Opioids are the contributing factor to increases in fatal overdoses in the U.S. and claimed more than 33,000 American lives in 2015.¹ Identifying effective public health approaches to reduce opioid-related morbidity and mortality is an urgent priority. Public messaging is one such intervention that can be used to help by shifting individual factors (e.g., attitudes and beliefs) associated with an increased likelihood of behavior change and supporting the development of larger social environments (e.g., promote community connectedness) that validate and motivate targeted behaviors. To date, several studies² have evaluated antidrug campaigns in the U.S.; however, findings of their efficacy were mixed and underscore the need for additional exploration of public messaging prior to its use for opioid-related outcomes.

Although the corpus of research on communications targeting opioids is currently underdeveloped, messaging has demonstrated the ability to improve outcomes for several other public health issues. Suicide is one U.S. public health problem where communication strategies have drawn considerable attention for their potential and popularity as universal interventions for prevention.³ Suicide is the tenth leading cause of death among Americans with sharp increases in rates over the past decade similar to mortality trends in overdoses.⁴ What’s more, a robust relationship exists between suicide and substance use disorders⁵ as well as evidence of its association specifically with opioid abuse.⁶ Similar contributing factors (e.g., trauma exposure) drive both behaviors with considerable overlap in the characteristics associated with increased risk (e.g., psychiatric disorders).^5–7 Such parallels point to an important opportunity for applying science from suicide prevention messaging to emerging communication efforts for reducing opioid-related outcomes.

Studies report associations between messaging and improved knowledge of risk (e.g., warning signs) and available services,^8–10 attitudes towards suicide and the benefits of treatment,^8–10 and intentions to seek help for suicidal thoughts and behaviors.^8–10 Recent research shows changes in related behaviors including increased crisis line use during campaign periods,¹⁰ and has also demonstrated efficacy to strengthen community capacity to support at-risk individuals (e.g., how to encourage treatment).¹⁰ However, these initiatives have not been implemented without limitations that significantly weaken the potential for messaging effects. Insights on barriers to effective public communication can improve the use of messaging yet are often underreported highlighting the potential for critical gaps in communication research and practice. This article gleans several lessons learned from the use of public messaging for suicide prevention to consider when planning opioid-related communications to increase their likelihood for improved effects.

If prior research is neglected and the basic tenets of communication are ignored, the same mistakes are doomed to be repeated and valuable resources languished on ineffective messages. Meta-analyses¹¹ show that the wide reach of campaigns helps to produce population-level effects; however, messages are not “one size fits all.” Rather, the evidence argues for their proper design to target different goals, behaviors, or groups.¹¹ Yet, suicide prevention campaigns have not regularly adhered to recognized best practices. In a recent study, one public education campaign was implemented across four European countries with little effort to target messages by subgroups.¹² The accompanying evaluation found significant variability in outcomes by region with limited changes in attitudes toward mental health and help seeking associated with these efforts.¹² Alternatively, well-defined campaigns, such as the Compass Campaign, used appropriate measures and identified improved outcomes (e.g., increased awareness, decreased barriers) among their targeted audience during implementation,¹³ further underscoring the value of applying foundational principles to messaging.

A single message is also not sufficient to address a host of outcomes across the risk continuum. In some cases, the same suicide prevention messages that target downstream behaviors (e.g., suicide prevention hotline use during crisis) have also been used to promote and improve upstream factors prior to the development of risk (e.g., reduce stigmatizing attitudes). These messages do not target appropriate outcomes across audiences and, consequently, fail to move important groups through the attitude and behavior change process. For example, broad awareness-based messages (e.g., “prevent suicide, treat depression—see your doctor”) have been found to be ineffective at promoting help seeking among vulnerable populations including depressed and suicidal individuals.¹⁴ Conversely, multifaceted approaches that have integrated coordinated messages, such as the U.S. Air Force program, have demonstrated a better ability to achieve overlapping goals across risk trajectories.¹⁵

Audience members not only talk back to campaigns but also to each other. Yet there is little evidence to suggest that suicide prevention campaigns have regularly considered communication from the perspective of the receiver. Public messaging strategies, such as those evaluated in a study by Karras et al.,¹⁶ that promote the use of crisis hotlines function under the assumption that an audience is universally ready to take action. Unfortunately, this may oversimplify the complexity of population dynamics; evaluation data revealed limited impact of these communication programs.¹⁶ Formative research that could reduce such responses and facilitate desired changes has been limited for suicide prevention campaigns.

Although direct message exposure is frequently sought (and important), campaigns are not implemented in isolation or in a vacuum free from social processes. Indirect pathways can also facilitate messages to mold antecedents and stimulate behavior change such as the diffusion of message themes through social institutions. This approach shows promise for suicide prevention messaging⁸ with analogous efforts becoming increasingly popular. For example, the “R U OK?” campaign facilitated social connectedness and loosened normative constraints by encouraging individuals to talk with others about their problems.¹⁷ Yet direct exposure is often used as the primary benchmark for campaign success,⁸ with the effects of indirect routes overlooked despite associations with increased likelihood to seek help for stigmatized issues.⁹

Public health campaigns have become so commonplace that it may be easy to forget they are sophisticated interventions driven by scientific inquiry. An appropriate conceptual framework is critical to guide communication strategies, and is standard practice firmly grounded by evidence of improved messaging effects.¹¹ However, conceptual models are conspicuously missing from many published suicide prevention campaign studies.^8,10,18 This may be partially an artifact of the message design process where practitioners rely on personal experiences and discipline-specific insight to develop messaging strategies. Recent research points to the drawbacks of this design process. An evaluation of a crisis line campaign implemented by the Department of Veterans Affairs noted limitations, such as a lack of a conceptual model and decreased use during implementation periods.¹⁶

Campaign evaluation consistent with the adopted framework provides key insights as to why certain outcomes were or were not achieved. Some evaluation of suicide prevention messaging is evident in the literature. For example, evaluation pointed to low message saturation as one reason for no significant attitude changes surrounding a suicide prevention campaign in Quebec, Canada.¹⁹ However, it’s unlikely this research fully captures campaigns implemented to date, particularly given their wide distribution during periods of increased national attention (suicide prevention week). Insufficient or inadequate evaluation lends itself to erroneous or inconclusive findings, but also denies researchers data when strategies are believed to be effective. Anecdotes of perceived success by campaign designers have not contributed to an evidence base and have, in part, limited the number of data-driven messaging strategies available for suicide prevention.

There is the potential for audiences to react unpredictably to public messaging particularly given the communicative and social processes inherent to campaigns. The Suicide Awareness Voices of Education billboard campaign intended to educate the public on suicide and promote help seeking among those at risk, but inadvertently produced increased maladaptive behaviors among vulnerable populations post-exposure.¹⁴ The realization that messages can produce unexpected effects has not gone unnoticed in the broader literature, but such outcomes are often undertheorized in suicide prevention campaign research. Several studies^8,10 have explored adverse effects associated with suicide prevention message exposure; however, outcomes that do not correspond with identified objectives were not captured (e.g., obfuscation; dissonance; boomerang).

Research must also consider when to expect change and to specify the lag, if any, from message dissemination or exposure. While some messages may find immediate effects, others may take time to find their place with their audience. Further, some promoted changes may take longer to appear as individuals may need to move toward behaviors or as opportunities to perform them may be delayed. Data published by the Department of Veterans Affairs elucidate this with marked increases in call volume to crisis lines occurring post-campaign.¹⁶ Most suicide prevention campaign studies have not examined their long-term impact underscoring the strong potential for missed effects without thoughtful evaluation design.

Looking ahead, it is prudent to consider these points when developing opioid-related messages rather than reinvent the wheel. Thus, several recommendations are offered. Rather than repeat the same mistakes previously made by others, look to existing research and apply foundational communication principles that have shown to be effective when developing messaging strategies. Currently, the strongest evidence for suicide prevention is the ability to modify knowledge and attitudes that subsequently influence behavior^8,10; thus, when prioritizing opioid efforts, messaging should seek to improve awareness (and subsequent use) of available services among those at increased risk for overdose (e.g., local harm reduction programs) as well as community education to enhance the capacity to respond to overdose (e.g., signs of overdose; attitudes toward naloxone access/use). As with the Air Force Suicide Prevention Program,¹⁵ partnering with communities when possible is likely to support help seeking and enhance the response to an increased need for services generated by campaigns.

However, messages must be carefully planned to produce desired effects and avoid the pitfalls related to ambiguous audiences or the use of generic messages as described above. Drawing from the findings reported on crisis line promotion,^8,10,16 audience research should be conducted so concepts can be developed, tested, and modified to ensure the correct message resonates and is conveyed to targeted groups, and that problematic responses are detected and mitigated prior to dissemination. This type of research may also uncover barriers to effective communication including message exposure issues, which has reduced the impact of suicide prevention efforts, such as the campaign in Quebec, Canada.¹⁹

Although direct exposure to opioid messages remains critical, so is consideration of the social contexts in which these efforts are disseminated. Methods for messages to permeate the environment to indirectly be shared with the audience offers opportunities to enhance effects and support promoted change as shown with the “R U OK” campaign.¹⁷ Even though several methods can be used to identify influential pathways for opioid messaging, the use of community-based approaches is increasingly popular. This approach encourages involvement of target populations to directly garner insights and includes them in the communication process to best address their needs.

Define a campaign framework and evaluate with consideration of timing and frequency. This is a critical element that has been overlooked in suicide prevention communication programs. Although there is certainly no shortage of theories to guide these efforts, health behavior change models offer valuable insights into the theoretic constructs (i.e., attitudes, norms, behavioral control, intentions) that drive behavior to target with communications.⁸ Controlled research designs should be prioritized to test message effects; however, campaigns do not always lend themselves to this design during implementation. For example, studies with natural campaign exposure consider alternative designs that include pre- and post-measures (e.g., time series surveys) to capture campaign outcomes among targeted groups. Findings from this work should inform modification of ongoing efforts or alternatively recommend de-implementation if there is little evidence to support message use. Qualitative methods are also useful, particularly during formative stages to inform message design. Finally, when developing this framework, designers should consider both intended and unintended campaign effects. Some measures of unintended consequences for opioid messaging can be captured with evidence-based typologies developed and used in prior campaign research.²⁰

This article points to the body of research from an analogous public health issue, suicide prevention, to aid the development of opioid messages that can contribute to reductions in disease burden. This work reinforces the larger communication literature that argues the need to build upon prior research to improve campaign planning and use.