Pop culture has the power to shape our beliefs, for better or worse. Now, as the United States grapples with an overdose crisis – one that has culminated in a record number of overdose deaths in 2020 (a nearly 30% increase from 2019) – TV and streaming shows are representing overdose and substance use disorder (SUD) as central plot lines. But are they getting it right or doing more harm than good?
To answer this question, I did some binge watching and detective work. I reviewed recent hits BoJack Horseman, Feel Good, and Shameless to see how they portray SUD. As an intern for Drug Policy Alliance (DPA), I’ve learned that while SUDs continue to increase across the country, harm reduction access remains sparse, inaccessible, and still criminalized (and unfairly vilified!) in much of the nation. In my review, I took a particular interest in seeing how harm reduction was portrayed.
Here’s why that’s important:
The Substance Abuse and Mental Health Services Administration (SAMHSA) notes that 90% of those with SUDs did not receive treatment in the past year due to common barriers including stigma, cost, lack of providers, as well as inflexible programming and approaches. In fact, the North American Syringe Exchange Program (NASEN) notes that eight states currently do not have a single syringe service program. America’s documented shortcomings on helping those who suffer from addiction makes these highly consumed and highly popular series exist not just as a form of entertainment, but also as opportunities to alter dominant and flawed narratives on substance use disorders.
So, let’s dive in and explore what these shows get wrong – and right – in their attempt to represent substance use disorder.
Feel Good is a semi-autobiographical comedy series about comedian Mae Martin that explores the gender/sexuality landscape through Mae’s relationship with their bisexual, formerly straight girlfriend, George. Mae struggles to navigate their relationship with George as she deals with PTSD and cycles of drug use. At the start of season two, Mae is out of contact with George and checks into rehab, only for them to drop out after less than 24 hours. The show ends with Mae overcoming their struggles and repairing their relationship with George.
Feel Good is where rom-com meets drug education at a point that feels, well... good. Through an undeniable wit, Mae is able to uncover taboo subjects relating to addiction with grace and ease. Explored primarily through themes of love, sexuality, friendship, and loyalty, Mae’s story becomes relatable to those who have experienced addiction and, frankly, to anyone human.
First, the show incorporates various flashbacks and conversations about Mae’s past to show how Mae’s drug use largely stems from their struggle with PTSD and childhood trauma. The show thus correctly identifies that treating SUDs requires an understanding of why people choose to consume drugs as a coping mechanism in the first place. DPA’s webinar “Why We Cope” explores this in detail, while DPA’s Safety First harm reduction-based drug education program utilizes a trauma-informed approach to helping teens develop a healthy relationship with drugs. Mae’s story also illustrates why those with SUDs should be able to get easy and free access to care.
In addition, Mae’s struggle to navigate the gender landscape at times throughout the show is demonstrative of how substance use treatment must be culturally sensitive. DPA highlights this in its resource on the foundational principles of SUD treatment, noting that “while all treatments should be individualized, different client populations (in this case LGBTQIA+ people) have unique strengths, vulnerabilities, and needs.”
Mae alludes to the importance of specialized treatment when they briefly enter a rehab facility at the beginning of season two as well, expressing the guilt they feel having to require treatment despite coming from a privileged background where cost was never a barrier to treatment. “You know I played the Oboe?” Mae confesses. The show is able to reject certain stigma about SUDs by explaining that no one should feel guilty about receiving treatment, (yes, even if you play the oboe), while simultaneously acknowledging the barriers marginalized communities face in accessing effective SUD treatment.
Overall, Feel Good brilliantly represents the challenges specific to minority groups when it comes to recovery. The persisting interaction between Mae’s addiction and their relationship with George makes rom-com an unexpected portal through which so many can come to understand the challenges of SUDs.
In truth, Feel Good is far more about Mae's self-described “addictive personality” and how it manifests itself in their relationships rather than their addiction to drugs. “I guess the big realisation was that addiction isn’t really about substances. The definition that I use is from [writer and physician] Dr Gabor Maté, which is: addiction is something that you crave, find relief from and can’t give up, despite knowing the negative consequences,” Mae told The Guardian last year. Although this perspective offers Mae a certain relatability in their show, it takes away from their ability to have more powerful conversations about drug use.
Suggesting that addiction is not at least partially about substances can be misleading. Take, for example, the consistent rise in overdose deaths over the past decade. Criminalization policies have led to the rise in synthetic opioids like fentanyl in the illicit drug supply, including more potent forms of fentanyl that are more likely to cause overdose deaths.
While I understand Mae's rhetoric about addiction being about more than the substances, I think she misses a timely opportunity to draw attention to the fact that due to the criminalization of drugs people are not able to trust the nature of the substances since they are not regulated. This is why practices like drug checking are so important. It allows people to check the purity of the drug and to avoid consuming adulterated substances. While this practice can save lives, a variety of barriers exist in the U.S. in accessing drug checking services because it’s considered illegal drug paraphernalia in the vast majority of states. See why criminalization is harmful?
So yes – the root cause of one's addiction may not be entirely related to the nature of a substance, but Feel Good also misses the opportunity to discuss substance use through a harm-reduction lens that is centered around ensuring the safety of drug users.
Set in a “low-income” neighborhood on the south side of Chicago, Shameless tells the story of the Gallagher family. Father and patriarch Frank has an alcohol use disorder, while his absent wife Monica lives and struggles with bipolar disorder and addiction, leaving their six children to fend for themselves and navigate growing up on their own. Eldest daughter Fiona functions in an over-parenting role, doing literally whatever it takes to make sure rent is covered while looking over both her five younger siblings and oftentimes Frank and Monica.
Shameless emphasizes SUD as a disorder that profoundly impacts one’s family- and rightly so. Everyone in a household can be affected by a loved one’s SUD, and recovery generally requires the support system of a family or equivalent.
Unlike Mae in Feel Good, Frank and Monica in Shameless continue to use problematically throughout the show and struggle to achieve recovery. In fact, Frank chooses not to seek treatment services entirely in the show. However, when Frank’s eldest son Lip (short for Phillip) develops an alcohol problem in his early adulthood, his recovery is juxtaposed cleverly with Frank’s in order to try to represent two different trajectories.
Lip’s recovery is aided by a support system of peers and his siblings, as well as frequent visits to AA – but is by no means easy. Lip’s recovery is a non-linear story of struggle and triumph, a celebration of many victories and an acknowledgement of largely inevitable lows. At every point, however, we are meant to root for Lip because of his unwavering compassion for others and his loyalty to his siblings. In this sense, Shameless perhaps gives a better representation of recovery challenges than many other shows of its time.
Shameless is additionally not devoid of social commentary. As a family with low-income and with multiple people with addictions, treatment access is a prevalent theme explored throughout the show. While Frank does not express a desire to seek treatment, the fact that he is unemployed and uninsured imply that treatment was not a desire of Frank’s nor a possibility. Frank’s comedic relief often comes in the form of remarks on the joke that is the U.S. healthcare system throughout the show, a barrier that DPA recognizes keeps many out of treatment and is working to address.
And even in the hypothetical scenario that Frank did want to seek out treatment, the abstinence-based approach of many rehab centers may not have been appealing to him. As DPA notes, programs should not require abstinence as a condition for starting or continuing treatment. Instead, drug treatment should be centered around harm reduction, a set of concepts and interventions that seek to reduce harms associated with drug use and ineffective policies. The importance of harm reduction is highlighted sporadically throughout the show, including a potential overdose at the end of season five, and when the youngest Gallagher, Liam, gains access to Fiona’s cocaine earlier in the show.
While Shameless does a remarkable job in representing recovery and the systemic issues that present barriers to drug treatment access, they are less successful in drawing attention to the racial disparities that are linked with SUDs and the drug war at large. With the exception of the youngest Liam, the Gallaghers are an entirely white family. And despite living in a predominantly BIPOC neighborhood, the ramifications of drug use are told from a white perspective.
Although Fiona ends up in a 90-day correctional facility after Liam’s accident, and Frank frequents jail (though for very temporary sentences) throughout the show, Shameless fails to demonstrate how BIPOC members of their Chicago community have historically been subjected to the drug war’s investment in incarceration at much higher rates, often resulting in long term sentences for drug possession.
The fact that Frank, in particular, can move in and out of the criminal justice system at will while the show fails to acknowledge the mass incarceration of BIPOC communities is a major flaw in the series. You would expect a series whose comedy is primarily derived from critiquing systematic inequalities to be a bit more abolitionist.
BoJack Horseman is the story of a humanoid horse (half person/half horse) who once ruled ‘Hollywoo’ as the star of a famous sitcom called Horsin’ Around before his career derailed. Now, BoJack’s battles against internal trauma and addiction often cause chaos in the lives of those close to him. Mixed in with comic relief, BoJack Horseman details a very human struggle with addiction because he both wants to achieve recovery yet struggles with multiple relapses.
While adult animation may not be the natural place for viewers to seek out a powerful representation of SUD, BoJack Horseman surprisingly delivers. Like in Feel Good, BoJack’s repeated binge drinking excursions and prescription pill popping are explained by flashing back to his youth where he was raised by an abusive father as well as a neglectful mother. As Zachary Siegel and Abraham Gutman explained in Variety, addiction recovery is, perhaps above all, learning about self-love and acceptance.
And BoJack had to learn that in the hardest of ways. Throughout the show, it appears as if at every breakthrough BoJack makes in his journey, an inevitable setback and spiral follows. Take, for example, when he reunites with Sarah Lynn, who once played a little girl on BoJack’s sitcom but is now 9-months sober and in recovery. Nonetheless, BoJack immediately takes her on a bender featuring the kitchen’s sink worth of drugs, with the episode ending with her overdose. Episodes like this remind the viewer at the end of the show that recovery is a long, difficult, non-linear path. It’s about acknowledging past mistakes as much as it is refraining from problematic patterns.
BoJack’s final season begins with him checking into a six-week, $100,000 Malibu rehab facility in the aftermath of Sarah Lynn’s death. Here, the show critiques the for-profit rehab industry.
“Can’t put a price on clean living!” says an employee at the rehab center.
“Yet somehow you found a way,” replies BoJack.
Ultimately, BoJack’s documented rehabilitation process points to the economic barriers that prevent those less fortunate than him from accessing the treatment that got BoJack’s life back on track (albeit temporarily). Cost should never be a barrier for those who wish to seek treatment for SUDs.
After rehab, BoJack seems to be in an unprecedented state of peace and self-acceptance while working as an acting professor at Wesleyan University, until the most problematic events of his past begin to resurface publicly. BoJack ultimately relapses and nearly overdoses in what may have been a suicide attempt.
Sarah Lynn’s overdose and BoJack’s near-overdose articulate the severity of SUDs but also forgo the opportunity to have a substantive dialogue about harm reduction. If BoJack or Sarah Lynn were equipped with the opioid overdose antidote naloxone during their excursion, Sarah Lynn’s life may have been saved while offering insight to viewers into how to reduce the harms associated with opioid use. Furthermore, both of them most certainly could have benefitted from overdose prevention centers during the points in the show when neither of them sought to pursue sobriety or treatment.
This past month, Rhode Island became the first state to pass a law that authorizes the implementation of overdose prevention centers, where those who use drugs can consume pre-obtained substances under the supervision of medical professionals. Centers like these significantly reduce the chances of overdoses like Sarah Lynn’s while connecting people to other life-saving services like treatment, case management, and health services.
BoJack Horseman thus missed an opportunity to be a catalyst in explaining the importance of looking at drug use as a public health issue rather than a criminalization issue, and to prove that groundbreaking legislation like Rhode Island’s should be considered common sense policymaking.
Overall, the good news is that compared to our parents and generations past, recent popular culture is increasingly more invested in generating more progressive conversations regarding SUDs and addiction. By creating characters that viewers are meant to root for, like Mae or Lip, pop culture is slowly beginning to portray drug users as they should be portrayed: human, everyday people navigating life as best they can.
Yet in the process of SUDs becoming mainstream topics of exploration, these shows also prove that misconceptions about SUDs and the best ways to treat them are persistent. Feel Good, Shameless and BoJack Horseman all fail to capitalize on the opportunity to shift narratives on risky drug use towards harm reduction.
More television and films will inevitably continue to discuss substance use as addiction rates and barriers to treatment remain high. But in order to fight for drug policy rooted in compassion, health, and human rights, popular culture has to demand more from a system that has repeatedly failed to offer those with SUDs the solutions they need.
Jake Samieske is a digital communications intern with Drug Policy Alliance.