Abstract
Toxic drug poisoning has claimed 53,821 lives since 2016 in Canada. After years of advocacy by people who use drugs and their supporters, the Canadian government funded a series of safer opioid supply (SOS) programs, where individuals who use unregulated opioids receive prescribed pharmaceutical opioids to minimize overdose risk. Twenty-six programs have been implemented in Canada since 2020, with media capturing varying positions on their implementation. Using the Narrative Policy Framework, we examined Ontario print and online news media from 2021 to 2022 to explore the narratives circulating about SOS during early implementation amid overlapping public health realities, namely the COVID-19 pandemic and the state of the toxic drug supply. We searched Canadian Newstream and conducted hand searches between February 2022 and January 2023. The retrieved media coverage was screened for: (1) a focus on SOS programs; (2) a focus on the province of Ontario; and (3) publication between 2021 and 2022. Thirty-four articles (n = 33 newspaper articles and n = 1 magazine article) were included in our final analysis. We found a metanarrative of “crisis management,” which positioned the “policy problem” of rapidly increasing opioid-related overdoses as a crisis that could be curtailed, or conversely exacerbated, with SOS. We therefore identified two dominant narratives on SOS to be operating toward this metanarrative—SOS as the “right crisis management solution” and SOS as the “wrong crisis management solution.” Each was importantly underlined by assumptions about the relationship between the “policy problem,” the “policy solution,” and structural conditions. This article offers insights into media communication strategies and their implications for advocacy and policymaking on SOS and broader harm reduction efforts.
Introduction
In popular and news media (e.g., television and newspapers), people who use drugs are often portrayed negatively as “criminals,” “addicts,” “lazy,” and “dangerous” (Cohn et al., 2019; Habib et al., 2023; McGinty et al., 2019; Orsini, 2017). Through these narratives, people who use drugs are characterized as “risky subjects” who are responsible for the ongoing substance use-related morbidity and mortality they face (Boyd, 2002; Fischer et al., 2004). These negative depictions can influence the broader public perception of people who use drugs as well as the services and polices that aim to support or regulate them (Lancaster et al., 2011). An example of this is “NIMBYism” (Not In My Backyard), which occurs when residents deem it inappropriate to implement certain interventions, such as supervised consumption sites, within or in the proximity of their neighborhoods by taking up narratives about people who use drugs as “dangerous” and “criminals” (Homlessness Hub, 2021; Kolla et al., 2017; Strike et al., 2004).
Canadian media has itself often reported negatively on harm reduction interventions, such as the already mentioned supervised consumption sites (The Canadian Press, 2008), needle and syringe programs, and, more recently, safer opioid supply (SOS) programs (Zivo, 2023), which are the focus of this article. Researchers have found various narratives about the acceptance and/or prohibition of harm reduction interventions or substance use generally within public media. This includes narratives which promote the dehumanization of people who use drugs built on moral panic and stigmatization (e.g., use of descriptive terms such as “meth mouth” or “crack baby”) (Gehring et al., 2022; Habib et al., 2023; Wild et al., 2017). Existing literature suggests that narratives portrayed in public media play a powerful role in shaping public opinion, which in turn influences the level of public support for certain interventions (Crow & Jones, 2021; Shanahan et al., 2011). Media-driven public sentiment can shape policy agendas by mobilizing support or opposition, thereby affecting the allocation of resources, the adoption of public health strategies, and the overall viability of evidence-based responses to substance use (Crow & Jones, 2021; Shanahan et al., 2011).
SOS programs provide individuals who use unregulated or street-acquired opioids a prescription to access regulated and pharmaceutical-grade opioids of a known dose and potency (Health Canada, 2019). They represent a novel (though historically grounded) response to the escalating rate of opioid-related overdoses occurring across Ontario. Using the Narrative Policy Framework (NPF) developed by Jones and McBeth (2010), we examined Ontario print and online news media from 2021 to 2022 to explore the narratives circulating about SOS during early implementation amid overlapping public health realities, namely the COVID-19 pandemic and the state of toxic drug supply. To date, no research has explored the narratives used to discuss SOS in Canada at that time. We focused on Ontario because half of the 26 pilot SOS programs funded by Health Canada were implemented in this province using a model different from other parts of the country (i.e., service delivery from community health centers). Once the piloted SOS program funding ends in 2025, the Government of Ontario will be responsible for deciding if and how it will continue funding these programs. 1 It is therefore timely to consider the narratives on SOS programs that were being propelled in the media during the first phase of implementation to understand and potentially disrupt their impact on imminent policy decisions in the province and beyond.
Context
The Current State of Toxic Drug Poisoning in North America
Our study is grounded in research that suggests North America's current opioid overdose epidemic, also known as the toxic drug poisoning crisis, is being driven by the unregulated and criminalized opioid supply which has increasingly been comprised of illicitly manufactured synthetic opioids (e.g., fentanyl and its analogues) instead of heroin (Armenian et al., 2018; Beletsky & Davis, 2017). This shift in the unregulated supply is associated with year-over-year increased rates of opioid-related deaths across North America, including 53,821 deaths since 2016 in Canada (Antoniou et al., 2019; Beletsky & Davis, 2017; Federal, provincial and territorial Special Advisory Committee on Toxic Drug Poisonings, 2024; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022). Border closures and travel restrictions due to the COVID-19 pandemic have been cited as further contributing to the production and selling of unregulated opioids, increasing their toxicity, and perpetuating overdose risk (Canadian Centre on Substance Use and Addiction & The Canadian Community Epidemiology Network on Drug Use, 2020; Health Canada Public Health Agency of Canada & U.S. Department of Health and Human Services, n.d.; Nguyen & Buxton, 2021).
Safer Opioid Supply Programs
SOS programs have been implemented across Canada as a new harm reduction intervention. “Safer supply” can include oral or intravenous doses of regulated opioids, with daily dispensed hydromorphone often together with slow-release oral morphine (brand name Kadian) being common in Ontario (Canadian Association of People who Use Drugs, 2019; Gomes et al., 2022). Medications are typically dispensed through pharmacies or health clinics under varying levels of supervision, with some programs requiring daily witnessed ingestion or observed dosing. SOS is understood as a clinical and public health intervention wherein pharmaceutical opioids are prescribed to minimize the usage of the unregulated street-level opioid supply. Clinically, these programs provide individualized treatment to lower overdose risk and improve patient outcomes (Tyndall, 2020). From a public health perspective, they aim to reduce community-level harms associated with the toxic drug supply, including overdose mortality, with some offering broader health and social supports structured to improve overall wellbeing (Schmidt et al., 2024).
Twenty-six SOS programs have been implemented across Canada with funding from the Substance Use and Addiction Program (SUAP) since 2020. There was also some informal prescribing taking place in a few communities across Ontario (Bieman, 2019; Rai et al., 2019) and British Columbia (Ivsins et al., 2021) before this federal funding. A variety of program models exist. For example, SOS can be prescribed as take-home doses or doses to be used under the supervision of a healthcare professional at a program site (e.g., supervised consumption site) or pharmacy. Some SOS programs also prescribe pharmaceutical-based stimulants or benzodiazepines, and many provide additional wraparound health and social care (McCrae et al., 2022; Young et al., 2022).
Studies on SOS programs across Canada support a number of positive outcomes, including decreased risk of opioid-related overdose; reduced reliance on the unregulated drug supply; reduced emergency department visits and hospital admissions; increased self-reported health and wellbeing; reduced infectious complications and injection-related health risks; better pain and chronic disease management, improved social engagement and financial security, and strong program retention (Gagnon et al., 2023; Gomes et al., 2022; Ivsins et al., 2020, 2021; Kolla et al., 2021; Olding et al., 2020; Ontario Drug Policy Research Network, 2023; Parkdale Queen West CHC, 2023; Perri et al., 2023; Schmidt et al., 2023a; Schmidt et al., 2023b). Gomes and colleagues (2022), for example, found that a SOS program implemented in London, Ontario reduced emergency department visits and hospital admissions, also leading to lower associated healthcare costs. Despite an increasing body of scholarship (over 25 peer-reviewed articles) to support their effectiveness, the scaleup of SOS programs will require considerable public and political support. To date, however, there has been some strong opposition to the implementation of these programs across political, health, and societal arenas (e.g., Zivo, 2023).
Methods
Narrative Policy Framework
The Narrative Policy Framework (NPF) uses longstanding insights from literary theory to examine how narratives inform public policy issues and their solutions (Jones, 2018). This framework views narratives as socially constructed entities. Initially applied to environmental policy analyses, NPF has since broadened its reach across various policy areas, including energy and gun control (Jones, 2018; Schlaufer et al., 2022). Notably, it has gained recognition as a research approach that can help understand and influence health policy (Schlaufer et al., 2022), including studies investigating how certain narratives lead to inflexible policy around supervised injection facilities (Fitzgerald, 2013). The expanding application of this framework underscores its potential as a tool in evaluating and shaping health policy around harm reduction interventions such as SOS programs.
NPF enables researchers to discern widely promoted narratives that provide a rationale for specific policy measures. Further, it allows for insight into the roles policy actors play in shaping narratives (Knoepfel et al., 2007). Policy actors can be represented by diverse groups of individuals who share collective perspectives across policy contexts (e.g., policy problems and solutions) and whose actions (e.g., evidence making, advocacy) have the potential to influence the trajectory of policy development (Knoepfel et al., 2007).
NPF argues that narratives can function independently or be contingent upon other well-known and accepted narratives. Moreover, these narratives can operate at one or more levels: individual insights, collective community perspectives, and overarching societal viewpoints (Jones & McBeth, 2010; Roe, 1994). It is an approach that seeks to identify the “policy narrative(s)” which “underwrite and stabilize the assumptions for policymaking in situations that persist with many unknowns, a high degree of interdependence, and little agreement” (Roe, 1994, p. 6). Its attention to context, ideologies, and the construction of characters, problems, and solutions is particularly relevant for the following analysis.
Data Collection and Analysis
We reviewed media coverage from 2021 to 2022 on SOS programs in Ontario, Canada using NPF (see Table 1). Media coverage was gathered from the Canadian Newstream database and with hand searches between February 2022 and January 2023 using the search terms: “safe supply,” “safe opioid supply,” “safer opioid supply,” “safer supply,” and “safe supply program.” Our search returned 181 pieces of coverage. Each piece was screened for eligibility, which included the following criteria: (1) a focus on SOS programs; (2) a focus on the province of Ontario; and (3) published between 2021 and 2022. Our final sample included 34 articles, 33 of which were newspaper articles and one which was a magazine article. Articles were analyzed using an inductive, collaborative approach (Saunders et al., 2018), where team members independently identified themes before consolidating into a single codebook with primary and sub-codes using NVivo software. Analysis of articles was guided by NPF, which facilitated a systematic examination of how the policy problem was constructed, the solutions proposed, and the identification of key stakeholders involved in the discourse. This approach enabled a nuanced understanding of the competing stories shaping public perceptions and policy debates around SOS.
Included Articles.
Findings
Across the 34 articles we reviewed, there was a common “policy problem”: the rising rate of opioid-related overdose experiences and deaths across Ontario. The story centered predominately around a “crisis management” metanarrative, which constructed opioid-related overdoses as a crisis that needed to be effectively managed through a targeted policy intervention. This metanarrative enabled the positioning of SOS programs—the focus of our research—as the “right crisis management solution” or the “wrong crisis management solution.”
The “right crisis management solution” narrative was commonly undergirded by the notion that SOS programs could effectively curtail the identified crisis but were ultimately a stopgap until broader structural conditions could be transformed. The “wrong crisis management solution” narrative largely propelled two contrasting notions: one, founded on the same idea as the “right crisis management solution” narrative but reaching a different conclusion, was that structural conditions have led to the identified crisis and SOS programs would only exacerbate it by keeping these conditions intact; or two, that SOS programs would exacerbate the crisis by destabilizing structures (albeit different ones from the former) that must be protected. We begin by describing the “policy problem” and metanarrative as they are presented in the articles we reviewed, followed by an exploration of dominant narratives with attention to their positioning of “victims,” “villains,”, and “heroes,” and their structural considerations.
The “policy problem” and metanarrative of “crisis management”
Across the 34 articles we reviewed, the “policy problem” was described as rapidly increasing toxic opioid-related overdose experiences and deaths occurring across Ontario, with one for example stating: In Ontario, opioid toxicity deaths have been on the rise, with this year expected to see the highest numbers yet […]. “We call it a shadow pandemic,” Ashley O'Brien, the manager of the Integrated Care Hub, explained in an interview with the Whig-Standard. (“Facing increasing toxic drug supply, advocates call for safe, legal option,” 2022)
We noted that a large portion of the articles referred to people who use drugs as “addicts” in titles, subheadings, and in the text used to articulate the “policy problem.” Substance use was frequently described as a disease, inhibiting disability, or, in some articles, as a criminalized pastime (Safe drug supply pilot starts early next year, 2021). Even when describing the strengths of SOS programs, some articles referred to them as being a means to treat the complexities of “addiction.” An example of this can be seen in an article published in the St. Catherine's Standard: “The key to keeping people alive, he said, is to provide people suffering from addictions with doctor-prescribed opioids” (“Niagara had worst year for opioid deaths,” 2021). We take this use of language as an indicator of the exclusion of people who use opioids from the conversation on the “policy problem,” and “policy solutions.” In general, few articles included the perspectives of people who use drugs or clients of SOS programs in their reporting.
Many articles attributed the “policy problem” to the COVID-19 pandemic, with some offering longitudinal data comparing rates of overdoses from 2019 to 2021 (Safe supply is “life or death for many folks,” support worker says, 2022). Others embedded the “policy problem” in deep structures that have perpetuated the risk of opioid-related overdoses over a long period of time. In an article published in the Waterloo Region Record, for example, an advocate and Ontario drug strategist was quoted as saying: “4,000 people died in Ontario in 2021 alone, and hundreds if not thousands more are disabled each year by a drug policy and practice that facilitates death and injury on an unprecedented scale, with no end in sight” (“The province needs to urgently declare the overdose crisis a public health emergency,” Waterloo Region advocates say, 2022). Nonetheless, most acknowledged that the rapidly increasing rate of opioid-related overdose experiences and deaths across the province posed a contemporary crisis that needed to be urgently and effectively addressed.
Based on these observations, we found the “policy problem” was thus positioned along a metanarrative of “crisis management.” Given our focus on SOS programs more specifically, in our case the “crisis management” metanarrative was deployed through the positioning of SOS as either the “right crisis management solution” or the “wrong crisis management solution.” Each of these also offered greater nuances in their conceptualizations of SOS as either having the capacity to effectively curtail the identified crisis until broader structural conditions could be transformed or, conversely, as exacerbating it by maintaining those structural conditions intact or interfering with existing structures that must be protected. We consider the dynamics of each below.
SOS as the “right crisis management solution”
The articles we reviewed primarily operated along the narrative of SOS as the “right crisis management solution” to the “policy problem.” This narrative positioned SOS programs as a critical public health policy measure, with providers and other harm reduction workers and advocates positioned as the “heroes” of the story. For example, an article published in the Waterloo Region Record in 2021 announcing $2.3 million for SOS programs in the region stated the following: Harm reduction advocates have long pushed for safe supply as a necessary tool in preventing opioid-related overdoses and overdose deaths because it gives substance users the regulated version of illegal drugs that are toxic and often laced with other substances. (“Feds announce $2.3 million for safe supply program in Waterloo Region,” 2021)
Most articles reported evidence produced by two policy actors, Dr. Gillian Kolla, an academic researcher, and Dr. Andrea Sereda, a SOS prescriber, who were the first to publish an evaluation of an Ontario-based SOS program. Both policy actors espoused the narrative that SOS was the solution to the growing rate of opioid-related overdoses, using scientific evidence to support claims of positive outcomes. Evidence included findings from evaluations indicating that SOS program engagement led to reduced opioid-related overdoses, improved income security, improved physical health, increased access to health and social services, and decreased engagement with the criminal legal system (e.g., fewer arrests and reduced engagement in criminalized income-generating activities). The London Free Press quoted Dr. Kolla in an article published in 2022, saying: The (SOS) program led to important declines in ED visits, inpatient hospital admissions, admissions for incident infections, and health-care costs […] There were no opioid-related deaths in the safer supply cohorts during the period under study. And this is nonetheless a period in Ontario where we saw the rate of overdose-related deaths increasing quite dramatically. (Richmond, 2022b)
Other articles similarly pointed to positive outcomes arising from SOS program engagement. They recorded greater stability in the lives of SOS program clients, a drastic reduction in opioid-related overdoses, and positive relationship development with peers, service providers, and family members. The medical director of the Guelph Community Health Centre's SOS program was quoted in an article published in the Guelph Mercury Tribune: She's [client of SOS program] found that her relationships have improved—specifically she talks about her mother. She's working and earning an income for herself now, and she's returning to school. She sees a path in front of her…. This intervention, this safer supply, will save lives. (“This safer supply will save lives”: Expanded Guelph program will provide prescribed opioids to up to 150,” 2021)
Importantly, we also identified an underlying assumption here of productivity, which was also present in other articles.
In articles aligning with the “right crisis management solution” narrative, people who use drugs, their families, and communities were positioned as the “victims.” Rather than “victims” of drugs, however, they were understood to be “victims” of persisting structural conditions, like criminalization, inadequate state policies, and stigma, which were in turn positioned as the “villains.” For example, in an article from the Peterborough Examiner published in 2021 about the pending implementation of a SOS pilot program, a prevention outreach coordinator at PARN (community AIDS resource network) explained that stigma plays an important role: “Stigma is driven by the attitudes collectively in society, because drug use issues and addictions continue to be criminalized and not seen as a health issue” (Safe drug supply pilot starts early next year, 2021). In making this statement, the prevention coordinator characterized drug use as a health issue and related broader practices that stigmatize and criminalize people who use drugs to the “policy problem.”
Indeed, several of the articles that positioned SOS as the “right crisis management solution” tended to describe the “policy problem” as a “public health emergency” and made connections to stigmatization and criminalization. For example, an article that included comments from Ruth Cameron, Executive Director of an AIDS service organization in Kitchener-Waterloo, Ontario, about the lack of attention to opioid-related overdoses and the connection this had to the decades of stigma faced by substance users stated: I can not [sic] imagine adding to the stigma experienced by people in our community, who literally have less than nothing and a very limited number of public spaces that they are allowed to be in without fear of harassment. (“The province needs to urgently declare the overdose crisis a public health emergency,” Waterloo Region advocates say, 2022) We’ve seen the growing impact that the opioid crisis has had, and people dying from that poisoned drug supply…. We need to take a health-care approach. We need to stop criminalizing it and instead offer people the support that they need. It's long overdue. (Richmond, 2022a)
We also found that while Members of Parliament were quoted in some articles with the “right crisis management solution” narrative, these actors were featured less than other policy actors such as researchers, activists, or frontline service providers. Members of Parliament who were quoted as supportive of SOS were typically from the New Democratic, Liberal, or Green parties of Ontario.
In line with the focus on criminalization, some articles pointed to the need for decriminalization as a broader policy direction. For example, an article published in the Canadian Press quoted the former Director of the Ontario Harm Reduction Network, Nick Boyce, who said: Until the federal government decriminalizes and regulates drugs, and other levels of government support safer alternatives, such as pharmaceutical quality options, we will keep seeing alerts and people will continue to die unnecessary deaths from the volatile, toxic unregulated drug supply. (Ziafati & Omstead, 2022)
As we can see, many of the articles we reviewed propelled the “right crisis management solution” narrative, with several of them positioning SOS programs as an evidence-based public health intervention that can address immediate concerns (i.e., the poisoned drug supply) while also working toward broader structural transformation. These articles positioned people who use drugs as “victims” of policies and other structural arrangements, and harm reduction workers and advocates as “heroes.” However, there was also a propensity in this narrative to rely on underlying assumptions of productivity and individual improvement that stopped short of meaningfully engendering harm reduction principles and challenging structural inequities.
SOS as “wrong crisis management solution”
Within articles propelling the “wrong crisis management solution” narrative, SOS programs were often questioned for their validity and “safety.” For example, in an article published in the Globe and Mail, Dr. Vincent Lam, a Toronto-based emergency physician, questioned the ability of SOS initiatives to address what he called “a national tragedy”: A national tragedy with complex origins demands a coherent response. Instead, Health Canada seems to be at cross-purposes, both calling for restrictions on the marketing and advertising of opioids, and for the increased availability of opioids under the guise of “safe supply.” (Lam, 2021)
Many of the articles aligning with the “wrong crisis management solution” narrative were guided by underlying assumptions about diversion. In the same article as above, Dr. Lam (2021) wrote: Studies are under way to assess whether the “safe supply” of hydromorphone actually helps those to whom it is prescribed. Supporters of “safe supply” often frame diversion as being a public-health benefit—because someone found hydromorphone instead of finding fentanyl, but we will only know after the fact if “safe supply” seeds the next decades of suffering for new patients who become addicted to hydromorphone bought off someone with a prescription. To replace a highly addictive street drug with another highly addictive prescribed opioid. Prescribing opioids could increase the chances of people either selling or sharing their medications with others who aren't prescribed to take the medication in the addiction community. (Dubey, 2022)
Similarly, an article published in the Waterloo Region Record raised concerns about SOS programs facilitating access to substances to individuals in the broader community: “There are others who might even disagree with the entire notion of a publicly funded safe drug supply program because they fear it will only make it easier for people to inject something that's bad for them.” (Giving addicts a safe drug supply will save lives in Waterloo Region, 2021)
The actors of these narratives, which predominantly included addiction medicine physicians and Members of Parliament who questioned harm reduction philosophy and instead promoted abstinence-based approaches, appeared to be informed by an underlying assumption that illicit opioids are necessarily harmful and their use inherently problematic, and that illicit opioid use could be curtailed, it would appear logically, through reduced access. The “victims” in this storyline were, therefore, people who abstained from illicit opioid use for some time and others who were or could be potentially exposed to opioids, and would not presumably be exposed otherwise, through SOS programs. Illicit opioids were positioned as the “villain” and physicians who kept their clients away from them as the “heroes.” We can see this play out in the following quote by Dr. Lam (2021): I decline to write these prescriptions because I am not convinced they are “safe.” Much of my discomfort with “safe supply” comes from what I am told by other patients who are also struggling with substances in their lives. They say that “safe supply” is harming them, as street availability has risen and prices have fallen. Patients of mine who were free of illicit opioids for years now struggle with hydromorphone, which they are buying from those to whom it is prescribed. One told me they prefer to sleep outside rather than in shelters, because they cannot avoid hydromorphone in the shelters. One who has never tried fentanyl—which hydromorphone is meant to protect them from—is injecting high doses of hydromorphone daily, struggling to get off, while their tolerance rapidly increases. What is difficult about “safe supply,” and what causes me and others moral distress, is that the same pills that one patient insists are needed to save their life may bring harm to another patient of mine, or one I have not yet met. In medicine we are taught primum non nocere, first do no harm.
Beyond just questions about validity, then, SOS programs were indeed positioned as the “villain” of the “wrong crisis management solution” narrative along with illicit opioids, suggesting their implementation would only further exacerbate the risk of opioid-related overdose experiences and deaths. In contrast to the “right crisis management solution” narrative, “wrong crisis management solution” articles thus tended to reduce the cause to an individual's use of drugs or subsequently to SOS programs themselves.
In some cases, those advancing the “wrong crisis management solution” narrative recognized structural determinants. For example, in an article published by the Globe and Mail, Dr. Vincent Lam (2021) quoted Dr. Lisa Bromley, an addiction medicine physician based in Ottawa, where Dr. Bromley located the “policy problem” in inadequate state policy decisions: Dr. Lisa Bromley, an Ottawa addictions medicine physician, says “the evidence for iOAT was stretched beyond recognition to apply to ‘safe supply.’ If doctors provide prescriptions, it lets governments completely off the hook to craft rational drug policy. It was a brilliant move by the federal government to dodge responsibility for drug policy.” Regional Councillor and Cambridge Mayor Kathryn McGarry […] asked how safe supply initiatives are viewed by citizens, pointing out that many in Cambridge would likely be against the idea of making a safe supply of drugs available to people. For years, the Cambridge council and residents have pushed back against bringing a Consumption and Treatment Services site into the city. (“Crime prevention council makes case for safe drug supply program in Waterloo Region,” 2021)
Together, articles advancing the “wrong crisis management solution” narrative questioned SOS programs for their validity and safety, raising concerns about diversion and the potential for exacerbating the existing or creating a new policy problem. SOS programs along with illicit opioids were positioned as the “villains,” those who might be exposed to them as the “victims,” and medical and political actors opposing them as the “heroes.” While some references were made to structural arrangements, the narrative centered mostly around individualized explanations and outcomes.
Discussion
Our examination of media coverage on SOS programs in Ontario during their initial implementation phase (2012–2022) pointed to an overarching “crisis management” metanarrative characterizing the “policy problem” of growing opioid-related overdose experiences and deaths across the province as an urgent crisis requiring immediate policy intervention. “Crisis management” was identified as the metanarrative because it appeared to best capture the set of articles we reviewed, which means it achieved hegemony over other possible narratives, for example those stressing community-led healing or structural transformation. It also set the parameters for SOS programs, which were the specific focus of our study, to be positioned as the “right crisis management solution” or the “wrong crisis management solution.” Although superficially bifurcated, each of these dominant narratives offered deeper reflections on structural conditions, “victims,” “villains,” and “heroes” in ways that at times united the two. Let us now consider these dynamics more closely.
The “right crisis management solution” narrative positioned SOS programs as an evidence-based, life-saving intervention that could effectively curtail the identified crisis while waiting for broader structural conditions to change. The narrative drew on harm reduction philosophy upholding human rights, health equity, and the expertise of people who use drugs (Adams, 2016; Earp et al., 2019), though as we discuss below, such expertise was rarely directly represented in the articles we reviewed. To this end, the narrative was most commonly deployed using medical and public health language, positioning SOS as a rational and evidence-based response that adhered to professional healthcare standards and scientifically proven models of intervention. This meant that advocates could claim scientific authority in an environment that typically values such knowledge over the lived experience of people who use drugs.
In this narrative construction, people who use drugs were positioned as “victims” of structural conditions. They were not, alternatively, positioned as “victims” of their own choices, histories, or moral failings, which tends to align with punishment, control, abstinence, detoxification, religious or morality-based forms of rehabilitation, and mandated treatment as solutions (Adams, 2016; Bush & Neutze, 2000; Frank & Nagel, 2017). They were understood, in line with harm reduction principles, as “victims” of criminalization, inadequate state polices, and stigma, with these broader structural factors cast as the “villains.” However, in several instances and tied to the positioning of medical professionals as “heroes” in the “right crisis management solution” narrative, people who use drugs were also seen as requiring protection and professional intervention rather than agents capable of organizing for their own liberation.
In general, we found that few articles included the personal perspectives of people who use drugs. Even though the “policy problem” impacted them directly, people who use drugs were rarely considered as experts or key stakeholders to engage in the conversation. Historically, people who use drugs have developed strategies and fought to implement approaches to protect themselves and their communities from harm (Marlatt, 1996). SOS is no different, with people who use drugs leading the call to action (Canadian Association of People who Use Drugs, 2019). Engaging people with lived experience of drug use to inform decisions on the development, implementation, and delivery of substance use related services is crucial and a key piece missing in the articles we reviewed. Like our study, others have similarly found that journalists often take messages out of context to fit their sound bites or describe people who use drugs as “junkies” or “addicts” (Morris et al., 2021), even in well-meaning coverage.
The “right crisis management solution” narrative thus contained interesting tensions that perhaps point to the limits of harm reduction discourse when it is operationalized within a “crisis management” framework. That is, although the dominant narrative characterizing SOS programs as the “right crisis management solution” was grounded in the lived experience of people who use drugs and acknowledged structural factors like perpetual criminalization and stigmatization, the articles we reviewed tended to reduce SOS to individualized explanations and outcomes. For example, employment, family relationships, and educational achievements were rendered as markers of success, which indeed strayed significantly from harm reduction's commitment to reducing harm without expectations of behavioral change. SOS programs, in this sense, were positioned as the “right crisis management solution”to the extent that they could restore normative (presumably non-crisis) order as opposed to intervening in the usual state of things, reducing suffering, upholding human dignity, or another alternative. Harm reduction approaches more generally have faced similar challenges in a neoliberal context where social and public health programs are expected to fit with goals of economic productivity and social order to appease unsympathetic policymakers (Kolla & Strike, 2021). These tensions suggest that even supportive narratives may inadvertently keep prevailing structures intact.
Researchers have similarly found that media reports about drug use and overdose trends in other contexts have ignored or otherwise minimized structural factors. For example, Johnston (2020) examined 122 media articles across Canada about opioid-related overdose deaths from 2014 to 2018. They found a lack of consideration of race across the media articles and highlighted that news reporting perpetuated stigmatized identities of racialized and Indigenous young people who use drugs as being “foreign drug devils,” while white young people who use drugs were described as “innocent victims” (Johnston, 2020). Their work underscores the ways Canadian media on substance use can perpetuate colonial, racist, and classist logics, which function to ignore structural factors that contribute to harm faced by people who use drugs. In our analysis, few articles presented evidence or attended to intersecting experiences of oppression (e.g., among racialized people, Indigenous people, women, and gender diverse people) that impact many people who use drugs. Hughes and colleagues (2011) also found that narratives on abstinence and criminality in their review of media articles on illicit drug use in Australia neglected broader structural aspects.
A similar trend could be observed in the narrative positioning SOS programs as the “wrong crisis management solution.” While there were notable references to problematic structural conditions in this storyline, illicit opioids and equally SOS programs were cast as “villains” upholding these conditions and thus perpetuating the identified crisis. This meant that more fundamental questions about how criminalization, capitalism, racism, and colonialism play into manufacturing drug-related harms could be deflected. At the same time, other structures, like professional medical designations and commitments, were safeguarded in the name of protecting people who may be exposed to SOS. People who abstained from illicit opioid use or could be exposed to SOS through so-called diversion were thus positioned as “victims.” People who were actively using illicit opioids or seeking SOS were, by extension and at times explicitly, rendered “villains.” The “heroes” of this storyline tended to be addiction medicine physicians and politicians who questioned or opposed harm reduction approaches.
The “wrong crisis management solution” narrative operated along several key underlying assumptions. It suggested, for example, that SOS created new demand for opioids rather than redirecting existing demand, which cannot simply be curtailed with decreased supply, toward safer products. Lower street prices and increased availability, as one physician noted, were positioned as harmful rather than, alternatively, as a harm reduction success that would make substances safer and more accessible, and could reduce the violence and exploitation produced by criminalization. Diversion was understood as an inevitable and negative outcome rather than an acceptable trade-off, if happening to any significant degree, for the lives saved through reduced overdoses and viral transmissions. And overall, the “wrong crisis management solution” narrative was informed by an underlying assumption that illicit opioid use was inherently problematic, hence the concern around perceived diversion, and that reducing access rather than improving safety was the appropriate approach. SOS programs, which promised to do the opposite, were inevitably positioned as the “wrong crisis management solution” according to this logic. This also suggests that different stakeholders interpret the same information differently (e.g., helpful program reach versus harmful diversion) depending on the assumptions and ideologies it is being filtered through.
By using NPF to examine print and online newspaper and magazine articles about Ontario-based SOS programs when they were first implemented, we gained insights into the metanarrative characterizing the “policy problem” of rising opioid-related overdose experiences and deaths as a crisis necessitating immediate management through a targeted policy intervention, the dominant narratives constructing SOS programs as a (non)solution to the identified “policy problem,” and the assumptions underlying them. Through this process, we were also able to identify unexpected and novel patterns that challenge common assumptions about media coverage on harm reduction interventions. These include the valorization of productivity in articles propelling supportive narratives of SOS programs, the unifying acknowledgement of structural conditions though with diverging conclusions, and the shared “crisis” metanarrative. This latter factor serves, in some instances, to obscure the ways in which opioid-related overdose experiences and deaths are a product or a permanent feature of current structural arrangements and not merely a temporal event. Our findings underscore the importance of critically examining how policy narratives are constructed, mobilized, and sustained in media coverage, as they have the potential to shape public understanding and create a feedback loop with policy decisions, either reinforcing or challenging the structural conditions that contribute to ongoing health inequities.
Limitations
The narrow scope of our review is a significant limitation and an analysis of articles from other jurisdictions (e.g., Basu, 2023) or more recent media coverage (e.g., Zivo, 2023) may have pointed to different narratives. Additionally, a broader or more temporally extended analysis may have revealed greater interaction between the two dominant narratives—for example, other instances where elements of “right” and “wrong” crisis management solution narratives overlap, conflict, or are strategically reconciled within media texts. As discourse around SOS continues to evolve across Ontario and Canada, such intersections may become more apparent, reflecting shifting political, social, and institutional responses to the evolving situation of the toxic drug supply.
Conclusion
The rapidly evolving context of SOS warrants ongoing attention to how public narratives develop alongside program maturation. The insights gained from our study suggest that communication strategies that acknowledge underlying assumptions as well as challenge how “problems,” “victims,” “villains,” and “heroes” are constructed in drug policy discourse are needed for shifting public perceptions, media coverage, and ultimately drug policy. While we found that most of the articles we reviewed were supportive of SOS as the “right crisis management solution,” their arguments have thus far been unsuccessful in establishing SOS programs as the “right policy solution” in practice, with even such supportive coverage often relying on productivity metrics and excluding the voices of people who use drugs. This disconnect suggests there may be some limitations in operating within a “crisis management” metanarrative for advocacy efforts, as the focus on managing or restoring rather than transforming structural conditions may inadvertently reinforce existing underlying assumptions and power relations that then translate to policy (in)action. Consistently positioning structural factors as active “villains” that require intervention through collective action would be an important element in advancing the demand for SOS, as some of the people quoted in support of SOS in the articles we reviewed have done. This could help strengthen existing coalitions and form new ones, including those traditionally resistant to harm reduction approaches. Another important element would be persistently positioning people who use drugs as “heroes”—that is, as experts and change agents. With this move, the narrative can shift from managing individual or community crisis to addressing systemic inequities every step of the way. Such positioning may be essential for translating supportive public sentiment into sustained policy implementation and expansion of SOS programs across Canada.
Footnotes
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by a SSHRC Institutional Research Grant gained through the University of Toronto.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.