions to help communities and fight against the consequences on societal levels. By highlighting issues and actors, as well as assigning attributes in terms of framing, news media arguably have the power to structure the crisis and allocate specific roles to actors. In particular, drug manufacturers and distributors were held responsible for the opioid epidemic as these actors were most strongly associated with the responsibility frame. However, they still play a comparatively minor role in reporting on the crisis, possibly due to the quick judicial settlements, with which the question of responsibility seems to have been set aside.
Limitations & Future Research
To inspire future research, some shortcomings should be mentioned: First of all, it should be noted that the applied method of automated semantic network analysis and subsequent factor analysis has a rather explorative and subjective character. Although the creation of frames is theoretically backed up, the decisions in the process of their
composition are mostly subjective. Furthermore, the validity of the results depends on the collected data and must be viewed critically due to their often high standard deviations. This may be related to newspaper characteristics, like size, weekday circulations, or journalists, which provide a good reflection of reality but can also cause irregularities. For this study, news outlets and time frame were based on the logic of the public’s interest in the crisis on Google Trends and on accessible newspapers on Nexis Uni. Extending the scope to more data from different newspapers, considering their characteristics, and widening the time
frame, can reveal even more precise results. Additionally, results are based on only one case study, which limits the ability to generalize. Therefore, future studies could examine similar socio-economic or health crises with the same methodology to validate these findings and to demonstrate comparative research. Moreover, as previous research suggests (Coombs & Holladay, 2002, 2010; Van der Meer et al., 2014), future research should pick up these media frames to study them in different contexts, like their impact among public’s perception, or concerning organizational framing of companies or distributors. Besides, the resulting frames could be compared to organizational frames in terms of frame alignment (Van der Meer et al., 2014), but this might be constrained by the time-limited access to press releases.
Despite these limitations, this study contributes to the existing literature in crisis communication as a first research on framing the opioid crisis, providing an understanding of what issues and which actors appeared, as well as how their communicative interplay was reported in terms of frames (Kleinnijenhuis et al., 2015a). Therefore, it marks a starting point for future research regarding the opioid crisis on a communicative aspect related to agenda setting and framing. This study implies that immense societal crises entail an ethical
character, where the media can play a role in contributing to its solution by focusing on humanistic care. Instead of persevering the past-related issue of responsible actors, news media uses a solution-oriented frame to focus on the future in the interest of the people affected, which means that corporate actors come off quite lightly.
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