Is It The Pills? The Pain? Or

Maybe The Despair? The Role

of the Problem Definition in

Crafting Legislative Solutions to

the Opioid CrisisBy Taleed El-Sabawi, JD

2

Introduction

3

• Understand the problem definition

process and how such a process affects

our approach to a social problem• Using causal stories to limit policy alternatives

In order to strategically affect change…

4

• Identify dominant causal theories/stories

used to define the Opioid Epidemic by

pressure groups in legislative testimony.

• Identify the solutions supported.

• Explain how these causes and solutions

limit our approach to addressing the

Opioid Epidemic.

Introduction

Purpose of this Presentation

5

Why legislative problem

definition?Why pressure

groups?

6

• Groups battle for legislator time and attention

so that they can have the opportunity to

define problems that affect their members.

• Legislators listen because…

o Legislative subsidy

o Campaign contributions -$$$$$$

o Public trust

o External validity

Legislative Influence

Organized Interests

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- Technical expertise

- Reports, Data

- Policy implementers & enforcers

- Powerful allies for organized interest

groups

Legislative Influence

Administrative Agencies

8

Problem Definition &

Policy Narratives

9

• The process through which actors in the

political process define a social problem.

• “Struggle over alternative realities.”1

• Contest and debate the problem in the

political sphere based on perceptions

Problem Definition

What is problem definition?

1THE POLITICS OF PROBLEM DEFINITION: SHAPING THE POLICY AGENDA (David

A. Rochefort & Roger W. Cobb eds., 1994) [hereinafter ROCHEFORT &

COBB]

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• Narrative used in the policy sphere to

structure and communicate our

understanding of the world.

• Resembles fictional narratives:• Characters

• Plotline

• Ending

• Judged on (1) credibility and (2)

believability

Policy Narrative

What is a policy narrative?

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Credibility• Experts

• Scientific or empirical evidence

Believability • Degree to which the narrative resonates with cultural and

societal norms

• The familiarity of the plotline (recycled plotlines)

• The degree to which the character descriptions coincide

with the audiences’ perceptions of that character from

their life experiences and encounters

Policy Narratives

Credibility & Believability

12

• A type of narrative

• Rhetorical, tool of persuasion

• Describes cause of the problem• Often action or inaction by the characters

• Assigns blame

• Assigns benefits

Policy Narratives

What is a causal story?

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Data &Methods

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• I conducted a search in WestlawNext of

all congressional hearing testimony

between 2014-2016, using the key terms:

opioid, addiction, overdose, heroin,

fentanyl.

• I then omitted hearing transcripts that did

not address the current opioid epidemic

Data:

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• Qualitative Content Analysis:• Sampled testimony & created categories

• Applied categorization to remaining texts.

• Adjusted categories. (Iterative process).

• Software: QDAMiner5

Methods:

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Content Analysis: Guiding Theory

Deborah A. Stone, Causal Stories and the Formation of Policy Agendas, 104 Political Science Quarterly 281 (1989).

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Results

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Implicit vs. Explicit Causal

Stories

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Implicit vs. Explicit Causal

Stories• Explicit Causal Stories

• Explicitly discussed the cause

• Intentional Causal Theories:

• Drug manufacturers intentionally misrepresented properties of

prescription opioids.

• Doctor’s intentionally prescribed opioids.

• Bad Apples:

• Doctor Dealers

• Doctor Shoppers

• Intentional Diversion

• Inadvertent Causal Theories :

• Act was intentional, but the harm was unintended.

• Doctors were driven by Pain as a 5th vital sign,

misrepresentations of pharmaceutical manufacturers that

drugs were safe, etc.

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Implicit vs. Explicit Causal

Stories• Implicit Causal Stories

• Did not unequivocally state the cause of the Opioid Epidemic, but

rather implied the cause through their support for a particular solution

and statistics

• Strategic Benefits:

• Did not point fingers avoids political ramifications of angering a

powerful group

• Shifted the focus of the discourse to the effectiveness of the

desired solutions

• Consequences:• Little to no discourse on discovering what the cause of the

epidemic is

• Superficial understanding; acceptance of causal as facially true

without much scrutiny

21

Supply vs. Demand

Narratives

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Supply vs. Demand Side Causal Stories

Over Prescription

Diversion

Patient Education

Lack of Treatment

Brain DiseaseImportation

Supply Narratives: The availability of addictive drugs

causes problem drug use.

Demand Narratives: The focus should be on remedying

what causes the user to demand the drugs.

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Supply vs. Demand Side Causal Stories

Over Prescription

DiversionBlamed

Medical

Community

Blamed the

System: 5th

Vital System

Importation

Blamed

Pharma.

Blamed

Bad

ApplesLeft-over

Prescriptions

Blamed Mexican

Cartels

Blamed Chinese

Manufacturers

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Supply: Over-Prescription

Over Prescription

Blamed

Medical

Community

Blamed the

System: 5th

Vital System

Blamed

Pharma.

Blamed

Bad

Apples

Ca

us

es

So

luti

on

s • Prescriber

Education

• Regulation

• Oversight

• System

Reform

• Find Opioid

Alternatives

• Identify

Bad

Apples:

PDMPs

• Punish

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Supply: Diversion

Diversion

Blamed

Bad ApplesLeft-Over

Prescriptions

Ca

us

es

So

luti

on

s • Identify Bad

Apples:

PDMPs

• Punish

• Drug Take-back

Programs

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Supply: Importation

Importation

Mexican

CartelsChinese

Synthetic Drug

Manufacturers

Ca

us

es

So

luti

on

s • Border

Control

• Criminal

Justice

Enforcement

• Regulation of

online drug sales

27

Supply vs. Demand Side Causal Stories

Lack of

Patient EducationLack of Treatment Brain Disease

• Public Awareness

Campaigns

• Fed. Admin.

Agency

Involvement

• Fund Treatment

System (Ambiguous)• Increase Access to

MAT

Cau

ses

So

luti

on

s

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What does this analysis tell us?1. Groups did not spend much time debating the causes superficial

explanations that were accepted as true.

2. Most of the purported causes used to explain the epidemic were SUPPLY

oriented Supply oriented solutions dominated.

• Downplayed criminal justice supply oriented solutions & substituted health

actors for criminal justice actors

3. The public health oriented causal theories and solutions were ambiguous &

piecemeal.

• Little to no discussion about ..

• what might be wrong with the treatment system (aside from too little

MAT)

• the socio-economic, psychological, behavioral, & environmental factors

that cause/correlate with spikes in problem drug use.

“Safety & Disease Approach” or “Assistentialism”

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Why does this matter?

• U.S. drug policy lags behind other developed countries.

• European Council & ALICE RAP: 200+ scientists, 5 years, 29

disciplines

• YSA, et. al. – policy analysis of EU nations

• Trendsetting countries did NOT emphasize supply

reduction.

• Trendsetting countries did…

• Define the problem as multi-factor & resulting from

both societal, behavioral & biological factors

• Emphasize public health harm reduction

• Prevention

• Well-being

• Coordination amongst social welfare agencies:

housing, employment, job skills, access to

healthcare, etc.

• The New Governance of Addiction: Gold Standard,

recommended “well-being approach”

TAMYKO YSA, ET AL., GOVERNANCE OF ADDICTIONS: EUROPEAN PUBLIC POLICIES (2014).