Public health crisis as problematization: A comparative analysis of opioid overdose and heart disease

Abstract

This paper takes a common concept in Foucault and governmentality studies, problematization, to demonstrate its operational usefulness for analyzing public health crises. Social scientists have draw on this concept to discuss how phenomena become named as problems or issues of significance. We draw on a methodological use of the concept of problematization, to describe the process by which events become “problems” for governing; doing so enables critical sociologists to examine the nuanced ways that problems are defined, and, importantly, how solutions are proposed as a consequence of this process. We contend that the process of problematization, in two cases of public health crises, opioid overdose deaths, and “premature” coronary heart disease deaths, tends to describe the problem as a result of individual choices, which is used to justify intervention at the individual level. The paper concludes with a discussion of the normative upshots of using this concept for critical sociological analysis of public health issues.

Introduction

This paper takes a well-known concept in Foucault and governmentality studies, problematization, to demonstrate its operational usefulness in comparative analysis of public health crises. Social scientists have long draw on this concept to discuss the ways by which phenomena become named as problems or issues of significance (e.g. Bacchi, 2016; Bowden and Kelly, 2018; Dean, 2013; Hanemaayer, 2016; Koopman, 2014; Osborne, 2003; Rose, 1999; Rose and Miller, 2017). We draw on methodological uses of the concept of problematization (Clough, 2010; Prinz and Raekstad, 2024; Riemann, 2023; Stengers, 2021; Terwiel, 2020; Vallgårda, 2008), to describe the process by which events become “problems” for governing; doing so enables critical sociologists to examine the nuanced ways that problems are defined, and, importantly, how solutions are proposed as a consequence of this process. We contend that doing comparative analysis of the process of problematization, in two cases of public health crises, allows social scientists to see the tendency of health discourses to describe the problem as a result of individual actions, which is then used to justify intervention at the individual level. These descriptions of individual actions as the cause of public health crises may foreclose the possibility of identifying the social, historical, political, and/or structural causes of these crises. This foreclosure constrains solutions that could be proposed at higher levels of description.

There are two objectives for this paper. First, to demonstrate one way to operationalize the concept of problematization for comparative analysis, by drawing on two studies with different research designs, across historical cases. The analyses of the data are structured by asking three questions, what is the problem? What is the cause of the problem? What needs to be regulated (and how)? The other objective of this paper is to show, for the reader, that the content of public health crises may be different, but the process by which individuals become responsible for the cause of and solution to public health crises is common in the literature. We conclude by discussing the normative upshots of using this concept in critical sociology ¹ and suggest further comparative research.

The paper’s comparative method examines two case studies and demonstrates how this process of defining problems in scientific terms becomes the basis for articulating an object that requires intervention and/or regulation. Our first case focuses on the opioid crisis and “overdose deaths.” We examine recent medical statements about the nature of the problem in North America. Our second case concerns “pre-mature deaths” due to cardiovascular disease in England, and statements from the lifestyle sciences. In both cases, the process of problematization articulates individual behavior as the cause of the respective crisis: prescribing practices or drug-seeking behaviors, in the opioid crisis; and poor lifestyle choices, in the case of heart disease. We argue that health sciences play a significant role in justifying individualized interventions, which raises a normative consideration about the role science plays in defining social problems: societal or institutional factors may also need to be addressed in the face of public health emergencies.

The explanatory objective of this paper is not to use the concept of responsibilization to explain how individuals become responsible for their health. While we are aware of the vast literature on the value of this concept for sociological analysis (e.g. Brown, 2021; Fullagar, 2008; Gray, 2009; Rose, 1999, 2001, 2007). Instead, we describe and explain how the scientific discourses problematize health crises in an individualizing manner, which is later taken up by governmental practices and policies. ² While responsibilization explains the assignment of responsibilities to individual actors in order to alleviate state responsibility (and related costs) for social problems (cf. Garland, 1996: 452), the discursive problematization process explains how an individual becomes the target of such responsibilization strategies. Research in critical sociology can benefit from separating these two processes in order to first identify the discursive mechanisms that later make responsibilization possible, thus offering a potential target for resistance (cf. Lorenzini, 2024).

To make our argument, the first section discusses the theory and methods, the nature of problematization and how it can be operationalized for research. The next section introduces the reader to both our historical cases and describes the various research methods used to investigate them. Third, we demonstrate in three subsections how each case was defined, what/who was considered responsible in the discourse, and how this informed the solutions. Our conclusion connects this research with a wider critical agenda to raise questions about how health sciences are used to justify individualized interventions in lieu of societal-level improvements.

Analyzing problems

To describe problematization, we draw on a sociological conceptualization of this process. Following Foucault (1998), the concept refers to an order, a process that traces “the development of a domain of acts, practices, and thoughts” (p. 384). From the French, ordre has connotations with causality, or that which organizes a domain along certain principles. Problematizations occurs in discourses, which are collections of statements that are structured by discursive relations. Discursive relations are principles of determination that “permit or exclude, within a certain discourse, a certain number of statements” (Foucault, 1972: 67). We focus on the discourses of the health sciences, which are maintained by a set of relations that make possible “the separation, not of the true from the false, but of what may from what may not become scientific” (Foucault, 1980: 197). This schema of conditions, to paraphrase Datta (2007: 278–279), contains “the conditions of possibility for the practical know-how of subjects.” These relations not only structure what is considered a scientific statement but also play a role in articulating who can speak with authority about the causes of problems. These “truth” statements serve to found and justify the assignment of authority and carry implications for interventions on human activity.

Osborne and Rose (1997: 97) operationalize the process for sociological inquiry: “To analyze problematizations is to investigate why certain things (behaviour, phenomena, processes) become articulated as problems, how they are linked up with or divided off from other phenomena, and the various ways (conditions and procedures) in which this actually happens” (cf. Foucault, 1988: 17). Importantly, things become problems at particular points in time in particular cultures (Deacon, 2000: 127). Studying a problematization process both renders descriptions of how problems are defined, but also provides an explanation as to why. In this paper, we focus on the process of articulation in the scientific discourse and how the opioid crisis (i.e. overdose deaths) and premature deaths (i.e. due to cardiovascular disease) are defined, and why they tend to include statements about individual causes. The process by which problems are defined may shape what kinds of solutions are deemed justifiable by regulatory agencies, which can support efforts of responsibilization.

Social scientists have used “problematization” as a conceptual tool to examine the uses of science in governing. Bacchi (2012), a researcher in the field of policy analysis, developed a framework for the analysis of problematization. Termed the WPR Approach (short for “what is the problem represented to be”), the method focuses on the ways practices are indexes of the process of problematization (Bacchi, 2016). Distinctly, in our project we take an archeological tactic, where the actual pronouncement of statements are the epistemic access to this process of problematization (cf. Datta, 2007; Hanemaayer, 2019), rather than what Bacchi calls the “enactment” of problems. ³ Our focus is on the relations of discourse that structure knowledge of public health crises. This approach to the study of the problematization process is generative for two reasons. First, it describes the relationship between underlying assumptions about what is understood as a problem, and how scientific discourses define problems. Second, by identifying the assumptions that ground claims about which behaviors become problematic, the evaluation of both the reasons and proposed solutions can occur with conceptual clarity. The conversation about public health crises can broaden, and additional causes and solutions could be put forward for debate.

The scientific justification that underpins the statements we have analyzed are taken as signposts for the process of problematization. In each case, there is an observed need to produce and classify types of behaviors and their relationship to the health issue. We observed the objects of opioid-related behaviors in the clinic and life-style behaviors in public health. These scientific statements identify the causes of problems, carry implications for interventions in human activity, as well as serve to add legitimacy to the moral regulation of individuals (Hunt, 1999). Moral regulation involves the targeting of individuals in a way that gets them to self-govern in the name of broader moral goods (cf. Rose, 1999). We will show how the process of problematization can shape the kinds of regulations that are commonly recommended to address public health issues.

To accomplish the analysis, we first consider the nature of each problem: how is it defined, what are the underlying assumptions, and what scientific statements support this? Second, we analyze the causes of the problem, and demonstrate that, for each case, individual behaviors are identified as the cause of the problem. We then utilize this individualizing process to examine the ways that it justifies, in discourse, the establishment of regulatory institutions and articulates how they should operate. The latter will elucidate for the reader the relationship between the problematization process and the use of scientific discourse to justify programs that are set up to intervene on individuals.

Cases and methodological approach

Our paper follows Fraser and Ekendahl’s (2018) assertion that comparative analysis can illuminate the similarities in policy approaches in different contexts. Doing so, they argue, can provide a means of questioning the individualized logics of programs (p. 102). For example, in the case of drug use and its treatment, new ways of thinking are said to be urgently needed (e.g. Stengers, 2011). What makes our study interesting is the ways that each case demonstrates the relationship between scientific discourses and policy interventions. The opioid case examines how, in medical literature, problems are defined and taken up in interventions (such as patient monitoring programs). The Coronary Heart Disease case examines how, in policy responses, there is a dependency on the scientific discourses that define problems. While these two cases reflect different types of discourses and source materials, our method (described below) demonstrates that comparison between different cases reveals the dynamics of scientific problematization from both a scientific and policy vantage point. In both cases, there is a predominant emphasis on an individualization of the causes of problems.

In this section we begin by introducing each case study, and why they were selected. Then, we briefly discuss the method of data collection and analysis. Next, we discuss our results.

Opioid Crisis

This case focuses on the causes of opioid deaths, as they are stated in the medical literature. Academic and official public health statements, as well as media reports point out that opioid-related deaths have worsened in the past 11 years (Crawford et al., 2021; Shreffler et al., 2021). Official reports marked 2021 as a landmark year for the opioid crisis in North America (Advocacy Resource Centre, 2022; Government of Canada, 2022; National Center for Health Statistics, 2022). As such, our research into the last 10 years of pain medicine explored statements made by world-leading pain physicians and researchers, who worked together to inform health interventions related to opioids through research, conferences, pain journal publications, and media circulations. With respect to the interventions applied to curtail the crisis, our sample demonstrates a reliance on regulation at the individual level, either physicians or users: for physicians, by improving vigilance and education, training them for better services and implementing a prescription drug monitoring program (PDMP); and for users, by surveilling their behaviors, learning addiction and family history, educating and building patient-awareness, and adhering to care regimens.

Although many articles in our sample (described under the “Method” section) emphasize improving health sectors and making legislative changes to offer better care to patients, including leveraging facilitators to improve naloxone prescribing in health systems, improving pain and addiction prescribing, and counseling users, no single article proposes a solution that predominantly focuses on broader social factors, such as inequality, discrimination, and poverty, which are linked to the opioid crisis (Hanemaayer and Parvin, 2024). Drug use and the harm reduction approach have been core pillars in managing the opioid overdose crisis. These approaches have not been shown to be sustainable because they miss the intersections among the overdose-related crisis and inequalities in employment (Alsabbagh et al., 2022), housing instability and homelessness (Fleming et al., 2023; Pérez-Figueroa et al., 2022), food insecurity (Heflin and Sun, 2022), and other social insecurities that may lead marginalized people to use opioids (Johnston, 2020; Lavalley et al., 2018; Persmark et al., 2020; Wallace et al., 2021).

While the concept of problematization was also used by Houborg (2014) to examine the ways drug use was handled in Norway over the long 20th century, our study was motivated by recent work in critical sociology. Choosing the opioid crisis as a case study extends the work of Whelan and Asbridge (2013). Writing 10 years after their article, “The Oxycontin crisis: Problematization and responsibilisation strategies in addiction, pain, and general medical journals,” we were encouraged to update their study about how the opioid crisis has been analyzed by some authors in medical journals, and who is considered responsible for it. Whelan and Asbridge (2013) concluded that alongside making Oxycontin a problem, the pain journal articles attempted to deproblematize the use of Oxycontin through the claim that “there is nothing special about Oxycontin abuse” as all drugs are similarly abusable (p. 406). In our study, the process by which individuals were problematized as the cause of the crisis was predominantly articulated as the users in the addiction journal, whereas it was health care workers, particularly prescribers, who were singled out in pain medicine journals. We not only expanded on Whelan and Asbridge’s (2013) study, we also conducted a comparative analysis.

Coronary heart disease crisis

Our second case explores “premature deaths” due to coronary heart disease (CHD) in England between the 1970s and 1990s. In 1991, the English Parliament presented a consultative document that amassed statistical data about the leading causes of death in England and Wales. CHD was at the top of the list, accounting for more than 26% of all deaths in 1989, more than cancer and stroke. CHD was an umbrella term that collected “a group of clinical conditions ranging from asymptomatic disease to angina pectoris, acute myocardial infarction (heart attack) and sudden death” (p. 57). Not only did the condition take up the majority of National Health Service (NHS) beds every day, it was also identified as a significant cause of lost working days, at 35 million. Although the death rate for CHD had been falling since the 1970s, England and Wales were still well behind other OECD (Organization for Economic Co-operation and Development) nations, such as the USA and Australia, in this downward trend, and so identified CHD as a kind of public health crisis that needed to be addressed.

In this case, we explore the development of the link between premature deaths and “lifestyles.” In the government’s green paper, the primary causes of CHD were thought to be preventable, and a variety of behaviors that were “modifiable” were identified for public health intervention. While some socioeconomic differences were noted in the report, such as a greater burden of disease in the lower social classes, the main factors that contributed to CHD overall were listed as “cigarette smoking, high blood cholesterol levels, raised blood pressure, overweight and obesity and lack of exercise” (p. 57). These behaviors would become the target of specific public health programs to regulate diet and smoking during the 1990s in England, while decreasing investment in NHS services and Districts Health Authorities continued.

We selected this historical case because of its significance in national public health programs and policies at the time. Our work also builds on the governmentality literature, which has established the ways that health policy individualizes CHD. For example, Hutchison and Holdsworth (2019) describe how health policy tends to focus on individual responsibility, taking for granted the nature of the problem as one of risk: “health promotion messages focusing on individualism and lifestyle appear to be privileged over structural explanations” of CHD (p. 300). Further, while some of the identified causal factors of the disease might easily lend themselves to individual choice (such as smoking), other health conditions, such as cholesterol or blood pressure, come to be reduced to individual choice as well. For example, cholesterol is linked to diet, which is defined in the sample a set of choices about healthy eating. The cause of the problem, then, at the time, comes to be defined as an individual issue, wherein, if “better” choices are made, then the disease burden would be reduced. In terms of our paper’s objectives, our interest in the process by which this “premature death” crisis is problematized focuses on the ways lifestyle science discourse narrows the policy conversation on habits rather than other, broader factors, such as poverty (Office for National Statistics (ONS), 2022). We were encouraged to consider the process by which individual choice became associated with CHD and added to understanding the comparative case of overdose deaths.

For each case, a different method was used, but our epistemological commitments make these cases commensurable for comparison and analysis. In both cases problematization was observable in the sample of statements via the process by which that the problem, deaths due to either opioids or CHD, was defined by scientific discourses. In order to sample the discourse, we used two methods. In the opioid case, no singular policy existed in North America, yet many recommendations had been made in the literature. For this reason, we collected the data and information ourselves in published medical journals. In the case of CHD, the English government relied on their own statistics and another survey, the Health and Lifestyle Survey, to problematize the causes of death. In the latter case, we analyzed the synthesis of the data in only a few sources, detailed below.

Method

In the case of the opioid crisis, we constructed a sample of 32 articles published between 2011 and 2021 from three medical journals, The American Journal on Addictions, The Journal of Pain, and Canadian Journal of Pain, to explore claims related to the cause of the crisis in the medical discourse. We chose these three journals because of their impact and citations. We chose to examine medical journals as they shape public health views about diseases and crises. In constructing our sample, we reviewed the abstracts and titles of all published articles during the identified timeframe from these three journals. In total, 2336 abstracts, 1365 from The Journal of Pain, 829 from The American Journal of Addictions, and 142 from Canadian Journal of Pain, were reviewed and selected based on whether or not they discussed the opioid crisis. Following assessment, 32 articles became a part of our sample: 12 from The Journal of Pain, 15 from The American Journal on Addictions, and 5 from Canadian Journal of Pain. These selected articles specifically made claims related to the cause of the crisis and proposed a solution. In this sample, opioid deaths were problematized as a series of behaviors that could be identified and intervened upon. ⁴

The second case comprised of a sample of statements from two government documents, a green paper (1991) and a white paper (1992), and two Health and Lifestyle Surveys (HALS) from 1987 and 1992, respectively, that were in dialog with the policy papers. The sample comprised 874 pages of scientific findings related to the causes of disease and its distribution in the population in England and Wales. Over 17 causes of death were studied in the sample statements, and 25 specific interventions were recommended in the government documents. We selected only two interventions to focus on, diet and smoking, in order to examine the link between the cause of disease, scientific statements about it, and the interventions recommended by public health policy. Following Hanemaayer’s (2019) analytic strategy, we narrowed our focus to the scientific discourses that rendered these behaviors measurable and something in need of regulation in order to prevent CHD. These discourses problematize CHD as a series of lifestyle choices, which could, through education, be changed. The assumptions that underpin lifestyles as a series of choices inform the policy interventions of health promotion. The failures of the health promotion strategy are also briefly explored in the discussion.

What is the problem?

We begin by focusing on the nature of the problem, as the underlying assumptions about the problem are expressed in scientific terms. It is from these ontological commitments that our analysis can demonstrate the process by which the nature of the problem itself plays a role in determining the “cause” of the problem, as it is laid out in the discourse.

The opioid crisis sample discursively reiterates that opioid misuse is a significant social, economic, legal, and medical problem. The drugs themselves were not the problem, but their use. Diverse uses were identified, including, the over-prescription of Oxycodone, the use of illicit opioids by acquiring them through family and friends, and ability to obtain and use opioids from multiple prescribers (also called “pharmacy shopping”). Primarily, the problem of the opioid crisis is defined in terms of behaviors that lead to death.

Overdoses, over-prescription, misuse of prescription, and street and illegal drug use were identified as contributing to the opioid crisis in the majority of articles of The Journal of Pain (8 of 12) and Canadian Journal of Pain (3 of 5). When drug use was identified as the nature of the problem, the conclusions that followed were how its use was possible. In Canadian Journal of Pain, Zhao et al. (2020) define the crisis in relation to physicians and the prescription of opioids for chronic pain which strikingly increased over the past two decades in Canada; the country is now “the third-largest per capita consumer of prescription opioids in the world, behind the United States and Germany” (p. 112). The province of Ontario was marked with “the highest rates of prescription opioid use in all of Canada”; and “In 2015, nearly one in seven people filled a prescription for opioids in Ontario” (p. 112). The use of “morphine, oxycodone, fentanyl” were identified as a part of the problem, which predominantly articulated the medical nature of the crisis. However, other authors also rejected the medical actions related to the crisis. For some statements, it was not over-prescription as the nature of the crisis, but that the opioid-related death rate increased because of the illicit use of drugs (Saïdi et al., 2018: 113), which in turn implied that users’ actions were at the heart of the problem. Interestingly, some authors placed blame on other countries, such as China, for the illicit opioids that circulate, noting that potent fentanyl and other synthetic opioids being smuggled into Canada is a significant issue (Lynch and Katz, 2017).

While authors in The American Journal on Addictions also identified over-prescription, overdoses, and the misuse of family members’ prescription and street drugs as problems, they especially emphasized the barriers of naloxone distribution and aimed to understand the connection between the life course (e.g. childhood development) and opioid addiction. The former represents an underexplored contributor to the perpetuation of the crisis, the circulation and distribution of a resource, while the latter individualizes the cause of the crisis. For example, Khantzian (2021) notes that people who have experienced physical and emotional neglect, sexual and emotional abuse, parental separation, “exposure to domestic violence, household substance abuse, and household mental illness” are more vulnerable to substance use due to a lack of self-regulation and self-care related to adverse childhood experiences (p. 302). While Khantzian does not explicitly make mistreated individuals blameworthy for their overuse of opioids, there is an implicit moral dimension related to mental health care, which is motivated by the discourse of psychiatry. Interestingly, not a single article in our sample addressed pharmaceutical companies’ involvement in the crisis as a problem.

Whereas use behaviors were defined as problematic in the medical literature about the opioid crisis, a different set of behaviors were defined with respect to heart disease, lifestyle behaviors. The process by which CHD became problematic was expressed predominantly in epidemiological terms, and this was later translated into policy. CHD in England was defined as a preventable condition. The Health of the Nation’s Green paper, published in 1991, represented the development of a national health strategy. The green paper was circulated among stakeholders for feedback, and a white paper was passed in parliament in 1992. In the green paper, CHD was among many possible targets for public health intervention. In this iteration, the paper made explicit connections between the problem, death, and, importantly, the behaviors that led to it:

The main risk factors for CHD are now accepted to be cigarette smoking, high blood cholesterol levels, raised blood pressure, overweight and obesity and lack of exercise. All these risk factors are determinants modifiable by changes in lifestyle. When combined they interact and multiply. However, there are also other factors thought to have an effect on CHD, including socioeconomic factors, influences in early life and stress. These are areas where as [sic] yet knowledge is limited. (p. 57)

Although various environmental and social factors were noted, the green paper proposed what would later come to pass: that health behaviors (related to lifestyle) could be defined in relation to the CHD problem.

Because the policy articulated that the goal was to intervene on the “premature” or “preventable” deaths due to CHD, it identified health behaviors that required intervention: “All the main risk factors can be influenced by changes in behaviour. For those who smoke, stopping smoking is the single most effective means of reducing risk for CHD and stroke. Excessive dietary intake of saturated fatty acids results in raised plasma cholesterol levels” (pp. 46–47). These identified health “risk factors” had been recently defined in a national survey.

The Health and Lifestyle Survey (Cox et al., 1987) published the results from a study on “a nationwide survey of the physical and mental health, attitudes and lifestyle of a random sample of 9,003 British adults” (i). In the chapter of the report titled “Healthy” Behaviour, authors describe the predominant attitudes and beliefs of the nation. One section surveyed what people do “to keep yourself healthy or improve your health” (Whichelow, 1987: 121). Respondents predominantly mentioned a healthy diet and exercise as their main activities to stay well. Only a small proportion of the sample (less than 15%) reported that they would like to reduce smoking to improve their health (p. 124). The national interest in health behaviors continued in the field of epidemiology over the next decade. The second report of the longitudinal Health and Lifestyle Survey (HALS2) (Cox et al. 1993) clearly showed that heart disease was the leading cause of death in their sample over the study period, which was consistent with national statistics (Cox et al., 1993: 33). They connected these rates of mortality with both diet and smoking: these factors were identified as having a higher risk of death between the surveys (pp. 36–37).

The relationship between the results of both surveys and social policy is evident. For all the articulated targets, the government supported their strategy with evidence. In 1992, HALS2 concluded their report summary with a section on the implications for Health Policy, where they discussed the risk factors selected in the white paper specifically. For many of the risk factors, the HALS2 concluded that health behaviors are but one piece of the public health puzzle. For example, the consumption of alcohol was related to broader life circumstances: “These longitudinal data show that, for a high proportion of the population, drinking habits are not a stable personal characteristic but change with the life circumstances. For health promotion [policy], this suggests a rather different model from that which sees behaviour as essentially a characteristic of the individual” (p. 330). Despite some of the disagreements among the epidemiological evidence and the health behavior targets, the policy continued to define the problem of CHD as one of behavior: “Because these factors can be influenced, much heart disease and stroke is potentially preventable. People of all ages can reduce their risk of CHD. . .Even late in life, changes in lifestyle can give considerable benefits” (HoN 47).

In both cases, the production of information about behaviors serves to render the problem an individual one, either as a matter of drug use or eating and smoking. “Lifestyle” behaviors had been previously identified as affecting poor population health, as a factor of the environment. The rise of the lifestyle sciences, however, contributed to this emerging problematization of CHD as not the product of socio-economic factors, but instead of individual choices, as will be discussed further in the following section.

What is the cause of the problem?

Given that in both cases, the public health issues were defined in relation to individual behaviors, in this section we explain how these behaviors were associated with specific kinds of people. In the case of the opioid crisis, use was associated with physicians and patients. In the case of CHD, health behaviors were associated with those “at risk.” For example, since CHD was defined as preventable due to lifestyle behaviors, particular behaviors came to be associated with characteristics of individuals, such as, smoking as an activity was associated with active and ex-smokers. The cause of each problem was defined through specific sciences (pain medicine and epidemiology, respectively) and those would later identify particular individuals who would need intervention. At the end of this section, readers will understand how the individual actions that were associated with the cause of the problem would serve to justify particular regulatory interventions, which will be elaborated in the next section.

With respect to the opioid case, The Journal of Pain and Canadian Journal of Pain most frequently associated the cause of the crisis with pain prescribers and street drug dealers for the crisis. In other words, there was a focus on those who handed out opioids. Physicians were identified in a variety of ways. In most of the articles (25 articles out of 32), over-prescription is recognized as contributing to the crisis in some way, whether the primary cause or not. For example, Furlan et al. (2018) stated that, in 2016, more than 21.5 million opioid prescriptions were filled “along with an increasing proportion of strong opioids among all opioids dispensed” (p. 219).

Physicians were also blamed for not using the prescription guidelines properly because of fear of being punished by the prescription drug monitoring system. McCracken et al. (2012) noted that: “In the UK. . .. . .42% [of] practitioners occasionally or never prescribe opioids to their patients. 57% of practitioner mentioned they do not use the guideline when prescribing opioids.. . .there is a need to develops methods that prompt the greater use of the guideline” (p. 32). These kinds of claims, where medical professionals call for greater uptake of evidence through practice guidelines has been noted in the sociological literature (e.g. Hanemaayer, 2019; Mykhalovskiy, 2003). These statements in our sample indicate that the scientific discourses made it not only necessary to know about the individuals causing the problem, but also what must be done about it. For example, certain types of physicians, those without skills, would become the object of regulatory intervention.

Some authors (Dassieu et al., 2021) in the pain medicine journals used patients’ perspectives to blame physicians for not providing appropriate pain care to the patients. For some, this referred to pain physicians who were blamed for their lack of training and skills in prescribing pain medicine by some authors (Dassieu et al., 2021; McCracken et al., 2012). However, some authors, such as Zhao et al. (2020), blamed medical education and training gaps as problems when raising questions about physicians’ skills in providing pain treatments. According to Zhao, physicians receive less than minimal training to prescribe safe pain treatment: medical students receive only 16 hours, and “family medicine residents receive less than 4 h[ours] of pain management training over the course of their two-year residency training in Canada” (p. 112). The authors’ focus on enhancing training and skills of physicians could be read as fostering clinical control over the problem. The remedy to the problem, in this regard, tended to be about correcting individual prescribing behaviors. As noted in the above section, while the nature of the problem is individualized use, so too is the solution – better prescribing practices, and this is said to require more training and education.

Our sample of articles in The American Journal of Addiction assigned the cause of the problem to not only physicians, but also the user. As to Martino et al. (2020), the opioid crisis could be reduced by providing opioid agonist therapy, but providers lack education in providing naloxone services, and users may be disinterested in using opioid agonist therapy. Although statements associated the cause of the crisis with users more frequently than in the pain medicine journals, we found an interesting association. In one way opioid “addicts” were blamed; and, in another, they were portrayed as victims of damaging family environments. Khantzian concludes that substance use disorder is a self-regulation problem; substance dependent individuals lack “regulati[on of] their emotions, sense of self and self-esteem, relationships, and self-care” (Khantzian, 2021: 304) and “derailed, damaging, or neglectful, a whole range of difficulties tragically result that especially impact the capacity for self-regulation” (p. 302). Khantzian suggests health professionals need to look at social and family issues when treating patients with “substance use disorders” (sic). Although Khantzian points out some social factors correlated with addiction and the opioid crisis, the author, however, focuses on the importance of identifying those types of patients who are likely to over-use; the lack of these “self-regulating” behaviors needed a medical remedy.

As observed in the pain medicine and addiction literature, there is an implied necessity to gain knowledge about the individual acting in a way that contributes to the identified problem. Articulated associations among CHD risk behaviors and the types of people who require intervention are evident in the epidemiological research and the health policy targets. Both diet and smoking were studied and typified by the lifestyle sciences, which then informed the implementation of the policy’s targets.

In order to understand eating patterns and smoking habits, HALS used the demographic age data to create age groups by which to stratify the behaviors. For example, all 29 tables in HALS collectivize the data across categorical age groups, 18–39, 40–59, and 60 and above. Further, meals were categorized as either snacks or meal, the latter defined as having a main course that is cooked, and the former being anything eaten in between. The number of meals and snacks in a week was asked and recorded. Another variable for both groups was manual and non-manual laborers. For example, the study found that those with manual jobs were far more likely to be heavy smokers (p. 101). In HALS2, diet and smoking information was compared with HALS, and conclusions were drawn about the characteristic behaviors and patterns of “at risk” lifestyles, which included weight gain and a rise in smoking habits.

HALS2 also breaks down the risk category of weight gain by age group. Between the first and second iteration of the survey, those groups who experienced the greatest acceleration in weight gain were listed as follows: “18% of women aged 32-38 were obese, twice the proportion in the same age group at HALS1, and 51% of men aged 32-38 were overweight or obese, compared to 41% of the age group at the first survey” (HALS2, 331). Both of these types of individuals, overweight and heavy smokers, were identified as in need of intervention.

The white paper (1992) used target categories. For example, the policy’s main CHD interventions were stated as follows: “To reduce death rates for both CHD. . .by the year 2000 (from 58 per 100,000 population in 1990 to no more than 35 per 100,000)” (p. 47) and these were associated with “stopping smoking, . . . [and] increasing physical activity.” When articulating who and what lifestyles were targeted, each health intervention was listed in relation to types of people, their age and activity:

To reduce the prevalence of cigarette smoking in men and women aged 16 and over to no more than 20% by the year 2000 (a reduction of at least 35% in men and 29% in women, from a prevalence in 1990 of 31% and 28% respectively). (p. 51)

To reduce the average percentage of food energy derived by the population from saturated fatty acids by at least 35% by 2005 (from 17% in 1990 to no more than 11%). (p. 52)

There were no targets in the policy for increasing physical activity.

For both the opioid crisis and CHD, scientific discourses played a key role in identifying the causes that required intervention. The kind of user, physician or patient, and the kind of lifestyle, were articulated in relation to the kinds of individuals who needed regulation. Those in need of correction were specified in these discourses, and that is the section we turn to now.

What needs to be regulated? And how?

The upshot of this section is to understand how public health crises develop individualized interventions to resolve problematized behaviors.

A variety of recommendations were made to address the opioid crisis; and, central to our thesis, these prescriptive statements were coherent with the assumptions that underpinned the problematization process. The addiction journal mainly focuses on strengthening opioid agonist therapy care and removing barriers for providing this care to users. According to Lott and Rhodes (2016), the barriers included prescribers’ reluctance to prescribe naloxone is also identified as a problem that can be resolved by providing training and education to health professionals. Alongside providing training and education to health professionals, improving naloxone prescribing in health systems and availability of naloxone in the community and homes is highly recommended (Siff et al., 2021). Public health administrators and policy makers’ advocacy for the implementation of opioid agonist therapy to reduce the rising number of overdose deaths in the United States and worldwide are highlighted in The American Journal of Addiction.

Pain journals particularly focus on strengthening the use of opioid prescription guidelines and prescription monitoring programs and physicians’ responsibilities to provide better care to patients. For instance, Martel et al. (2014) note that “opioid craving should be routinely assessed and monitored over the course of opioid therapy, particularly among patients with high level of negative affect” (p. 96). Also, treatments and interventions are a stated requirement to stop the craving and withdrawal symptoms which leads to prescription misuse (p. 96). Given that physician behavior was identified as a cause of the crisis, the normative recommendations tend to target individual behaviors, such as requiring physicians to follow evidence-based guidelines and enroll in monitoring programs. Across all journals, the importance of providing training to health professionals, developing proper guidelines, and education sessions for physicians is mentioned. For physicians, they should take steps to reduce the risk of overuse through safe and careful prescribing. For patients and physicians, evidence-based, timely, accessible, user friendly, gender-sensitive and responsive care that addresses both the clinical and social needs of patients with Opioid Use Syndrome were recommended to reduce the overall death toll of persons with Substance Use Disorder by the addiction journal. Also, besides clinicians and patients, parents were said to need to educate adolescents about the appropriate use of opioids, “pain management, and communication with prescribers” (McCabe et al., 2013: 1213).

These statements articulate the regulation of particular behaviors, demonstrating a relationship among the problematization of the crisis and the kinds of behaviors that require regulation. Broader social factors, such as infrastructure or access to care, were not discussed with respect to the societal factors that contribute to the opioid crisis. We note that while policy changes are stated benefits in some of the articles (e.g. Crawford et al., 2021; Levin and Cates-Wessel, 2018; Sullivan et al., 2016), these policies are meant to change behaviors first and foremost, and not focused on system investment or support beyond the health system, such as meaningful outpatient care or free access to mental health resources.

When it comes to CHD, the idea that diet or smoking are related to lifestyles informed the idea that better choices would impact the prevention of deaths. Part of this assumption was based upon the predominant ideas within the population studied by HALS in the 1980s. For example, a specific section of the survey asked questions that linked people’s beliefs about disease and health behaviors. HALS1 reported that only about 42% of people said that they believed diet was connected with better health, and “fewer people. . .[believed] diet is implicated in heart disease” (HALS1: 132). Younger people were more likely to relate diet with healthy lifestyle choices, while activity was the most prominent idea that people reported as being connected to a healthy lifestyle.

The white paper serves to implement these ideas that beliefs inform choices, and intervention on those choices would prevent ill health. For example, under the section “general action,” the policy states “Every individual should be aware of the risk factors associated with CHD. . .and how to make the lifestyle changes necessary to avoid them. They also need to be encouraged and supported in making – and sustaining – decisions on this information” (1992: 48). Interestingly, although the NHS is listed as a significant contributor to the achievement of the health target through early detection and treatment, predominantly, government investment centered on taskforces to study nutrition and produce diet guidance. These messages would be disseminated to the public to make healthier choices. For example, the Health Education Authority (HEA) would receive funds to continue “to develop nutrition education resources for health professionals and the public” in addition to enlisting media to give “the public information about diet, nutrition and health which encourages health eating” (p. 54). The HEA was government’s commitment to preventing premature deaths due to CHD in the national population, and the primary intervention would be to encourage better decisions about what people eat and how much people smoke through health messaging.

Discussion

For both the opioid crisis and for CHD, a comparative analysis demonstrated how scientific discourses served to render the problem in scientific terms. For each case, the problem was defined in terms of use behaviors, in the latter case lifestyle behaviors. These statements informed the “kinds of people” that could be identified as playing a causal role in the public health problem. By identifying the “at risk” individuals, whether they were patients with the potential to over-use or those people who smoke too much or eat the wrong kinds of foods, a type of individual would become the target of regulation. For example, patient monitoring programs are meant to regulate use of at-risk individuals and to get them to see themselves as at-risk, and in need of self-regulation. Similarly, the at-risk individual was the overweight and/or heavy smoker; their premature death due to the CHD could be prevented if the right information was given and new choices were made by that individual. The lifestyle sciences played a significant role in stratifying the population to this effect, and its knowledge can be seen in the setting of targets in the 1990s in England.

Here is the intersection with responsibilization literatures. As the problem is articulated in scientific discourse at the individual level, medicine and/or public health could intervene upon it through responsibilization strategies, such as health surveillance or health promotion. Our analysis focused on describing and explaining the ways that the health sciences played a role in defining the nature of the problem and the kind of individual in need of correction. These definitions and explanations were deployed in medical journals, health policies, and institutions to justify the regulation of these at-risk peoples. The processes by which these regulatory programs enjoined the individual to take responsibility for their behavior (cf. Rose, 1999), would be the object of analysis for a responsibilization explanation.

What is also significant is the ways that these scientific discourses shape the kinds of interventions that gain investment and funding. Monitoring programs and health education messages cost far less than large scale investments in social welfare, despite a wealth of evidence demonstrating the significance of social factors in shaping one’s life course and risk of illness. What both these cases demonstrate is the way that regulatory bodies may not target the societal or infrastructure aspects (e.g. social determinants of health; health institutions) that might support individual choices, even though many of these are in the remit of governance. In both cases, doctors become teachers and educators: in using pain treatments and in advising on the best lifestyle choices. By examining which discourses define public health problems and how their causes are articulated, social analysis can raise questions about the kinds of solutions that are often proposed for dealing with public health emergencies. To paraphrase Lorenzini (2024), examining problematizations of public health crises has a “possibilizing” dimension (cf. Foucault, 1984a, 1984b): revealing the relations of discourse that articulate individuals as the cause of these problems makes it possible for publics to ask whether these are the kind of questions they want to pose, whether these are the sciences they want to define the problem, and whether these solutions are desirable or viable.

Conclusion

This analysis operationalized the process of problematization through three questions: what is the problem? which sought to identify the nature of the problem; what is the cause of the problem?, which identifies the kinds of people who need intervention; and what needs to be regulated (and how)?, which connects the scientific nature of the stated problem with a justification for the kinds of intervention needed. This analysis follows a Foucauldian, archeological analysis of the process of problematization by following two separate case studies, from two different historical and cultural contexts, and used two separate forms of data. The comparison of these cases was possible through the focus on the process by which things become articulated as problems, to paraphrase Osborne and Rose (1997), which allows the social scientist to focus on the statements in the scientific literature as indexes for the process of problematization. Public health crises often utilized scientific discourses to define problems and solutions. Comparing across contexts demonstrated the predominant way that behaviors are assumed to the be cause of public health problems. We noted that some known causes of public health crises are left out of the process of problematization, which can have potentially detrimental effects on societies. Systemic issues are often left out of the scientific discourse, and behavior becomes the political target of thought and action.