Heroin, diacetylmorphine, has been recognized, for most of the 20th century, as a drug of abuse. There is significant evidence to support such a characterization. Unfortunately, the stigma associated with heroin has prevented it from being viewed as a drug with any legitimate medical use. Unlike its pharmacological analogs, morphine and hydromorphone, heroin's abuse potential has overshadowed, even eliminated, its consideration as a clinical agent.

This unidimensional view of diacetylmorphine is one which has developed slowly over time. It began in the early 1900s when grave concerns about the potential adverse effects of heroin resulted in its virtual exile from the arsenal of agents used in pain management. It was further developed during the drug culture of the 1960s and 1970s when heroin became a symbol for a generation of Americans using illicit substances. The resultant "opiophobia," referred to by Morgan and Pleet, led to not only the underprescribing of "accepted" narcotic analgesics, but also to the further alienation of diacetylmorphine from legitimate medicine.1 It has become difficult, if not impossible, for the public to equate heroin with legitimate drug therapy.

Given this backdrop, the authors undertook a project to examine heroin from a public policy and ethical stance. What impact has the public perception of heroin had on its ability to be viewed as a legitimate medication, worthy of classification as such? Has this public perception also influenced governmental officials, the creators of policy, who may not wish to be considered advocates of heroin? In what ways, if any, have professional organizations within health care acted unethically, or at least unprofessionally, in their policies opposing heroin's legalization? What are the rights of patients, both legally and ethically, to have available medications which are of potential therapeutic use? This paper examines how the public's perception, with regard to heroin, has been influenced by the media. Future papers will address these additional questions.

The views of many Americans are shaped, at least in part, by what they are exposed to via the media. Both electronic and print media play an important role in shaping conclusions that are drawn by the public about a wide range of issues. This study focuses on how the print media has addressed the heroin issue and its potential influence on public perceptions. What has the media portrayed about heroin and heroin use, and have these images influenced society's perceptions? How reflective of individual and societal beliefs and public policy are these media reports?

Background

American society did not arrive at their attitudes towards heroin over night. Concerns about the availability and usage of opiates extends back to at least the Civil War era of 1860-65. So-called "Soldier's Disease," opiate addiction which allegedly afflicted Civil War veterans as a result of freely used analgesics during the war, is an early such reference. Ironically, as Mandel points out, Soldier's Disease is a myth, concocted in the 20th century. No evidence exists that such widespread addiction, as a result of the use of opiates, ever occurred.2 It appears that misinformation about these drugs is not solely a creation of modern times. Mandel goes on to argue that opiate abuse was not the extensive social problem it was suggested to be in the early 1900s, prior to the passage of the Harrison Narcotic Act. Further, that devoid of such a social problem, legal restriction of these agents was an unnecessary exercise. Interestingly, in sharp contrast to our present day context, the mass media virtually ignored the opiate issue.3

As we are all well aware, the role played by the media in the lives of Americans is much more significant than it was 80 or 90 years ago. The development and expansion of electronic media alone has made more information available to a wider audience. More importantly, the influence of the mass media in shaping public opinion is greater than ever before in the past. As Winick argues, the expectations and hopes of patients, the responsiveness of government and the marketing strategies of pharmaceutical manufacturers all may be affected by the content of the media.4 It would be naive to suggest that our views of issues and events are not at least partially the result of the method of presentation and slant to a story provided by the media.

This impact of the mass media on the formation of public opinion may take several forms; overt endorsement, subtle support or documented opposition of an issue may all be tactics used, whether or not done so consciously. One would hope that when the media does adopt such strategies to influence public opinion, they would do so only after careful analysis of the factors involved. Unfortunately, most members of the media are not scientists, and therefore cannot be expected to utilize the scientific method in such analyses. This becomes especially frustrating to those of us trained as biomedical scientists and accustomed to careful evaluation prior to arriving at a conclusion. Cohen, writing about the media's portrayal of benzodiazepines reflects this frustration. He writes, "Trial by media can never take the place of careful scientific evaluation of a psychotropic drug. The two methods are antithetical. Scientific inquiry depends on careful examination of data. The media cannot present information in detail. It titillates, dramatizes and pulls facts out of context. It is unfortunate, but it is so."5

This approach to news reporting also places the media at risk for manipulation. Special interest groups with a particular social agenda, and the ability to frame their viewpoint clearly and concisely, can utilize the media to influence public opinion. DiChiara writes about just such a tactic relative to drug law reform. He argues that the media can be used to present a substance abuser as either an anomaly and a danger to society, or as the victim of an illness in need of treatment.6

Among the many areas in which the media plays a role in shaping societal beliefs is that of drugs and their reputations. The public's perception of penicillin, for example, is quite divergent from that of an opiate like heroin. Why? For one thing, the vast majority of individuals in the United States have taken penicillin at one time or another. The same cannot be said for heroin. With penicillin, its familiarity to the public allows people to rely less on the information provided by others—the government and media, for example to inform them about the drug. As Mal off asserts, "The power of formal controls (with media support) to influence drug reputations is particularly salient in the case of drugs like heroin, known rarely by firsthand (or even secondhand) experience. In the absence of widespread use or transmission of users' unique knowledge to nonusers, cultural images are easily manipulated by society's so-called experts."7

In this paper, heroin is used as a case study of the broader relationship between the mass media and the public. We contend that heroin's negative reputation has, in large part, been created by the media. However to argue that this influence is solely unidirectional assumes that the media can insulate itself from popular opinion. We would assert that the media is both influential and reflective relative to the public at-large. As Maloff writes, "Media coverage may also be taken as an indicator of public sentiment, reflecting as well as shaping heroin's reputation"8
 

Methodology

A total of 405 articles, which mentioned heroin or diacetylmorphine in either the title and/or text, published in The New York Times, Washington Post, Christian Science Monitor, USA Today, Time and Newsweek were found and reviewed. Due to factors including chronological limit of the database, number of articles in each periodical and age of the periodical, the inclusive dates of collection vary. These dates, by periodical, are listed in Table I. The periodicals were chosen for reasons of demographic diversity among readership, national distribution and database availability.

All articles were content analyzed. Article titles, prominence and themes were reviewed in an attempt to determine the way in which heroin, vis-a-vis the popular press, has been portrayed to the American public.

Article title themes and content themes were assigned to categories that were both created prior to analysis as well as created during article analysis. This method combines both well accepted approaches in content analysis to the creation of categories. During article review, content themes which fell into multiple thematic categories were assigned to as many categories as seemed appropriate. Therefore, the total frequency of content themes exceeds that of the total number of articles analyzed. Title themes were assigned to only a single thematic category. If the theme of the article was uncertain, it was assigned to the "unclear" category. Because of this difference in recording frequencies between title and content themes, it was impossible to do a direct correlation between the two. However, the format of Table IV does allow for comparison of frequencies between title and content themes for each thematic category.

A metaphorical analysis was conducted as a component of the content analysis of article titles. This methodological approach has been used by several other investigators, most recently in a study examining the nature of drugs and drug-taking.9 The use of metaphors and symbols pervades newspaper headlines. They provide a description of an issue or event in terms other than those commonly used to describe it. For example, an article title which reads "Heroin Abuse Spreads Like a Plague Across the Nation" makes use of a metaphorical description. The same title without the use of a metaphor might read "Heroin Abuse on the Increase Across the Nation ." The use of the metaphor "plague" provides a certain degree of fear or menace that is associated with an actual plague. Our decision to analyze these article titles in terms of metaphors was based on just such a potential public reaction. Stereotypes or biases about heroin can be based as much on the metaphors employed in article titles as they can on the actual content of the titles.

Results

Although the articles analyzed date back to 1965, the vast majority of articles, 96.3 percent, were published between 1980 and 1991 (see Table II). Consequently, our results are more representative of pub- lic exposure during the past decade, than during the previous 15 years. Additionally, it is important to note that all the pre-1980 articles reviewed were from Time and Newsweek, representing a significantly smaller portion of our sample size as compared to the other periodicals.
 

Article Authorship and Prominence

Nearly three quarters (73 percent) of the articles reviewed were written by a staff reporter. An additional nine articles were editorials. It is our contention that such a result indicates that the periodical considered the story to be significant enough to assign a staff member to cover it as opposed to relying on the wire services. One reason for this decision could certainly be that the story was of local importance, but considering the periodicals chosen for analysis, this is unlikely. Rather, it is more likely that the issues involved were significant to American society at-large.

Additional data listed in Table III do not suggest a similar degree of importance. Only 3.3 percent of articles appeared either fully, or began, on the front page of the periodical. When those articles which appeared on the first page of a newspaper section were included (17 percent), this total still represented only slightly more than one-fifth (20.3 percent) of all articles reviewed. Similarly, more than three quarters (76.6 percent) of articles were of a length of three columns or less. This data indicates just the opposite of the authorship data, that the issues and stories covered were of lesser importance. This perception is further strengthened upon examination of one additional piece of data. We theorized that articles which held greater prominence would be accompanied by pictures, illustrations and graphs to further explain and/or elaborate the issues discussed in the story. If we are correct in our assumption, then the fact that more than two-thirds (68.8 percent) of the articles studied contained no such embellishment would seem to support a lower level of importance.

One explanation for the mixed results may lie in the differentiation between the decision to cover a story and the subsequent reporting. One might argue that an issue thought to be important enough to send a staff reporter to cover it, may have lost some significance when the story is reported and written. Such an argument is difficult to use, however, to explain such an overwhelming disparity. Still another possible explanation is how the story is covered over time. A new story might break on the first page, but subsequent coverage usually occurs further back in another section.

Article Title and Content Themes

The results of the article title and content thematic categorization are listed in Table IV. The predominance of themes, in both the title and content thematic categories, relating to the illicit, as compared to the legitimate use of heroin, represents a significant finding. Less than four percent (1.2 to 3.2 percent) of all articles analyzed had as the theme of their title or content the therapeutic use of heroin either in the treatment of pain or addiction. On the other hand, the theme "Drug Traffickers" was represented in 14.8 percent of the article titles and nearly a third (31.7 percent) of the content of the articles studied. Likewise, the theme "Heroin Possession/Arrests/Raids" was found in more than one quarter (26.9 percent) of title themes, though substantially less (3.9 percent) content themes. When these two categories are combined, they represent 41.7 percent of title themes and 35.6 percent of content themes, by far the greatest plurality of articles.

The question of the decriminalization of heroin and other illicit drugs did receive some discussion in the periodicals studied (2.0 percent title and 5.1 percent content themes), but this was more than offset by the theme "Heroin's Adverse Effects/Deaths/Overdoses" (8.1 percent title and five percent content). This would suggest that although the public has been ex- posed to some degree of discussion relative to the lessening or eliminating of legal penalties related to substance abuse, it is quickly reminded of the morbidity and mortality these substances cause. At the same time, however, a relatively small number of articles (0.2 percent title and 4.1 percent content) focused on the abuse liability of heroin.

One of the categories created during content analysis, "Heroin Abuse by Widely Known Individuals," showed interesting results. Although only 1.8 percent of the articles were assigned this theme based on their content, a relatively significant number, 5.2 percent, contained this theme in their title. Given the fact that individuals often read only the headlines of newspapers and are more likely to remember an article if a famous name is mentioned, the negative stereotype toward heroin as a result of these titles bears note.

Metaphors and Symbols for Heroin in Article Titles

"Heroin: Preparing for a New Invasion," "Busting the Heroin Pipeline,""Europe: The Heroin Plague," "Riding a Mare" and "Washington Struggles to Stem Heroin Tide" represent only a small sample of the article titles analyzed which make use of metaphors and symbols. The results of our metaphorical analysis, summarized in Table V, demonstrate a definite negative connotation relative to heroin. This negative stereotype, as expressed through the metaphors, follows several distinct, undesirable approaches. The first of these, is to associate heroin with things that are bad or evil and to equate it with the devil. The second, provides a medical twist by thinking ofheroin symbolically as a disease or plague which ultimately leads to death. A third approach utilizes a war analogy in that it equates fighting heroin abuse to waging a military battle with heroin as the enemy. The fourth visualizes heroin abuse as an ocean wave or tide which cannot be controlled or as a pipeline or other machinery funneling the drug into the country. The final, and in our view most disturbing metaphorical approach, is the use of the racial element. Blaming certain groups for substance abuse or drug trafficking in America plays on and unfortunately reinforces certain biases already existent among the public.
 

Discussion and Conclusions

The results of our study indicate that, in general, heroin has been portrayed by the print media in a very negative manner. In these portraits, this substance has been associated with crime, disease, illicit use and death. There exists a paucity of articles which discuss potential medical benefits relating to the use of heroin as an analgesic. It is therefore reasonable to suggest that the negative reputation of heroin held by society has been reinforced, and quite possibly generated, by mass media.

If in fact our conclusions are valid, what impact has this representation had on the genesis of public policy and a potential therapeutic role for heroin? As mentioned earlier, this paper represents only the first phase of a more complex study examining the issue of policy, ethics and the therapeutic use heroin. Future papers will examine how the actions of the federal government may be influenced not only by their personal perceptions of heroin, but also by public opinion. A bill to make heroin available for therapeutic use in certain circumstances has been introduced in Congress each session since 1984 (accounting for most all ofthe articles analyzed that had title or content themes addressing the medicinal use of heroin). Unfortunately, despite the sponsorship of an influential legislator in each House, the bill has not met with success. Has heroin's portrayal in the mass media been contributory?

Both Great Britain and Canada have approved heroin's availability for therapeutic use. We will take a close look at heroin policy and use in these countries and, through in-depth interviews and policy analysis, establish a frame of reference for heroin's history in the United States. Great Britain and Canada differ in both the restrictiveness of their policy toward heroin as well as in the attitudes of health professionals towards its use as an analgesic. They should provide us with a useful contrast.

The final portion of this multi-phase study will examine the moral and ethical obligations of medical professionals, specifically pharmacists, and their professional organizations to patients. There is strong evidence to suggest that these organizations may not have fulfilled their hippocratic responsibilities by opposing medicinal heroin. This evidence can be seen in both Congressional testimony and policy statements in which such groups undertook steps to block the availability of heroin for therapeutic use.

For its part, we hope that this phase of our larger study will assist in understanding how the negative stereotyping of heroin by the public has been influenced by its portrayal in the popular press. And, how that portrayal has prevented its evaluation as a legitimate therapeutic agent by health professionals on a clinical and scientific basis, rather than by society on moral, cultural or political grounds.

Michael Montagne, Ph.D., is an associate professor of social pharmacy at Northeastern University.

360 Huntington Ave., Boston, Mass. 02115.

Robert L. McCarthy, M.S., is an assistant professor and the assistant chair of Pharmacy Health Care Systems at Massachusetts College of Pharmacy and Allied Health Sciences.

179 Longwood Ave., Boston, Mass. 02115.

Endnotes
1 'Morgan, J.P. and D.L. Pleet. "Opiophobia in the United States: The Undertreatment of Severe Pain," J.P. Morgan and D.V. Kagan (eds.) Society and Medication. Lexington, MA: Lexington Books, 1983, pp. 313-325.

2 Mandel, J. "The Mythical Roots ofU.S. Drug Policy: Soldier's Disease and Addiction in the Civil War," A.S. Trebach and K.B. Zeese (eds.), 1989-90, A Reformer's Catalogue, Washington, DC: Drug Policy Foundation, 1990, pp. 110-133.

3 Mandel, J. "The Mythical Roots ofU.S. Nag Policy: Soldier's Disease and Addiction in the Civil War," A.S. Trebach and K.B. Zeese (eds.), 1989-90, A Reformer's Catalogue, Washington, DC: Drug Policy Foundation, 1990, pp. 110-133.

4 Winick, C. Reporting Drug Truth in the Media. In: Morgan, JP and Kagan, DV (eds.) Society and Medication. Lexington MA: Lexington Books, 1983, pp. 221-231.

5 Cohen, S. "Current Attitudes About the Benzodiazepines: Trial by Media."Journa/ ofPsychoactiveDrugs, 1983;15:109- 113.

6 DiChiara, "A. Changing Media Presentations of the Drug User: the Social Deconstruction of Moral Devils." A.S. Trebach and K.B. Zeese (eds.) The Great Issues of Drug Policy, Washington, DC: Drug Policy Foundation, 1990, pp. 303-310.

7 Maloff, D. "Controlling Drug Reputations: The Case of Heroin." Journal of Psychoactive Drugs.1984;16:129-140.

8 Maloff, D. "Controlling Drug Reputations: The Case of Heroin." Journal of Psychoactive Drugs.1984;16:129-140.

9 Montagne, M. "The Metaphorical Nature of Drugs and Drug Taking." Soc Sci Med.1988;26:417-424.