Project Douglas Fir

Mediated Narratives of Lumpen Abuse & Addiction

A Proposal for Technological Interventions at the Intersection of Poverty, Media Technologies & the Opioid Epidemic in San Francisco

December 3, 2022

 Introduction

Media Technologies, Structural Inequities & the Response to the Opioid Epidemic

The opioid epidemic in the United States is a public health emergency that has been influenced by media practices that shape and reinforce stigmatized attitudes, policy-making, and law enforcement. In 2020, there were an estimated 9.5 million people aged 12 or older who had misused opioids in the past year (Richesson and Hoenig 2021). Furthermore, the age adjusted mortality rate due to drug overdose more than quadrupled from 1999 to 2020 and is now the leading cause of injury-related deaths in the United States [In 2020, there were an estimated 92,000 drug overdose deaths in the United States, 75% of which involved opioids (Centers for Disease Control and Prevention 2021; Hedegaard et al. 2020).].

The roots of the crisis is complex and multifaceted—beyond the need to research addiction as a biological disease, many experts agree that the response to the crisis must address the upstream structural inequities that plague people who suffer from opioid use disorders (OUDs) and also consider risk reduction approaches that prevent premature mortalities.[e.g. Saloner et al. 2018; Hernandez et al. 2018; Sadang et al. 2021; Bourgois and Schonberg 2009] Furthermore, contemporary media practices that surround the opioid crisis in the United States have helped to shape multiple dimensions of stigma [A 2019 paper provided a typological framework to understand various types of stigma including public stigma, anticipated stigma, internalized stigma, enacted stigma, courtesy stigma, and structural stigma (Tsai et al.).] that influence everyday attitudes and policy-making (Tsai et al. 2019). To that end, this paper serves as both a review of the current academic literature as well as a proposal for a technological intervention that addresses the multitude of factors that drive the opioid epidemic, including poverty, homelessness, and digital inequities. By reviewing the current literature [The recent academic literature reviewed in this paper was collected based on the intersecting topics of poverty, addiction, and entanglements of media and technology.] and employing a theory of lumpen abuse by Philippe Bourgois and Jeff Schonberg (2009) and a framework for understanding stigma (Tsai et al. 2019; Garett and Young 2022), we can better understand how structural issues intersect with opioid use disorders, which in turn will inform our proposal for the response to the crisis.

For this current paper, the primary research questions that drove this proposal were: what is the nature of the relationship between media practices,[Including traditional mass media (e.g. print and television news media and forms of entertainment such as film and television) and newer more participatory forms (e.g. YouTube, TikTok, Instagram).] notions of stigma, and the people suffering from poverty, homelessness, and OUDs (i.e. the lumpen population) in San Francisco? How are they represented in media? How do such representations affect the public perceptions of the crisis and the response to the overdose death issue? And most importantly, how can new technologies be developed to help resolve the opioid crisis in San Francisco? As we will see, media practices play a major role in shaping and reinforcing stigmatized everyday attitudes and policymaking towards people suffering from structural violence and OUDs. To that end, this paper serves as a call to action for a technology-driven intervention that holistically addresses the issues of stigmatized perceptions and gaps in the public health knowledge while also providing a centralized resource of social support services, social support communities, and evidence-based treatment for the marginalized lumpen population.[The proposed technological intervention explicitly acknowledges and addresses the growing digital divide that further marginalizes people and families living in poverty.]

Background

The Context of Homelessness, Mediated Stigma & the Opioid Crisis in San Francisco

San Francisco has an unusually high number of unsheltered homeless people for a large American city. As of February 23, 2022, there were an estimated 7,800 homeless people in San Francisco, 4,400 of whom were unsheltered (Rezal and Caughey 2022).[This accounts for about 0.54% of the San Francisco population.] In 2020, of the 711 drug overdose-related deaths in San Francisco, 331 of the deaths were among people experiencing homelessness (Thadani 2021; Cawley et al. 2022). During the first year of the COVID-19 pandemic (March 17, 2019 to March 16, 2020), the premature mortality rate was more than double of any previous year, with drug-related overdose being the overwhelming cause of death (82%). It’s also important to highlight that a disproportionate number of such deaths were Black (27%).[As compared to the San Francisco’s Black population of 5.6% (Cawley et al. 2022, 4-5).] Maria Raven, MD, MPH, the Chief of Emergency Medicine at UCSF and a Vice Chair in the UCSF Department of Emergency Medicine has said,

“Mitigating death among people experiencing homelessness will require a multi-faceted approach and a willingness to invest significant resources.”(Kutzman 2022).

Accordingly, much of the current research underscores the complex relationship between poverty, homelessness, and drug-related overdose deaths, and many scholars have called for interventions that address multiple determinants including upstream structural issues[Structural forces are a reflection of the social, political, and economic conditions that perpetuate the suffering of marginalized groups due to historically reproduced power dynamics (Saloner et al. 2018, 27).] (e.g. employment opportunities, education, violence, discrimination, homelessness), the inadequate management of chronic pain, and poor access to addiction treatment and harm reduction services [Evidence-based risk reduction approaches include clean needle exchanges, safe injection sites, naloxone distribution, and buprenorphine treatment, and heroin prescription.] (Saloner et al. 2018; Bourgois and Schonberg 2009). Furthermore, as we will see, the inequities from the lack of access to information and communication technologies (ICTs) has further marginalized those living in poverty and at risk of becoming homeless [Also including the homeless drug-injecting population on a path to successful recovery.]—which may also be a contributing factor to the growing opioid epidemic [According to a survey conducted by the city and county of San Francisco, 30% of households with under $25K income did not have internet access and 21% did not have access to smartphones (City and County of San Francisco 2019).] (Joanne and Stevenson 2014).

Alongside the growing population of people suffering from poverty and OUDs, many studies have shown the role stigma plays in shaping everyday attitudes, policy-making, and law enforcement (e.g. Garett and Young 2022; Kennedy-Hendricks et al. 2017; Saloner et al. 2018; Tsai et al. 2019), and how media practices propagate and reinforce those stigmatized perspectives.[Webster, Rice, and Sud 2020; Federman 2018; Scholten and Henningfield 2016; McGinty et al. 2019a, 2019b; Netherland and Hansen 2016.] What is clear from the research is that stigmatized attitudes towards people with OUDs is correlated with low public support for opioid treatment resources (i.e. evidence-based treatment, risk reduction approaches) and a preference for punitive policies—which many experts claim is a result of the “war on drugs” and “war on crime” policies (Saloner et al. 2018, 29). To address such issues, many experts have called for efforts to de-stigmatize representations of people with OUDs by communicating stories of people suffering from OUDs and emphasizing the effectiveness of evidence-based treatment as a pathway to successful recovery.

Literature Review

Poverty, Homelessness & Macroeconomic Forces

In the review of the current academic literature, many scholars have explored the intersection of poverty, homelessness, and the opioid epidemic. In the visual ethnography Righteous Dopefiend (2009), Philippe Bourgois and Jeff Schonberg throughly investigates the lived experience of an unsheltered heroin injecting community living in the San Francisco Bay Area (what they refer to as the lumpen population). Through a critical analysis of the broad social, economic, and political structural forces that marginalize the lumpen community, the authors develop a theory of lumpen abuse, which contextualizes the individual experience of suffering [A spectrum of violence that spans the structural, symbolic, everyday, and intimate (Bourgois and Schonberg 2009).] among the socially vulnerable within the context of structural dynamics (e.g. political, economic, institutional, cultural) and physically-manifested suffering (17).

Similarly, other studies have investigated the prevalence of trauma, substance abuse, and mental illness amongst transitional age youths (ages of 18-24) experiencing homelessness in San Francisco (Dawson‐Rose 2020). Along the same lines, a 2021 study looked into a large group of woman who injected drugs and were experiencing homelessness in San Francisco and found that they were more vulnerable to physical and sexual violence, and other diseases such as HIV and HCV (Sadang et al. 2021). When it comes to approaches to housing the homeless, many scholars have explored the effectiveness of housing first policies, which views housing as a basic right and a critical component needed for people suffering from OUDs to successfully complete recovery treatment.[e.g. Kertesz et al. 2009; Aubry, Nelson, and Tsemberis 2015; Tsemberis, Gulcur, and Nakae 2004] As for the root causes of homelessness, researchers have investigated macroeconomic forces such as the de-industrialization of industry dependent cities as being a major driving factor in the rise of opioid addiction and deaths due to overdose (McLean 2016; Hollingsworth, Ruhm, and Simon 2017).

Public Health Strategies

Public health researchers have critically examined the opioid epidemic from a multitude of perspectives and have provided a framework to resolve the crisis (Saloner et al. 2018). The authors of the study have recommended improving public health and clinical practice by enhancing data collection to improve resource allocation and including steps to increase safer prescribing of legal opioids, stigma-reduction campaigns, increased resources for harm reduction and treatment services, criminal justice policy reform, and regulatory changes to controlled substances. Similarly, other scholars have examined how Massachusetts, Vermont, and New York are responding to the opioid crisis and have recommended expanding provider capacity, launching public awareness campaigns, and improving the prescribing of legal opioids (Hernandez et al. 2018).

Role of Stigma & Misinformation

On the topic of stigma and misinformation, many studies have examined the role stigma plays in shaping the response to the opioid crisis. A 2019 study outlined a typology of stigma and provided a framework to implement evidence-based primary, secondary, and tertiary preventative interventions [Minimize opioid use to opioid-naive patients (primary intervention). Among opioid exposed patients, non-medical use of prescription opioids and incidence of OUDs should be minimized (secondary prevention). Expanded evidence-based treatment for OUDs for people suffering from OUDs (tertiary prevention).] (Tsai et al.). Similarly in 2022, Garett and Young examined how stigma and misinformation about opioids negatively affects treatment compliance among people with OUDs and discusses the role social media, education, and the community can play in mitigating misinformation and misconceptions about opioids and treatment options. Along the same lines, a 2017 study analyzed a nationally representative online survey and found that respondents expressed high levels of stigma towards people with OUDs and also concluded that reframing the crisis to emphasize structural factors that contribute to prescription opioid use disorder and reduce barriers to evidence-based treatment may help improve public support for policies that affect people with OUDs (Kennedy-Hendricks et al. 2017). Additionally, a 2020 paper examined how compassion fatigue and burnout from West Virginian emergency responders created a hostile environment for people with OUDs and negatively affected their willingness to access treatment services (Ondocsin et al. 2020). The authors of the study claim that greater resourcing of overdose prevention education and naloxone peer distribution would address opioid-related overdoses and alleviate the burden on emergency services.

Mass Media Reporting & Effect on Public Health Policies

There is a wealth of research on the role mass media plays in perpetuating stigmatized everyday attitudes, and how that in turn affects public health policies that target the opioid crisis. Many scholars have agreed that the U.S. news media coverage of the opioid crisis tends to use specific language to describe people with OUDs such as “addict” and “substance user” which perpetuates stigma and reinforces the barrier to implementation of evidence-based interventions.[e.g. Webster, Rice, and Sud 2020; Federman 2018; Scholten and Henningfield 2016; McGinty et al. 2019a, 2019b; Netherland and Hansen 2016] Additionally, scholars have concluded that U.S. new media coverage of the opioid crisis tended to focused on criminal justice-oriented solutions to the opioid crisis and minimized evidence-based risk reduction solutions such as syringe exchange programs and safe injection sites (McGinty et al. 2019; Webster, Rice, and Sud 2020).

Participatory & Social Media

Beyond mass media representations of the opioid epidemic, newer more participatory forms of media such as social media and video-sharing platforms have also played a role in the epidemic. There are numerous studies that have investigated the many facets of participatory media practices in the opioid epidemic including: a review of YouTube videos involving Naloxone created by health care professionals, consumers, and TV or Internet-based media channels (Kernan et al. 2020); an analysis of alternative treatments for opioid use recovery on Reddit—an online discussion community (Chancellor et al. 2019); media-based campaign to educate young adults around opioid misuse (Rath et al. 2022); the effects of online community participation on substance use recovery (Naserianhanzaei and Koschate-Reis 2022); a frame analysis and thematic content analysis of YouTube videos involving the lived experience of families affected by the opioid crisis (Johnson, Worth, and Brookover 2019); a study of an online community as an effective behavioral intervention tool for chronic pain patients on opioid therapy (Young et al. 2018); a study of the representations of addiction and stigma in feature films (Cape 2003); a study of the use of peer-to-peer social media as an effective prevention strategy for drug use (Evans et al. 2020); and a study investigating social media as an emerging tool for reducing prescription opioid misuse (Young et al. 2020).

Storytelling & Narratives

Scholars have also looked into the ways storytelling and narrative ties into the response to the opioid crisis. As an example, researchers in 2021 claimed the importance of patient narratives in communicating the lived experience of people with OUDs and underscored the complexity of opioid abuse and addiction (Damiescu et al.). Other studies on similar topics included: a 2021 study on how television shows and documentaries disseminates narratives of “white disability nationalism” (Knadler); an ethnographic study of storytelling in a central Appalachian community-based theater and what sociopolitical impact that can have on a community of people suffering from OUDs (Barron 2021); a study on how narrative-based communication was effective for promoting health behavior change as opposed to using facts and figures (Henry et al. 2021); and a study published in 2022 explored the relative effectiveness of celebrity (versus non-celebrity) narratives on opioid addiction prevention (Vafeiadis et al. 2022).

Role of Technology & Technology-Aided Solutions

Many studies have examined the ways technologies factor into the opioid crisis in the United States and in Western Europe. As an example, in one study (2014) out of the U.K., researchers explored how the physical, human, cultural, and social capital of homeless drug users (HDUs) influenced their access to information and communication technologies (ICTs) which they conclude is a vital prerequisite for meaningful participation in society—and in particular an important resource for recovery (Neale and Stevenson 2014). Other studies have explored how digital technology can help aid in the response to the crisis, including a 2020 study in which researchers conducted an experiment that used immersive media technologies (i.e. virtual reality) to deliver opioid overdose reversal training and found that it was just as effective as in person training (Herbert et al.); a study out of Texas concluded that most mobile apps available were clinician facing and there was a general gap in technological solutions for OUD management (Nuamah, Mehta, and Sasangohar 2020); a study developed a educational training materials for opioid use management and distributed it over the internet (Kameg and Mitchell 2020); and a 2022 study out of Tennessee concluded that wearable sensor technologies were a viable method to detect and monitor the self-administration of opioids after dental surgery (Garcia et al.).

Evidence-Based Treatment and Risk Reduction Approaches

There are numerous studies that have explored the effectiveness of treatment programs for OUDs and risk reduction approaches to the opioid-related overdose crisis. In a handful of studies, researchers have concluded that wide distribution of naloxone [The studies examined naloxone access in New York City, Connecticut, Kentucky, and Wisconsin.] will help address the rising drug-related overdose deaths.[e.g. Spector et al. 2022; Allen et al. 2020; Parkin et al. 2020; Kirane et al. 2016] As for other risk reduction approaches, scholars have concluded that by providing on-site healthcare personnel and clean needle supplies, safe-injection sites are an effective way of reducing opioid-related overdose deaths and other drug-related health issues.[e.g. Kennedy, Clare, and Kerr 2017; Gaddis et al. 2017; Karamouzian et al. 2018] Further, some scholars have concluded that co-locating detoxification services will help deliver critical treatment services to people suffering from OUDs (Gaddis et al. 2017).

Addiction, Theory of Lumpen Abuse & Spectrum of Violence

Linking Upstream Structural Issues to the Opioid Epidemic

Many public health researchers and government officials agree that the response to the opioid epidemic and overdose crisis must consider multiple determinants including improving access to addiction and risk reduction approaches and addressing structural factors (Saloner et al. 2018; Bourgois and Schonberg 2009). Based on their decade-long ethnographic research into a homeless drug-injecting population living in San Francisco, Philippe Bourgois and Jeff Schonberg (2009) developed a theory of lumpen abuse which situates the physically manifested suffering caused by substance abuse disorders in the context of larger social, cultural, political, and economic forces—including de-industrialization, discrimination, public health policies, and punitive approaches [Also known as the war on drugs and the war on crime (Hinton 2016, 276-332). ] to addressing the opioid crisis (13-16). Additionally, the theory of lumpen abuse incorporates various notions of violence (structural, symbolic, everyday, and intimate) and helps to illustrate the idea that addiction and the suffering caused by OUDs are a result of historically reproduced structures of inequality and not necessarily a result of individual character or action (Farmer 2003).

While structural violence helps link upstream structural issues (e.g. poverty, housing, discrimination) to opioid use disorders, Pierre Bourdieu’s concept of symbolic violence [Symbolic violence is the concept wherein power differentials (based on socially constructed characteristics such as nationality, gender, sexual orientation, or ethnic identity) are are embodied in the individual and are reproduced through practice (Bourdieu 1977).] helps explain why many people consider drug use and poverty to be an outcome of personal choices [In Bourgois and Schoenberg’s understanding, everyday, intimate, and structural violence produce and are legitimized by symbolic violence (17-20).] (Bourdieu 1977). Nonetheless, the crisis response needs to go beyond treatment programs and risk reduction approaches and needs to address the upstream structural issues that disproportionally affect the marginalized communities.[The overdose death crisis in San Francisco disproportionally affects males, and the Black and Latino communities (Cawley et al. 2022, 4-5).] However, while scholars widely agree [e.g. Saloner et al. 2018; Bourgois and Schonberg 2009; McLean 2016; Dawson-Rose et al. 2019] that multiple structural determinants must be addressed, the discussions within the current literature largely fails to recognize the significance of digital or technological inclusion. In one study out of the U.K., the researchers concluded that information and communications technologies (ICTs) such as smartphones and broadband internet access [The researchers have found that in addition to broader access to ICT devices, broadband connectivity, education, training, and technical support are also necessary.] was crucial to the successfully completing drug treatment programs (Neale and Stevenson 2014). To that end, the link between digital inequities, homelessness, and the opioid epidemic is poorly understood and must be further researched.[The city and county of San Francisco has explicitly recognized that the technological gaps must be closed through a program known as San Francisco’s Digital Equity Strategic Plan, which includes the goals to improve access to broadband internet and support digital literacy (City and County of San Francisco 2019).]

Mediated Narratives, Stigma & Its Effect on the Crisis Response

Everyday Violence & Stigmatizing Representations in Media

As we have seen, there is a robust corpus of research that has linked stigmatized attitudes to traditional and participatory media practices.[e.g. Webster, Rice, and Sud 2019; Federman 2018; Scholten and Henningfield 2016; McGinty et al. 2019a, 2019b; Tsai et al. 2019; Garett and Young 2022] Studies of mass media practices (e.g. print and broadcast television) in the United States have shown that the news media coverage of the opioid crisis tends to frame the issue as a criminal problem and heavily focuses on criminal-justice oriented solutions rather than evidence-based treatment and risk reduction approaches. Scholars have theorized that this is a result of the policies known as “the war on drugs” and the subsequent “the war on crime” which have disproportionately affected Black Americans (Hinton 2016, 276-332; Bourgois and Schonberg 2009). Beyond the analysis of news media, some scholars have concluded that the depiction of addiction and substance use in popular movies also perpetuate the stigma around substance use and drug use disorders (Cape 2003). To that end, the theory of lumpen abuse and the concepts of structural, symbolic and everyday violence [Everyday violence refers to the socially constructed indifference to the structural violence and suffering of marginalized people (Scheper-Hughes and Bourgois 2004).] helps explain how the practices of media production assist in perpetuating indifference towards the suffering of others and reinforce, reproduce, and expand existing structures of power.

Furthermore, beyond traditional news and entertainment media, even within the more participatory forms of media (i.e. video sharing platforms such as YouTube and TikTok), the suffering of homeless people in San Francisco with OUDs are often times depicted negatively and with stigma. As an example, many travel-related channels on YouTube such as “Yellow Productions” [As of December 2022, Yellow Productions has 278 thousand subscribers on YouTube with over 59 million total views (Yellow Productions n.d.).] and “Peter Santenello” [As of December 2022, Peter Santenello has 1.36 million subscribers on YouTube with over 173 million total views (Santenello n.d.).] has created videos about the state of the homeless and drug problems in San Francisco and whether or not it’s safe for tourists to visit the city (e.g. Yellow Productions 2022; Santenello 2022). In one video produced in 2022 titled “How DANGEROUS is SAN FRANCISCO for Visitors?”, Yellow Productions lists off the problems due to the homeless drug-injecting population (e.g. crime such shoplifting and car break-ins and human excrement on the sidewalks) and warns prospective travelers to stay within the borders of “safer” neighborhoods. Such examples show how acts of everyday violence can be normalized through media production practices and reinforce the stigma that shapes the public perceptions and attitudes surrounding the opioid epidemic. Additionally, the various forms of capital [Sociologist Pierre Bourdieu saw societal power manifested as four types of capital: economic, social, cultural, and symbolic; with each type of capital being viewed as a resource that could be accumulated and exchanged (Bourdieu 1986; Richardson 1986).] needed to produce such content is another example of the digital inequities that ultimately deprive the lumpen population of their agency and their ability to socially represent themselves.

Framework for Understanding Stigma & De-Stigmatizing Strategies

While the theory of lumpen abuse can situate the current opioid epidemic within the context of larger structural forces, the general public still frames addiction as a criminal justice issue rather than a public health emergency (Hernandez et al. 2018). The stigma [“Stigma is defined as a process wherein people with a particular social identity are labeled, stereotyped, and devalued, unfolding within the context of unequal and often pre-existing power relations, leading to discriminatory behavior against people with the stigmatized identity (Tsai et al. 2019, 2).”] that is reproduced and reinforced through various media practices act as a fundamental barrier to the successful outcomes of the opioid crisis response (Tsai et al. 2019). To that end, a 2019 paper by Tsai et al. has outlined a framework to understand the typology of stigma [Public stigma is based on negative stereotypes about people with OUDs. Anticipated stigma (similar to symbolic capital) when the negative stereotypes are embodied by people with stigmatized identities. Similarly, internalized stigma is when the stigmatized person has accepted those identities as valid. Enacted stigma occurs when public stigma is set into practice. Courtesy stigma occurs when family members and friends experience other forms of stigma as a result of their relationship with people with OUDs. Structural stigma is the ways in which societies impose restrictions on people with stigmatized identities through institutions, norms, policies, and resources (Tsai et al. 2019, 3).] and provides suggestions on how to address such barriers—including recommendations for direct and indirect interventions.[Direct interventions include reducing public and enacted stigma through persuasive communication or education interventions (e.g. mass media campaigns, law enforcement training, schools). Indirect interventions target institutions such as providing guidance for mass media organizations.] While useful, such recommendations lack concrete details and are primarily focused on improving the understanding of evidence-based treatment and risk reduction approaches and not necessarily targeting upstream structural issues that target the most vulnerable sectors of society.

To that end, many studies have shown that personal narratives are an effective way of improving the general understanding of the opioid epidemic (e.g. Damiescu et al. 2021), promoting evidence-based treatment (e.g. Henry et al. 2021), and creating a post-treatment support community (e.g. Barron 2021). Furthermore, while we have seen that social media practices often depict the lumpen community in a negative light, other non-profit organizations such as Invisible People [As of December 2022, Invisible People has 1.06 million subscribers on YouTube with over 264 million total views (Invisible People n.d.).] are leveraging video sharing platforms and social media to give voice to the community of homeless people in the United States (Invisible People 2019). In one example, the organization interviews a homeless man named Keith in Los Angeles talks candidly about his experiences of losing his job during the housing crash of 2008, becoming addicted to painkillers, and switch to heroin because it was cheaper (Invisible People 2011). Keith continues on to describe the phenomena of opioid withdraw (i.e. dopesickness), and the sheer amount of pain and suffering that induces. He says,

"I ended up losing my job in the housing industry when the market went down and I was addicted to painkillers. And when the painkillers got too expensive I switched to heroin, and everything went downhill from there. I lost the apartment, the girl, the dog and ended out in the street. I basically gave everything up for heroin. So if anyone asks what it's like to shoot heroine, it's probably the only thing that will get a man to give up everything. (Invisible People 2011).”

Such videos (with 9.26 million views and 229 thousand “likes”) shows that participatory media platforms can have broad reach of audiences, and based on the aforementioned research it shows how personal narratives can be an effective method to garner compassion and support from the public on the opioid crisis.

Proposal for Technological Interventions

Equitable Technological Access, Localized Narratives of Lumpen Abuse & Community Support

To help address the aforementioned issues of upstream structural factors (e.g. poverty, homelessness, and the digital divide) and stigma towards people with OUDs in San Francisco, this paper calls for a technological intervention that has two main components. First, the county and city of San Francisco should expand their strategic plan for digital equity by including wider access to smartphone devices and mobile broadband. Beyond simply expanding access to the digital devices, as noted by other researchers, technical support, education, and training is also of vital importance (Neale and Stevenson 2014). Second, great efforts can to be made to de-stigmatize perceptions of people suffering from OUDs through the creation of a website/app that hosts a repository of video-based narratives and life histories of people and families living in local neighborhoods suffering from OUDs and structural violence (e.g. including poverty, racism, sexism). In addition, concerted efforts need to be made by local stakeholders to educate the public on the efficacy of evidence-based treatment and risk reduction approaches (i.e. primary, secondary, and tertiary intervention) (Tsai et al. 2019). Ultimately, the goal is that the narratives presented on the website/app will help foster compassion and empathy from local community members by humanizing (and de-stigmatizing) the people who suffer from the effects of OUDs, and help link the various upstream structural issues (e.g. poverty, homelessness, digital inequities) to the epidemic. Beyond simply garnering public sympathy, the website/app should be developed with clear call-to-actions (CTAs) as to remove any barriers that may currently exist and allow empathetic community members to take concrete action and contribute to the crisis response—either through volunteering opportunities, donations to local community group,[Studies have found that projects such as kiva.org are an effective means of leveraging the public will towards philanthropic efforts (Schwittay 2019).] or contact information for local policymakers.

Discussion & Conclusion

Intersection of Lumpen Abuse, Addiction & Media Practices

The current opioid epidemic and the overdose crisis in the United States is a public health emergency. In cities such as San Francisco, the premature death due to overdose disproportionally affects marginalized groups of people who are living in poverty, are homeless and are identified as Black or hispanic. Furthermore, stigma within the general population plays a critical role in the response to the crisis, and as we have seen, stigmatized attitudes that perpetuate the spectrum of violence is mutually reinforced through practices of media production and consumption. To that end, while numerous scholars have outlined for strategies to de-stigmatize opioid use disorders, more research is needed to understand how stigma directly affects perceptions towards upstream structural factors—such as poverty, homelessness, and digital inequities—and how personal narrative-based content can foster compassion and social action from the general public and policy-makers.

To that end, this paper serves as a proposal for a technology intervention that addresses two major issues—the widening technological gap among people living in poverty and within minority racial and ethnic groups; and a holistic plan to address stigma that persists among the general public about people living under various forms of structural violence and suffering from opioid use disorders and help bolster compassion and social justice action from the public. In sum, this proposal is meant to elicit discussions around the relationship between current technologies and the opioid epidemic in the United States, and the question of how can future technologies can be developed to address the drug overdose issue and the upstream structural issues. Ultimately, we need more research on what that means exactly and how we can allocate resources to make that happen.

References

Allen, Bennett, Laura Sisson, Jennifer Dolatshahi, Jaclyn Blachman-Forshay, Ariel Hurley, and Denise Paone. 2020. “Delivering Opioid Overdose Prevention in Bars and Nightclubs: A Public Awareness Pilot in New York City.” Journal of Public Health Management and Practice 26 (3): 232–35. https://doi.org/10.1097/PHH.0000000000001014.

Aubry, Tim, Geoffrey Nelson, and Sam Tsemberis. 2015. “Housing First for People with Severe Mental Illness Who Are Homeless: A Review of the Research and Findings from the at Home—Chez Soi Demonstration Project.” Canadian Journal of Psychiatry 60 (11): 467–74. https://doi.org/10.1177/070674371506001102.

Barron, Ben Nevis. 2021. “Re-Creating the Homeplace: More-Than-Human Constellations and the Political Consequences of Storytelling in Central Appalachian Community-Based Theatre.” Social & Cultural Geography ahead-of-print (ahead-of-print): 1–19. https://doi.org/10.1080/14649365.2021.1983859.

Bourdieu, Pierre. Distinction : A Social Critique of the Judgement of Taste. London: Routledge & Kegan Paul, 1986.

———. 1977. Outline of a Theory of Practice. Translated by Richard Nice. Cambridge: Cambridge University Press.

Bourgois, Philippe I., and Jeff Schonberg. 2009. Righteous Dopefiend. Berkeley: University of California Press.

Cape, G. S. 2003. “Addiction, Stigma and Movies.” Acta Psychiatrica Scandinavica 107 (3): 163–69. https://doi.org/10.1034/j.1600-0447.2003.00075.x.

Cawley, Caroline, Hemal K Kanzaria, Barry Zevin, Kelly M Doran, Margot Kushel, and Maria C Raven. 2022. “Mortality Among People Experiencing Homelessness in San Francisco During the COVID-19 Pandemic.” JAMA Network Open 5 (3): e221870–e221870. https://doi.org/10.1001/jamanetworkopen.2022.1870.

Centers for Disease Control and Prevention. 2021. “Drug Overdose Deaths | Drug Overdose | CDC Injury Center.” Www.cdc.gov. September 9, 2021. https://www.cdc.gov/drugoverdose/deaths/

Chancellor, Stevie, George Nitzburg, Andrea Hu, Francisco Zampieri, and Munmun De Choudhury. 2019. “Discovering Alternative Treatments for Opioid Use Recovery Using Social Media.” In CHI 2019: PROCEEDINGS OF THE 2019 CHI CONFERENCE ON HUMAN FACTORS IN COMPUTING SYSTEMS, 1–15. NEW YORK: ACM. https://doi.org/10.1145/3290605.3300354.

City and County of San Francisco. 2019. “Digital Equity Strategic Plan 2019-2024.” https://sf.gov/sites/default/files/2022-10/SF_Digital_Equity_Strategic_Plan_2019.pdf.

Damiescu, Roxana, Mita Banerjee, David Y. W. Lee, Norbert W. Paul, and Thomas Efferth. 2021. “Health(care) in the Crisis: Reflections in Science and Society on Opioid Addiction.” International Journal of Environmental Research and Public Health 18 (1): 341. https://doi.org/10.3390/ijerph18010341.

Dawson‐Rose, Carol, Deena Shehadeh, Jennifer Hao, Jasmine Barnard, Ladan Khoddam‐Khorasani, Adam Leonard, Kristen Clark, et al. 2020. “Trauma, Substance Use, and Mental Health Symptoms in Transitional Age Youth Experiencing Homelessness.” Public Health Nursing (Boston, Mass.) 37 (3): 363–70. https://doi.org/10.1111/phn.12727.

Evans, William, Elizabeth Andrade, Michaela Pratt, Alexandra Mottern, Sergio Chavez, Anthony Calzetta-Raymond, and Jiayan Gu. 2020. “Peer-to-Peer Social Media as an Effective Prevention Strategy: Quasi-Experimental Evaluation.” JMIR mHealth and uHealth 8 (5): e16207–e16207. https://doi.org/10.2196/16207.

Farmer, Paul. 2003. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.

Federman, Peter Stanley. 2018. “In the Midst of an Epidemic: How Print Media Shapes Policy Feedback to the Opioid Crisis.” Journal of Public Management & Social Policy 25 (3): 40–55.

Gaddis, Andrew, Mary Clare Kennedy, Ekaterina Nosova, M.-J. Milloy, Kanna Hayashi, Evan Wood, and Thomas Kerr. 2017. “Use of on-Site Detoxification Services Co-Located with a Supervised Injection Facility.” Journal of Substance Abuse Treatment 82: 1–6. https://doi.org/10.1016/j.jsat.2017.08.003.

Garcia, Francisco I. Salgado, Premananda Indic, Joshua Stapp, Keerthi K. Chintha, Zhaomin He, Jeffrey H. Brooks, Stephanie Carreiro, and Karen J. Derefinko. 2022. “Using Wearable Technology to Detect Prescription Opioid Self-Administration.” Pain (Amsterdam) 163 (2): E357–E367. https://doi.org/10.1097/j.pain.0000000000002375.

Garett, Renee, and Sean D. Young. 2022. “The Role of Misinformation and Stigma in Opioid Use Disorder Treatment Uptake.” Substance Use & Misuse 57 (8): 1332–36. https://doi.org/10.1080/10826084.2022.2079133.

Hedegaard, Holly, Arialdi Miniño, Rose Spencer, and Margaret Warner. 2021. “Drug Overdose Deaths in the United States, 1999-2020 Key Findings Data from the National Vital Statistics System.” https://www.cdc.gov/nchs/data/databriefs/db428.pdf.

Henry, Stephen G., Bo Feng, Susan Verba, Richard L. Kravitz, and Ana‐Maria Iosif. 2021. “The Story vs the Storyteller: Factors Associated with the Effectiveness of Brief Video‐recorded Patient Stories for Promoting Opioid Tapering.” Health Expectations : an International Journal of Public Participation in Health Care and Health Policy 24 (3): 991–99. https://doi.org/10.1111/hex.13243.

Herbert, Natalie, Sydney Axson, Leeann Siegel, Kyle Cassidy, Ann Marie Hoyt-Brennan, Clare Whitney, Allison Herens, and Nicholas A. Giordano. 2020. “Leveraging Immersive Technology to Expand Access to Opioid Overdose Reversal Training in Community Settings: Results from a Randomized Controlled Equivalence Trial.” Drug and Alcohol Dependence 214: 108160–108160. https://doi.org/10.1016/j.drugalcdep.2020.108160.

Hernandez, Yamilette, Sarah Meyers-Ohki, Sarah Farkas, Samuel Ball, Kenneth Leonard, John Rotrosen, and Richard Saitz. 2018. “How Massachusetts, Vermont, and New York Are Taking Action to Address the Opioid Epidemic.” American Journal of Public Health (1971) 108 (12): 1621–22. https://doi.org/10.2105/AJPH.2018.304741.

Hinton, Elizabeth Kai. 2016. From the War on Poverty to the War on Crime : the Making of Mass Incarceration in America. Cambridge, MA: Harvard University Press.

Hollingsworth, Alex, Christopher J. Ruhm, and Kosali Simon. 2017. “Macroeconomic Conditions and Opioid Abuse.” Journal of Health Economics 56: 222–33. https://doi.org/10.1016/j.jhealeco.2017.07.009.

Invisible People. 2019. “Invisible People - Changing the Story of Homelessness.” Invisible People. Invisible People. 2019. https://invisiblepeople.tv.

Invisible People. 2011. “Homeless Man Talks Openly about Being Addicted to Heroin. We Have an Opioid Crisis in America.” YouTube. https://www.youtube.com/watch?v=H6ZFzEW7_Q4.

Invisible People. n.d. “Invisible People - YouTube.” www.youtube.com. YouTube. Accessed December 2, 2022. https://www.youtube.com/@InvisiblePeople/about.

Johnson, Kaprea F., Allison Worth, and Dana Brookover. 2019. “Families Facing the Opioid Crisis: Content and Frame Analysis of YouTube Videos.” The Family Journal (Alexandria, Va.) 27 (2): 209–20. https://doi.org/10.1177/1066480719832507.

Kameg, Brayden N., and Ann Mitchell. 2020. “Technology-Based Educational Approaches to Address Opioid Use Management by Advanced Practice Registered Nurses.” Issues in Mental Health Nursing 41 (10): 940–45. https://doi.org/10.1080/01612840.2020.1749917.

Karamouzian, Mohammad, Carolyn Dohoo, Sara Forsting, Ryan McNeil, Thomas Kerr, and Mark Lysyshyn. 2018. “Evaluation of a Fentanyl Drug Checking Service for Clients of a Supervised Injection Facility, Vancouver, Canada.” Harm Reduction Journal 15 (1): 46–46. https://doi.org/10.1186/s12954-018-0252-8.

Kennedy, Mary Clare, and Thomas Kerr. 2017. “Overdose Prevention in the United States: A Call for Supervised Injection Sites.” American Journal of Public Health (1971) 107 (1): 42–43. https://doi.org/10.2105/AJPH.2016.303523.

Kennedy-Hendricks, Alene, Colleen L Barry, Sarah E Gollust, Margaret E Ensminger, Margaret S Chisolm, and Emma E McGinty. 2017. “Social Stigma Toward Persons With Prescription Opioid Use Disorder: Associations With Public Support for Punitive and Public Health–Oriented Policies.” Psychiatric Services (Washington, D.C.) 68 (5): 462–69. https://doi.org/10.1176/appi.ps.201600056.

Kernan, William D., Corey H. Basch, Leslie E. Segall, and Philip Garcia. 2020. “A Review of YouTube Videos About the Opioid Antagonist Medication Naloxone.” Journal of Consumer Health on the Internet 24 (2): 135–46. https://doi.org/10.1080/15398285.2020.1752079.

Kertesz, Stefan G., Kimberly Crouch, Jesse B. Milby, Robert E. Cusimano, and Joseph E. Schumacher. 2009. “Housing First for Homeless Persons with Active Addiction: Are We Overreaching?” The Milbank Quarterly 87 (2): 495–534. https://doi.org/10.1111/j.1468-0009.2009.00565.x.

Kirane, Harshal, M.D, Ketteringham, Michael, M.D., M.P.H, Bereket, Sewit, M.P.H, Dima, Richie, M.D, Basta, Ann, M.D, Mendoza, Sonia, M.A, and Hansen, Helena, M.D. 2016. “Awareness and Attitudes Toward Intranasal Naloxone Rescue for Opioid Overdose Prevention.” Journal of Substance Abuse Treatment 69: 44–49. https://doi.org/10.1016/j.jsat.2016.07.005.

Knadler, Stephen. 2021. “Opioid Storytelling: Rehabilitating a White Disability Nationalism.” Journal of American Studies 55 (5): 1098–1124. https://doi.org/10.1017/S002187582100027X.

Kurtzman, Laura. 2022. “Homeless Deaths Doubled in San Francisco during the Pandemic’s First Year, Mostly from Drug Overdoses | UC San Francisco.” Www.ucsf.edu. March 10, 2022. https://www.ucsf.edu/news/2022/03/422436/homeless-deaths-doubled-san-francisco-during-pandemics-first-year-mostly-drug.

McGinty, Emma E., Elizabeth M. Stone, Alene Kennedy-Hendricks, and Colleen L. Barry. 2019a. “Stigmatizing Language in News Media Coverage of the Opioid Epidemic: Implications for Public Health.” Preventive Medicine 124: 110–14. https://doi.org/10.1016/j.ypmed.2019.03.018.

McGinty, Emma E., Elizabeth M. Stone, Alene Kennedy-Hendricks, Kaylynn Sanders, Alexa Beacham, and Colleen L. Barry. 2019b. “U.S. News Media Coverage of Solutions to the Opioid Crisis, 2013–2017.” Preventive Medicine 126 (September): 105771. https://doi.org/10.1016/j.ypmed.2019.105771.

McLean, Katherine. 2016. ““There's Nothing Here”: Deindustrialization as Risk Environment for Overdose.” The International Journal of Drug Policy 29: 19–26. https://doi.org/10.1016/j.drugpo.2016.01.009.

Naserianhanzaei, Elahe, and Miriam Koschate-Reis. 2022. “Effects of Substance Use, Recovery, and Non-Drug-Related Online Community Participation on the Risk of a Use Episode During Remission From Opioid Use Disorder: Longitudinal Observational Study.” Journal of Medical Internet Research 24 (8): e36555–e36555. https://doi.org/10.2196/36555.

NBC Bay Area. 2018. “Gov. Brown Vetoes San Francisco’s Safe-Injection Sites Bill.” NBC Bay Area. October 1, 2018. https://www.nbcbayarea.com/news/local/gov-brown-vetos-san-franciscos-safe-injection-sites-bill/207321/.

Neale, Joanne, and Caral Stevenson. 2014. “Homeless Drug Users and Information Technology: A Qualitative Study with Potential Implications for Recovery from Drug Dependence.” Substance Use & Misuse 49 (11): 1465–72. https://doi.org/10.3109/10826084.2014.912231.

Netherland, Julie, and Helena B. Hansen. 2016. “The War on Drugs That Wasn’t: Wasted Whiteness, “Dirty Doctors,” and Race in Media Coverage of Prescription Opioid Misuse.” Culture, Medicine and Psychiatry 40 (4): 664–86. https://doi.org/10.1007/s11013-016-9496-5.

Nuamah, Joseph, Ranjana Mehta, and Farzan Sasangohar. 2020. “Technologies for Opioid Use Disorder Management: Mobile App Search and Scoping Review.” JMIR mHealth and uHealth 8 (6): e15752–e15752. https://doi.org/10.2196/15752.

Ondocsin, Jeff, Sarah G. Mars, Mary Howe, and Daniel Ciccarone. 2020. “Hostility, Compassion and Role Reversal in West Virginia's Long Opioid Overdose Emergency.” Harm Reduction Journal 17 (1): 74–74. https://doi.org/10.1186/s12954-020-00416-w.

Parkin, Stephen, Joanne Neale, Caral Brown, Aimee N.C. Campbell, Felipe Castillo, Jermaine D. Jones, John Strang, and Sandra D. Comer. 2020. “Opioid Overdose Reversals Using Naloxone in New York City by People Who Use Opioids: Implications for Public Health and Overdose Harm Reduction Approaches from a Qualitative Study.” The International Journal of Drug Policy 79: 102751–102751. https://doi.org/10.1016/j.drugpo.2020.102751.

Rath, Jessica M., Siobhan N. Perks, Donna M. Vallone, Alexis A. Barton, Daniel K. Stephens, Bethany Simard, and Elizabeth C. Hair. 2022. “Educating Young Adults About Opioid Misuse: Evidence from a Mass Media Intervention.” International Journal of Environmental Research and Public Health 19 (1): 22. https://doi.org/10.3390/ijerph19010022.

Rezal, Adriana, and Erin Caughey. 2022. “Key Facts about Homelessness in San Francisco.” The San Francisco Chronicle. June 29, 2022. https://www.sfchronicle.com/projects/2022/fixing-san-francisco-problems/sf-homelessness-data.

Richardson, John G. 1986. Handbook of Theory and Research for the Sociology of Education. Westport, Conn.: Greenwood Press.

Richesson, Douglas, and Jennifer M. Hoenig. 2021. “Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health.” Substance Abuse and Mental Health Services Administration (SAMHSA). October 2021. https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.

Sadang, Katrina Grace, Desmond Miller, Danielle Veloso, Jessica Lin, and Willi McFarland. 2021. “Unmet Health and Social Welfare Needs of Women Who Inject Drugs in San Francisco.” Journal of Health Care for the Poor and Underserved 32 (1): 204–19. https://doi.org/10.1353/hpu.2021.0019.

Saloner, Brendan, Emma E. McGinty, Leo Beletsky, Ricky Bluthenthal, Chris Beyrer, Michael Botticelli, and Susan G. Sherman. 2018. “A Public Health Strategy for the Opioid Crisis.” Public Health Reports (1974) 133 (1S): 24S–34S. https://doi.org/10.1177/0033354918793627.

Santenello, Peter. n.d. “Peter Santenello - YouTube.” www.youtube.com. YouTube. Accessed December 2, 2022. https://www.youtube.com/@PeterSantenello/about.

Santenello, Peter. 2022. “San Francisco 1 Year Later (Still as Bad?).” www.youtube.com. YouTube. April 17, 2022. https://www.youtube.com/watch?v=nJNdloJyeok.

Scheper-Hughes, Nancy, and Philippe Bourgois. 2004. “Introduction: Making Sense of Violence.” In Violence in War and Peace: An Anthology, edited by Nancy Scheper-Hughes and Philippe Bourgois, 1–27. Oxford: Blackwell.

Scholten, Willem, and Jack E. Henningfield. 2016. “Negative Outcomes of Unbalanced Opioid Policy Supported by Clinicians, Politicians, and the Media.” Journal of Pain & Palliative Care Pharmacotherapy 30 (1): 4–12. https://doi.org/10.3109/15360288.2015.1136368.

Schwittay, Anke. 2019. “Digital Mediations of Everyday Humanitarianism: The Case of Kiva.org.” Third World Quarterly 40 (10): 1921–38. https://doi.org/10.1080/01436597.2019.1625267.

Spector, Galletly, C. L., Christenson, E. A., Montaque, H. D. G., & Dickson-Gomez, J. (2022). A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin. BMC Public Health, 22(1), 1–1387. https://doi.org/10.1186/s12889-022-13741-5

Thadani, Trisha. 2021. “2020 Was S.F.'S Deadliest Year for Overdoses, by Far.” San Francisco Chronicle. January 15, 2021. https://www.sfchronicle.com/local-politics/article/It-didn-t-have-to-happen-2020-was-15872937.php.

Tsai, Alexander C., Mathew Kiang, Michael L. Barnett, Leo Beletsky, Katherine M. Keyes, Emma E. McGinty, Laramie R. Smith, Steffanie A. Strathdee, Sarah E. Wakeman, and Atheendar S. Venkataramani. 2019. “Stigma as a Fundamental Hindrance to the United States Opioid Overdose Crisis Response.” PLoS Medicine 16 (11): e1002969–e1002969. https://doi.org/10.1371/journal.pmed.1002969.

Tsemberis, Sam, Leyla Gulcur, and Maria Nakae. 2004. “Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis.” American Journal of Public Health (1971) 94 (4): 651–56. https://doi.org/10.2105/AJPH.94.4.651.

Vafeiadis, Michail, Weirui Wang, Michelle Baker, and Fuyuan Shen. 2022. “Examining the Effects of Celebrity (Vs. Noncelebrity) Narratives on Opioid Addiction Prevention: Identification, Transportation, and the Moderating Role of Personal Relevance.” Journal of Health Communication 27 (5): 271–80. https://doi.org/10.1080/10810730.2022.2097752.

Webster, Fiona, Kathleen Rice, and Abhimanyu Sud. 2020. “A Critical Content Analysis of Media Reporting on Opioids: The Social Construction of an Epidemic.” Social Science & Medicine (1982) 244: 112642–112642. https://doi.org/10.1016/j.socscimed.2019.112642.

Yellow Productions. n.d. “Yellow Productions - YouTube.” www.youtube.com. YouTube. Accessed December 2, 2022. https://www.youtube.com/@YellowProductions/about.

Yellow Productions. 2022. “How DANGEROUS Is SAN FRANCISCO for Visitors?” www.youtube.com. YouTube. May 26, 2022. https://www.youtube.com/watch?v=3goXdQMfVXc&list=PLxVhFpv-PS3RprmJqKZr-JVvT0rTrpIKP&index=62&t=439s.

Young, Sean D., Maryann Koussa, Sung-Jae Lee, Hendry Perez, Navkiran Gill, Lillian Gelberg, and Keith Heinzerling. 2018. “Feasibility of a Social Media/Online Community Support Group Intervention Among Chronic Pain Patients on Opioid Therapy.” Journal of Addictive Diseases 37 (1-2): 96–101. https://doi.org/10.1080/10550887.2018.1557992.

Young, Sean D., Sung-Jae Lee, Hendry Perez, Navkiran Gill, Lillian Gelberg, and Keith Heinzerling. 2020. “Social Media as an Emerging Tool for Reducing Prescription Opioid Misuse Risk Factors.” Heliyon 6 (3): e03471–e03471. https://doi.org/10.1016/j.heliyon.2020.e03471.