University of Southern California Dissertations and Theses

How it hurts: culture, markets, and pain in the U.S. opioid epidemic

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How it hurts: culture, markets, and pain in the U.S. opioid epidemic

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Copyright 2018 Melina Sherman

HOW IT HURTS: CULTURE, MARKETS, AND PAIN IN THE OPIOID EPIDEMIC

by

Melina Sherman

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(COMMUNICATION)

December 2018
ii
Acknowledgements

Thank you to the members of my committee – Sarah Banet-Weiser, Andy Lakoff, Henry
Jenkins, Chris Smith, and Patti Riley – whose steadfast support, constructive criticism, and
crucial insights made this project possible.
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Table of Contents
Acknowledgements ......................................................................................................................... ii
List of Figures ................................................................................................................................ iv
Abstract ........................................................................................................................................... v
Chapter 1: Introduction ................................................................................................................... 6
Chapter 2: A Genealogy of Pain Management ............................................................................. 42
Chapter 3: Branding Pain Relief ................................................................................................... 81
Chapter 4: The Logics of Regulatory Failure and the Rise of the Opioid Grey Market ............. 119
Chapter 5: Addiction’s “New Face”: Classifying Opioid Patients and Addicts ......................... 158
Chapter 6: Subjectification and the Construction of White Victimhood .................................... 200
Chapter 7: Conclusion................................................................................................................. 232
References ................................................................................................................................... 250

iv
List of Figures
Figure 1.1. 61
Figure 1.2 183
Figure 1.3. 185

v
Abstract

This project develops a historical, cultural and institutional analysis of the ongoing
epidemic of opioid abuse and overdose in the United States. In particular, it is focused
on unpacking the social, cultural, and historical conditions underlying the epidemic and on
examining the ways in which pain – its conceptualization, regulation, and problematization in
medicine, culture, economics, and politics – conditions the legibility of the epidemic and gives
rise to the production of new kinds of opioid-addicted subjects and subjectivities.

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Chapter 1: Introduction

America’s 50-state problem. Its deadliest drug scourge. The worst addiction crisis in
modern history. A national public health emergency. A mounting death toll. A killer epidemic.
These are but a few of the words and phrases that have recently been put to use in characterizing
a phenomenon which, over the past two decades, has been creeping slowly but surely into the
lives of millions of people living in North America. The rate at which Americans are now
overdosing (and often dying) from the use of opioid drugs is astonishing: Since 1999, overdose
deaths involving opioids have quintupled, to the extent that drug overdoses now constitute the
leading cause of accidental death in the United States (CDC, 2017a; 2017b; 2017c). According to
the most recent CDC estimates, in 2017 alone overdoses killed about 72,000 people – a tally
which far surpasses the total number of fatalities caused by motor vehicle accidents and gun
violence, combined (Ahmad et al., 2018). Opioids, which account for two-thirds of all drug
overdoses, are the principal force driving up this body count.
Opioids, to be clear, represent a class of drugs that includes substances derived from the
opium poppy (including morphine and heroin) as well as synthetic and semi-synthetic drugs that
act on opioid receptors in the brain. These include both prescription drugs such as codeine,
oxycodone (OxyContin) and hydrocodone (Vicodin), as well as illicit substances such as
fentanyl and its more powerful analog, carfentanil. Every year, millions of Americans use and
abuse these drugs: In 2016, 11.5 million Americans misused prescription opioids, while nearly 1
million used heroin (SAMHSA, 2016a). And despite various efforts on the part of regulators and
law enforcement to crack down on opioid abuse at local, regional, and federal levels, these
numbers continue to climb. Indeed, the extent to which opioid drugs have penetrated our lives is
incredible. According to a survey released by the Kaiser Family Foundation, roughly half of all
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Americans say that they personally know a friend or a family member with either a current or
past addiction to prescription opioids (NCADD, 2016). And there are many others, no doubt,
who know someone addicted to opioids outside of this medical domain.
How is it that opioids have come to wreak such disastrous havoc in the lives of so many
people in such a short amount of time? How did it come to pass that in 2014, in 12 different
states, the number of opioid prescriptions outnumbered the number of people living in that state?
How did these drugs – which we have known for thousands of years are potent, addictive, and
potentially dangerous – come to occupy space on the shelves in our medicine cabinets where,
tucked inside orange plastic bottles, their meanings have shifted – re-defining them as cures
rather than poisons and as first-line medications rather than dangerous narcotics of last resort.
And how, in the proliferating discourse regarding the “opioid epidemic,” have these meanings
shifted yet again, and what effects and consequences have followed in their wake? These are
some of the questions I had in mind when I first began developing this research project – a
project which, from its inception, sought to identify, analyze, and understand the cultural and
institutional processes that have undergirded the emergence of what has become one of the most
formidable social issues of our time.
While the opioid epidemic is not the first drug crisis ever to plague the U.S., it is novel in
a few important ways. The first has to do with its scale: Between 1999 and 2015, the opioid crisis
killed 309,603 people (NIDA, 2017), a number that outpaces the number of American soldiers
killed in battle during World War II (DVA, 2017). And in 2016 alone, drug overdoses driven by
opioids have produced more American fatalities than did battle casualties throughout the entire
Vietnam War, and far more than car crashes, gun violence, and HIV/AIDS ever killed in one
year alone (CDC, 2017a; DVA, 2017).
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Second, the opioid epidemic is unique in that it represents a drug scourge that was largely
initiated by the use of perfectly legal substances – chemical compounds produced by
pharmaceutical companies, regulated by the federal government, prescribed by doctors, and
distributed through official channels within the U.S. health care industry. In many ways, as this
text will argue, it is precisely the legal/legitimate/official/regulated context in which these drugs
first began to circulate that helps us account for their rapid uptake, as well as for the production
surpluses that have saturated the pharmaceutical market and have since caused these drugs to
spill out of their original contexts into other domains – namely, into black and grey drug markets.
In these unregulated spaces, opioids are produced in laboratories outside the U.S. and their sale is
advertised through internet platforms (drug forums as well as social media platforms like
Instagram) and distributed at will through U.S. mail system, at semi-legal brick-and-motor “pill
mills,” and on the street. The fact that these shadowy grey and black markets have grown rather
directly out of the legal market for prescription opioids points to another key characteristic of the
current epidemic, which is the threat its existence poses to the legitimacy of U.S. health
institutions as well as to its law enforcement agencies and regulatory administrations, all of
which are now charged with intervening in a problem space that they themselves helped to
create.
Put another way, the opioid epidemic sheds light on a fundamental paradox: The
institutions we would typically hold responsible for identifying solutions to this problem now
find themselves struggling to do so; and it’s no surprise, considering that many of the logics,
norms, and procedures that bolster their legitimacy and define their functions have also served to
enable (and in some cases, to actively encourage) the unchecked production, circulation and
consumption of opioids.
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A final characteristic of the opioid epidemic that is worth noting is related to its
demographics: Opioid addiction and overdose today occurs among populations of consumers
who are overwhelmingly white. Indeed, much has been made of the fact that for the first time in
a generation, the life expectancy of white Americans is declining and, as the numbers suggest,
this decline is in no small part driven by deaths incurred by opioid drug overdoses. It is no small
thing then, that by the time I finish writing this introduction at the end of this particular Friday in
the Spring of 2018, 115 more people in this country will be dead and their autopsy reports will
indicate that it was opioids that killed them (CDC, 2017a).
The Problem of Pain in American Culture
As I dug deeper into the opioid epidemic – its images, narratives, the stories of people
who take opioids as well as those who manufacture, prescribe, regulate, and police them, I
realized that I couldn’t answer any of the questions I laid out in the previous section without first
addressing another issue: Pain. For in the years I spent trying to learn everything I could about
opioids – which meant sifting through decades of medical journal articles, opioid advertisements,
FDA meeting transcripts, court cases, congressional hearings, and drug forum threads, among
other things, I found time and time again that the debates around opioids as well around the
development of interventions aimed at dealing with them were nearly always developed in
relation to the question (or rather the problem) of pain:
In medicine, arguments regarding the possibilities and pitfalls of using opioids were
divided along this same question, where debates were waged among those with differing
approaches to the problem of how to adequately measure and treat the problem of patient’s pain.
Those who saw pain as a “vital sign,” an objectively-measurable object equal in importance to
that of heart rate, breathing rate, and temperature, tended to advocate on behalf of opioid-based
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pain interventions, while those who approached pain as a behavioral symptom of a more
complex underlying problem, subjective rather than objective, were often opposed (or at the very
least, reluctant) to the uptake of opioids in pain management.
Outside of this strictly medical domain, the problem of pain has been a powerful driving
force in the cultivation of consumer demand for opioid products. For instance, consider the rapid
uptake of the now-notorious drug OxyContin, which was made famous as the painkiller that
jumpstarted the current crisis. Many have attributed this uptake to the wide-reaching and
incredibly aggressive marketing campaign that its manufacturer, Purdue Pharma, launched in
order to sell it. And while I certainly do not disagree, what I found in my close examination of
this campaign is that the successful branding of OxyContin was better explained not in terms of
the promotional claims (many of which have since been outed as lies) that were made about the
drug itself, but in terms of the way in which Purdue branded and claimed ownership over the
interrelated concepts of pain and its relief. The branding of OxyContin was as much (or even
more so) a campaign geared toward the branding of pain relief than it was toward the promotion
of a particular product.
These are but two examples – two domains which, for me, illustrate how neither opioids
nor addiction nor the opioid epidemic writ large can be severed from the problem of pain. And it
is the central argument of this text – and one that I think distinguishes it from the other narratives
that have recently analyzed the epidemic – that the crux of the opioid epidemic is not drugs, but
pain.
Pain was, after all, the problem that ultimately led to the so-called “opioid revolution” – a
phrase which has been used to discuss the rapid popularization of opioid-based treatments in
medicine and their normalization in culture, more generally. So too has pain marked a consistent
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presence in opioid advertising; and it has never been absent from regulatory discussions nor from
the countless institutional debates in which it has unfailingly manifested as a key point of
contention between regulators and their scientific/medical advisors. On the political stage, pain
has informed calls (made by politicians, patients, and advocates alike) to break away from the
United States’ historically punitive stance toward drug use and opt instead for a “compassionate”
approach to the problem. In many recent political speeches pain is the pathos, the affective link
through which politicians accrue support and promote platforms that commit to put an end to
opioid addiction, to the misery that accompanies it, and to the escalation of drug-induced
fatalities now being rendered as “deaths of despair.” Through the pathos of pain, the opioid
epidemic has itself becomes legible – not so much as a criminal scourge but as a national
tragedy, one which communicates a complex web of meanings, symbols, rituals, discourses, and
dynamics that are continuing to take shape within American culture today.
It makes sense, then, that in the face of all this we would start to see the emergence of
headlines and book titles that hail us as citizens living in “a nation of pain.” But what, exactly,
does this mean? Who is the “us” that lives here? What kind of pain do we live? Is our pain the
same? Did we all arrive at this experience through the same routes? Do we experience it in
similar ways? What does it mean to us? Considering these questions and the complexity involved
in attempting to provide straightforward answers to them, it seems to me that describing the
opioid epidemic in terms of a unified “nation in pain” may not be a very useful or accurate
approach to understanding it. And while this turn of phrase does point to certain realities
(namely, the prevalence of opioid addiction in every corner of the country) it obscures more
about the opioid epidemic and its relation to pain than it reveals. With this in mind, I’d like to
propose a different approach to the epidemic, one that does not diagnose the problem in the fixed
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and unified terms of “a nation in pain,” but rather tries to dig deeper into the specificities of this
phenomenon by tracing the routes that pain and opioids have taken over time, by interrogating
how and why these paths eventually merged, and by identifying the specific mechanisms,
processes and dynamics that played into the construction of certain kinds of medical/scientific
knowledges, political discourses, institutional logics, and cultural representations – all of which
have made opioid epidemic meaningful and, to some extent, have made it possible.
Indeed, from what I have learned about opioids, addiction, and the current crisis, it would
neither be fair to characterize the epidemic in the unilateral terms of a “nation in pain,” nor to
diagnose the crisis as a symptom or result of any one particular thing – be it pharmaceutical
greed, lack of regulatory foresight, the decline of America’s white working-class, or something
else. I don’t think we can trace its emergence so linearly. The opioid epidemic has developed
unevenly within a complicated matrix of contingent forces operating in a variety of domains. It is
not cohesive, but contradictory. Its meanings are not fixed but in flux. It is not a symptom of life
under of capitalism, neoliberalism, globalization, de-industrialization, or anything else, but
should be seen as an ensemble – one made up of discourses, practices, actors, technologies,
strategies, truths, and the various tensions exist (and shift) between them. As such, it seems to me
that a better way of approaching the interconnected problems of opioid use and pain would be to
re-frame them in more dynamic terms – not by asking what or why, but how did we get here in
the first place?
To that end, the project contained in the following pages is geared toward the
characterization and analysis of the shifting terrain on which the opioid epidemic was
constructed and has since continued to develop, with particular attention paid to the processes
and mechanisms that help us understand how it has come into being – both as a network of
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concrete actors/institutions/practices and as an evolving narrative about pain and its connection
to particular kinds of drugs. It asks, how have discourses about pain both within and outside the
field of medicine shaped our understanding of what the epidemic is, who is responsible for it,
why it matters, and to whom? And how well do these discourses explain the uptake of opioids as
the best (if not only) solution to the problem of pain?
Contingencies and Materialities
A central assumption that informs the theoretical perspective I take up in this project is
one that emphasizes the contingency of the opioid epidemic. That is, as I see it, the opioid
epidemic is not a unidimensional phenomenon. Nor can it be traced back to any one particular
source. There is no such one thing as the opioid epidemic. On the contrary, it is something that
has been both materially and discursively constructed through a variety of forces (actors,
institutions, technologies, knowledges, practices, strategies) and their interactions. Seen in this
way, we might characterize the opioid epidemic as more of a matrix, an apparatus, or what
Michel Foucault (1977b) has referred to as a “dispositif” – a “heterogeneous ensemble” made up
of various elements and the “system of relations that can be established between these
elements…the nature of the connection that can exist between [them]” (Foucault, 1977b: 194-5).
It is also worth noting that the heterogenous ensemble of forces, relations, and interactions that
make up the basic machinery of the epidemic have evolved over time and in collaboration and
contestation with one another. Thus, the opioid epidemic is better understood as a problem space,
one that is couched within the broader contexts of capitalism, neoliberalism, and the
social/cultural/historical conjuncture of life in the United States today.
This approach to the epidemic is heavily influenced by poststructuralism – an approach
which rejects the existence of fixed meanings, coherent selves, absolute “truths,” and their linear
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development over time. Instead, poststructuralism emphasizes the contingent features of
meaning, truth, and ideas about the self – all of which are seen as always-already in flux, as
constructs which have shifted over time and in conjunction with other social forces, dynamics,
and commitments. Poststructuralism has long come under fire by critics who have accused it of
being over-determined by discourse – by its focus on forces and relations which are largely
immaterial and therefore have little to say about the concrete structures, realities and
fundamental truths that define our experience of the world. That is to say, by focusing primarily
on discourse, analyses influenced by poststructuralism run the risk of drifting too far into the
ether, where it is difficult to observe and consider life in terms of its materiality. This critique is
an important one, one that I recognize and attempt to address throughout the analysis developed
in the following pages. What I acknowledge – and what I hope my analysis demonstrates – is the
coupling of immaterial and material forces and the relationships between them. In doing so, I
hope to avoid drifting too far into the immaterial ether by attending to the ways in which
discourses related to the opioid epidemic are always-already coupled with practices, to the extent
that neither exists without the other, that both are entangled in a dynamic, recursive, and (above
all else) productive relationship. In this relationship, the discourses that give the opioid epidemic
its form (which includes the strategies, rationalities, and interests that are the basis for its
existence) also condition the development of concrete operations (procedures, protocols,
technologies, policies) and are incorporated into them in ways that either reinforce, disrupt, or
transform their meanings and functions. In being attentive to this recursive relationship, whereby
discourse both informs practice, is incorporated into it, and transformed by it, I hope to show
how the discourses that make the epidemic intelligible as such have evolved alongside and in
constant interaction (and often contention) with material practices such as the development and
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implementation of health policies, the manufacture and marketization of new drugs, the
economic shifts that move opioid use into new terrains, the lived reality of pain and opioid
consumption, the development of prescription surveillance technologies, of rehabilitation
technologies, and the ways in which these various institutions, experiences, technologies, and
tools get distributed unevenly across opioid-using populations.
With that said, I want to return briefly to a statement I made a few pages back – that there
is no such one thing as the opioid epidemic. By making this statement, I am in no way trying to
deny the painful realities and devastating material consequences that follow in the wake of
widespread opioid use and addiction. Addiction is real. Pain is real. To argue otherwise would
be both unfair and irresponsible. But while I am not trying to cast doubt on the significance of
these experiences and realities, I do want to stress that my particular approach to the epidemic
sees it both as a reality that is lived, felt, and experienced, and as an object of historical ontology
– as something that has been cultural constructed and can’t be productively understood apart
from the immaterial forces that have shaped its construction. For, as Nikolas Rose has explained,
“The realities that are fabricated, out of words, texts, devices, techniques, practices, subjects,
objects and entities are no less real because they are constructed, for what else could they be?”
(Rose, 1998, p. 168). So too is the opioid epidemic a reality fabricated out of words, texts,
practices, and more – all of which have been constructed and all of which are very real indeed.
This study is indebted to the research by other scholars who have sought to analyze and
understand addiction in terms of the lived experiences that condition it. For addiction, as Raikhel
and Garriot (2015) have suggested, is not only significant as a disease category but also as “an
increasingly prominent way of experiencing, thinking about, and intervening into contemporary
forms of life.” Indeed, the lived experience of addiction is a crucial dimension within the opioid
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epidemic, one that has much to teach us about what it means to “be” an opioid addict and what is
the particular nature of the attachments that bind opioid users to their drugs of choice, to the
extent that they continue to remain loyal to their relationship despite the horror and destruction
that it nearly always entails (Gomart, 2004). Attending to experience would also help us
understand how such toxic attachments get articulated to broader webs of relationships (both
material and affective) and how these also work to re-produce or strengthen the ties between
users and their drugs and make recovery (or escape) a nearly impossible task. Is addiction
maintained through keeping addicts locked in “the zone,” as Natasha Schull has suggested in her
analysis of video gambling addiction? And could we assume that “the zone” of gambling addicts
is also something that characterizes the phenomenology of opioid addiction? How is the
phenomenology of addiction, which defines it as a particular kind of experience, connected to
broader networks of structure and agency? These inquiries, which are addressed Schull’s,
Addiction by Design, are also being undertaken by other scholars who similarly locate addiction
within broader networks of human and non-human forms of agency (Gomart & Hennion, 2002,
2004, Weinberg, 2013) and stress addiction’s role in identity-formation and the construction of
subjectivity (Knight, 2015). As Kelly Knight suggests (2015), our understanding of addiction
relies on the “embedded rationalities and embodied experiences of the West [which are] shaping
and limiting” our conceptualization of it (178). These conceptualizations, which often cast
addiction in the individualistic terms of choice and personal transformation, are called into
question in phenomenological and ethnographic accounts of it, which have shown the opposite to
be true – that the “encounter” produced in addiction is not always a lonely one but can also be
understood as a shared experience of illness and recovery, generational struggle and loss, of
collective hustling and survival (Bourgois & Schonberg, 2009; Garcia, 2010; Knight, 2015). Still
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other studies have taken a similar approach to understanding the subjective experience of
suffering and pain – which are, of course, crucial affects within the phenomenology of addiction.
As these studies have shown, even experiences thought to be universal – such as pain – are made
meaningful and experienced by individuals in highly different ways (Kleinman & Kleinman,
1991; Stonington, 2016).
I want to highlight the importance of all the work cited above at the outset of this project
which is both indebted to it and in some ways departs from it in that it does not take up the kind
of phenomenological framework that would allow it to examine the lived experiences of opioid
addiction. What this project does attempt to do, however, is to hone in on other aspects of the
ever-evolving network that encompasses opioid addiction and which (as many of the authors
above have stated) is involved in the co-production of addicts’ experiences and subjectivities. In
particular, it attempts to identify and analyze the discursive trajectories that condition and co-
produce lived encounters and experiences with opioids, addiction, and pain. It does so through
the application of discourse analysis and genealogical analysis – where discourse is approached
as a part of a longer “history of the present,” as something that was constituted out through the
various routes that, in their development, interaction and competition for dominance, carved out
the conditions of its possibility (Foucault, 1977b). As a product of genealogy, the opioid
epidemic is a problem space riddled with different kinds of narratives – all of which have
attempted to define, delimit, diagnose, and intervene upon it in different ways.
In lieu of this, I chose to take up discourse analysis in order to try and make some sense
out of the discursive chaos and the cluttered media landscape in which opioids, addiction, and
pain have been represented and articulated. While the opioid epidemic is a cluttered and chaotic
problem space, its messiness is useful in that it offers us a number of choices and different lenses
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that we might apply in our attempt to analyze and understand it. Discourse analysis attempts
provide readers with a set of analytical tools through which they can assess the form and function
of these different lenses, identify and critique the narratives they produce, and offer up counter-
narratives in response to them. My hope is that in doing so, we might be able to offer up more
useful explanations that help us understand the intertwined relationship between opioids, pain,
and addiction, how their relationship is problematized in the opioid epidemic, what this
problematization has to tell us about the ways in which the meanings of these three categories are
being transformed and re-routed along new paths within American culture.
What is the “Opioid Epidemic”?
As I have stated, the “opioid epidemic” is a problem space. But it is a problem space not
only for medicine, nor for science, nor for policy, but also, importantly, for media and
communication. This is because the opioid epidemic is not only a tragic reality, but a media event
– one that is constituted by a web of competing discourses and representations that render it
legible as a particular kind of problem, involving particular types of persons, and demanding
specific kinds of interventions as solutions. By focusing on the ways in which opioid use is
mediated and communicated through mediatized contexts, my project is situated within the broad
and multi-faceted discipline of communication studies, where it connects to scholarship in media
studies, health communication, and risk communication, in particular.
First, this project shares a deep connection with media scholars whose work attempts to
unpack the various forms and functions of different kinds of media events – particularly that
which has been written about the cultural construction and circulation of media spectacles (e.g.,
Duncombe, 2015; Jenkins, 2013; Kellner, 2003; Tomlinson, 1997), mediatized rituals (e.g.,
Cottle, 2005, 2006; Couldry, 2003; Pedelty, 2013; Kertzer, 1998; Rothenbuhler, 1998), public
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crises and catastrophes (e.g., Fearn-Banks, 1995; Hariman, & Cintron, 2015; Mnookin, 2012,
2014; Peck & Stole, 2011; Zelizer, 2015), issue-related publics (e.g., Kim, 2009; McClusky &
Kim, 2012), and moral panics (see Cohen, 1972; Cricher, 2003; Jacobs, 2000; McRobbie, 1994;
Peters, 1993; Thompson, 1998). More specifically, communication scholars have also been
concerned with the ways in which medical and scientific controversies, crises, and panics are
mediatized in public debate and popular culture (Ceccarelli, 2011a, 2011b; Maxwell, 2014). So
too does this study resonate with work being developed in these domains, many of which have
emerged from the field of health communication. In this field, my project resonates with work
that emphasizes the inter-connectedness of media and medicine (e.g., Fuqua, 2012; Hallin,
forthcoming; Turow, 2010) and the crucial role that communication plays in the domain of
public health institutions (Bernhardt, 2004; Capella & Hornik, 2009; Hallin, 2013; Hornik et al.,
2008; Riley, 2015). For, as many have noted, communication and media are not only spaces in
which medical discourses circulate, but also play a crucial role as mechanisms for influencing
both the attitudes, beliefs, and health-related behaviors of individuals at the level of individual
consumers as well as at the level of health policy, more generally (Nabi, 2003; Niederdeppe,
Heley, & Barry, 2015; Niederdeppe, Roh, & Dreisbach, 2016; Steinhardt & Shapiro, 2015). Even
more closely related to this project is the work being advanced by some health communication
scholars that considers how pain and suffering are produced, circulated, and consumed in
mediatized contexts – contexts which call up a need for communication theories that can help us
understand how and why these phenomena are articulated and represented in ways that they are,
and how such representations are capable of producing both bridges and chasms between
spectators and the individuals whose suffering they observe at distance (Chonliaraki, 2006).
Additionally, the opioid epidemic is a topic that coheres with many of the interests of scholars in
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the field of risk communication, where the relationship between communication and uncertainty
is of central concern (e.g., Babrow, 1992; Brashers & Babrow, 1996; Donovan [in press]), and
can be shown to impact behavior both at the individual, inter-personal, and organizational levels
(e.g., Giarni, & Stahel, 1989; Jennott III, Lu, McComas, Buttke, Roh, Wild, & Decker, 2017;
Taboul, 1994).
Because the opioid epidemic is squarely situated in the problem space of communication
and media studies, it is worth taking time to try and identify what kind of mediated phenomenon
the opioid epidemic is and to say something about how well this characterization explains the
processes through which the meaning of opioid consumption has shifted over time.
For opioid use to break through the noise of our cluttered media ecosystem, where it now
consistently appears in national headlines, suggests that it is something important or, at the very
least, something important enough to strike a chord in the American imagination. But which
chord did it strike? How and why is it meaningful? What kind of media events play into the way
in which the opioid epidemic is represented in popular culture? Before attempting to answer this
last question, it is worth saying something about mediatized rituals in general and what others
have written about the role they play in culture and society. In particular, I want to consider two
different frameworks and see which makes the most sense as we attempt to categorize and
understand the mediated nature of the opioid epidemic.
The first framework I want to consider is one that has been widely theorized, utilized, and
critiqued in cultural studies, media studies, sociology, and communication studies. This
framework centers on the concept of “moral panic,” which was first elucidated by Stanley Cohen
in his classic book, Folk Devils and Moral Panics: The Creation of Mods and Rockers (1972). In
his book, Cohen examines the ways in which society deals with the emergence of problematic
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(or rather, “deviant”) subcultures. The rise of such a subculture – of a group of persons whose
behavior is deemed as deviant or otherwise non-normative – often gives rise to a slur of media
attention and collective expressions of anger and fear that congeal in a mediated mass movement
which the author characterizes as a “moral panic.” Moral panics, as he defines them, crystallize
when a “condition, episode, person or group of persons emerges to become defined as a threat to
societal values and interests.” While moral panics are, in their essence, mediated responses to
such social threats, they also contain a number of other key characteristics: In a moral panic, the
nature of the threat “is presented in a stylized and stereotypical fashion by the mass media,”
where “the moral barricades are manned by editors, bishops, politicians and other right-thinking
people.” Simultaneously, moral panics serve to mobilize “socially accredited experts [who]
pronounce their diagnoses and solutions.” Over time, “ways of coping are evolved or (more
often) resorted to…[and] the condition then disappears, submerges or deteriorates and becomes
more visible.” While some moral panics are transitory, others leave thick material traces,
inspiring changes in legal and social policies “or even in the way the society conceives itself”
(Cohen, 1972: 1).
With this definition in mind, we can break it down more systematically and consider it in
relation to the opioid epidemic. First, what is most important about moral panics as Cohen
defines them is that they emerge in response to a personified threat – a specific person, group of
persons, or episode/condition for which a particular person or persons is to blame. This emphasis
on deviant persons, which Cohen famously termed “folk devils,” is largely absent in the
mediatized constructions of the opioid epidemic. This is not to say that blame does not circulate
in discourses related to the epidemic, for it certainly does. Depending on who is writing/speaking
about it, the culprits identified may be drug addicts, pharmaceutical companies, physicians, pain
22
specialists, regulators, or some other actor or institution. But there is no one person or group that
is consistently rendered as the foil for this country’s escalating opioid problem. Moreover, the
kind of labelling that occurs in the identification of moral panic “folk devils” differs in a
significant way from the labelling that takes place in the construction of the opioid crisis. In
moral panics, folk devils are identified through a labelling process that positions them, their
behaviors, values, etc., in a direct negative relation to a broader set of social norms. That folk
devil always-already represents a violation of social norms; he or she is deviant, and must either
be punished, expelled, or brought back into the social fold. Such a labelling process does not fit
easily into the framework of the opioid epidemic. First, because the epidemic does not identify a
particular folk devil; here, there is no patient zero, no smoking gun. What is of greatest concern
is not the non-normative behavior of certain persons but, on the contrary, the widespread
normalization of a dangerous practice (opioid consumption, abuse, and addiction). To provide
one illustrative example of a discourse within the opioid epidemic that departs from the labelling
of specific, deviant others, is that which emphasizes how the epidemic “doesn’t discriminate”
(Aiello, 2017; Hayden, 2017; Scott, 2018;). In such narratives, which proliferate across the
media landscape, the opioid crisis is a cause for concern precisely because it does not belong to
any one kind of person or group; it is a social threat because it affects everyone. That opioid
addiction is understood as happening to Americans from “all walks of life” is a crucial discourse,
one that gives cause for widespread panic and provides a basis for articulating opioid addiction
as a grave threat capable of destroying the integrity of American society writ large (Committee
on Education and the Workforce, 2018; Kaplan, 2018; Whitehouse.gov, 2018).
A final point to make about moral panics is the way in which they rely on the
mobilization of experts, who pronounce diagnoses and develop solutions to mitigate the threat-
23
at-hand. In the opioid epidemic, if there is any group we could pinpoint as a foil, as a “folk
devil,” it would be precisely these experts: The opioid epidemic’s representation across the
media landscape is littered with accusations and denunciations that almost never apply to opioid
addicts themselves (a phenomenon which makes the epidemic relatively unique, as drug
scourges go), but instead targets the people/groups who were themselves charged with
preventing, diagnosing, and resolving these kinds of problems: In recent years across a variety of
media platforms, experts and specialists ranging from physicians to pharmaceutical
manufacturers to pharmacists, pain specialists, scientists, and regulators, have all come under fire
for the ways in which they are understood to have contributed to the current crisis. What blaming
these actors suggests is that the opioid epidemic is not so much about decrying and policing the
behavior of deviant folk devils who disrupt the social system but is rather about undercutting the
legitimacy of those various actors who constitute that system. Thus, it seems to me that it would
be a stretch to classify the mediated nature of the opioid epidemic as a kind of “moral panic.” For
in the American imagination, concerns about the opioid epidemic say less about the problematic
behavior of certain folk devils than they do about fault-lines in a larger system. It would seem
then, that what we need in terms of an analytic is one that refers to a media event in these terms –
where the problem-at-hand is situated in relation to, and further characterized by, the
representation of system failure. I turn now to another framework, one which entails this kind of
system-wide focus, to consider how epidemics are constructed in public health in the language of
public health emergency.
On October 26, 2017, President Trump signed a presidential memorandum ordering the
acting secretary of health and human services to declare the opioid epidemic a “nationwide
public health emergency” (Hirschfeld Davis, 2017; Wagner, Bernstein, & Johnson, 2017). But
24
what does it mean to frame the opioid epidemic in this way? What kinds of characteristics belong
to public health emergencies as another type of media event? And what can these characteristics
tell us about the opioid epidemic and the way it is becoming articulated and understood in the
American imagination?
In Unprepared (2017) Andrew Lakoff asks, what makes a situation an emergency? This
question, as Lakoff explains, has a long answer, rooted in the history of public health – a field
which developed in the 18
th
and 19
th
centuries as a means of learning about and intervening upon
disease outbreaks. During these early years, public health approached emerging threats by
linking them to material structures – to sanitation systems, water supplies, and the ways in which
the population within this field lived and circulated through it. Intervening upon public health
threats in this domain was done mostly through reliance on past knowledge, through the
calculation of probabilities based on patterns of similar outbreaks that had taken place in the past
and utilizing that knowledge in order to craft timely responses to the present threat. The approach
to managing public health threats in recent decades, however, looks markedly different, largely
because today’s “threats” do not resemble their historical precedents. Instead, they are novel,
something we’ve never experienced before (often because it is unique in its character or
unprecedented in its size and scale). When it comes to managing such novel and uncertain
disease “events”, public health officials are often disastrously “unprepared” (Lakoff & Collier,
2008; Lakoff, 2017). “Unpreparedness” is both a problem central to the construction of public
health emergencies today and one that sheds lights on some of its other key characteristics: First
is the kind of interventions that are often sought in the face of uncertainty – interventions which
cannot rely on historical data, but must instead engage in the ongoing production of knowledge
through the mobilization of surveillance techniques designed to identify and mitigate health risks
25
as they are unfolding in real time. Indeed, the mobilization of interventions rooted in the problem
(and reality) of extreme uncertainty characterizes much of the discourse in circulation around the
opioid epidemic as well as much of what has taken place in response to it. In the context of
opioid regulation, in particular, the sudden uptake of prescription opioid abuse spurred the
development of a variety of “pharmacovigilance programs,” the sole purpose of which was to
collect and monitor data as it emerges in real-time.
1

Second, as Lakoff and Collier (2008) have suggested, one can understand the declaration
of a public health emergency to function as a response by experts and opinion-leaders to the
widespread public concerns, doubts and condemnations launched against them and at their
failure to anticipate or respond to a particular threat. This is to say that public health
emergencies, which are defined by experts (in science, government, etc.), often reflect the
shortcomings of these same actors and, as such, are “product[s]…of the scientific frameworks
and governmental practices that seek to know and manage” them (7). One way of understanding
this relationship between public health emergencies and the experts who are centrally involved in
their construction is through looking at the way in which emergencies involve the identification

1
As I’ll discuss in detail in Chapter 3, the use of pharmacovigilance and similar
surveillance techniques in opioid regulation can be understood as a response to a horrible system
failure – in which the FDA attempted to regulate a particular opioid medication using an older
approach to public health (on that relied on historical data and analogies of patterns of use with
“similar” kinds of drugs) that would end up producing a serious gap in knowledge, one which
prevented the FDA from predicting the soon-to-be surge of opioid overdoses that, in some
accounts, represent the start of the entire epidemic.
26
of risks that Ulrich Beck (1992) articulated as “modernization risks.” That is, the risks that give
rise to public health emergencies are risks that were produced from within the workings of
modernization itself, often by the very same institutions, knowledges, and practices that were
meant to prevent, understand, and contain them. As a public health emergency, the opioid
epidemic is likewise articulated in relation to such modernization risks: It is a problem that did
not emerge out of thin air, but is understood instead as something that grew out of the specific
knowledges, practices, and logics being applied from various domains of expertise within our
health-related institutions (medicine, pharmacology, regulation, accreditation, etc.) – those same
institutions which Americans have relied on for the promotion and protection of their health,
comfort, and safety. In the opioid epidemic, these experts and institutions are widely imagined as
being key contributors to the current crisis and, in many media accounts of the epidemic, are
vehemently disparaged for their irresponsibility in failing to predict it as well as for their
subsequent failure to respond to it (e.g., Frydl, 2017; Von Drehle, 2018). Indeed, the
accumulation of such disparaging accounts could very well be understood as something that
provided a justificatory basis for the (much delayed) designation of the opioid epidemic as a
nationwide public health emergency.
It seems clear then, that as a particular kind of media event, the opioid epidemic is much
better characterized in the language of emergency than it is as a moral panic. For emergency – in
particular in the domain of public health – signals the kind of system-wide failure that is also
represented in media accounts of the opioid crisis. Additionally, similar to what Collier and
Lakoff noted in their analyses of global public health and biosecurity threats, the declaration of a
public health emergency is a performative act that signals (and augments) a crisis of expertise
and institutional knowledge. This much is likewise clear in the opioid epidemic and is reflected
27
in my account of it, which examines the ways in which specialized logics, knowledge, and
practices in various domains of health-related expertise are undercut (often by themselves) and
called into question as the rates of opioid abuse and overdose have continued to climb.
One example of expert knowledge, which is also an institutional logic, that appears to
have completely collapsed under its own weight in the opioid epidemic is the logic (used by
physicians, pharmacists, and regulators, and manufacturers alike) of medicine taken “as
prescribed.” This logic, which is most often expressed as a directive in medication guides,
suggests that a given medicine will work as it should so long as it is taken in the proper way, so
long as patients use it “as prescribed.” By extension, when a patient takes her medicine in a way
other than “as prescribed,” she is seen as having put herself at risk – and the risks are unknown.
This rule of as prescribed has a number of key functions within the U.S. health system: First, it
serves as a safety measure, that helps fulfil one of the FDA’s basic regulatory tenants (safety and
efficacy). Second, it provides a legal logic that protects regulators, manufacturers, physicians,
and pharmacists from prosecution should a patient suffer an injury or die as a result of taking her
medication “not as prescribed.” Third, it provides a means of classifying individual consumers as
well as their consumption behaviors: Those who take their drugs “as prescribed” are patients and
their behavior is neutrally understood as medication “use.” Those who deviate from the rule of
“as prescribed” take on a different status; they are not patients but something that more closely
resembles an addict. Their consumption is not medication use but takes on a new connotation as
“abuse.” The rule of “as prescribed,” which clearly has many useful functions that help organize
and police people and practices within the domains health and medicine, are breaking down. We
see this in media accounts of the opioid epidemic which recount the widespread panic directed
toward the sudden transmogrification of patients into addicts (Calabressi, 2015). So too do we
28
read stories that signal to use a sharp escalation of fear and doubt – doubt which is expressed
with regard to these supposedly legal medications that are now killing off patients by the
thousands just like a drug, or a poison would do. And there are other narratives, some which tell
us that doctors are no longer doctors but drug dealers, and these narratives are supplemented with
news about cases launched against doctors (including the physician of the late musician, Prince)
whose patients died from taking their medications “as prescribed” (Deprez & Barrett, 2017;
Moshtaghian & Meilhan, 2018; Pazanowski, 2018). Indeed, the dissolution of the boundaries that
were set in place by the rule of “as prescribed” are breaking down all over the place, in mediated
accounts of the epidemic and in the official statements made by government officials and health
experts who (while not exactly admitting anything) hint that the problem is, by now, too far out
of their reach.
Doubt, fear, and uncertainty expressed from every corner of this nation’s health
establishment makes it clear that this epidemic, as a particular kind of media event, is best
understood in terms of the modernization risks, crises of expertise, dissolution of logics,
categories and other such boundaries, and the urgency that prompts the creation and mobilization
of new institutions and technologies aimed at confronting the mounting crisis – for these are the
phenomena that dominate the front pages, alongside the escalating death toll that has rooted itself
in many American’s imaginations. Thus, the following analysis sees the opioid epidemic as
being highly significant in the following ways – as a phenomenon that points to fault-lines in the
larger health system, as a discursive product of the those same institutions that find themselves in
crisis because of it, and as problem space that has sparked doubt and fear in the American
imagination, which is attuned to the inherent risks of relying on a health system that has not only
failed to promote the wellness and ensure the safety of American citizens, but which has
29
(whether intentionally or not) helped enable the breakdown of its own boundaries. Cracks within
this system have made it possible for waves upon waves of prescription opioids to tumble out of
their official contexts and flow into the grey and black markets where they now often circulate.
The Opioid Grey Market
It would be difficult to provide a comprehensive analysis of the opioid epidemic without
saying something about the markets in which opioids travel and the broader political economic
context within which these markets have crystallized and grown. The political economy that
surrounds the opioid epidemic is animated by the governing logics of neoliberal capitalism – a
term which I use to refer to a specific form of governmental rationality characterized by the
expanding role of market forces and market relations in the regulation of society (Barry, Osborne
& Rose, 1996; Foucault, 2008; Rose,1999) and as a political economic system further
characterized by the dominance of free-market economics, the widespread deregulation of
finance and industry, increased privatization, the globalization of capital flows, and the
conception of society centered on the role of the individual, self-enterprising economic subject
(Crouch, 2013; Kotz, 2015). And while I would not diagnose the opioid epidemic as merely a
symptom of neoliberal capitalism, it is undoubtedly the case that the emergence of this epidemic
– which is largely encompassed by sudden, surging rates of injuries and deaths resulting from
surges in both the supply and demand of legal, pharmaceutical drugs – is coherent within the
neoliberal framework. Specifically, a political economic context marked by de-regulation
corresponds with the relative ease through which opioid narcotics have been released onto the
market and allowed to flourish there, despite growing awareness and concerns expressed by
regulatory institutions and the public with regard to the dangerous associated with their use.
Moreover, the privatization of health care – marked by the formation and proliferation of
30
alliances between public regulatory institutions, semi-public accreditation organizations and
private industry actors such as pharmaceutical companies – is yet another key dynamic that not
only corresponds to but can also be said to have promoted the continued expansion of a market
for opioid products.
At a slightly different level of analysis, the structuring context of neoliberal capitalism
also frames the relationship between the prescription opioid market and the millions of
individuals who make up its consumer base. Though opioid addiction now affects a broad swath
of the American population, it began (and remains) highly concentrated in Appalachian
communities and the American Rustbelt and, within these areas, among the “white working
class” – a cultural construction commonly used to represent a socio-economic demographic
which, as many have recently noted, were standing in the vanguard when the forces of neoliberal
capitalism came to lay waste to them - stripping away their social security nets, outsourcing their
labor, and eating away at the ethos of their communities (Murray, 2013; Quinones, 2015; Vance,
2018). Within the opioid epidemic, individual opioid addicts belonging to the white working
class are hailed as victims of these larger dynamics. To provide one example of this discourse,
one only need consider the quick rise to fame of the idea that White America is now dying from
“deaths of despair” and that, more often than not, these deaths are attributed to “accidental
poisonings” and suicides involving opioids (Case & Deaton, 2015). Indeed, the swift decline of
life expectancy among white Americans is shown to be, at the very least, related to the
widespread use of opioids among this group – these white Americans who are (and have been for
a while) the opioid industry’s most loyal customers.
That the current drug scourge began with (and still centrally involves) the abuse of legal,
regulated, institutionally-channeled products, distinguishes it somewhat from previous drug
31
crises, where the substances-in-question were confined to the street and to the black market
where their manufacture, distribution and consumption was clearly legible as illicit, and its
domain, criminal. This is no longer the case with opioids which – as previously noted – call into
question the durability of these concepts, and of the binaries within which they have long been
positioned. When you have a drug like a prescription painkiller that is legally manufactured,
regulated by the FDA, but which circulates as much through informal channels (namely, through
gifting practices among friends and family members) as it does through official ones (through a
physician’s written prescription), and is likewise consumed in ways that are often “other than
prescribed,” how do you classify it? At which point does a legally obtained medicine become an
illicit drug? Where is the point-of-no-return where family members suddenly become re-
classified as drug dealers, where patients become addicts? And what happens when the legal
market for prescription opioids gives way to the opioid black market? How are we to
characterize the new contexts wherein these slippages take place?
The processes through which such categories are breaking down and in which the
boundaries that made them legible are being slowly but steadily dissolved signals the rise of
what I refer to as the “grey market” for opioid drugs. The emergence and growth of the opioid
grey market is both a crucial dynamic within the opioid epidemic itself and also something that
points to its significance in the larger landscape of American culture and society. By “grey
market,” I am referring to contexts, dynamics, and practices related to the production,
distribution, and consumption of opioids that – in their interaction – have troubled, at times, and
completely undercut, at others, many of the key institutional logics within our nation’s health
system and in domains related to it (drug enforcement, regulation, etc.). The grey market,
moreover, gives us a lens through which we can analyze and (hopefully) provide some
32
provisional answers to the question of how it was that this opioid epidemic was allowed to
emerge and grow unchecked for so many years and why it has continued to expand even in the
face of efforts by multiple stakeholders to contain it? In chapters 2 and 3 of this text, I will speak
more directly to this question. But for the purposes of this introduction, I want to say something
more about what the opioid grey market is, what its key processes are, and why we should care
about it.
The emergence and growth of the opioid grey market has relied primarily on two key
processes, both of which are dedicated their own chapters in this book: Branding and regulation.
The branding of opioids, as chapter 2 lays out in detail, has played a decisive role in re-
articulating the meaning of opioids in ambiguous ways, which have rendered their circulation
and consumption in terms that are neither wholly legible as legal/medical or
criminal/recreational. The processes through which the branding of opioids proceeded can be
understood in terms of familiarization and domestication, processes which transformed –
seemingly overnight – what was previously understood as a dangerous narcotic into a first-line
medical treatment, a staple in medicine cabinets across the country. Part of the steady
domestication of opioids, as I argue, has much to do with the way in which these drugs were
articulated to the problem of pain, and how pain was incorporated in pharmaceutical branding
efforts not only as a bothersome symptom, but as entirely antithetical to certain American values
and as a hindrance to individuals’ pursuit of the “American Dream.” Re-writing opioid use in
this way played an important role in conditioning their uptake among doctors and patients alike.
The extensiveness of this uptake, which led to sharp increases in opioid production quotas,
resulted in a pharmaceutical market that was positively flooded with these drugs. This inundated
market and the presence of opioids in so many American households goes hand in hand with
33
shifts in the contexts of their circulation – where, being in large supply, these drugs moved into
far more casual domains, where they could be borrowed, gifted and exchanged. In the grey
market, drugs are not “copped” on the street, nor “purchased” at a pharmacy; instead, the
exchange opioids often takes place in more ambiguous situations – where a friend takes a
palmful of his mom’s pain pills (which maybe she uses or maybe have been sitting on the shelf
collecting dust) and hands them over to his buddy who has a bad toothache and no prescription.
Though these unofficial forms of exchange are technically illegal, the contexts within which they
take place (which are domesticated and familiar) make them difficult to read as such. In this way,
branding has functioned as a process that through familiarizing opioids as household objects and
promoting their incorporation into these domestic domains, has provided some key conditions of
possibility for a new kind of market, painted in ambiguous shades of grey.
In addition to branding, regulation is the second key process that has contributed to the
development of the opioid grey market. As chapter 3 discusses in more detail, the logics that
undergirded many of the regulatory decisions that were made with regard prescriptions opioids
were operationalized under conditions of extreme uncertainty and, at times, a rather more
intentional “strategic ignorance.” Consequently – and rather ironically – many of the measures
regulators took to anticipate and mitigate the risks associated with opioid use also laid the
groundwork for those risks to become realities, and for opioid use to spiral out of control in ways
that regulators did not predict (and, to be fair, probably could not have predicted). One such
consequence has been the development of what critics of U.S. drug policy refer to as a “balloon
effect” – where regulation in one domain produces a host of new regulatory problems and
challenges in another (like squeezing the air out of a balloon). In the case of opioids, regulatory
interventions that sought to replace older, more addictive opioid drugs with newer “abuse
34
deterrent” technologies did not deter abuse so much as they reconfigured it. In the wake of this
measure, patterns of opioid use shifted away from prescription drugs toward more powerful (and
far deadlier) synthetic opioids – namely the illicit drug fentanyl. Fentanyl – because of the
unique characteristics of its chemical composition as well as because of the difficult-to-regulate
channels through which it is manufactured and distributed – poses a grave threat to regulators
and law enforcement, whose current tactics for policing illicit drug use are (for reasons that are
discussed in chapter 3) ill-equipped to combat such a novel threat. Here, the sudden slippage
between the white and black worlds of licit and illicit opioid use – where one regulatory decision
leads smoothly into a mass movement of opioid users from their doctor’s offices into the street –
indicates the existence of a meaningful connection, or perhaps even a shared territory that links
regulatory institutions to the unregulatable black market. Opioid regulation and consumption in
this shared terrain, as I argue, is a fundamentally grey matter – one that is re-shaping the broader
landscape of drug use and contributing to a growing crisis of legitimacy within America’s health
institutions.
Chapter Overview
As stated earlier in this introduction, the problem of opioid addiction is inseparable from
the problem of pain. Thus, this volume begins its analysis by developing a genealogy of the
medical field of pain management and the so-called “pain revolution,” wherein opioids suddenly
emerged as the hallmark treatment for managing different types of pain. Before the mid-1990s,
attitudes within the medical community toward opiates were reluctant at best. Physicians were
wary of prescribing what they understood to be extremely potent and addictive drugs and did so
sparingly, usually as a last resort for patients suffering only the most agonizing forms of cancer-
related pain. Yet, in the mid-1990s, the idea took hold that most doctors were undertreating pain,
35
and that opioids were not nearly as addictive as previously thought (Meldrum, 2016). From 1999
to 2013, opiate prescriptions quadrupled, reflecting a profound shift in medical thinking around
the risks and benefits of these drugs.
While this chapter focuses on shifts in medical knowledge and on the corresponding
development of instruments for measuring the subjective experience of pain, it also examines –
in genealogy’s non-linear fashion of analysis – how forces outside the domain of medicine acted
upon and in conjunction with medical expertise in ways that helped spark the pain revolution. As
I show, the discourses, practices, and strategies enacted by politicians and pharmaceutical
companies, patients and policymakers, doctors and chronic pain advocates, worked together to
construct a fertile landscape in which the problem of pain became significant – not only for
medicine, but for politics and culture in general. Within this landscape, pain management
became re-articulated as universal human right. The moral significance that pain management
gained with its articulation in rights-based discourse has been complicated, and to some extent
augmented, by the question of pain’s subjective nature. Put another way, the rights-based
discourse attached to pain provided a strong justification for a concerted push (in both medicine
and politics) to develop new ways of measuring and treating it. The rather paradoxical task of
objectively assessing an inherently subjective phenomenon and the ways in which it was put into
practice resulted in the development of a protocol for understanding pain as a “5
th
vital sign” and
for assessing its treatment in ways that gradually institutionalized it as part of the common-sense
of clinical practice, where opioids were quickly incorporated as an effective tool for treating pain
within the clinical encounter. By tracing the various trajectories through which opioids and pain
become conceptually and materially attached to one another, this chapter attempts to take an
36
initial step at understanding how opioid use became normalized as the best, if not only solution
for addressing the medical, political, and cultural problem of pain.
Chapter 2 investigates the processes through which opioids became normalized outside
the domain of medicine and, specifically, how it came to be that the meaning of these drugs –
which had long been understood in terms of their dangers – was re-configured in the American
imagination, where opioids were (throughout the 1990s) incorporated into American households
and re-situated as familiar, domesticated objects therein. As this chapter argues, the
domestication of opioids cannot be understood apart from the branding of pain and its
management – nor from the aggressive and wide-ranging efforts made by pharmaceutical
companies to market opioid products to a growing base of potential consumers. Indeed, as others
have written, branding is a key cultural process – one that takes place through strategic meaning-
making and, as such, can be thought of as both a cultural process and a form of governance
(Ouellette & Hay, 2008; Zwick, Bonsu, & Darmody, 2008) that acts on the “minds, bodies, and
self” of consumers (Moor, 2003). In doing so, branding also seeks to define and delimit the ways
in which consumers will relate to and interpret their relation to products as well as to their own
experiences, values, behaviors, and the world around them (Banet-Weiser, 2012; Hearn, 2010;
Turow, 2011). This chapter develops an analysis of the branding of pain relief through a case
study of the marketing of what is perhaps today the most famous of all the prescription opioids –
the infamous painkiller OxyContin – and its manufacturer, Purdue Pharma.
Through an analysis of dozens of print advertisements, video campaigns, and other
marketing techniques that Purdue used to promote this product, this chapter argues that the
branding of OxyContin proceeded through two key themes, both of which center on the problem
of pain and the goal of finding relief: The first constructed pain relief as a necessary first step
37
toward individual self-actualization and to the promise, that Purdue Pharma granted to all
potential pain patients, that OxyContin would help them rediscover their best, authentic self. A
second and related theme advanced within the branding of OxyContin was one that constructed a
vision of pain as the antithesis to individual productivity and responsibility. These branding
discourses called upon pain patients to reassume their roles as responsible citizens, consumers,
and economic subjects, all of which they could accomplish simply by incorporating OxyContin
into their daily treatment regimens. In the case of both the above themes, OxyContin was
branded in ways that hinged on the articulation of pain relief (and by extension of pain-relieving
drugs) to a liberal ethic and vision of the “American Dream” constructed around the inherent
value of productivity and self-enterprise as necessary requirements for restoring meaning to
one’s life. These discourses, as I show, were likewise transplanted into institutional settings,
where they became embedded in organizational protocols that were (and still are) used to govern
clinical practice. In this way, I argue, the branding of pain relief is significant not only for the
ways in which it commodified a particular medical phenomenon, but also for the ways in which
it has functioned as a technique of governance-at-a-distance, one that channeled both individual
behavior and clinical practice in ways that led consistently to opioids. Moreover, the branding of
OxyContin provides a powerful example of one route through which the problem of pain itself
has been re-articulated in American culture, where it has been bound up with specific cultural
logics, norms, and values that continue to frame and delimit the ways in which we understand
our relationship to it.
Though the branding of pain relief is indeed a crucial moment in the longer trajectory of
the opioid epidemic, it is also the case that neither opioids nor any other pharmaceutical drug can
enter the market and become a brand without first passing through the regulatory apparatus of
38
the U.S. Food and Drug Administration (FDA). To that end, chapter 3 investigates the regulatory
logics that undergirded the FDA’s decision to approve the release of certain opioid drugs onto
the market and its subsequent decisions to leave them there, in spite of growing awareness of the
dangers associated with their use. This chapter, which focuses on the regulation of OxyContin,
among other opioid medications, shows how the FDA’s ability to anticipate and prevent the risks
associated with these drugs was undermined at nearly every step of its regulatory process, where
extreme uncertainty, strategic interest, and an over-reliance on industry alliances rendered it
blind to the lived realities of opioid use and abuse. Additionally, this chapter discusses the ways
in which opioid regulation has contributed to the formation of a grey market for opioid drugs – a
phenomenon which has only served to further debilitate its regulatory capacities and threaten its
legitimacy in the midst of an evolving landscape of synthetic opioid use that it must now
confront but, with the tools and logics it has at hand, cannot hope to contain.
These new contexts that constitute the opioid grey market are conditioned by – and
themselves help to reproduce – an environment of extreme uncertainty. Within this environment,
the categories that have long been employed to make sense of and to manage the world of drug
have begun to erode. Indeed, narratives of the opioid epidemic are brimming with evidence of
such categorical breakdowns, where patients become addicts, doctors become dealers, cures
become poisons, and solutions give rise to new and greater problems. Each of these semantic
shifts reveals a crack in the larger classificatory system. And in the face of such a system failure,
the need to re-classify and re-establish meaningful distinctions becomes all the more acute. Thus,
the fourth chapter in this volume focuses on such attempts to restore order to what now appears
to be a system in crisis. It does so by focusing on the processes of subjectification through which
institutions and the media engage in efforts to name and classify opioid users as different kinds
39
of subjects. Through these processes of subjectification, which are mobilized from “above” by
institutions as well as in the grassroots of popular culture, three different kinds of subjects are
produced, which I refer to as “patients at risk,” “pathological consumers,” and “consumed
addict-victims.” Each subject, as I show, performs a specific function within the opioid
epidemic, though all are deeply related to and have been influenced by a longer historical process
centered on the discursive construction of patients and addicts. I trace several key moments in
this larger history to show that while the subjects of the opioid epidemic in many ways resemble
constructions of addicts and patients in the past, they are also being re-articulated in ways that
shed light on the ways in which our understanding of addiction is currently shifting, as well as
how and why this is occurring under the auspices of the opioid epidemic.
The construction of addicts and patients also points to a larger question – one which is
addressed in both the fourth and fifth chapters of this text: Whose pain matters? And, relatedly,
how is it made to matter? Addressing this question requires us to look at subjectification
processes – both to see how they proceed through the categorization of different kinds of users
and how such categorization nearly always relies on problematic hierarchies of both class and
race. Indeed, as many other scholars have written, discourses that mediatize difference through
emphasizing race and ethnicity have a profound effect on the cultural imaginary and on the ways
in which individuals interpret events taking shape in the world around them (Joseph, 2012;
McIlwain & Caliendo, 2011; Rodman, 2014). Indeed, as I detail in the fifth and final chapter,
subjectification in the opioid epidemic has been mediatized in ways that construct the problem
around the social categories of race, ethnicity, class, and difference. In particular, subjectification
in the opioid epidemic has contributed to a narrow rendering of this problem as a narrative that
applies specifically (and solely) to white America, who are not seen as pathological drug
40
consumers but as victims of larger social, cultural and economic forces, which have consumed
them.
2
When seen as a white-only problem, specifically one which is constructed along the lines
of a specifically white form of victimhood, the opioid epidemic begins to function in ways that,
borrowing from George Lipsitz (2009), reflect a “possessive investment in whiteness.” That is,
the opioid epidemic, when it is constructed directly in terms of the plight of white America,
provides a justificatory basis for developing interventions and solutions in the name of
whiteness, and for channeling those solutions toward white users and away from others who
might also need them. This chapter then, examines how narratives of race and class get
channeled into the material realm of addiction rehabilitation, where the discourses that make
opioid legible as a white problem anticipate the augmentation of a material reality defined by
systematic inequality – where the best and newest resources, technologies and interventions into
opioid addiction are selectively oriented toward the rehabilitation of white opioid users, while
their access to people of color is subsequently limited.
Finally, this volume concludes by considering the implications of its method, analysis,
and findings for the development of policies and future research related to health, medicine, and
their relationship to culture. In particular, I suggest that developing a rich understanding of the
opioid epidemic – of something that might otherwise be understood as a purely medical
phenomenon (and indeed, it has often been articulated this way) – is better achieved by taking a
more comprehensive approach that considers its relation to other social problems, to politics,
economics, and to American culture, more generally. For the opioid epidemic is, without

2
For another take on the construction of whiteness as victimhood, see Michael Lacy’s
work on white innocence (Lacy, 2010a; 2010b)
41
question, a multi-faceted phenomenon, one that says as much or more about the hopes, fears,
dreams, values, and transformations taking place within the broader landscape of American
culture than it does about any particular medical truth. Yet while the opioid epidemic is indeed a
multi-faceted phenomenon, one which carries a great deal of significance for countless actors
and groups, it is animated, first and foremost, by the problem of pain – a problem which, like the
epidemic itself, is both medical and scientific, political and economic, social and cultural. It
makes sense then, that if the opioid epidemic has much to tell us about American culture and if
the epidemic itself cannot be understood apart from the problem of pain, that this is the point
where we must begin.

42
Chapter 2: A Genealogy of Pain Management

On November 1, 2011, the U.S. Centers for Disease Control and Prevention (CDC)
issued a press release that warned of a mounting death toll. The rate at which Americans were
now overdosing (and often dying) from prescribed opioid medications had reached “epidemic
levels,” killing more people than car accidents, more than cocaine and heroin combined (CDC,
2011). In the same press release, the CDC also referred to prescription opioid abuse as a “silent
epidemic.” Indeed, the numbers of Americans dying from prescription painkillers had been
creeping upwards for some time: According to a report by the National Institute on Drug Abuse
(NIDA), overdose deaths quadrupled between 1999 and 2007, escalating from 3,000 to 12,000
each year. Compare this with the number of deaths from cocaine, which killed about 6,000
people in 2007, or heroin, which killed about 2,000 (NIDA 2015). That prescription opioids –
drugs which circulate largely through tightly regulated channels – kill so many people every year
is striking.
Accounts of the increasing numbers of opioid prescriptions, overdoses, and deaths
typically rely on medical explanations: These include attributing transformations in prescribing
habits to an evolution of medical knowledge regarding the safety of opioids, or to growing public
awareness of the prevalence of chronic pain, or to surges in patients’ demand for opioid-based
pain medications. Such explanations, I contend, assume a linear evolution in scientific and
medical thinking and, in doing so, capture only part of the bigger picture. While I don’t deny that
evolutions in medical thinking have played a significant role in conditioning the practice of pain
medicine, relying on medical explanations alone does little to help us understand the current
epidemic. In order to develop a richer understanding of contemporary drug-related phenomena
such as the opioid epidemic, we need to broaden our lens beyond the world of medicine to re-
43
think and add to what have previously been identified as the key issues at stake. For the most
part, these issues have been confined to one of two discursive poles: One, which has been
focused on the development of medical knowledge and expertise and another, which has been
constructed around a moral discourse of pain relief as a fundamental human right. Examining
these discourses along with the ways in which they have intersected, combined, and clashed, will
help us understand the conditions which anticipated the upsurge of opioid prescriptions that now
signifies the existence of a nationwide “epidemic” of opioid abuse and addiction.
However, to understand the epidemic, we must re-focus our attention away from the
problem of opioids toward the interconnected problems of pain and pain management – a
problem to which opioids nearly always refer. The ways in which pain has been defined – both
within and outside of medicine – have narrowed the possibilities for its management in clinical
settings. To that end, this chapter develops a genealogy of pain management. As a “history of
the present,” genealogy offers three major benefits: First, it provides us with a path to
understanding the opioid epidemic as it exists in our current moment, which is characterized by
skyrocketing rates of opioid prescriptions and opioid-related deaths nationwide. Second, as an
example of what Stuart Hall (1987), has referred to as “conjunctural analysis,” genealogy does
not assume linear evolutions in knowledge/practices but rather attends to the generative effects
of contingent forces – of the coalitions, collisions, and contradictions originating from a variety
of domains (both within and outside medicine) that, in their interaction, over-determine a given
historical moment. These contingencies are the tools with which we can better understand
present-day phenomena. Finally, because it is a non-linear form of analysis, genealogy also helps
us recognize the recursive relationships between different domains of knowledge and practice,
for pain is not – and has never been – just a medical object: It is also a social, cultural,
44
economic, and political problem. The politics of pain are particularly revealing of the co-
mingling of medicine and government. In this partnership, medical knowledge and practice are
strategically utilized by the state as means of governance-at-a-distance, which guide decision-
making in health-related policy and clinical practice. A genealogy of pain management, which
focuses on the contradictions and collaborations that emerged within and between medicine and
politics, attends to the intersecting discourses, practices, institutions, and technologies that
helped to legitimate, universalize, and promote opioids as the best – if not the only – way of
solving the problem of pain.
A Brief History of Pain Medicine: 1945-1975
“I swear to fulfill, to the best of my ability and judgment, this covenant: I will
remember that I do not treat a fever chart, a cancerous growth, but a sick human
being, whose illness may affect the person's family and economic stability. My
responsibility includes these related problems, if I am to care adequately for the
sick…I will remember that I remain a member of society, with special obligations
to all my fellow human beings…May I always act so as to preserve the finest
traditions of my calling and may I long experience the joy of healing those who
seek my help.” (From the Hippocratic Oath, modern version, 1964).
That medicine has long been bound up with morality is nothing new. Even a cursory
glance at the Hippocratic Oath quoted above asserts that those who practice medicine must also
commit to a kind of practice which extends far beyond the lab or clinic, beyond the diagnosis and
treatment of disease. The “special obligations” of the physician positions her in two roles: She is,
at once, a scientist whose value lies in the specialized knowledge, objectivity, and expertise that
distinguishes her from her patients, and a caregiver who is valued in terms of her humanity and
45
the oath that she has sworn to reduce the suffering of her fellow human beings. These discourses
which define the role of the doctor as a scientist and a caregiver are integrated in the Hippocratic
Oath and are particularly pertinent to the discourse and practice of pain management, for which
attending to the suffering of others is not only a humanitarian act, nor a principle latent in
medicine, but is a unique medical object, a diagnosis that has, over the past half-century, given
rise to a set of theories, procedures, and interventions that together constitute the field of pain
medicine – and the focus of physicians who specialize in the management of intractable pain.
The history of pain management extends thousands of years into the past, to somewhere
around the year 4000 BC, when the Sumerians created an ideogram for the poppy plant (from
which opium is derived) and likened it to “rejoicing” or “joy” (Conrad & Schneider, 1980). In
the seventeenth century, pain was recognized as a virtue, a means to spirituality and a signal of
life’s vitality (Rey, 1995). And while the sensibility that bearing pain without complaint is noble
or dignified has not entirely disappeared, the past two centuries have modified our relationship to
it. Understanding pain in terms of its symbolic value has given way to a more pragmatic
approach, in which pain is explained and examined not in relation to the soul or as the price to be
paid for existence but in relation to the body and the psyche. If pain is an embodied experience
rather than an existential phenomenon, then it is something to be researched, treated, prevented,
manipulated, and controlled. It is this pragmatic approach to pain that underlies its
transformation into an experimental object, and to the development of theories of pain in
semantics, psychology, physiology, and therapeutics (Rey, 1995). Ultimately, then, it was the
orchestration and (perhaps more commonly) the contestation of these various disciplines,
hypotheses, and theories that paved the way for “modern” pain management.
46
In the nineteenth century, pain management swiftly evolved with the isolation of
morphine and its industrial production in Germany in the 1820s. Another key development was
researchers’ widespread experimentation with different forms of anesthesia and the invention of
the hypodermic needle which simplified the administration of pain-reducing drugs. The needle
also facilitated recreational self-administration, a practice which, as it became more widespread,
aroused concerns about habituation and addiction (Campbell, 2007). In the United States, these
concerns were addressed through the government’s initial attempts at drug regulation and put
into place in the 1914 Harrison Act, which regulated and restricted physicians’ legal use of
opioids in clinical practice. Not long after, the first World War normalized the medical use of
narcotic pain medication. The use of new military technologies that resulted in mass casualties
and even more grave injuries, mean that medics relied heavily on morphine – not only to treat
soldiers’ injuries but also as an improvised form of anesthesia for emergency surgeries and
amputations (Campbell, 2007; Tousignant, 2006).
The history of pain medicine that matters most begins during the Second World War and
with a man named Henry Beecher who, in the aftermath of battle, was charged with treating the
wounded soldiers remaining on the field. Beecher routinely offered morphine to the wounded
who, to his surprise, continually refused it. When he asked them about their pain, the soldiers –
many of whom had suffered grievous wounds – reported shockingly low levels of discomfort.
Yet, once they were removed from the battlefield and placed in the army hospital, their pain
intensified, suddenly transforming from moderate discomfort to unbearable agony, even though
their injuries had not worsened. What was this strange phenomenon, these patients’ experience
of horrific pain which, for some reason, seemed not to correspond with their injuries? Such a
phenomenon did not fit within any of the previously established medical frameworks
47
(Baszanger, 1998). Indeed, the dominant theory of pain at the time, specificity theory, posited
that “real pain” is a proportionate response to a noxious stimulus. As such, it could not explain
what Beecher witnessed on the battlefield (Meldrum, 2007). Ultimately, what Beecher concluded
from his interactions with wounded soldiers was that the experience of pain contradicted much of
the laboratory knowledge about it, as expressed in the specificity theory of pain: Patients’
experience of and reactions to pain are not necessarily proportional to the intensity of a noxious
stimulus. Rather, the nature and mechanisms of pain must be more complex. And pain’s
complexity, Beecher argued, must be studied not in terms of its relationship to a physical lesion,
but in terms of the patient, the person who experiences and responds to it. This insight that pain
is, fundamentally, a multi-faceted and highly individual subjective phenomenon, would inform
the development of pain management – both in theory and practice – for decades to come.
The assertion that pain is, first and foremost, what the patient feels and thinks it is
unfettered the scientific problem of pain from the laboratory context in which it had formerly
been confined. The theory and practice of pain and its management could now move freely into
new spaces – namely, into clinics. In the clinical context, pain research was to be conducted at
the intersection of science and care, where it would necessarily center on individual patients and
their self-reported experiences. A key assumption guiding the research was the need to take
patient narratives at face-value since, “Any attempt to evaluate pain must begin with the
recognition that pain is a subjective phenomenon, and many factors influence the perception,
response, and report of subjective events” (Jacox 1979, p. 895). The consensus within pain
medicine to emphasize the importance of subjectivity would eventually – and somewhat
paradoxically – give way to the quantification and objectification of pain in the clinical context.
This process, as will be discussed in more detail, has proved essential for both the formation of
48
pain medicine as an established discipline and area of specialized expertise and for the narrowing
of the practice of pain management, which is today centered on the use of pharmacological
treatments.
In the United States, another physician was following Beecher’s footsteps. John Bonica
was an anesthesiologist whose interest in pain stemmed from his own experience dealing with
chronic pain related to the numerous injuries he suffered during his former career as a wrestler.
Like Beecher, John Bonica, who is now widely known as the leading pioneer of contemporary
pain management, studied pain in the context of the war, treating soldiers who had recently
returned home from overseas. Bonica was struck by the prevalence of soldiers who reported
experiencing pain in the limbs they previously lost in battle, even though the wounds themselves
were fully healed (Oral History Interview with John Bonica, 1993). This problem of lesionless
pain (otherwise known as phantom limb syndrome) was not intelligible in terms of the
contemporary theories, and often would not respond to treatment. Bonica was also frustrated by
the lack of available treatments – which at the time, were mostly limited to neurosurgeries (such
as lobotomies) and the administration of anesthesia, which was based on a mechanical medical
model that defined pain as a symptom which signaled the existence an underlying problem (Oral
History Interview with John Bonica, 1993). Physicians thus focused their attention on treating
the “real problem” to which pain was secondary and, certainly, much less important. Yet often,
in Bonica’s practice and in others’, no “real problem” could be identified. It thus became clear to
Bonica that pain could no longer be understood as merely a symptom but needed to be seen as a
diagnosis in its own right. What was also clear to him was that the diagnosis of lesionless pain
had a distinct set of psychological effects and that to understand how to treat it would require the
expertise not only of anesthesiologists and neurosurgeons, but also of psychologists and
49
psychiatrists. Therefore, as Bonica asserted in his now famous book The Management of Pain
(1953)
3
, the study of pain and its management must be a multi-disciplinary effort.
In 1960, as Bonica’s ideas about pain gained traction, he was named Head of the
Department of Anesthesia at the University of Washington and provided with funds to set up a
clinic in which he could put his theories into practice. Bonica’s clinic, which he named the
Multidisciplinary Pain Clinic, was structured on basis of his assertion that pain is a multi-
dimensional phenomenon and that advancing medical understanding of it requires specialists
from different fields to pool their knowledge. At his clinic, practitioners gathered from a variety
of medical disciplines, each with a different stake in the management of pain and armed with
specialized methods for treating it. Especially key to the practice of pain management at the
Washington Clinic was the influence of psychology – the science of subjectivity, a particular
kind of expertise that was now at the center of pain’s definition as “an unpleasant sensory and
emotional experience associated with actual or potential tissue damage or described in terms of
such a damage” (IASP, 1994).
It bears noting, briefly, the influence of behaviorism, a branch of psychology that, by the
late 1970s, was a critical component of many of the multi-disciplinary pain clinics that had
begun popping up around the country. The behavioral approach to pain management is generally
attributed to the work of Wilbert Fordyce, a psychologist who was also stationed at the
University of Washington, where he worked in the rehabilitation department at the university

3
Bonica’s book is now known as the first modern textbook of pain medicine and is
regarded by many as the “bible” of pain management. See Baszanger (1998) for an extended
discussion of Bonica’s textbook and its reception within the medical community.
50
hospital. Fordyce, in an oral history interview he provided in 1993, explained that he had become
frustrated with his lack of success in rehabilitating his patients, many of whom were heavily
medicated and could not perform the physical tasks that their therapy required. Desperate for a
solution, Fordyce decided to pursue the “hairebrained idea” of experimenting with a Skinnerian
approach to rehab therapy (Oral History Interview with Wilbert E. Fordyce, 1993, p. 11). B.F.
Skinner’s famous theory of operant condition posits that the behaviors of an individual are a
result of environmental stimuli, which, in an experiment can be manipulated by the researcher in
his or her attempt to alter a subject’s behavior. With this in mind, Fordyce designed an
impromptu experiment: He told his staff to ignore the complaints of their patients and to refuse
them medication which, he hypothesized, would only serve to reinforce and perpetuate their pain
behaviors (Turner, Calsyn, Fordyce, & Ready 1982). Instead, the staff were told to give positive
reinforcement only in response to their patients’ attempts to exercise, socialize, and engage in
other productive activities.
To his surprise, Fordyce’s “hairebrained idea,” actually worked. His patients’ complaints
became less frequent, and the patients themselves began to improve. In lieu of his success,
Fordyce developed a behavioral approach to pain management which involved assigning to his
patients a strict regimen of exercise, combined with a schedule of gradually reducing the doses of
their pain medication. When his patients obeyed the regimen, they received therapeutic attention
– the care they received was contingent on their good performance. This behavioral approach to
pain management impressed John Bonica, who then invited Fordyce to join his Multidisciplinary
Pain Clinic (Oral History Interview with John Bonica, 1993. As pain historian Marcia Meldrum
has written, Fordyce’s approach to pain management not only provided the field with a new
treatment option but also contributed to a richer understanding of pain itself: For Fordyce and his
51
colleagues had “completed the conceptual shift from what real pain ought to be to what real pain
actually is and does. Real pain, as defined by the patient, could now be understood as a
legitimate concern of many disciplines” (Meldrum 2007, 7).
In 1973, as interest in pain medicine was spreading throughout the U.S. and Europe, John
Bonica and his colleagues decided to organize what became the first international symposium on
pain
4
. The symposium was held in May that same year, in the remote area of Issaquah,
Washington, where 350 people gathered to pool their knowledge about pain. Importantly,
Issaquah brought together the folks working at Bonica’s Multidisciplinary Pain Clinic with
specialists from the British hospice movement, with a group of New York-based researchers who
were conducting research treating cancer-patients with opiate medication. Also present were
Ronald Melzack and Patrick Wall, who in 1965 developed the gate control theory of pain (GCT)
– which is to this day perhaps the most widely known (and disputed) theory about the
mechanisms of pain. GCT, which attributed the experience of pain to a spinal cord mechanism,
5

4
Issaquah jumpstarted the process of institutionalizing and globalizing Bonica’s ideas
about pain and its medical management. It is widely noted that this symposium laid the
groundwork for the formation of the International Association for the Study of Pain (IASP) in
1974 and the development of the renowned medical journal, Pain, in 1975. A year after Pain
published its first issue, IASP had already acquired 1,575 members from 55 countries who
together represented 81 different fields of research (Baszanger 1998).
5
GCT posited that pain can be understood in terms of a spinal cord mechanism that
normally blocks the transmission of painful stimuli to the brain by overwhelming them with a
52
provided a basis for acknowledging the physiological processes that contribute to pain and, in
doing so, helped to legitimize pain management as a field within medicine (Melzack & Wall,
1965; Wall, 1978).
By the mid-1970s, the field of pain medicine had already crystallized. A new medical
journal, Pain, was established in 1975 and immediately began to publish the latest research on
pain from around the world. That same year, the International Association for the Study of Pain
(IASP) held its first world conference, which highlighted the importance of pain as a global
public health problem and initiated the development of the first pain taxonomy, which was
created to provide a “universal vocabulary” to health care professionals around the world. The
goal of universalizing pain management was also furthered by the development and proliferation
of instruments and tools for “objectively” measuring the intensity of pain and the effectiveness of
pain medications. The use of these tools spread, becoming the focus of various sets of
“guidelines” developed by the World Health Organization and the American Medical
Association, along with numerous other administrative and professional organizations. As these
technologies spread, pain management became a routine medical practice outside of the
multidisciplinary clinics and pain specialists. By 1979, a survey of pain clinics counted 426
around the world, with 278 (65%) of those located in the United States (Meldrum, 2007).
Multidisciplinary pain programs quickly spread throughout the country and were soon referred to
as “medicine’s new growth industry” (Leff, 1976). Thirty-some years after John Bonica began
attempting to “sell” the idea of pain medicine and a multidisciplinary approach to its treatment,

larger number of normal, non-painful stimuli. Only stimuli of sufficient intensity can break
through the “gate” and reach the brain, which then arouses the perception of pain.

53
his efforts finally appeared to be producing results. And so it was that the modern discipline of
pain medicine was born. (Oral History Interview with John Bonica, 1993).
To conclude this brief (and admittedly incomplete) history of the development of pain
management in the 20
th
century United States, I want to emphasize the importance of considering
the broader context of the field’s development throughout these formative years. It is not enough
to show how pain management was able to assert its legitimacy in medicine, since pain was also
a widely-discussed topic in politics, culture, and society more generally. Specifically, throughout
the late 1970s and 1980s, the problem of pain was debated in cultural and political discourse
related to the “War on Cancer,” which helped fuel a movement of patients and patient-allies who
decried the health industry’s inhumane treatment of cancer patients, while promoting the
recognition of patient autonomy and a moral framework around the clinical practice of cancer-
related pain management. The articulation of pain management within the cultural and political
debates about cancer laid the groundwork for the former’s extension from medicine into political
and legal domains. As I discuss in the following sections, the problematizing of pain
management in these new domains played a crucial role in conditioning our current
understanding of pain – what it is, how to measure it, and what kinds of interventions should
constitute its treatment in clinical practice.
The Politics of Cancer Pain
Many of the issues concerning the problem of chronic pain were, in the 1970s and 1980s,
first articulated in the broader debate around the problem of cancer and the politics of managing
cancer pain. The politics of cancer and cancer pain are shaped by several key discourses and
practices that frame the politics of pain, more generally, and the ways in which pain would be
defined, measured, diagnosed, and treated for decades to come.
54
Throughout the 1960s, 70s, and 80s, the problem of cancer became a headlining topic in
the U.S. and around the world, in large part due to growing awareness and recognition regarding
massive increases in cancer diagnoses, deaths, and reports which linked them to specific
products and practices – of industries, institutions, and individuals. The rising interest in cancer
was accelerated by the advent of new technologies that facilitated the early detection and
treatment of lung, breast, cervical, colon, and skin cancer throughout the 1950s, 60s, and 70s
(Bode & Dong, 2010). Such advances also corresponded with increasing rates and types of
cancer diagnoses, which skyrocketed from 195,400 in 1950 to 400,000 in 1979 - a year in which
765,000 new types of serious cancers were also identified (American Cancer Society, 1980;
National Cancer Institute, 2013).
The increasing prevalence of cancer in U.S. society during these years instigated the start
of what would amount to several decade’s worth of debates and critiques that were targeted at
the various institutions and industries that were either seen as complacent or actively involved in
the manufacture and production of cancer-causing substances (Proctor, 1996). For example, in
the 1960s, the tobacco industry came under fire for the ways in which it was attempting to
suppress information about the real dangers of cigarette-smoking. In the same decade, debates
also raged around the role of industrial manufacturing in environmental pollution. The 1960s and
1970s also mark decades of extreme pressure on regulatory institutions such as the FDA, which
was repeatedly criticized for its hasty approval of drugs that became associated with different
kinds of cancers and birth defects (see Carpenter, 2010; Langston 2010). Perhaps most famous is
the Thalidomide scandal of the late 1950s and early 1960s, when the FDA approved the
immunomodulatory drug for the treatment of cancer – only to find that it resulted in the birth of
55
thousands of deformed children around the world.
6
The FDA also came under fire, as Nancy
Langston has chronicled in her book, Toxic Bodies, for its approval of and subsequent failure to
recall artificial hormones such as DES, which were linked to the spread of cervical and other
types of cancer among new mothers and their children (Langston, 2010).
As Langston suggests, the failure to regulate cancer-causing substances like DES was
conditioned by alliances between regulatory institutions and pharmaceutical companies (and
other businesses with interests in keeping DES on the market) as well as by dynamics within the
broader cultural landscape – where technological optimism combined with scientific uncertainty
helped to legitimize regulatory inaction and the continued use of such substances. Langston’s
analysis reveals an important dimension of the politics of cancer, which is characterized by the
enabling relationships developed between science, industry and regulatory bodies, and the ways
in which these relationships have also provided a basis for institutional and industrial critiques.
Yet Langston does not attend to another dimension of the political debates that have been waged
around the problem of cancer, debates which provide an alternative framing of the disease not in
terms of institutions and industries but in terms of individual cancer sufferers and the
moralization of the disease itself. In this moral-individual framework, the cancer patient him or
herself has been positioned as the central object of critique – with his or her disease being
understood as a kind of punishment – one that nature inflictes on those individuals who have
failed to adhere to certain ethical obligations and/or social norms.
Put another way, the problem represented by a cancer diagnosis has been framed within a

6
Thalidomide was also a problem in Europe, where it was widely prescribed for
pregnancy-induced nausea.
56
kind of moral panic, where it has been represented and understood as the inevitable result of a
patient’s poor lifestyle choices and failure to take responsibility for his or her own health. For
example, in Illness as Metaphor and AIDS and its Metaphors, Susan Sontag (1989) speaks to the
ways in which cancer, like AIDS, has been stigmatized by its associations with personal excess –
as “the fault of someone who has indulged in ‘unsafe behavior’ – the alcoholic with cancer of the
esophagus, the smoker with lung cancer: punishment for living unhealthy lives” (p. 153). The
stigmas of cancer and AIDS are, as Sontag suggests, undergirded by broader cultural
assumptions in which excessive/indulgent lifestyles are framed as perilous violations, where
health is linked to moral virtue and sickness is linked to vice.
The link between health and individual responsibility has also played an important role in
the formation of discourses about cancer and in health-related self-help literature for the past
half-century (Jain, 2013; McGee 2005). The assumption that individuals are responsible for their
own vitality (and inevitably also for any illness that befalls them) has been bolstered by
heightened cultural interest in self-improvement and the rapid growth of a self-help industry that
promotes personal fitness, hygiene, and other health-related practices as basic requirements for
individuals aspiring toward happiness, self-fulfillment and (financial) success (Illouz, 2008;
McGee, 2005). The discourse of individual responsibility that is foregrounded in health-related
self-help literature can be seen as one effect of the desire to “govern at a distance.” The link
between governmentality, self-help, and illness (and specifically cancer) has been usefully
articulated by Samantha King (2008), in her examination of the discourses of individual
responsibility and citizenship that undergird the culture of breast cancer in the United States. In
her book, King shows how breast cancer culture – in particular the discourses of volunteerism
and philanthropy that are central to it – is enrolled in the governance of individual conduct.
57
Breast cancer philanthropies, the author explains, govern conduct “from a distance” by appealing
to the ethical sensibilities of consumers, who are called upon to participate in “character-
building” activities that reinforce a link between health, activism and citizenship. That is to say,
breast cancer volunteerism requires individuals to see themselves in terms of their health, and to
see their health, in turn, as a “yardstick against which the capacities of individuals to become
‘proper’ Americans are measured” (p. 449). By articulating health to ethics, individual
responsibility, and good citizenship, cancer discourses enter into the rationalities of governing,
where they are incorporated into the processes of “conducting conduct” without having to resort
to the traditional, institutionalized forms of governance (i.e., the State) in order to do so.
Finally, I also want to point out that ethical and moral discourses surrounding cancer
have not only been enrolled in the governance of individuals but have also been taken up by
individuals themselves (be they patients, advocates, or health professionals) in critiques that call
into question the legitimacy and authority of medical and scientific expertise (Frickel, 2004). For
example, patients engaged in the creation and distribution of experience narratives and
“testimonial pathographies,” genres which provided a new means of denouncing medical
expertise and calling out some types of medical practice as negligent and inhumane. Also
collaborating in patients’ efforts were physicians and professional spokespersons. More often
than not, these individuals framed the problem of cancer in terms of the inadequacies of medical
and scientific knowledge about it, and subsequent lack of available forms of treatment (Seymour,
Clark, & Winslow et al. 2005).
7

7
See Audre Lourde’s The Cancer Journals (1980) and the writing of journalist Rose
Kushner for examples of cancer advocacy targeting medicine.
58
Particularly important to the story of pain management is this focus within cancer
discourse on the problem of under-treatment. Such a focus reconstituted cancer as not only in
terms of the individual, but also as a social problem – a public health epidemic that would
necessarily require the collaboration and combined intervention of science, medicine, industry,
and government. It also provided a basis for the intensified research into and development of
new treatments. As these treatments became increasingly available throughout the 1980s, the
meaning of cancer began to shift – from a near certain death-sentence to a chronic (albeit not
necessarily terminal) illness. Once it was understood that cancer was not necessarily a death
sentence, the problem of living with cancer and, in particular, living with cancer-related pain,
became a new object of concern for many cancer patients and their doctors. And so it was that
the vital connection between cancer and chronic pain helped push the latter into the limelight. No
longer seen as a natural side effect of a separate and more serious disease but as a medical
problem in its own right (and one that existing cancer treatments did not address, and often
exacerbated), the problem of chronic pain became the topic of widespread attention both inside
and outside of medicine.
The problem of cancer not only provides us with a milestone for mapping out the
genealogy of the field of pain management, but also reveals several important discursive threads
which will from this point on constitute the main focus of this genealogy: Specifically, central to
the discourses and practices related to the treatment of cancer and chronic pain are the themes of
governance (at the level of the individual and at the level of clinical practice) and the ways in
which governance at both these levels proceeds through discourses of ethics, morality, and
expertise. The next section focuses more specifically on intersection of these discourses and the
ways in which they materialized in the process of pain management’s entrance into the realm of
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global public health. In this context, one can witness how different forces came together in ways
that conditioned the development of pain management – both by delimiting its application in
clinical practice and by extending the problem of pain from medicine into politics, where it
became tied up in legal debates around the governance of life and the protection of basic human
rights.
Pain Management in Global Public Health
The related problems of living with cancer and cancer-related pain provided an impetus
for collaboration among a medical experts and policymakers, a partnership which drove the
expansion of the clinical problem of pain and its management into the broader realm of global
health. A key event that marks this expansion is the development of the World Health
Organization’s 1986 report, “Cancer Pain Relief.” The report itself is significant not only in that
it signals a growing awareness of the problem of pain and the necessity of efforts to improve its
medical management, but also in the ways in which it contributed to the narrowing of the field of
pain medicine and the governance of its clinical practice. Numerous scholars and practitioners of
pain medicine have commented on the significance of this report (e.g., Ballantyne & Sullivan,
2015; Nobel et al., 2005; Norton et al., 1999; Seymour et al., 2005); in an article published in the
prestigious Journal of Pain and Symptom Management (2005), Marcia Meldrum noted that soon
after its development “hardly any article discussing cancer pain did not make reference to the
WHO method” (p. 51). Doubtless that the political clout of the World Health Organization had
some effect in bolstering the report’s authority and its ability to shape the field of pain medicine
in a meaningful way. For indeed, the report – and the method it developed for the management
of pain – is credited with having fixed an important standard for dealing with pain in both
medical practice and in national drug policies. I also want to suggest that the WHO’s initiative to
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improve pain management marks an early instance in which the medical problem of providing
adequate pain relief was articulated within a political framework, in which a medical concept of
pain relief gets articulated to a rights-based discourse of freedom.
The WHO report was developed over several years, and the method it espouses was
influenced by medical expertise emanating from two distinct traditions in pain management. The
first was represented by eminent cancer pain specialist Kathleen Foley, who was stationed at
Memorial Sloan-Kettering Center in New York, where pain specialists were conducting
analgesic trials with cancer patients. The Sloan-Kettering approach to pain management was
focused mainly on examining the effects of analgesic drugs and identifying the precise
differences between and among them. The second was rooted in the British hospice care
movement and a philosophy of pain management that prioritized the patient’s spiritual,
psychological, and physical wellbeing (Meldrum, 2003; 2005; Saunders 1959; 1978). While
these two groups varied in their objectives – the search for an ideal analgesic, on the one hand,
and the achievement of patient wellbeing, on the other – both advocated for a patient-centered
approach to pain management that included the regular administration of pain-relieving
medication. So too does the WHO’s report state that “The use of analgesic drugs is the mainstay
of cancer pain management” (WHO 1986, p. 18).
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In its recommendations related to the practice of drug therapy, the report recommends a
specific method for achieving cancer pain relief which involves the use of a “3-step analgesic
ladder” – which visualizes a treatment protocol based on the premise that doctors and health
practitioners “should learn to use a few drugs well” (p. 18). That the protocol is visualized as a
ladder presupposes the idea of titration in drug therapy, which assumes that the proper dose is the
one that provides relief and therefore involves increasing a patient’s dosage step-by-step, until
she no longer feels pain.
Figure 1.1
A visual analysis of the ladder signals the connection (see Figure 1 above) between pain,
opioids and a rights-based discourse of freedom: The floor beneath the ladder indicates the
patient’s experience of “pain,” where all pain management must begin. From there, the patient
starts climbing a wall that leads to the first step. The initial climb is accomplished with the use of
“non-opioids,” (a weak analgesic such as aspirin). The patient who makes the “non-opioid”
climb and reaches the second step, which indicates the experience of “pain persisting or
increasing” will then begin to climb again, this time with the help of “weak opioids.” Continuing
upward is a third step/state of “pain persisting” which the patient can only supersede by climbing
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the next wall with support from “strong opioids.” Finally, the “strong opioid” climb leads to the
top of the ladder – the final state of “freedom from cancer pain.” This analogy between pain
relief and freedom is significant in that it establishes the discursive connection that would later
be strengthened in health-related law and policy between pain management and basic human
rights. What the WHO’s analgesic ladder communicated in visual terms was soon after re-
emphasized in a speech by Jan Stjernsward, the chief of the WHO’s Cancer Unit, who declared
that, “If the people know that freedom from cancer pain is their right, I am sure they will demand
it. That will certainly change things” (132) (quoted in Dahl, 1990). Additionally, the text of
WHO’s report called upon governments to address the problem of chronic pain management
within their citizenries. Those countries that recognized the authority of the WHO were
encouraged to think about the problem of pain under-treatment human rights-based terms, which
could be addressed through a variety of means including government-funded pain research and
liberalized national drug policies.
As Nobel et al. (2005), have pointed out, the significance of the WHO report also lies in
its legitimation of the use of opioids for pain as a therapeutic skill rather than a risky practice.
Indeed, that an agency charged with the oversight of international public health would publish a
document declaring opioids to be the mainstay of pain management is noteworthy in and of
itself. The WHO’s paradigmatic “analgesic ladder,” and its widespread uptake in clinical
practice, constructs a clinical paradigm in which pain and opioids are always-already tethered,
where opioids are represented as a sure solution to the clinical problem of pain. But the WHO’s
report is meaningful in (at least) two other ways: First, in that it functioned as a technology of
governance of pain medicine in clinical practice and did so by advancing a paradigm in which
the use of opioids for treating pain were normalized as a reliable solution for the clinical problem
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of pain and its management. Second, the report is emblematic of a critical moment in the
genealogy of pain management in a larger sense – one in which the medical concept of pain
relief (and thus the corresponding theory and clinical practice of pain management) gets
articulated to a rights-based discourse of “freedom” and, in so doing, takes on a political valence.
The question of human rights in pain management, which the WHO report framed in
terms of the rights of pain patients, also extends to practitioners – particularly those who have
been enrolled in the process of improving the treatment of chronic pain. Soon after the WHO
published its report on cancer pain relief, many states began adopting “intractable pain
regulations,” which sought to confront the problem of pain under-treatment – which was by then
becoming more widely recognized as a growing social problem. The “Intractable Pain Treatment
Acts” (IPTAs) that many states – beginning with Texas in 1989 – prohibited the persecution of
physicians who prescribed opioids for pain, so long as their practice could be considered within
the bounds of responsible health care. Such a policy was meant to encourage physicians to utilize
narcotics when treating intractable (chronic) pain – a practice that, as previously discussed, many
physicians refused to use, both because of their fears that patients would become addicted or
overdose and their concerns that such events would result in their being sued for malpractice. It
is no surprise then, that the movement for states to adopt IPTAs was often led by physicians and
that it could have functioned as a means of responding to cultural stigmas and restrictive
regulations that were preventing them from prescribing opioids to their chronic pain patients.
Yet, somewhat paradoxically, IPTAs also had the effect of instigating their own wave of
malpractice lawsuits – this time coming from patients who felt their pain had not been
adequately treated. It would seem then, that while the IPTAs may have granted physicians more
freedom in terms of their ability to prescribe narcotics, these freedoms were also limited by the
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possibility that physicians who refused to do so could now be punished. Most importantly, the
IPTAs provide a concrete example of how the clinical practice of pain management is governed
at the intersection of medicine and politics, where it is delimited by morally inflected discourses
and discussions of how pain should be treated and to what extent physicians should be deemed
responsible for providing it.
Addressing the Problem of Subjective Pain
In the discussion above, the moral quandaries that frame the issue of pain management in
global health, law, and politics have been made increasingly complicated by the subjective
nature of pain itself. That is to say, while the enactment of Intractable Pain Treatment Acts may
have laid down a legal precedent for understanding pain relief as a human right, they did not
answer the question of how the experiences of pain, on the one hand, and relief, on the other,
were to be assessed and measured. The subjective nature of pain – which was acknowledged by
John Bonica early on in the field’s development and has since become the basis of pain’s
medical definition – and the ways in which it has been addressed in health policy represent
another important conjuncture in the genealogy of pain management. At this conjuncture, the
moral obligation to provide citizens with their right to pain relief was addressed in policy
through a discourse of expertise, one which explicitly placed the burden of proof on medical
experts who were called upon to transform the subjective experience of pain into an objectively
measurable phenomenon.
The problem of subjective pain was first addressed in the Social Security Disability
Benefits Reform Act (hence forth referred to as “Reform Act”) of 1984. The Reform Act was
enacted as a response to the Social Security Amendments of 1980, which were passed in order to
temper the skyrocketing cost of supplemental security income (SSI) and social security disability
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insurance (SSDI) which, over the previous 25 years, had jumped from $59 million to $18.5
billion (Rubinson, 1988). The main change enacted by the 1980 Amendments was a new
requirement that recipients participate in an eligibility review process every three years. Yet, this
attempt to weed out false disability claims ended up resulting in hundreds of thousands of
recipients having their benefits terminated (Rodgers, 1991). Four years later, in response to
widespread public outcry and demands that deserving recipients have their benefits reinstated,
Congress passed the Reform Act. This act was held by many as a victory for liberals (though it
had bipartisan support and passed by a unanimous vote in both houses of Congress) because it
put the burden of proof on disability decision-makers to provide evidence that a claimant’s
disabling condition had improved before his or her benefits could be suspended.
Yet the Reform Act’s most significant feature was its Section 3, which demonstrated
Congress’s concern over the subjective nature of pain: During congressional deliberations,
several members expressed concern over recent Federal court decisions that had ruled that
subjective pain testimony could be considered sufficient as evidence of a claimant’s disability.
These court opinions, members suggested, had moved beyond the intentions laid down in
previous disability policies. Furthermore, they gave far too much weight to subjective reports of
pain and thus failed reflect the administration’s current position on the evaluation of pain in
disability cases. In response to these court decisions, many members of Congress began to
advocate for a more restrictive definition of pain and a more rigorous process for its evaluation.
Their efforts to do so bore fruit, resulting in the first statutory standard for the evaluation of pain,
which proceeded as follows: "An individual's statement as to pain or other symptoms shall not
alone be conclusive evidence of disability as defined in this section; there must be medical signs
and findings established by medically acceptable clinical or laboratory diagnostic techniques,
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which show the existence of a medical impairment that results from anatomical, physiological,
or psychological abnormalities which could reasonably be expected to produce the pain or other
symptoms alleged and which, when considered with all evidence required to be furnished under
this paragraph (including statements of the individual or his physician as to the intensity and
persistence of such pain or other symptoms which may reasonably be accepted as consistent with
the medical signs and findings), would lead to a conclusion that the individual is under a
disability…Objective medical evidence of pain or other symptoms established by medically
acceptable clinical or laboratory techniques (for example, deteriorating nerve or muscle tissue)
must be considered in reaching a conclusion as to whether the individual is under a disability."
(Social Security Disability Benefits Reform Act of 1984, 1799-1800).
Somewhat paradoxically then, the Reform Act acknowledged the subjective nature of
pain but at the same time set a standard that would fail to cover many chronic pain sufferers
(those without “objective medial evidence” of an “underlying medical impairment”) under the
current law. To resolve this paradox, the Reform Act then called upon the authority of medical,
legal, and administrative expertise to resolve this paradox by directing the Secretary of Health
and Human Services to appoint an expert “Commission on the Evaluation of Pain.” The
Commission, as the Act lays out, would be required to conduct a study in collaboration with the
National Academy of Sciences on the assessment of subjective pain and to set a medical standard
for determining when an individual claiming chronic pain could be deemed eligible for disability
benefits. It would contain at least 12 members from the fields of medicine, law, and disability
program administration, who would then work in collaboration to address concerns about the use
of subjective evidence in determining disability eligibility and to submit its evaluation to
congressional committees the following year.
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Thus, in the 1984 Reform Act, Congress intervened in the political problem of pain not
through eliminating the possibility for pain to be recognized as a disability, but through
legislation that restricted the definition of pain to “objective medical evidence” and other signs
and symptoms established by “medically acceptable clinical or laboratory techniques” (Social
Security Disability Benefits Reform Act of 1984, 1799-1800). The amendment’s reliance on the
authority of expertise – as manifested in its call for more science, objectivity, and neutrality – set
a political precedent for the medical practice of managing pain based primarily on the existence
of observable evidence. In doing so, the policy also hints at an epistemological paradigm in
science and medicine, one which would, throughout the course of the 1980s, become understood
as the “gold standard” of medical/scientific expertise (Timmermans & Berg, 2003). The result of
this political outcome, ultimately, was to restrict the diagnosis of pain and its treatment to
dealing specifically with symptoms without having to confront the broader context of pain (the
environmental and structural conditions which disempower individuals attempting to live with
debilitating chronic pain), a context which, as previously discussed, was already well understood
by those who opted for a multi-disciplinary approach to pain management. By limiting their
purview to symptoms, rather than context, the 1984 policy imposed limits on the treatment
options that would be readily available to practitioners.
Yet the treatment of pain management has also been limited in other ways, by other
tendencies that were taking shape in the realm of health care decision-making during these same
years. In particular, the development and eventual normalization of evidence-based medicine
(EBM) has limited the practice of pain management in clinical contexts. Thus, it is worth saying
something about the development of EBM – in particular in terms of the new standards this
approach put in place for assessing the quality of clinical evidence and expertise and how its
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application in clinical contexts has played out in practice, in contexts where practitioners are
forced to work within its limits. Such considerations are important – not least because EBM is a
paradigm that not only impacts the clinical practice of pain management but also holds saw over
decision-making across virtually all levels of our health care system: In health-care related
policy, medical research, and in the development of clinical guidelines/recommendations, the
dominance of EBM has re-shaped medical practice in hospitals and clinics across the nation.
The Triumph of Evidence-Based Medicine
The paradigm of evidence-based medicine, which was first defined by health care
analyst, mathematician and physician David M. Eddy, was consolidated in the second half of the
1980s in a series of population-level policies, guidelines, and reports related to health-care
related decision-making. It has since become the “gold standard” for decision-making across
nearly all levels of health care – in the development of health-related policies, the design and
implementation of medical research and, eventually, in clinical practice (see Eddy 1982, 1984,
1988; Beltran 2005). In brief, evidence-based medicine refers to an approach to medical practice
that emphasizes the use of evidence from research (typically research conducted in randomized
control trials). According to this approach, the quality of “evidence” depends on its
epistemological strength which is associated with research methodologies that attempt to control
for human bias (e.g., the placebo-effect). Today, evidence-based medicine (EBM) guides not
only medical research but decision-making at nearly every level of our health care system.
The EBM paradigm played a key role in the medical debate about opioid drugs by
providing physicians and nurses with a scientific, objective criterion for deciding whether or not
to prescribe these drugs to their pain patients. Moreover, it offered physicians a method for
assessing pain according to a higher objective standard – one that was supposedly amoral and
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independent of the biases that are inherent to clinical judgement and individual decision-making.
As an approach that emphasizes the value of objective evidence and subsequently devalues
subjective testimony, evidence-based medicine has taken shape as a crucial norm that has guided
the development pain management and contributed to the formation of a narrowly-defined form
clinical practice – one that has been and continues to be centrally focused on the use of opioid-
based treatments.
To demonstrate the connection between the norms of evidence-based medicine and the
shaping of pain management in clinical practice, one can look to a (now infamous) article
published in the New England Journal of Medicine in 1986 by two leading pain specialists,
Russell Portenoy and Kathleen Foley. The article was focused on demonstrating the safety and
efficacy of opioid drugs in pain management by disaffirming the belief that such drugs are prone
to abuse and addiction. To test their hypothesis, the authors conducted a clinical trial among 38
non-cancer pain patients and found that only two of those individuals became physically
dependent on their medication. The remaining 36 showed no signs of addiction and claimed to
have been cured of their pain. Thus, in line with their hypothesis, the authors concluded that
opioid painkillers were not inherently addictive but instead offered a “safe, salutary and more
humane alternative to the options of surgery or no treatment in those patients with intractable
non-malignant pain and no history of drug abuse” (Portenoy and Foley 1986, p. 171).
The article, which was soon widely cited within and outside of pain management, is now
infamous. In recent years, it has even been pointed to in a variety of news articles (e.g., Offit,
2017; Moghe, 2016) as a key impetus that drove the widespread transformation in physician’s
attitudes toward opioids – one that ultimately resulted in the skyrocketing prescription rates and,
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by extension, an epidemic of opioid abuse
8
. While I do not aim to reinforce the vilification of
this article and its authors (both of whom are renowned in the field of pain management and have
been diligent advocates for chronic pain patients), I do agree that the article itself is important –
but for a different reason. It is important in that it serves as an example of the power of evidence-
based medicine as a norm that has conditioned the clinical practice of pain management.
For the impact of Portenoy and Foley’s article, I suggest, can also be explained by the
normative power of evidence-based medicine which, by 1986, had taken center stage as a
standard for anticipating and prescribing the actions of health care professionals (Timmermans &
Berg, 2003). As one of the article’s authors, Kathleen Foley, has pointed out, even by the time of
the 1986 article’s publication there were “no published long-term data” to provide evidence of
opioids’ addictive potential among pain patients. In fact, there weren’t any long-term controlled
studies of opioids in pain management to be found at all (Meldrum, 2016). As one of the earliest
examples of a study that did not rely primarily on the use of patients’ self-reports or on
physician’s anecdotal experience, the NEJM piece stood out from the other less reliable studies.
It furthermore bolstered the idea, implicit in the EBM norm, that experiential evidence is
inherently inferior to evidence produced from controlled trials (Timmermans & Berg, 2003).
The epistemological hierarchy that elevates “objective” evidence over experience also serves as
the basis for the argument – which was implied in Portenoy and Foley’s article and reproduced
by many chronic pain specialists and advocates thereafter – that those practitioners who refused

8
An editorial published in 1980 by Porter and Jick is also frequently gestured to as
having “fueled the opioid crisis” (Zhang, 2017). The editorial, which suggested that less than 1%
of opioid patients become addicted, is also cited in Portenoy and Foley’s NEJM piece (1986).
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to prescribe opioids were doing so based on information that was, at best, unreliable and, at
worst, dangerous. Their negative attitudes toward opioids then, were better explained as an
irrational effect of “opiophobia” and cultural “myths” about the dangers of these drugs than to
decision-making based on objective evidence.
The influence of Portenoy and Foley’s 1986 article illustrates the material effects of
discourse, in this case the discourse of evidence-based medicine, and the influence it has
demonstrated through re-constituting many of the standards of knowledge production and
decision-making in medical practice and health policy, among other domains. The next section
elaborates on this assertion by showing how norms such as EBM are embedded in clinical
practice guidelines, where they have function as important mechanisms for governing the clinical
practice of pain management.
The Dilemma for Medical Practitioners
As mechanisms through which the practice of medicine is governed, clinical practice
guidelines “aim at increasing the base of objective evidence underlying health care work”
(Timmermans & Berg, 2003: 118). Indeed, pain management clinical guidelines, particularly
those advocating for a reconceptualization of pain as the “fifth vital sign,” engage in the work of
attempting to render subjective experience into objective evidence. These guidelines, moreover,
which were developed according to an evidence-based medicine approach to clinical practice,
are crucial for the way in which they served to limit the treatment practices of the many
physicians and nurses who were working in clinical settings and attempting to respond to a rising
wave in patient demand for pain relieving drugs. And while it is also the case that these standards
and guidelines have not necessarily been followed by all practitioners in the ways that the health
reformers who promoted them may have intended or expected, they have nonetheless played an
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important role in deliminiting the field of pain management – particularly with regard to the
ways in which practitioners measure, diagnose and treat their patients’ pain. Finally, these
guidelines can also be understood as providing a response to the moral quandaries bound up with
the problem of pain management (whose pain may be treated and how) and the subjective nature
of pain itself.
Pain as the 5
th
Vital Sign
In February 1999, the U.S. Department of Veterans Affairs (DVA) added pain as a ‘fifth
vital sign’ to be regularly assessed as a major indicator of health. As the Washington Post
reported, ‘VA officials said the change in routine is designed to call physicians’ attention to what
is widely considered one of the most unrecognized and untreated symptoms in American health
care’ (Schuster, 1999). The treatment of pain as a vital sign, equivalent in importance to a
patient’s heart rate, temperature, breathing rate, and so on, illustrates just how central the
measurement and treatment of pain had become to medicine by the end of the century and, as
such, marks an important moment in the genealogy of pain management.
In 1996, the president of the American Pain Society, Dr. James Campbell, gave a speech
in which he stated that, “if pain were assessed with the same zeal as other signs (vital) are, it
would have a much better chance of being treated properly. We need to train doctors and nurses
to treat pain as a vital sign” (Campbell, 1996). In the years that followed, Campbell’s suggestion
that pain be recognized as a sign in equal importance to other vital signs, and that it be
consistently and regularly measured in the clinical context, was gradually institutionalized – first
in the Veterans Health Administration, which published a report in 1998 declaring the
implementation of a “comprehensive national strategy for pain management” in which pain
would be treated like a vital sign – in order to “trigger further assessment of the pain, prompt
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intervention, and follow-up evaluation” – across its clinics and hospitals (2000, 5). Campbell’s
speech is quoted within the VHA’s report, alongside a declaration that the “VHA recognizes the
importance of making pain ‘visible’ in an organization” (5). Two years after the VHA published
its report and “toolkit” for the implementation of its new pain management strategy, the Joint
Commission on Accreditation of Health Care Organizations (JCAHO) followed suit by releasing
a set of new pain management standards which echoed the sentiments being expressed by the
VA, American Pain Society, and other professional societies dedicated to spreading awareness of
the problem of untreated and undertreated chronic pain. The Joint Commissions standards
declared that all “patients have the right to appropriate assessment and management of pain”
(RI.1.2.8, p. 2) and laid out a number of tools that practitioners could use in order to ensure their
patients’ rights were acknowledged and protected. JCAHO’s new pain management standards
were likewise accompanied by a wave of clinical practice guidelines for pain management,
which emerged from a variety of advocacy groups, professional societies, and other health care
organizations, including the American Geriatric Society (1998), American Medical Directors
Association (1999), US. Department of Health and Human Services’ Agency for Health Care
Policy and Research (Jacox et al., 1994), the American Academy of Family Physicians (Marcus,
2000), and the American Society of Anesthesiologists (Wilson et al., 1997). Common to all these
guidelines is the pain the mandate that this new vital sign be assessed using a numerical rating
scale (0-10), and that this assessment must be performed in every clinical encounter.
The initiative to re-frame pain as a vital sign also represents an institutional response to
the need (as expressed in health-care policies a decade earlier) for “more objectivity” in pain
management and for the design of tools that would enable the objective measurement of pain in
terms of its level of intensity and, after treatment, of relief. At the same time, the guidelines also
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provided practitioners and policy-makers with an institutionalized, evidence-based procedure
that would address the moral dilemma of pain by ensuring that every patient would have his or
her pain measured, diagnosed, and treated in the same way every time he or she visited the clinic.
It is worth noting the contradiction inherent to the VA’s guidelines, which attempt to
assess and manage pain through the use of “objective,” unidimensional tools, even while the
organization recognizes that pain is a subjective phenomenon – that patients’ self-reports are “the
single most reliable indicator of pain,” followed by reports from patients’ family and friends
(DVA, 2000, p. 13). Though it also seems that the use of measurements such as the NRS go
some way toward resolving this contradiction: A patient’s assertion that his pain is a level 10 is,
after all, a kind of self-report, but one that has been abstracted from lived experience. Through
tools such as the NRS, which reduce pain to a number, the complexity of its lived experience is
made manageable. So too does this abstraction attempt to address the problem of pain’s
psychological dimensions. For, as Andy Lakoff (2007) has discussed, there is an additional
struggle in assessing illnesses that, like pain, are often lacking physiological markers. In the
measurement of mental illnesses such as depression, as in the case of measuring complicated
chronic pain, the absence of visible signs of illness (whether physiological or behavioral) shores
up a need for tools (such as numerical rating scales) that promote consistency and attempt to
limit the bias of evaluators’ subjective judgement. Such tools aim to “turn amorphous,
heterogeneous experience into a calculable problem” (Lakoff, 2007, p. 58).
And there are other practical reasons underlying the use of numerical rating scales for
measuring pain, which have to do with its clinical context: One has only to consider the busy,
sometimes chaotic environment of most clinics, where tools such as the NRS offer doctors and
nurses a means of rapidly assessing, treating, and re-assessing pain and pain interventions (Nobel
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et al., 2005; Pasero & McCaffery, 1997). In such cases, unidimensional measurements offer
many benefits: They enable practitioners to take patient experience into account within the limits
of a five to ten-minute long appointment, while also transforming this experience into a number.
In doing so, such measurements help create a universal vocabulary for the clinical practice of
treating patients’ pain.
On a more theoretical note,Theodore Porter (1996) has argued that such quantification
should be seen not only as a practical tool but also as a social technology. As a social technology,
the quantification of pain through the use of measurement scales such as the NRS unburdens
physicians of their hermeneutic responsibilities and thus provides a means for building consensus
– for universalizing the diagnosis and treatment of pain. Indeed, as Porter aptly suggests,
processes of universalization are essential to solving the problem of how science, or medical
practice, becomes socially legitimized and known. Numbers are also used, as Porter argues, as
responses to challenges to an agency’s legitimacy or authority. As such, they form part of a
broader array of attempts to counter concerns regarding the biases inherent to expertise. Thus,
they can be useful tools for justifying the use of particular protocols or practices to outside
observers. Finally, quantification is also a way in which researchers and practitioners can
manage many of the exigencies of regulatory norms and the demand that medical interventions
demonstrate a quantitative improvement in a patient’s or patient population’s illness.
The idea that pain interventions should quantitatively demonstrate the effects of a drug
and map them directly onto a specific illness is supported by the assumption that diseases are
stable entities that can be explained by simple causal mechanisms. This idea, which underlies the
use of numerical rating scales in pain management is also consistent with the logic of specificity
that underlies drug development (Lakoff, 2007). That is, drugs purport to act directly on disease
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in a way that other kinds of interventions (behavioral therapies, psychoanalysis, physical therapy,
occupational training, etc.) do not. Thus, the normalization of the NPRS, which reinforces the
logic of specificity in drug development, also supports a theory of pain management where pain
is defined always-already in terms of pain relieving drugs. Put another way, the numerical scale
for measuring pain actually measures two variables: The intensity of the pain itself and the
degree of relief, which can only be measured after a treatment has been administered. What this
means is that the scale does not only measure pain. It is also designed also measure the efficacy
of pain medications. This is particularly significant when considering the other key component of
clinical practice guidelines discussed above – the mandatory scheduling of routine follow-up
appointments for all pain patients – since the first appointment in which a patient’s pain is first
assessed and diagnosed anticipates the possibility of future diagnoses and the ongoing use of
medication.
The movement to address pain as the “fifth vital sign,” which was quickly adopted by
other organizations within the medical community, was also a movement to redefine pain – to
cast what otherwise would have been understood as a purely subjective phenomenon in objective
terms, as something that could be accurately measured and quantified. Crucially, these new tools
for objectively measuring the intensity of pain worked to separate the patient from his or her
pain, abstracting the phenomenology of his or her lived experience of it into a quantified variable
and medical/scientific fact. Quantified pain thus represents a radical departure from the
consensus within pain medicine’s multi-disciplinary community (and which had been established
in John Bonica’s 1953 textbook) that defined pain as a multi-dimensional and subjective
phenomenon, which must be understood primarily in terms of its lived experience – its
phenomenology, the ways in which persons-in-pain experience and respond to it.
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In clinical research and practice, quantified pain legitimates and normalizes (and is, in
turn, legitimated and normalized by) the focus on opioid medications as the mainstay of
treatment. For if, upon reassessment, a patient reports a lower level of pain, his or her self-report
is viewed not as a change in perception but as a correction – proof that the treatment is working
and should continue to be administered. A treatment that is held to be effective, moreover, is
seen as directly acting on pain itself, rather than on perception or on the
environmental/contextual factors that may also influence how patients experience their pain.
The development of the guidelines promoting the measurement of pain as a “5
th
vital
sign” can therefore be understood as a moment that pre-meditated the ongoing opioid epidemic.
The moment at which pain became meaningful as a vital sign is indeed crucial, but not only
because it expanded recognition and measurement of pain in clinical context. It also transformed
the definition of pain and re-positioned it in a context that changed its nature by attaching it to
government initiatives and to a rapidly transforming landscape of health care and medicine – one
dominated by the rules, norms, and values of evidence-based medicine and biomedical models.
The Biomedical Model of the Cure
The biomedical practice of working toward a cure is also a key element in the story of
pain management because it illustrates how and why certain practices within field were
legitimated and rose to dominance while others fell to the wayside: Put another way, the
hegemony of the “cure” can help us understand why a unidimensional approach to pain became
the dominant approach to its management in clinical settings and why multi-dimensional pain
clinics such as those first envisioned by John Bonica in the 1960s and 70s were ultimately
marginalized. For by the time evidence-based medicine and its corollary discourses and practices
had crystallized as dominant paradigm in health care-related decision-making, the number of
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multi-dimensional pain clinics had already plummeted (Meldrum, 2007). The rise and fall of
multi-dimensional pain clinics illustrates but one of the factors that contributed to the
legitimation and prioritization of an approach to pain management that is always-already
informed by (and oriented toward) the use of analgesic drugs.
Unlike in its treatment as a vital sign, the approach to pain in multidisciplinary clinics
was not entirely oriented toward a search for its “cure.” That is, the total elimination of pain
(achieving a 0 on the NRS) was never seen as the core objective of pain management therapy in
these contexts. Instead, these clinics have tended to insist that a more important therapeutic task
is to spend time teaching patients how to live with pain. Such a task requires a combination of
psychological, and medication-based treatments, together with a physical rehabilitation program
that rewards patients based on their performance rather than routinely administering analgesic
medication to them. Even while such approaches have been proven successful, the evidence of
their efficacy does not meet the epistemological standards set out by evidence-based medicine,
which can only grant legitimacy to practices that are associated with randomized clinical trials,
such as the use of placebos in drug development. The norm of controlling nuisance variables
with the use of placebos remains central to the armature of biomedical research despite the fact
that they can also be shown to debunk the very assumptions that underlie their use (such as the
superiority of objective evidence over clinical experience). Ted Kaptchuk has written extensively
about what placebos can actually teach us: In a randomized control trial of two placebo
treatments (Kaptchuk et al., 2006), Kaptchuk and his team found that a sham device his team
used as a chronic arm pain treatment had greater effects than the second placebo, in the form of a
pill, on self-reported pain and the severity of pain symptoms. From this, Kaptchuk concluded
that even the placebo effect is malleable and, as was the case in his experiment, is subject to
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change based on the kind of patient-physician interaction that accompanies it. What experimental
norms such as the placebo effect affirm, as Kaptchuk and others argue, is not as much the
superiority of biomedical paradigms as it is the key role that medical ritual, imagination, and
other aspects of the clinical encounter play in the healing process.
And yet – the biomedical approach to medical research and practice persist. In pain
management, this persistence has had the effect of marginalizing multi-dimensional approaches
to chronic pain treatment along with its more time-consuming clinical encounters that often
would not end with the prescription of a pill.
Conclusion: Objective Frameworks and Limiting the Practice of Managing Pain
In October 2000, Congress passed the Conquering Pain Act of 2001, a bipartisan effort
led by Darlene Hooley, a democrat from Oregon, and Nancy L. Johnson, a republican from
Connecticut. The Act declared the beginning of a ‘Decade of Pain Control and Research’ – a
new medical era that would be characterized by an intensified focus on promoting ‘research,
education, and clinical practice’ (American Medical Association House of Delegates 2000). The
Conquering Pain Act provides a final example of the ways in which the U.S. government has
relied on a biomedically-inflected discourse that prioritizes “objective” science as the most
viable method of ensuring its citizens’ right to pain relief. While protecting individuals’ right to
pain relief is indeed an admirable goal, the assumptions that underlie it are questionable. The
Conquering Pain Act’s proposal to address the problem of chronic pain through the development
of more objective, quantitative evidence reinforces the assumption that the right to relief is best
secured through the sponsorship of research that adheres to the standards of EBM. Such an
assumption, which relies on discourses of neutrality and objectivity, obscures the reality that pain
is anything but – that it is unevenly distributed in society and that patients’ access to relief is not
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only limited because of a lack of research/education, but is also restricted by structural
constraints. Without acknowledging the other conditions such as institutional norms, cultural
stigmas, and structural inequalities that underlie the nation’s high incidence in under-treated
pain, we are destined to remain tethered to a limited idea of what good pain management is and
could be – one that, for the moment at least, is highly dependent on unidimensional measures
and pharmacological solutions. And, as has been discussed in this chapter, these are the same
solutions that can be understood as having anticipated many of the problems we now face as the
nationwide rates of pain, opioid abuse, addiction, and overdose continue their ascent.

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Chapter 3: Branding Pain Relief

Though medicine is a crucial starting point for coming to understand how opioids became
prioritized as solutions to pain, the scope and scale of their uptake doesn’t stop here. On the
contrary, what’s also important to understand is how these drugs became normalized outside of
the medical domain – in society as a whole. For it is in this domain – the domain of culture and
the American imagination – which has also provided some of the most fertile ground for the
growth of an opioid epidemic.
Yet this is easy to forget, in part because much of the discourse surrounding the opioid
epidemic has tended to characterize it as a medical phenomenon – as the manifestation of so
many waves of pain patients who suddenly transformed into addicts. While this idea is a
powerful one that undergirds and animates the anxiety that now surrounds the use of prescription
painkillers, it does not reflect the reality of this country’s opioid problem. In fact, it is a far cry
from the data that reveals that less than a third of first-time opioid abusers obtain them by being
“patients” – that is, with a physician’s prescription
9
. In contrast, most users initially get the drug
from their friends or family members (49%) (Daubresse et al., 2013). So, if we are to try and
account for the prolific presence of opioid abuse and addiction in this country, we should turn
our attention to consider not only how opioids became normalized in medicine, but how they

9
In this context, “abuse” refers to taking a drug in a way other than “as prescribed.” In
other studies, it has been defined in terms of the following four criteria: “1) use to get high; 2)
use in combination with other drugs to get high; 3) use as a substitute for other euphorogenic
drugs of abuse; and/or 4) use of the drugs to treat opioid withdrawal’ (Cicero, Inciardi, & Muñoz
2005, 664).
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became integrated into the everyday lives of so many Americans – many of whom were not
patients to begin with. Seemingly overnight, opioids have become household objects, objects
which anyone might stumble upon even in the most innocuous of spaces – under the seat of a
contractor’s pickup truck, in the office of a school nurse, in Dad’s medicine cabinet, Mom’s
dresser, Grandma’s purse.
The speed and extent to which the meaning of these drugs has shifted – from utterly
taboo in the 1970s, to a dangerous medicine of last resort in the 1980s and 90s, to an ordinary
household object by the mid-2000s – is somewhat jarring. And yet, this shift has not occurred by
accident. It is my contention that the normalization and indeed, the domestication of opioids in
everyday life has been driven, at least in part, by the branding of pain relief, most notoriously
through the aggressive marketing of the blockbuster drug, OxyContin. Building on the previous
chapter, I argue that the increasing willingness of physicians to prescribe opioids to their
patients, which stemmed in part from mounting awareness (in medicine and in culture, more
generally) of the problem of chronic pain under-treatment, carved out an enormous space for a
prescription opioid market. In this opening, pharmaceutical companies began to intervene and
contribute to the growth of that market. They did so namely through the strategic branding of
pain relief and pharmaceutical solutions for it.
To that end, this chapter develops an analysis of the branding strategies underlying the
promotion of OxyContin. Doing so expands on the existing literature related to branding, in
general, and pharmaceutical branding, in particular, and the argument held by many scholars that
branding functions as a political technology, one which fosters a relationship between people and
products and, in doing so, functions as a means of “conducting the conduct” of potential
consumers (Elliott, 2003; Foucault, 1991; Miller, 2008; Rose, 2006; Swenson, 2010). Indeed, the
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branding of OxyContin signals a desire on the part of opioid manufacturers to govern the
behavior of potential consumers – whether they are patients or physicians. But equally important,
as I aim to show, are the ways in which the branding of pain relief has been mobilized by these
manufacturers as a tool for responding to the ongoing crisis of opioid overdoses and deaths –
which is often pointed to as an inevitable outcome of pharmaceutical companies’ insatiable
appetite for profit (e.g., Bourdet, 2012; Meier, 2001; Meier & Peterson, 2001). Additionally,
examining the branding of opioids may enable us to better understand why these drugs continue
to be prescribed and consumed, despite the waves of negative press, impending lawsuits, and
public outcry regarding the dangers they pose to society (Ingraham & Johnson, 2016; Pérez-
Peña, 2017; Satterfield, 2017).
In the pages that follow, I will consider how the branding of pain relief has bolstered the
growth of a market for prescription opioids through acting on the behaviors, bodies, and
subjectivities of potential pain patients and their physicians. Throughout this analysis, I show
how the branding of OxyContin proceeded through two key themes – one which equates pain
relief to the restoration of an authentic self and another which focuses on individual
responsibility and positions chronic pain patients as responsible consumers and economic
subjects. Both these discourses articulate pain relief (and by extension pain relieving drugs) to a
liberal ethic and vision of the “American Dream” in which it is incorporated as a foundational
requirement for living a meaningful, productive life. These discourses, as I show, are also
transplanted into institutional settings, where they are embedded in organizational protocols and
used to govern clinical practice. In this context, the branding of pain relief becomes significant
not only as a means of commodifying illness, but as a cultural logic that frames and limits both
medical practice and the the ways in which we understand our relationship to pain and
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patienthood today.
Governing Opioid Consumers
Branding, as many scholars have noted, is a key activity within commercial capitalism
and plays a central role in the process of capital accumulation. Moreover, as Sarah Banet-Weiser
(2012), Laurie Ouellette (2012), Allison Hearn (2010), Liz Moor (2007) and others have noted,
branding is not only a crucial mechanism that sustains the growth of market but is also a cultural
process that organizes meanings and reflects fundamental social and cultural relations. The
meanings that are organized and the knowledge that is produced through branding processes
create a context for consumption, which frames the ways in which consumers relate to and
interpret their relation not only to products, but to their own experiences, values, and the world
around them (Banet-Weiser, 2012; Hearn, 2010). Through meaning-making, branding not only
influences consumers’ behaviors, but also their minds, bodies and selves which, as Elizabeth
Moor (2003) has suggested, have become “both the object and the medium of brand activity” (p.
42).
Scholars have also examined branding processes in the context of U.S. health industry
which, unlike the health industry in any other country (save New Zealand) allows pharmaceutical
companies to advertise their drugs directly to consumers (Angell, 2004; Dumit, 2012; Elliot,
2003; Miller, 2008; Moynihan & Cassels, 2005; Rose, 2006; Swenson, 2010). The literature on
pharmaceutical branding and advertising shows how branding processes in this context may be
understood as a means of “selling sickness,” in which companies enroll themselves in the
process of designing and defining new disorders, which are then used to hail a growing
population of individuals as sick, or potentially sick (Dumit, 2012; Moynihan & Cassells, 2015).
But branding in the drug industry not only works toward the promotion of pharmaceutical
85
products; it also functions as a political technology and mechanism of governance – one which
attempts to shape the conduct of potential consumers and condition the formation of new kinds
of subjectivities in ways that align with companies’ profit motives (Elliott, 2003; Miller, 2008;
Rose, 2006; Swenson, 2010).
As each of the above scholars has discussed, branding is crucial to the success of
pharmaceutical companies, particularly those attempting to bring new products onto the market.
This was certainly the case for Purdue Pharma who, in December 1995, was notified that the
U.S. Food and Drug Administration (FDA) had finally approved the release of its newest product
– a strong opioid painkiller that would be sold under the name, OxyContin. The efforts Purdue
poured into marketing its new drug were extensive and they were rewarded by the near
immediate success of its product: Just one year after its release, OxyContin had garnered more
than $48 million in profits – a number which, by 2001, had skyrocketed to a whopping $1.1
billion, surpassing the sales of Viagra, which had formerly been the most popular drug on the
market (Van Zee, 2009; Bourdet, 2012). In retrospective analyses of the escalating prescription
rates of OxyContin, the initial success of the drug is attributed less to its superiority than to the
dedication and aggression with which the company promoted its use (Van Zee, 2009). Indeed,
Purdue’s marketing campaign for OxyContin was impressive – simultaneously wide-reaching
and highly targeted and comprised of a variety of promotional practices that aimed not only at
physicians and patients but also nurses, pharmacists and insurers. In 2001 alone, Purdue spent
$200 million in the marketing and promotion of OxyContin, an expenditure which is not
uncommon for large pharmaceutical companies but was a serious outlay for Purdue, a family-
owned business with a much smaller staff (and budget) than many of its competitors at the time
(OxyContin, 2002). However, along with its success, Purdue’s aggressive campaign to promote
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its new drug has also earned the company regulatory and legal scrutiny: In addition to receiving
multiple warning letters from the FDA regarding its advertising practices, the company also pled
guilty to a criminal charge of misbranding OxyContin and attempting to mislead consumers and
doctors. (Ensuring that death and serious injury are more than a business cost, 2007).
As Moynihan and Cassells have discussed, pharmaceutical companies often mobilize a
host of different tactics to sell their products. One of the oldest and most common is the use of
sales representatives who are paid to travel to hospitals, clinics, and private practices to promote
products directly to physicians in their place of work. Moynihan and Cassells characterize this
practice in terms of the efforts pharmaceutical companies’ make to buy “doctors for doughnuts”
by providing them with incentives (free meals, vacations, etc.) to begin promoting or prescribing
a particular drug. In 2000, Purdue hired 671 sales representatives to promote OxyContin using a
physician call list that included roughly 75,000 to 94,000 names. The team also drew from an
eclectic arsenal of sales tactics, which included the distribution of OxyContin branded hats, toys,
golf balls, coffee mugs, luggage tags, CDs, pedometers, pens, and coupons that provided patients
with a free 30-day supply of the drug (U.S. General Accounting Office, 2003).
As others have written (e.g., Angell, 2004; Dumit, 2012; Rose, 2006), the branding of
pharmaceutical products has likewise relied on the strategic mobilization of medical experts and
expertise. That is, when marketing a new product, companies commonly employ expert “thought
leaders” in medicine and related fields as paid speakers, who are then charged with advertising
the company’s products to professional audiences in academic/professional conferences and
workshops. Purdue also made use of this tactic by promoting its new drug in medical journals
and through “continued medical education” workshops, which it paid physicians, nurses, and
pharmacists to attend. From 1996 to 2001, Purdue sponsored more than 20,000 pain-related
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“educational programs” (roughly ten a day, every day of the week) and 40 national pain
management conferences in popular vacation destinations (Temple, 2015; Van Zee, 2009). These
“continuing medical education” events are known to have a strong influence on physicians’
prescribing behaviors (DeJong et al., 2006). Moreover, doctors in most states are required to
attend them in order to keep their licenses (Angell, 2004). It should come as no surprise then that
Purdue’s events were well-attended. Five thousand health professionals showed up to these all-
expenses-paid events, many of whom were also recruited to join the company’s bureau of paid
speakers. In just a few years, the company had acquired a dossier of paid speakers that included
more than 2,500 physicians and other medical professionals (Temple, 2015).
In addition to promoting their products within already established networks of expertise,
drug companies also market new drugs through forming alliances with other companies and
patient advocacy organizations (Dumit, 2012; Moynihan & Cassells, 2005). Purdue has engaged
in similar practices through the partnerships it formed with professional societies, patient
advocacy groups, and other drug companies (Ornstein & Weber, 2012; Wydon, 2015). In 2012,
the U.S. Senate Finance Committee launched an investigation into the financial relationships
between opioid manufacturers and leading pain advocacy organizations and found that Purdue
Pharma had “deep financial ties” to at least 26 such organizations (Wydon, 2015). By acting as a
benefactor to professional organizations such as the American Academy of Integrative Pain
Management, American Chronic Pain Association, American Pain Society, and the National
Fibromyalgia and Chronic Pain Foundation, among others, Purdue has attempted to harness the
legitimacy of their members’ expertise to promote its product within the medical community.
Additionally, the company forged an alliance with pharmaceutical giant Abbott, to whom it paid
half a billion dollars to help promote OxyContin (Armstrong, 2016). This partnership provided
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Purdue with access to a huge swath of marketing resources, contacts, and the experience of
Abbott’s salesforce.
Finally, as previously mentioned, the function of pharmaceutical branding is not limited
to the “selling” of sickness or products. Drug companies are also enrolled in the governance of
their consumers’ subjectivities. The work of scholars who have investigated the relationship
between medicine and subjectivity illustrates that pharmaceutical branding is a useful site for
exploring basic questions about the construction of subjects and selves. These questions are also
at the root of Toby Miller’s (2008) analysis of the American health and wellness industry, which
explores the construction of identity and subjectivity in the drug and talk therapy industries. As
Miller suggests, the discourses that underlie (and attempt to legitimate) these industries rely on a
conceptualization of life and self as ongoing projects in which individuals are obliged to
participate if they are to achieve happiness and self-fulfillment. Yet, the assumption that through
medication one might achieve self-actualization is somewhat contradictory: Carl Elliot (2003)
has examined this contradiction in his analysis of “enhancement technologies” (such as drugs
and cosmetic surgery) and their uptake in Americans’ quest to “find themselves.” That a person
only feels “like herself” once she is medicated or otherwise medically directed to conform to
social/cultural norms may seem like faulty logic, but it is indeed the driving force of an ever-
growing industry for health and wellness and is consistent with deeper currents in American
culture, in which pursuits of the self are always-already influenced by the demands of cultural
conformity.
Likewise, Kristen Swenson (2010) has commented on the ways in which cultural currents
are reflected in the consumption of “lifestyle drugs.” In Lifestyle Drugs and the Neoliberal
Family, Swenson unpacks the cultural logics and norms embedded in drug advertisements. For
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Swenson, these ads’ discourse illustrates how family experience (as well as the experience of
living, more generally) is delimited by the norms and policies of neoliberalism, which requires
individuals to invest in health as a means toward becoming economically productive subjects.
Pharmaceutical advertising discourses geared toward the construction of enterprising subjects are
themselves reflective of a larger governmental rationality that Michel Foucault (2008) has
characterized as neoliberal governmentality – a logic in which governance is outsourced from
the State to individuals, who are charged with playing an active role in their own self-
management. Nikolas Rose (2006) has expanded on this concept in his analysis of biopolitics in
the twenty-first century. Rose suggests that one of the tendencies of contemporary biopolitics is
the development of an “ethopolitics,” which “concerns itself with the self-techniques by which
human beings should judge and act upon themselves to make themselves better than they are” (p.
27). Likewise enrolled in ethopolitics are pharmaceutical companies, who are eager to capitalize
on the notion that achieving health and improving one’s self are ethical obligations. This “ethic
of vitality” is mobilized by companies in an attempt to make themselves legible as “ethical”
companies, who work not in the interest of profit but of humankind and do so by developing new
products so that others might live. The ethic of achieving optimal health is also intertwined in
their marketing campaigns, particularly those attempting to spread “awareness” of certain
diseases and “educate” potential consumers about the individual and social benefits of their
products.
The remainder of this chapter focuses on two interrelated practices through which Purdue
Pharma constructed a market for pain relief: Purdue marketed OxyContin in promotional videos
and through the creation of “education” campaigns, which the company used both to sidestep
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public criticism of its marketing of a highly addictive drug,
10
while framing itself as a socially
responsible actor in the fight to address undertreated chronic pain and as a means of cultivating a
base of “educated,” responsible consumers.
Branding, Pharmaceuticals, and the Authentic Self
In 1998, Purdue released a video titled, “I Got My Life Back: Patients in Pain Tell Their
Story.” Two years later, the company created an updated version – “I Got My Life Back, Part 2:
A Two-Year Follow Up of Patients in Pain” (Lyons Lavey Nickel Swift, Inc., 1997; 1999). The
two films were distributed to 15,000 and 12,000 physicians, respectively, and were made
available for consumers to purchase through a website Purdue created, named Partners Against
Pain. Physicians who received Purdue’s videos were also encouraged to show them to their
patients, who could watch them in the waiting room before their appointment (GAO, 2003).
In both films, the promise of OxyContin is depicted through the personal stories of six
individuals suffering from different types of chronic pain, along with their physician, Dr. Alan
Spanos. The film chronicles the personal journeys of these six individuals through their struggles
to find an effective treatment for their chronic pain. After years of failed surgeries, physical
therapies, and frustrating doctor-patient interactions, each person claims to have finally found
relief with OxyContin. In her 2012 analysis of branding in contemporary culture, Sarah Banet-
Weiser suggests that we think about brands as “a story told to the consumer” (Banet-Weiser,
2012, p. 4). The story that is told in the branding of OxyContin is one centered on the self – in
particular, on the loss of an authentic self and the possibility of its restoration. The self is lost, the

10
By 2004, OxyContin had become the most-abused prescription opioid and a leading
drug of abuse in the United States (Cicero et al., 2005).
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story goes, because of pain. It is only through the elimination of pain, which OxyContin
promises to provide, that the individual may hope to find herself again.
These videos instigated a whirlwind of controversy when it was discovered that Purdue
had neglected to submit them to the Food and Drug Administration (FDA) for review as it was
required to do before distributing them. According to a government report published in 2003, the
first film, “I Got My Life Back, Part 1,” circulated for three years before the FDA finally
reviewed (and subsequently recalled) them. Upon reviewing the films, the Administration found
that they utilized a variety of information that was, at best, seriously misleading. In fact, both
videos featured a series of unsubstantiated claims regarding the benefits of OxyContin and
frequently minimized the various risks and negative side effects that are associated with its use
(GAO, 2003). That Purdue knowingly circulated misleading information about its drug was, in
fact, crucial to the development of the OxyContin brand: Despite the legally and ethically
questionable content of its two promotional films, both demonstrate how hard Purdue has
worked the treatment of pain using brand-name OxyContin as a moral and ethical obligation for
physicians, who are explicitly reprimanded for erroneously attempting to “manage” pain when
they “should be treating it…should be making it better,” and should use every tool at their
disposal to effectively “shut it down.” Luckily for these doctors, the films suggest, OxyContin
offers the possibility for atonement. To compensate for not having prescribed OxyContin before
now (an oversight which the film likens to medical negligence), all these physicians must do is
start prescribing it.
The ethical obligation constructed within these films, which demands that physicians
treat all their patients’ pain with a particular drug, is illustrative of what Nikolas Rose has
referred to as the “pharmacological ethic” (Rose, 2006). While some have argued that the use of
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prescription drugs (or any other health technology) is driven by the ethical principles of self-
enhancement and optimization, Rose says otherwise. He argues (and I tend to agree with him)
that the ethic underlying the use of pharmaceuticals is not about optimization but is rather geared
toward the achievement of authenticity. That is, the motivation for using these drugs is
oftentimes less about achieving an optimal state of happiness/well-being than it is about restoring
one’s true self – an essence that has been, presumably, obscured by the illness, syndrome, or
disease from which one suffers. As Rose states, “In a regime of the self that stresses self-
fulfillment and the need for each individual to become the actor at the center of his or her life,
these drugs…do not promise a new self, but a return to the real self, or a realization of the true
self” (2006, p. 100). Indeed, the theme of returning to the authentic self is a discourse that runs
throughout the two “I Got My Life Back” videos. But what, exactly, constitutes an authentic
self? In Purdue’s promotional videos, the self that is envisioned is, first and foremost, an
economically productive, enterprising self – a self which is sought and can only be achieved
through the long-term use of OxyContin.
Restoring the Enterprising Self in “I Got My Life Back”
Throughout the videos, interviews of the six OxyContin patients are filled with
descriptions of how the medication gave them their life back. Yet it is interesting to note that the
lives they lost are consistently (and often unilaterally) described in terms of livelihood - of
“getting back to work” and restoring their former productivity, activity, and financial
independence. For Jonny Sullivan, a civil engineer and construction business owner, chronic
pain cost him his business and therefore his financial security. Lauren C. shared a similar story,
one where life before OxyContin consisted of many lost workdays and the hours she wasted
cooped up at home. For Lauren, OxyContin was a “godsend” that got her out of the house and
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back to work, where she could become “a productive person again.” She is shown sitting at her
desk, where she takes a break from typing to turn toward the camera and announce with a smile
that, “Since I’ve been on this new pain medication I have not missed one day of work and my
boss really appreciates that!”
Indeed, the ability of opioids to get one “back to work” is a key theme in these videos,
one that is repeated in each of the six patients’ recovery stories. The tight connection that binds
the work of individuals to their own identities and selves is something that many scholars have
written about. This is particularly the case in the United States, where it has been shown that the
link between what an individual does and who that individual is, is particularly strong – a
remnant of Puritan ideology in which an individual’s honest labor was understood as the key to
his or her salvation (e.g., Giddens, 1991; Sennett & Cobb, 1972). The OxyContin videos
reinforce this connection between work and the self. Patients repeatedly describe Purdue’s new
painkiller as a “godsend,” the key to self-improvement, to becoming as “good as I’m going to
be.” In another interview, patient Mary C., attributes her career success to OxyContin, saying
that “Before I had good treatment, by the end of the day I was hobbling…now I work until 6, 7,
7:30 at night oftentimes and I’m fine. I feel as if opioids have given my life back to me.” Mary
also credits OxyContin with getting her a job promotion, an achievement which she explains has
made her “feel whole again.” Mary’s statement explicates an assumption that underlies the
stories of the other five patients: For each, what is understood as a “real life” and a “real self”
was obscured by the intensity of their pain. It is only with this new medication that they have
been able to recover these fundamental truths: OxyContin, which got them back to work, has
made them whole again.
The “whole self” that is envisioned in the two films is not characterized solely in terms of
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its relation to work, but also in terms of its vitality – it is not only productive, but energetic,
enthusiastic, and constantly active. Vitality is a reoccurring theme in the videos, which
emphasize time and time again the problematic “myth” that opioids such as OxyContin cause
passivity, due to their sedative-like effects. Yes, the films admit, drowsiness and “tired feeling”
are officially listed as two of the drug’s most common side effects. But what the FDA refers to as
“common side effects” are reinterpreted in the films to be “common myths,” which are then
undermined by the real lives of OxyContin patients, who are documented gardening, shopping,
working, swimming, kayaking, and living lives that are “anything but passive.” Johnny Sullivan,
the construction business owner with lower back pain, describes the drowsiness effect of
OxyContin as a “zombie myth.” On the contrary, Johnny asserts, with OxyContin he is
motivated to pursue all manner of projects: In addition to taking the 50 foxhounds he owns to
local competitions, Johnny exclaims that, “I ride a horse, I ride a motorcycle, I operate a
backhoe, I move heavy equipment on my own…I go hunting and fishing, we go to the movies -
there’s never a drowsy moment around here!” The videos’ rejection of “passivity” also extends
to physicians who are reprimanded for their hesitance to prescribe OxyContin to their patients, a
practice which is framed as a “passive” approach to treating pain. Spokesman Dr. Alan Spanos
demands that physicians change their ways and begin treating pain “energetically” and
“vigorously” – presumably with OxyContin, which he declares is the “new standard” of pain
management.
Though, as these examples illustrate, Purdue’s videos sought to construct a link between
OxyContin and images of vitality and life, this has not played out in practice. In 2008, before
Johnny Sullivan left to go home from work, he called his wife to complain that his medication
was making him feel drowsy. That night, Johnny’s car ran off the road and overturned after he
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fell asleep at the wheel. He was killed instantly. The tragedy of Johnny’s death – which his wife
has since attributed directly to OxyContin – belies the optimistic vision portrayed in Purdue’s
branding of it. The branding of OxyContin envisions pain relief as something that, once
achieved, automatically ignites the self-activating capacities of its consumers, who are
themselves assumed to be endlessly energetic and productive – perfect examples of the
“enterprising self” which is central to the construction of neoliberal subjects. By articulating this
vision to the problem of chronic pain, branding functions not only as a means for cultivating a
market for pain relieving drugs but as a political technology – one which establishes a dynamic
between the domains of the market and the self, with the ultimate aim of guiding the behavior of
potential consumers, in this case through consumers’ own volition and desire to live a
meaningful life. The films address OxyContin patients (and potential patient-consumers) as
productive, enterprising subjects or, as Nikolas Rose puts it, as “individual[s] striving for
meaning in work, seeking identity in work, whose subjective desires for self-actualization are to
be harnessed” (Rose, 1999: 244). Purdue’s marketing of OxyContin follows the logic of
branding, more generally, in that it articulates the promise of its product within the framework of
consumers’ desires for self-fulfillment, desires which Purdue can then harness and, ideally,
transform into concrete consumption practices. The successful branding of OxyContin, as “I Got
My Life Back” suggests, entails its normalization and, indeed, domestication, in the ordinary
spaces and daily routines of its subjects.
The Cost of Pain
As a political technology, branding attempts to guide behavior not only at the level of the
individual consumer, but also through establishing a relation between individuals, their behavior,
and broader economic and social domains. In both versions of “I Got My Life Back,” the
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construction of a life free from pain is articulated not only as an individual goal but also as a
social undertaking. That is, the productivity that characterizes the pain-free OxyContin consumer
is also characterized in terms of the ways in which it contributes to the larger, social whole: For
example, “I Got My Life Back, Part 1” begins with a statistic displayed in bold type across the
center of the screen: Each year, it reads, “50 million workdays are lost to chronic pain” (Lyons
Lavey Nickel Swift, Inc., 1997). OxyContin, the videos suggest, provides an answer to the
broader social and economic cost of pain. Dr. Spanos reinforces this idea when he informs
viewers that patients who take this drug are not only better workers, mothers, husbands, and so
on, but also better citizens – for when they take their medicine, “they are also using fewer
medical resources – these reductions in health care utilization have important implications for
managed care plans and for society as a whole.”
Through its promise to address the social and economic “cost” of pain through the
management of individual patients, the branding of OxyContin enters into the government of
life, or what Foucault referred to as biopolitics (1978; 2008). Building on Foucault, Nikolas Rose
(2006) has argued that in health and medicine, the government of life applies at the level of the
social, though is conducted through individuals vis-à-vis discourses and practices that work to
incentivize and guide behavior. As Rose explains, intervention in this domain “no longer
operates in a problem space defined by population,” instead the “individual substitutes for
population” while “the political territory of society gives way to the domesticated spaces of
family and community, and responsibility now falls not on those who govern a nation in a field
of international competition but on those who are responsible for a family and its members”
(2006, p. 64). So too, the branding of OxyContin attempts to manage the behavior of a
population of patients through the administration of a pharmaceutical product that promises to
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restore their quality of life – to provide them with a renewed ability to function and to “enjoy
themselves” at work and home, while enabling them to fulfill their social roles as workers,
mothers, husbands, wives, and patients.
Chronic Patienthood
For Purdue, providing consumers with the vital energy that comes with taking OxyContin
is also part of an investment strategy, one that promises to serve the company’s economic
interests in the long-term. As previously mentioned, Purdue Pharma released not one, but two
promotional videos: The first, which was released in 1998 and the second, which was released
two years later in 2000 titled, “I Got My Life Back Part 2, A Two-Year Follow-Up of Patients in
Pain” (Lyons Lavey Nickel Swift, Inc., 1999). The concept of a “two-year follow up” is
significant for the way in which it positioned the problem of pain (as well as the solution of its
treatment using OxyContin) within the framework of “chronic illness.” Put another way, while
the message of the first film is that OxyContin provides a near immediate solution for the
problems associated with pain, the second video asserts that the quick-fix OxyContin offers is
one that must be continuously administered.
In an interesting paradox, the notion that OxyContin provides a “quick-fix” for chronic
pain is situated in the films alongside the marketing of its unique ability to control pain
symptoms for up to twelve hours. Highlighting the long-acting potential of OxyContin can also
be understood as a method for extending its hold over individual patients and physicians, whose
adherence to a specific consumption routine has no foreseeable end. If the first video makes it
clear how the branding of pain relief, along with OxyContin itself, might function as a technique
of governance, then the second “follow-up” video illustrates how such control might be extended
over time. Branding OxyContin as the drug to “start with and stay with” reflects what Joe Dumit
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(2012) has referred to as “dependent normalcy,” the idea that an individual must keep taking
pharmaceutical drugs if she is to continue feeling normal. In line with Dumit, Purdue’s
promotional videos suggest that, with the continued use of OxyContin, the patient-in-pain will be
able to remain “dependently normal” (Dumit, 2012, p. 171).
Indeed, the restoration of one’s authentic, pain-free self takes more work than the one-
time administration of a pill. On the contrary, it requires the ongoing labor of performing a
patient role. Since OxyContin is a Schedule II narcotic, one cannot simply go to the pharmacy to
refill it at will. To get more pills, a patient must first make an appointment to see a physician and
obtain a hand-written prescription, which he or she must then take to a pharmacy to be filled.
Thus, what is required when one decides to “start with and stay with” OxyContin is an ongoing
relationship with medicine that includes, for the physician, the ongoing labor of re-assessment
and record-keeping; for the patient, it means adhering to a schedule of regular appointments,
follow-up examinations, trips to the pharmacy, and more, if one is to continue consuming the
drugs that he or she needs to maintain the “new normal” of his or her life with OxyContin. Such
is the irony of the pharmacological ethic, in which continually performing a patient role and
adhering to a routine of pharmaceutical consumption is also the key to restoring one’s
authenticity as a productive, enterprising individual. OxyContin patient Dorothy M., touches on
this paradox rather directly: By time of the second video’s creation, Dorothy is consuming 1,200
milligrams of OxyContin every day (a huge amount in relation to the other five patients, who
consume between 40-80 milligrams a day). She explains that she started taking the drug because,
“It was important for me to get out of the patient role.” And yet - if Dorothy stays with
OxyContin, a drug which she describes as enabling her to “find life again,” she likely never will.
Training Potential Consumers
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Another way in which the branding of pain relief has been affected through attempts to
guide consumers’ beliefs and behaviors is through the development of “educational” and
“awareness raising” campaigns. Marcia Angell (2004) has written that pharmaceutical
companies often mobilize “education” campaigns around a particular diagnosis (rather than a
drug) to achieve two purposes: First, they do so in order to indirectly market a “cure.” Second,
companies also promote diagnoses as a means evading legal constraints that restrict the ways that
companies advertise their drugs to consumers and limit the uses for which they can be explicitly
promoted. Though I do not dispute these arguments, I also want to suggest that such campaigns,
which are also prevalent across the beauty and self-help industries, do more than enable a
company to circumvent restrictions on its marketing practices. Rather, branding under the guise
of education provides companies with an opportunity to position themselves as socially
responsible and trustworthy corporate actors while simultaneously securing the long-term
stability of their market through constructing a base of “educated” and responsible consumers.
The process of re-positioning one’s company as trustworthy can be particularly useful
when that company has fallen under intense public scrutiny – as has been the case for Purdue
Pharma. By 2000, the company had already begun to witness an outpouring of negative press
regarding the addictive properties of OxyContin (e.g., Meier, 2001; Ordway, 2000; White, 2001).
In lieu of these reports, Purdue’s creation of the education/advocacy websites Partners Against
Pain (1997) and Team Against Opioid Abuse (2015) work strategically to legitimate the
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marketing of what was fast becoming an infamous brand of narcotic painkiller.
11
While both
websites are technically “unbranded,” (that is, they do not explicitly mention or promote any of
Purdue’s products by name) they nonetheless function as promotional tools.
On its homepage, Partners Against Pain defines itself as “an alliance of patients,
caregivers, and healthcare providers working together to alleviate unnecessary suffering by
leading efforts to advance standards of pain care through education and advocacy” (Homepage,
2004, April 2). One of the ways in which Partners Against Pain grooms potential consumers is
through the use of assessment tools, which are available for visitors to download directly from
the site. These tools include checklists and lists of questions used to guide patients through the
process of obtaining medication from their doctors (“Checklist: 11 Ways to Ensure Proper Pain
Management”) as well as the “Find a Doctor” tool – a database visitors can search to find
physicians who are trained in provide pain management and whose offices are located close to
the individual’s zip code (Checklist, 2004, June 10; Find a Doctor, 2004, June 10). As of July
2002, over 33,000 physicians were included in this database (GAO 2003, p. 24). Tools such as
these go further than education: They also function as technologies of power, which manage
communication and information in a way that is normative and directional and, in doing so,
guide visitors’ behavior toward actions that benefit the company. They accomplish this by
activating visitors’ own capacities in ways that attempt to train them how to participate in the
market for pain relief. In Laurie Ouellette’s words, such technologies incite us to “govern

11
Though both websites have since been shut down, a glimpse into the past through the
Internet Archive’s “Wayback Machine” provides us with images of the two domains as they
appeared in early 2004 and 2015, respectively.
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ourselves through our own choices and initiatives, while steering [us] toward desired outcomes”
(Ouellette 2012, pp. 68-9). Indeed, tools such as the “Find a Doctor” database incite visitors to
mobilize their lay expertise in ways that guide them toward the best sources from which they can
obtain a chronic pain diagnosis and opioid-based treatment plan. In doing so, they also reinforce
a “do-it-yourself” ethic of health in which individuals – rather than governments or companies –
are called upon to take charge of their own vitality and well-being. According to this DIY ethic
(which will be elaborated on later in the chapter), it is the individual and she alone who is
empowered to seek out treatment, and who is encouraged to do so through her own initiative.
By 2003, Purdue’s Partners Against Pain, along with its other unbranded websites were
drawing criticism: The FDA expressed concern about the accuracy of and intentions behind
much of the information published on the site, which “appeared to suggest unapproved uses of
OxyContin for postoperative pain” that were inconsistent with the drug’s labeling and “lacked
risk information about the drug” (GAO, 2003). Four years later, the company pleaded guilty to a
felony charge of “illegally misbranding OxyContin in an effort to mislead and defraud
physicians and consumers” (Statement of U.S. Attorney John Brownlee, 2007, p. 1).
Consequently, Purdue was forced to pay a whopping $600 million in a settlement – one of the
largest ever paid by a drug company (Meier, 2007). Then, in 2015, in the midst of an
investigation launched by the New York Attorney General’s office into the company’s business
practices, Purdue decided to unveil yet another unbranded website, Team Against Opioid Abuse,
which it characterized in a press release as, “a new website designed to help healthcare
professionals and laypeople alike learn about different abuse-deterrent technologies and how
they can help in the reduction of misuse and abuse of opioids” (Purdue Press Release, 2015). As
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in the case of Partners Against Pain, Purdue’s new site was not clearly identified as being
associated with the company, save for a small copyright logo at the bottom of its homepage.
In a way, Team Against Opioid Abuse can be understood as a response to the mounting
concerns and critiques regarding Purdue’s business practices and the dangers associated with its
products. By the time the site went live, the U.S. Centers for Disease Control and Prevention
(CDC) had already declared the existence of a nationwide “epidemic” of prescription opioid
abuse (CDC, 2011). And as the maker of the best-selling opioid OxyContin, Purdue was
implicated as the “small but ruthlessly enterprising manufacturer” responsible for causing the
epidemic (Mariani, 2015).
As its name indicates, the Team Against Opioid Abuse website is discursively constructed
around the theme of abuse-prevention – a decision which works strategically to shield the
company from the negative press and attention that was being directed toward its products. And
yet, this site also functions as a marketing platform for those same drugs, which it frames as a
solution to the problem of opioid addiction and abuse. This contradiction – of intending to
prevent the abuse of opioids while simultaneously promoting the use of those same drugs – is
reflective of similar contradictions within the broader economy of opioid use, particularly as it
relates to the emergence of a new consumer demographic: At the time of the site’s release, the
FDA had just approved the use of OxyContin for pediatric populations (ages 11-17) – a
controversial (and contradictory) decision, considering that another government agency, the
Substance Abuse and Mental Health Services Administration (SAMSHA), had recently released
a report showing a surge in prescription opioid abuse among this same population, whose rates of
addiction had nearly doubled between 1994 and 2007 (SAMHSA, 2014; American Society of
Addiction Medicine, 2016).
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Fittingly, the website’s imagery constructs an anti-abuse discourse that appears to target
this younger demographic. As its name indicates, Team Against Opioid Abuse plays on a sports-
based metaphor, one which positions site visitors as part of a “team” competing to defeat opioid
abuse. The imagery on site’s homepage bears a more specific reference to football, a sport that is
central to the culture of many high schools and universities across the country. Centered on the
homepage is an image of a “team” of healthcare professionals: A doctor, along with several
nurses and a pharmacist are shown standing side-by-side in a “line-up” formation, each sporting
eye black and a competitive stance – with stares fixed directly on the viewer and arms crossed in
front of their chests (Homepage, 11 October 2015).
Marketing abuse-deterrent opioids using a football theme seems, at first glance, a curious
choice. Yet perhaps not when one considers that around the same time the site went live, the
media landscape was littered with coverage of painkiller abuse in the NFL. Indeed, the website’s
design seems to reflect a keen awareness of the fact that opioids had become, according to
various media reports, a “football problem” (Easterbrook, 2014; Silverman, 2014). Without
claiming to know what the exact intentions behind this design decision were, it suffices to say
that one of its effects was to reinforce a link between football and opioids which was, at the time
of the site’s release, already circulating in the public imaginary. But this association, which was
depicted in much of the media’s coverage of it in more spectacular terms, is reframed on the site
as familiar and above all else, manageable. Situated on either side of the physician-led football
team are links that lead visitors to various kinds of technical, specialized content (regulatory
documents, prescribing guides, CDC datasets, etc.) – a not-too-subtle suggestion that the
manageability of opioid abuse depends on the cultivation of the visitor’s own expertise. The site
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calls on its visitors – physicians, pharmacists, and patients alike – to become experts in the fight
against opioid abuse and diversion.
This call to action also signals the site’s second purpose – the promotion of Purdue’s
newest products, opioid drugs with newly developed “abuse-deterrent properties.” While the
company does not explicitly mention any of its specific brand-name products, it is nonetheless
promoting them: For when the website was created, there were only four abuse-deterrent opioids
on the market, all but one of which were manufactured by Purdue (FDA Facts: Abuse-Deterrent
Opioid Medications, n.d.). However, the cultivation of this new market did require Purdue to
compete – this time not against the specter of addiction, but against the numerous pharmaceutical
companies that manufacture opioid products without these new properties. On the website, a
page with the header, “What’s Your Role?” addresses different types of consumers – listing
physicians, … and the “part you can play in the effort to reduce opioid abuse.” In each case,
physicians, pharmacists, patients, and third-party payers are advised to change the ways in which
they practice medicine (and participate in the opioid market) by refusing to use any opioid other
than those sporting the newest abuse-deterrent technologies.
12

On the company’s website, Purdue specifically refers to its development of abuse-
deterrent drugs as constituting a “corporate responsibility” initiative – one aimed at curtailing
opioid abuse and diversion (Opioids & Corporate Responsibility, n.d.).
13
One might consider the
company’s claims to advocacy and responsibility to be a form of what Roopali Mukherjee and

13
“Diversion” refers to the movement of a drug out of the contexts in which it legally
circulates into the black market.
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Sarah Banet-Weiser have termed, “commodity activism” – a mode of activism that involves
“grafting philanthropy and social action onto merchandising practices, market incentives, and
corporate profits (2012, p. 1). As Banet-Weiser demonstrates in her analysis of Dove’
advertising, the activist practices of commodity activism can also be utilized by companies and
corporations. On its unbranded websites, Purdue grafts its marketing practices onto existing
social problems: The epidemic of addiction and abuse, which the company insists is the reason
for website’s creation, also provides the company with a rationale for marketing of its new
products. Commodity activism, then, is what enables Purdue to reframe itself and its business
practices within a moral framework that legitimizes the company’s actions while simultaneously
feeding its bottom line.
14

As with its older website, Partners Against Pain, Purdue’s newer advocacy platform also
emphasizes the importance of “education” and, to that end, provides its visitors with a variety of
instructive materials. On the Team Against Opioid Abuse site, it is health care professionals,
specifically, who are called upon not only to see themselves as responsible actors, but to utilize
the tools provided on the site to “train” themselves to perform their jobs differently – in this case,
by using new abuse-deterrent products. For instance, one of three hyperlinks embedded on the
site’s homepage leads to a review of the FDA’s “2014 Guidance for Industry” mandates, which
explain the different methods one can use to identify which opioid formulations boast the latest

14
It is also worth noting that Purdue has recently been granted a patent for a new drug to
wean addicts from opioids, representing yet another move to re-frame the company’s practices
under the banner of corporate social responsibility – while still driving up company profits
(Bever, 2018)
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FDA-approved, abuse-deterrent properties and which do not (FDA Guidance for Industry, 2015,
December 12). Health care professionals are guided through the FDA document to a link located
at the bottom of the page. The link then leads them to a selection of videos, press releases, and
other documents that tout the potential of abuse-deterrent formulations to reduce the prevalence
of prescription drug abuse.
The tools that Team Against Opioid Abuse provides to train its visitors form part of the
political technology through which branding operates as a mode of “governance-at-a-distance,”
establishing a relay between the aims of authorities (in this case the government, which aims to
prevent drug abuse/diversion and the pharmaceutical companies, which aim to sell their products
and protect their reputations) and the aspirations of autonomous citizens (Rose, 1999). The
“relay” that is utilized in Purdue’s branding on this website exists in the form of bureaucratic
expertise – expert knowledge which is imparted to visitors through their “training.” But what,
exactly, are visitors “training” to become? Better citizens? Perhaps. Better physicians? Some.
Better consumers? All – for this particular kind of training does not end with the cultivation of a
well-educated public but with a public that is also seen as a potential market, a population that
has been groomed to exercise choice in a specific way, by becoming responsible consumers.
Branding Pain Relief and the Government of Medical Practice
The branding of pain relief vis-a-vis educational campaigns has not been limited to the
creation of Purdue’s websites. On the contrary – much of the information (as well as the
strategies) within these spaces have been extended into institutional settings, where they have
become embedded into the logics and practices of pain management in hospitals and clinics.
In 2001 and 2002, Purdue Pharma funded a series of nine programs across the country to
extend its “education” efforts into hospital settings. The programs were centered on teaching
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hospitals and other health care organizations how to comply with the new “Pain Standards” that
had recently been implemented by the Joint Commission for the Accreditation of Health Care
Organizations (GAO, 2003). The Joint Commission (JCAHO) is perhaps the most widely
recognized accreditation body in the country; it is responsible for the accreditation and
certification of tens of thousands of health care organizations throughout the United States.
Accreditation is a key component of a health care system where the administration of quality
assurance and standard-setting programs is conducted by entities that are, for the most part,
independent of government control. Moreover, hospitals and clinics are incentivized to pursue
state licensure through JCAHO’s accreditation process, as doing so will enable them to receive
hefty federal reimbursements for their Medicare and Medicaid expenses.
Through its partnership with JCAHO, Purdue Pharma effectively transplanted the liberal
ethic of individual responsibility, enterprise, and training that was central to its branding of pain
relief in the “I Got My Life Back” videos and on its websites into the U.S. hospital system.
Remarkably, Purdue was one of just two companies that were given the opportunity of
sponsoring JCAHO’s pain management training programs. Yet of these two companies, Purdue
was the only one allowed to distribute its own branding materials among JCAHO-accredited
health organizations and on JCAHO’s website (GAO, 2003).
While a partnership between a pharmaceutical company and an independent organization
such as JCAHO may not, at first glance, seem out of the ordinary, it is significant for two
reasons: First, Purdue’s partnership with JCAHO facilitated the company’s access to tens of
thousands of hospitals and health care organizations across the country and, in doing so,
extended the reach of its marketing campaign into these domains (GAO, 2003). This practice of
dispersing branding materials into new contexts is emblematic of what Joe Dumit (2012) has
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referred to as “strategic ubiquity,” a tactic in which companies attempt to create a “universe” of
syndicated and sponsored content through forming alliances with advocacy groups and
developing partnerships with other influential third-parties. For potential consumers navigating
this landscape, every piece of information they read or hear about inevitably directs them toward
specific actions that will serve the benefit of that company. Purdue’s alliance with JCAHO goes
a significant way toward crafting a universe of branded pain relief. As of 2001, the patients
sitting in the waiting room of any one of the thousands of organizations that adhere to JCAHO’s
pain management standards will likely find themselves reading brochures and watching videos
that were created by Purdue with the intention of selling its latest pain-relieving products.
Second, the Purdue-JCAHO partnership is a striking example of how the branding of pain
relief, through its institutionalization in the U.S. health care system, has been used to govern
clinical practice: In 2001, the Joint Commission began requiring hospitals seeking accreditation
to adhere to the requirements of its newly released pain management standards. These standards,
which Purdue helped develop, mandated that accredited organizations use particular educational
tools (namely those developed by Purdue) to educate health practitioners (along with patients
and their families) about the importance of pain management (JCAHO, 2001). Additionally, the
new standards included a requirement that physicians begin administering “patient satisfaction
surveys” to every one of their patients before discharging them – to begin polling these patients
about the degree to which their pain had been adequately acknowledged, assessed and treated.
The results of these surveys were then used to dictate whether a hospital would be eligible to
receive Medicare and Medicaid reimbursements. Importantly, a recent survey of 182 health care
organizations in the U.S. found that 66% also rely on patient satisfaction surveys to rate the
performance of their staff (Falkenberg, 2013). For physicians, the scores they received from
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these surveys became key variables for determining whether they would receive extra
compensation or, potentially, lose their jobs.
15

In the two years following the uptake of these new pain standards, the U.S. saw steep
increases in both the number of opioid prescriptions written by physicians and the average rate of
patients’ consumption of these drugs (Frasco, Sprung, & Trentmon, 2005). This surge in opioid
prescriptions, though it may be consistent with the process of normalization that these drugs
underwent in medicine in the 1990s, also clashes with mounting public awareness in the 2000s of
the dangers that accompany their use. And yet, as the above discussion indicates, the
apprehension that surrounds the use of opioids in our current moment belies the extent to which
these drugs have become deeply situated within the institution of medicine, where they are
embedded into, and have themselves become, mechanisms for limiting the ways in which pain
management is practiced within its clinical context.
Branding Pain Relief in the Self-Help Industry
Before concluding it is worth noting that the branding of pain relief, as a key cultural
process that conditions our relationship to pain and patienthood, has not been mobilized by
pharmaceutical companies alone. In fact, the self-help industry – which actively positions itself
against “Big Pharma” – has likewise been participated in this process. By and large, companies
operating within the self-help industry have contributed to the branding of pain relief through
marketing an assortment of non-pharmaceutical products, which are positioned as inherent
valuable for the ways in which they offer consumers “drug-free” methods for managing pain.

15
As Forbes reported in 2013, nearly two-thirds of physicians had annual incentive plans
tied to the scores they receive from patient surveys (Falkenberg 2013).

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Yet while this industry’s products are positioned in opposition to the pharmaceutical industry,
the discourses which undergird the branding of pain relief in this context closely resemble those
utilized by Purdue in campaign to market OxyContin: By calling upon individuals to become
active participants in their own pain management by taking control of their symptoms, self-help
and wellness discourses have also contributed to the normalization of pain relief as a both an
everyday practice and a necessary requirement for consumers’ self-actualization. Put another
way, in a move nearly identical to those made by its competitors within the pharmaceutical
industry, companies devoted to drug-free “wellness” and “self-help” attempt to frame the search
for pain relief as a journey of self-restoration and actualization. Both industries, moreover, oblige
potential consumers to take responsibility for their pain (whether through pills or self-work) and
do so by acknowledging that pain (once thought to be a vital part of human existence) is both
unnecessary and antithetical to human vitality.
A quick Amazon search reveals a world of self-help products and literature that reinforce
the obligation of individuals to take control of their pain – a world which is geared toward the
practice of what I’ll refer to as “do-it-yourself pain management.” The DIY approach to pain is
promoted through various tools and techniques, all of which assert the need for pain sufferers to
turn away from pharmaceutical treatments, surgeries, and expensive physical therapies toward
products that enable them to create their own, individualized program. The options for what such
a program might include abound: There are books and manuals brimming with at-home
exercises, yoga techniques and various forms of mindfulness training, along with all the
necessary gear and equipment that such training might require. There are loads of pain-relieving
vitamins, nutrition supplements, and diet plans. Outside of Amazon, the online world of DIY
pain management is replete with YouTube videos, tutorials, and a host of websites and blogs that
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provide advice and reviews of the various programs, products, and physical/mental/spiritual
exercises that are currently available on the DIY market. Many of these websites boast their own
patented “methods” for achieving pain relief, each of which claims to be “backed by science” as
an effective, drug-free approach to pain management. To take but one example, the website of
“world leader in non-medical pain relief” Pete Egoscue is host to the owner’s “Egoscue Method”
along with links to his book (an Amazon Bestseller) titled, Pain Free: A Revolutionary Method
for Stopping Chronic Pain. Egoscue’s “easy and gentle method,” which reportedly “has a 94
percent success rate,” is mostly made up of different kinds of calisthenics (or “motioncises”)
which “teach YOU how to regain control of your health without becoming dependent on another
person or machine” (www.egoscue.com).
I’ve chosen to present the Egoscue method because it seems to highlight many of the
themes/discourses that are prevalent across the domain of self-help-oriented, DIY pain
management. In this domain, pain management is driven by an ethos of individual autonomy:
Consumers are hailed as always-already in control of their pain, as empowered, and as having a
“choice” in whether or not they will continue to suffer. In DIY pain management, to choose to
remain a victim is anathema to recovery. While individual autonomy, in contrast, can be
characterized in the mantra of “mind over matter.” As Micki McGee has shown, “mind over
matter” is a discourse that legitimates the promise of self-help, particularly as it relates to the
body. The pull of self-help literature (whether diet and exercise manuals or methods for DIY
pain management) lies in this vision of autonomy where “mind is master, body is slave…where
the body is controlled by willpower or self-hypnosis” (McGee, 2005, p. 155).
Indeed, the branding of pain relief in the self-help industry reinforces a discourse of
individual autonomy/empowerment that relies on the inherent superiority of the mind over the
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body. This discourse assumes that pain is as much “mental” or “emotional” as it is physical. As
such, pain can be treated most effectively through various forms of “self-work” – in which the
consumer invests in a product/book/method in order to train his or her mind to acknowledge,
confront, and eventually “let go” of pain. Take for example, “The Tapping Solution,” one
particularly popular DIY method for managing pain. “The Tapping Solution” is run by its CEO,
Nick Ortner, who popularized the technique in a New York Times Best Selling book, The
Tapping Solution: A Revolutionary System for Stress Free Living (2014) and a documentary
titled, “The Tapping Solution” (2008) which provided the basis for creation of five “Tapping
World Summits” and various tapping-related charities (Ortner’s Wikipedia page mentions
ProjectLight: Rwanda, The Veterans Stress Project and You Can Thrive). As a therapeutic
technique, the Tapping Solution is reportedly based on the theory of EFT or “emotional freedom
technique,” a counseling intervention that is derived from various theories in Eastern and
alternative medicine, including that of Chinese acupuncture. EFT, like acupuncture, assumes that
many disorders can be treated by redirecting and balancing the body’s energy flows. The body’s
vital energy circulates through different channels, which in traditional Chinese medicine are
sometimes referred to as meridians, which are connected to different bodily organs and
functions. In acupuncture, needles are placed along specific meridians order to correct an energy
imbalance that is affecting the associated organs/functions. Similarly, EFT typically relies on
placing pressure on meridian points. In a typical EFT session, a person will focus on the specific
problem she is having, while tapping on various points on her body and often while repeating
some kind of affirmation or mantra.
A quick YouTube search turns up a plethora of videos of different people demonstrating
the “tapping” technique - some of which have amassed hundreds of thousands of views. These
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videos show that the tapping solution is, more or less, exactly what it sounds like: Do-it-yourself
pain management accomplished through the physical “tapping” of different body parts. If you are
working with this technique, you may begin by tapping repetitively on your temples, then above
your eyebrows, under your nose, beneath your collar bone, all the while repeating various
mantras. In one often-viewed video, Ortner himself demonstrates the technique using the
following mantras: “Even though I have this pain in my body, I deeply and completely accept
myself” and “I’m so frustrated by this pain, and I wonder if I can let it go.” The assumption that
underlies this method (and which is echoed across many others
16
) is that by “tuning in” to one’s
emotional state, one can access the “truth” behind his or her pain. As Ortner writes, “Your
emotions are entry points into the core of whatever ails you. By burrowing deeper into how you
feel, you’re able to discover and unlock whatever it is that’s holding you back and even hurting
you” (2014, page).
In the “Tapping Solution” and similar programs that constitute the field of DIY pain
management, the body is subordinated to the mind and to the individual him or herself who is
empowered by his or her ability to “choose” to take control of his or her pain. Such a philosophy
brings to mind Foucault’s discussion in The History of Sexuality (1978) of the Greek’s concern

16
See, for example, the DIY pain management method espoused in the book, The
Mindbody Prescription: Healing the Body, Healing the Pain, by John E. Sarno, M.D. Another
popular pain management self-help text, the “Mindbody Prescription” takes a Freudian approach
to pain relief, a kind of “talking cure” that understands pain as “rooted in repressed emotion.”
This method holds that recovery can only be achieved through one’s “becoming conscious” of
one’s emotional state – which is articulated as the true source of pain.
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with achieving mastery over their bodies. The Greeks believed that for an individual to become
truly free, he would need to be able control his bodily urges and, in so doing, become the master
of his body. The Greek’s relation to self, which Foucault characterizes through a “triad” of self-
mastery – freedom – truth, and which mirrors the logics of liberal individualism, is reinforced in
the “Tapping Solution” and the paradigm underlying DIY pain management, more generally.
This paradigm reinforces an understanding (which is also part of the discourse in Purdue’s “I Got
My Life Back” videos) of pain as an obstacle to realizing and restoring one’s authentic self. An
individual who utilizes the Tapping Solution and finally makes the choice to “let go” of his or
her pain achieves self-mastery over his or her body. Achieving this kind of mastery is, according
to the paradigm, akin to freedom, and the individual who is free of his or her body is likewise
empowered to access the “truth behind the pain.”
The promise of freedom is not unique to DIY pain management but has been said to
characterize the self-help industry as a whole. In Self-Help, Inc. (2005), Micki McGee analyzed
the function of this freedom discourse within the self-help industry as one that is enrolled in the
construction of “belabored selves.” As McGee explains, the belabored self is a result of the
industry’s attempts to insulate its consumers from “affronts to [their bodies’] vulnerabilities
through constant efforts at self-mastery and self-management” (2005, p. 174). These attempts,
McGee suggests, are “futile” at best, for the belabored self can never be free. Freedom will
remain out of reach because the “belabored self” is always-already defined only in terms of its
ability to labor – to be engaged in constant work, “not only at the office on one’s professional
tasks, but at home, on one’s self” (p. 174). Indeed, the DIY pain management industry is also
involved in the making of belabored selves. For if the pain is to remain at bay, one must
constantly labor to uphold one’s mastery over it. Just as in Purdue Pharma’s branding of pain
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relief in its promotional videos, the branding of pain relief in DIY pain management belies the
reality that freedom requires more work than the one-time administration of a pill, or a program.
What is actually required is an ongoing commitment to invest in that which enables one to
maintain control over his or her pain and to integrate an ongoing search for total relief as a
normal component of one’s daily life.
Conclusion: The Opioid Zeitgeist
In an age where pain is considered to be the “fifth vital sign,” we are all confronted with
the obligation to consider the problem of pain – and the possibility of finding relief. Whether we
are the patients being asked in a checkup to assign a number to our pain (which we may or may
not be experiencing in that moment) or the nurses who are required to do the asking (tens or
maybe even a hundred times a day), the question of pain materializes and extends to all of us in
an open invitation. To participate in the question of pain today is to participate in the possibility
of finding a solution for it – and the solution which has been for some time now the most
accessible and most readily available is opioids.
The problem of pain and its relief and the ways in which it was so effectively branded in
the United States, has resulted in millions of Americans inviting opioids into their lives. But, as
we know, what was initially an invitation has since mutated into a catastrophic invasion. Yet, in
much less spectacular terms, it is precisely the everydayness of opioids that has enabled their
migration into medicine cabinets across the country. The processes through which opioids – as a
first-line solution for the problem of pain – have been constructed as both familiar objects and
objects articulated to familiar narratives of happiness, success, and the American Dream, help us
explain the formation of today’s opioid “zeitgeist.” I am using the term zeitgeist, specifically, to
indicate a couple of key points: First is my argument, which was asserted at the beginning of this
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chapter, that instead of seeing the opioid epidemic as the consequence of millions of patients
suddenly morphing into addicts we should instead examine it in terms of the ways in which
opioids have become normalized as both ordinary household materials and extraordinary
immaterial signifiers – of authenticity, actualization, and inner truth. Relatedly, opioids are a
zeitgeist because they cannot be understood only in terms of their materiality, but must be
considered in terms of their discursivity, their meaning-making potential that, while itself is
something immaterial, has resulted in incredibly substantial and, indeed, devastating material
consequences.
As mentioned in the beginning of the chapter, most first-time opioid users do not get their
drugs from physicians but receive them as gifts from friends and family. I presented this statistic
initially as a way of bridging a discussion about the ways in which these drugs have become
normalized and domesticated. But now I bring it up again in order to argue that it illustrates
something even more significant: The unforeseen emergence of what I am referring to as a
massive “grey market” where these drugs (and the various practices and relations that come with
them) now circulate reflects just how complex the issue of abuse and addiction in this country
has become. By “grey market,” I am referring to contexts and practices of production,
distribution, and consumption that disrupt institutional logics in several key domains. As I see it,
the grey market is what best characterizes today’s opioid epidemic and the difficulties facing the
various companies, regulatory bodies, law enforcement agencies, policymakers, and other
stakeholders who are attempting to combat it. One of the key characteristics of the opioid grey
market is the context within which the practices of opioid distribution and consumption often
take place. These are increasingly embedded in private and domestic domains and, as such, are
often not as readily legible as illicit; today, opioids circulate among family members and friends,
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where they are exchanged via informal bartering and gifting, just as often as they circulate on the
black market, among street dealers and their clients.
Recently, the Pew Research center released a survey report titled, “America’s New Drug
Policy Landscape” (2014). What the survey showed was that the American public is, by and
large, ready for a dramatic shift in drug policy and the methods that have typically been used in
America’s waging of its three-decade long “War on Drugs.” Of the respondents, 67% said the
government should focus less on the typical criminal justice approach to drug use and the
prosecution of drug offenses and more toward the treatment and rehabilitation of drug users.
Only 26% thought the government should focus more on its prosecution of drug users. Indeed,
local law enforcement around the country are also attempting to reorient their approach to drug
criminalization – namely by distinguishing those who use drugs from those who deal drugs, and
by prosecuting only the latter group. Yet, the grey market for opioids presents an enormous
challenge to regulators and lawmakers attempting to flesh out these distinctions, as it is
becoming increasingly difficult to identify who exactly is a “user” and who is a “dealer.” If my
grandmother gives my dad, her son, a half-used bottle of OxyContin for his lower back pain, is
she now considered a drug dealer? Depending on the quantity of pills she handed over, the
answer could actually be yes. By some other standard (perhaps a legal standard of “intent”), the
answer would be no. And what about physicians? Who is to say whether prescribing a month’s
supply of an addictive opioid is “reasonable” within the standards of medical practice? It could
just as easily, depending on what that prescription amounted to (whether or not the patient
became addicted to it, overdosed, etc.) be interpreted as malpractice, manslaughter, or even
murder (as is now increasingly the case) (Cohen, 2016; Sullivan, 2017; Wootson Jr., 2017).
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As is clear from the ever-rising rates of addiction and overdose, the systems we currently
have in place for regulating illicit opioid use and enforcing the laws that have enabled us to wage
a “War on Drugs” are becoming less and less useful. Their futility is, in large part, due to the fact
that opioids became rather suddenly embedded in private and domestic domains where their use
is not as clearly legible in terms of addiction but may instead be more readily understood (in the
terms of branded pain relief) as a necessary requirement of vitality, that which enables an
individual to get out of bed in the morning, to go to work, to spend time with his or her family, to
do all the things that make his or her life worth living.
Thus, to talk about the opioid zeitgeist is to acknowledge the ways in which managing
and regulating their use seems to many (especially to those who are charged with this
responsibility) an impossible task. Indeed, as someone who regularly follows the news regarding
the opioid epidemic, it seems like the harder we try to get a grasp on this thing, the more it slips
away from us. As it moves further out of reach, the opioid zeitgeist seems increasingly
incomprehensible. And in many ways, it is. At the very least, we cannot hope to understand this
phenomenon, nor to counter it, using the tools we currently have in our repertoire. Systems that
rely on the black-and-white categorization of users versus dealers/patients versus addicts/cures
versus poisons cannot help us understand what is, fundamentally, a grey matter. What is instead
required is a more profound re-thinking of those outdated terms, their histories, functions, the
interests they serve. This chapter considered some of these questions in its examination of
branding; the next turns to examining drug regulation as another of the domains that has played
a key role in shaping our relationship to medicine and conditioning the ways in which we have
come to relate to opioids, addiction, and pain.

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Chapter 4: The Logics of Regulatory Failure and the Rise of the Opioid Grey Market

From 1994 to 2014, the FDA approved more than 24 new opioid drugs (“Timeline of
Selected FDA Activities,” n.d.). Even in the later years of this period, years when opioid
overdose deaths were skyrocketing, the FDA continued to approve their sale, while the DEA
repeatedly sanctioned hikes on opioid manufacturing quotas. How can we explain the
government’s contradictory approach to the opioid epidemic during these years? To answer this
question, this chapter will investigate the regulatory rationalities behind the approval of new
opioid medications – rationalities that have guided a series of calculations and decisions, of all of
which have contributed to the flooding of the medical market with narcotic drugs.
At the time of this writing, 27 different states and many more of the cities and counties
within them have filed lawsuits against the manufacturers and distributers that make up the $13
billion-a-year opioid industry (Smith, 2018). Among law enforcement, public health officials,
and citizens alike, fear and frustration continues to grow in the face of rising death rates and
states’ inability to bear the costs of attempting to curb the ever-growing public health crisis. And
yet, the widespread consensus among these different parties is that the current epidemic could be
minimized, or at the very least controlled, by regulatory processes at the federal level. This
consensus is based on the (not unreasonable) assumption that the regulatory process and its
enforcement in federal law are key institutional mechanisms, which work to prevent the
exigencies and undesirable side effects that can often accompany the widespread use of
prescription drugs. Yet as is clear from the flurry of news stories and outpouring of overdose
data, our regulatory process is not working as it we need and expect it to.
The pages that follow develop an analysis of regulatory failure that seeks to understand it
in terms of the institutional logics and structures that underlie it. But to do so, we must return yet
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again to OxyContin – to the steps that regulators took to evaluate the safety and efficacy of
Purdue Pharma’s newest painkiller and to the discussions and debates that led to its approval and
release into the market. But of course, we cannot stop here: For the story of OxyContin’s
regulation climaxes after its release – when reports of its abuse began piling up, obligating
another wave of post-market regulation. But how did regulators respond to the risks of
OxyContin? What measures did the FDA take to anticipate its effects? How were these
measures developed, how were they implemented, and – most importantly – how and why did
they fail? And what consequences have followed in their wake? These are complicated questions
with answers that are anything but simple. But if we are to identify a starting point in our search
for them, that point is undoubtedly pain. For the trajectory of opioid regulation is marked time
and time again by regulators attempts to wrestle with endless uncertainties around the problem of
pain. These uncertainties have been both practical (how to objectively assess and measure it, how
to intervene upon it and to what extent) and moral. Is treating pain a moral imperative? To whom
does this obligation extend – doctors, regulators, companies, consumers themselves? And how
should this obligation be put into practice?
Taken together, the uncertainties about pain have paralyzed opioid regulation –
conditioning regulatory indecision and legitimating non-intervention. By doing nothing,
regulators both failed to mitigate the dangers of opioid drugs and succeeded in bolstering the
growth of new markets for them. These new systems of exchange – which I characterize as the
opioid grey market – have in turn presented regulators with a host of novel risks and
uncertainties that further disrupt regulatory logics and render useless the tools that regulatory
institutions have at their disposal for dealing with the current crisis.
The Logics of Regulatory Failure
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In December 1995, Purdue Pharma received a letter from the FDA approving the
company’s application for a new prescription painkiller to be named OxyContin. The drug was
approved for “the management of moderate to severe pain where use of an opioid analgesic is
appropriate for more than a few days.” (FDA OxyContin NDA, 1995). Immediately, the
company began promoting its drug widely. And its efforts bore fruit: OxyContin prescriptions
for patients with non-cancer related pain increased tenfold, from 670,000 in 1997 to 6.2 million
in 2002, while prescriptions for cancer pain increased fourfold, from 250,000 to 1 million (Van
Zee, 2009).
Meanwhile, dozens of stories began surfacing in local and regional newspapers that
warned their readers of a dangerous new painkiller and corresponding slew of problems
associated with it: Already by 1999, the DEA reported that 85 percent of arrests for false
prescriptions in Maryland were written for OxyContin and other oxycodone products. The
following year, the president’s Office of National Drug Control Policy’s Pulse Check Report
stated that OxyContin abuse had emerged as a significant problem in Baltimore, Boston,
Billings, Montana, Denver, Detroit, Honolulu, New Orleans, Philadelphia, St. Louis, and
Washington, D.C. (Diversion Control Program, DEA, 2001). In April 2002, the DEA conducted
an expanded review of autopsy data to assess the damage that OxyContin was wreaking on local
communities: The report concluded that the drug had played a role in at least 464 overdose
deaths. In all but 10 of the overdoses, users had taken the drug orally – just as it had been
prescribed (DOJ, 2001).
The rapid uptake of OxyContin and the corresponding rise of overdoses and deaths linked
to it leads one to the obvious conclusion that this drug, contrary to the FDA’s initial assessment
of it, is treacherous. Why, then, did the FDA approve it? And why, some twenty years later, has
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it continued to approve new formulations of OxyContin and similarly potent opioids? Why
hasn’t it done anything to restrict these drugs’ circulation, or remove them from the open
market? Long before the agency first approved opioids for medical use, it was widely known that
such drugs are habit-forming and, for first-time users, present a significant risk of accidental
overdose. In fact, the recreational (and indeed, habitual) use of opioids is a documented fact that
goes back thousands of years. Was this history unknown to U.S. regulators? Or was it known and
simply ignored? Rather than attribute blame directly to any given regulatory actor, it makes more
sense to examine the logics that are inherent to the process of new drug approval. These logics
define the scope of drug regulation and, in doing so, limit the ways in which regulators can think
and act.
The first and perhaps most obvious regulatory logic that limits the scope of regulators’
abilities is the FDA’s reliance on two principles, which form the basis of its approach to
assessing new drugs: These are the twinned requirements of safety and efficacy. Before a drug
enters the market, it must be shown to be both safe and effective for its target population. While
these principles may seem obvious, they were not always a part of U.S. drug regulation. The
requirement for drug manufacturers to demonstrate their product’s safety was enacted in 1938,
with the passing of the Food, Drug and Cosmetic Act – a piece of legislation that was developed
to respond to the public harms inflicted by the patent drug industry. And it wasn’t until 1962,
when Congress passed the Kefouver-Harris Amendments, that the FDA was endowed with the
authority to demand that drug sponsors provide evidence the effectiveness of their products – in
addition to their safety. The Amendments also dictated that the evidence drug sponsors presented
would need to come from three separate rounds of clinical trials: An initial round to determine
the toxicity of their product, a second to assess its therapeutic effect in patients with the specific
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illness it claimed to target, and a third, which would assess the drug’s effects in a series of
blinded comparative trials with a wider patient population (Helm, 2007). These trials must
produce results that demonstrate a drug is both safe and effective - which in practice, means that
it must be shown to be no less safe and no less effective than other FDA-approved drugs of the
same class. It is, moreover, up to the drug’s industry sponsor (rather than the regulators) to
provide evidence that its drug meets both requirements.
Historian Daniel Carpenter has argued that defining pharmaceutical politics solely in
terms of safety and efficacy excludes many other important questions from regulatory discourse,
among which are “the heterogeneity of individual responses to drug treatment, the therapeutic
experience of millions of human subjects in ongoing clinical trials, the continued operation of
placebo effects in markets for prescription pharmaceuticals, and the therapeutic implications of
drug advertising and labeling” (Carpenter, 2010, pp. 16-17). Indeed, when the FDA was
considering the new drug application for OxyContin, it did not consider the possible
heterogeneity of individuals’ responses to the drug, in part because the clinical trials it reviewed
did not present this information. In its first clinical trials in 1989, Purdue recruited a group of
women recovering from abdominal and gynecological surgeries at two different hospitals in
Puerto Rico. In the study, 90 women were provided a single dose of OxyContin while the others
were given either short-acting opioids or placebos. The logic of control that was central to the
design of these studies – and which is central to all controlled trials – required research subjects
to take the drug, whether OxyContin or a placebo, exactly as directed by the experimenters. That
is, subjects were not allowed to manipulate the drugs in any way and were not to deviate from a
prescribed dosing schedule. Right from the start then, the OxyContin trials excluded the
possibility for analyzing heterogeneous consumption data. Moreover, even if some of the
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research subjects did deviate from the prescribed dosing instructions, these deviations would
have occurred outside the context of the trial itself – in subjects’ homes, for example – and
therefore would have been neither observed nor recorded. Moreover, the trials relied on a subject
pool that was not representative of the differences among opioid-using populations. The
volunteers who participated in Purdue’s experiments were not chronic pain patients, nor were
any of them regular prescription drug users; none had reported a history of drug abuse nor of
long-term opioid use. How could a study like this, formed around a rather homogenous group of
research subjects, even begin to assess the abuse potential of the drug in question?
To approve OxyContin’s release, the FDA required that it be proven effective for at least
12 hours in at least 50% of the patients who tried it. But in the Puerto Rico trials, more than 30%
of the women who took the drug reported their pain returning within the first eight hours, while
just shy of 50% needed more medication before the 12-hour mark (Ryan, Girion, & Glover,
2016). These numbers were all noted in Purdue Pharma’s New Drug Application; what was not
noted, however, was the fact that the patients the company recruited to take the drug failed to
resemble the medication’s target population in (at least) one significant way: For these women
were not chronic pain patients (OxyContin’s target population), but post-surgical patients
suffering from acute pain – pain that was directly related to surgically induced wounds and to
likely abate after a short period of time. The fact that these participants were suffering acute
rather than chronic pain gives us cause to question this study’s results, which may have been
skewed by the fact that acute pain is, for the most part, much easier to treat than chronic pain.
For chronic pain is complex; it often lacks a unified source – such as a visible lesion – and
instead involves a host of complex psychological factors. As such it is difficult to treat directly.
Acute pain, on the other hand is nearly always traceable to a specific source (e.g., a surgical
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lesion) and can therefore be treated directly with a targeted intervention (such as an opioid). A
clinical trial where pain is acute – with a visible lesion and unified source – will likely also
produce clearer results than a trial involving other kinds of chronic pain which cannot always be
treated in this way.
Additionally, because none of these women were chronic pain sufferers, most of whom
typically have at least some previous experience using opioids, they were, for the most part,
opioid-naïve. The fact of their opioid naiveté also meant that their tolerance to oxycodone (the
active ingredient in OxyContin) would have been much lower than that of the average chronic
pain patient. The medication would have a stronger effect on them – and these effects would last
longer than they would in other patient populations. Thus, the study’s weak results, which just
barely met the FDA’s efficacy requirement, were likely achieved only because of the
homogeneity and naiveté of its research subjects. Even so, Purdue Pharma was able to declare
that its Phase 3 clinical trials proved that OxyContin was not only safe (or rather, that it was no
less safe than other FDA-approved opioids) but also effective (or rather no less effective), a
status would ultimately grant its manufacturer the license to declare it superior to the other
painkillers in its class.
In addition to evidence gleaned from clinical trials, other “data” was used to prove
OxyContin’s safety and efficacy. But this data was not produced in a laboratory but was rather
lifted from recent history – specifically, from the history of another drug, a morphine-based
painkiller named MS Contin approved by the FDA in 1987 and which, like OxyContin, was
developed by Purdue Pharma. Also like its sister-drug, OxyContin, Purdue’s MS Contin offered
a novel benefit for opioid users in that it boasted a slow-release mechanism, which would
lengthen the effects of the morphine it contained for up to 12 hours. Thus, MS Contin would
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require consumers to dose only two times a day, rather than every four to six hours, as was the
case with every other opioid medication on the market at the time.
Jumping ahead in time for just a moment, it is worth noting that in recent years, both the
FDA and Purdue Pharma have come under scrutiny for their failures to anticipate the widespread
abuse of OxyContin. In such cases, both actors have frequently responded by pointing to the
similarities between OxyContin and MS Contin. In doing so, they made an argument that went
something like this: Because MS Contin was proven safe and because OxyContin so closely
resembled this older drug in both form and function, neither the FDA nor Purdue could have
anticipated the upsurges in OxyContin abuse. Because the FDA had no reason to suspect that
OxyContin would be any less safe, nor any less effective than its predecessor, approving its
release onto the market was a reasonable thing to do. At the time of this writing, the FDA’s
website described the agency’s rationale for approving OxyContin as one that was grounded in
the agency’s trust in MS Contin, stating that, "At the time of approval, FDA believed the
controlled-release formulation of OxyContin would result in less abuse potential, since the drug
would be absorbed slowly and there would not be an immediate “rush” or high that would
promote abuse. In part, FDA based its judgment on the prior marketing history of a similar
product, MS Contin, a controlled-release formulation of morphine approved by FDA and used in
the medical community since 1987 without significant reports of abuse and misuse” (FDA, n.d.).
In OxyContin’s early years on the market, when it was already becoming clear that the
drug posed a number of risks to its consumers, Congress convened a series of Hearings during
which FDA officials, industry representatives, and other stakeholders were called upon to
evaluate the drug’s risks and benefits and to assess the Administration’s rationale for approving
it. In two separate hearings in 2002 and 2005, the FDA’s then-Director of the Center for Drug
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Evaluation and Research, Robert Meyer, and its then-Director of the Office of New Drugs
(OND), John K. Jenkins, supplied prepared statements re-articulating what had by then become
the agency’s boiler-plate explanation for its lack of foresight: “Based on the information
available to FDA at the time of its approval, including the record of other modified release
Schedule II opioids, the widespread abuse and misuse of OxyContin reported over the past few
years were not predicted. In fact, at the time of its approval, FDA believed that the controlled-
release characteristics of the OxyContin formulation, when taken properly, would result in less
abuse potential, since the drug would be absorbed slowly and there would not be an immediate
‘rush’ or high that would promote abuse” (FDA, n.d.; Jenkins, 2002, p. 14; U.S. House
Committee on Government Reform, 2005, p. 30). Moreover, as Director Meyer emphasized in a
2005 hearing before the House Committee on Government Reform, the FDA had absolutely no
reason to assume that OxyContin’s risks would outweigh its benefits because, after all, MS
Contin had been safely marketed in the United States “without significant reports of abuse and
misuse for many years” (Meyer, 2005, p. 30). Though as it turns out, this statement was far from
the truth: Just three years after MS Contin hit the market, an article published in the journal
Cancer that reported skyrocketing rates of MS Contin abuse in Ohio, particularly in the area in
and around Cincinnati. According to the authors, shortly after it was approved, MS Contin
rapidly became a “highly desirable preparation for opioid abuse” (Crews & Denson, 1990, p.
2642). The drug had even surpassed the popular painkiller hydrocodone (i.e., Vicodin) as the
most abused prescription opioid in the area. Apparently, it had not taken opioid users long to
realize how easy it would be to extract a huge quantity of morphine from Purdue’s 12-hour pills,
which – since they contained no liver-damaging filling such as acetaminophen or paracetamol –
could then be injected intravenously for a powerful (and long-lasting) high.
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The knowledge that the drug’s controlled-release mechanism could be so easily defeated
by those who wished for a stronger effect was, for all effective purposes, lost on the FDA, which
was caught off-guard when, some ten years later, the same thing happened with OxyContin. For
in theory, OxyContin offered the same novelty as MS Contin, with the additional benefit that it
contained the opioid oxycodone – calculated to be around 1.5 times stronger than its morphine-
based antecedent (Stanford School of Medicine Palliative Care, 2017). When the pill was not
swallowed but was instead crushed or chewed or melted down into an injectable fluid, it
transformed into an instant-release medication, one that would provide users with a bigger and
more intense rush than MS Contin ever did.
The FDA defines its approach to risk management as “safety or risk assessment
combined with efforts to minimize known risks” (Meyer, 2005, p. 35, emphasis added). One of
the many problems inherent to this definition of risk management which stands out in the case of
the Administration’s quick approval of OxyContin is this reliance on the “known.” Trusting what
you already know to help you anticipate a future that can only be unknown is problematic for a
number of reasons: For the FDA, it meant that turning to historical analogies rather than thinking
through possible risk scenarios formed a central part of its regulatory efforts and blinded it to
alternative risk scenarios – scenarios which, in the case of OxyContin, would soon become the
norm. This approach to risk management also exemplifies a rejection of what others have
identified as the “precautionary principle in drug regulation” (Langston, 2010; Sunstein, 2005).
As Cass Sunstein explains in his analysis of risk and reason, a precautionary approach assumes it
is “better to be safe than sorry” and, in doing so, takes into consideration those questions about
which there is a lack of certainty. However, the case of OxyContin regulation was not
characterized by this precautionary approach to risk. Instead, the FDA’s risk management
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framework might be better understood as having adhered to a permissive principle (Abraham &
Davis, 2009). The permissive principle, in stark contrast to a precautionary approach, does not
take into account risks that are not already known. Instead, it simply assumes that what is
unknown does not exist. As long as a drug can be proven to be no less safe and no less effective
than other FDA-approved drugs of the same class, its potential risks are considered to be
outweighed by its potential benefits. Thus, when regulation operates according to this principle,
it does not place the burden of proof on drug sponsors to prove their drug’s worth but rather
tends toward the approval of products even when they don’t measure up to the highest standards
of safety and efficacy. This principle was certainly at work when the FDA’s medical review
officer Curtis Wright signed off on the New Drug Application for OxyContin, for he did so even
though he had concluded earlier in the document that that the efficacy the drug was not higher
than other drugs on the market but could only be said to be “equivalent” to them. Yet, even while
he decided that he “would not allow a ‘better’ claim,” he approved it anyway. And so it was that
OxyContin first entered the pharmaceutical market (Purdue Pharma, 1995, n.p.; Wright, 1995)
Labeling and the Unintentional Advertising of Risk
When it comes to minimizing potential risks at the FDA, risk communication or
“labelling” is defined as the “cornerstone of risk management efforts for prescription drugs”
(FDA, 2005). This being the case, one of the first preventative measures the FDA took to
mitigate OxyContin abuse was to include a “black box” warning on all OxyContin packages
informing patients that “OxyContin tablets are to be swallowed whole, and are not to be broken,
chewed, or crushed. Taking broken, chewed, or crushed OxyContin Tablets could lead to the
rapid release and absorption of a potentially toxic dose of oxycodone” (OxyContin, 1995). For
the FDA, placing such a warning inside a thick-framed “black box” on a product’s packaging
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constitutes the highest level of warning for an approved product and most emphatic form of risk
communication the agency has at its disposal.
The decision to include this black box warning was made in light of the knowledge that
the drug about to be approved could be manipulated in ways that would defeat its controlled-
release mechanism. This knowledge was published in Purdue Pharma’s toxicology reports,
which showed that 68% of the pure oxycodone in the pill could be quite easily extracted – either
by crushing the pill or dissolving it in liquid (Meyer, 2005). This fact contradicted the company’s
claim that because of its timed-release ability, its new product was inherently less abuse-prone
than other opioids on the market. The black box labeling, naturally, was included as a means of
minimizing this potential risk. But it failed. Rather than preventing patients from “accidentally”
misusing their medication, the labeling seems to have functioned more like an advertisement for
a large population of consumers wishing to get more out of their pills (Griffin III & Spillane,
2012).
The faulty logic behind the FDA’s labeling decision is twofold: First, despite the FDA’s
claim that labeling is a key process that protects the public from the dangers associated with new
drugs, it functions less as a mechanism of consumer protection and more as a legal tactic, a
means of protecting the interests of pharmaceutical companies and regulatory institutions while
immunizing them from legal consequences. Another shortcoming of labeling can be linked to
the FDA’s approach to risk minimization and to the idea that by communicating risks, one can
successfully manage them. Doing so supposes that communication works through what James
Carey (1992) has described as a “transmission model,” where communication functions vis-a-vis
the unidirectional transmission of a message from sender to receiver and is deemed to be
successful so long as the message is received. What is not taken into consideration in such an
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approach to communication is the possibility that while the message may indeed be received, its
reception may differ depending on the ways in which the message is interpreted. Moreover, its
interpretation by different kinds of receivers, each of whom has her own particular interests and
desires, will condition the function of that message as well as the effects it may have on the
beliefs and behaviors of those who receive it. Because the FDA failed to consider these
contextual factors that inform the communication of risk, it could not foresee the ways in which
its labeling would be interpreted and utilized within OxyContin’s heterogeneous population of
consumers. Rather, the FDA assumed that the interests of OxyContin consumers would align
with its own and that all consumers would want to take their medication in the way that its
labeling indicated, and that any misuse of the drug would be accidental, rather than intentional.
The assumption that patients should want to take their opioids “as prescribed” is a problematic
one for it does not take into account the dynamics of opioid consumption, nor of pain, as lived
experiences. Yet it was and is precisely these experiences and the various needs and desires that
condition them (for example, to obtain the 12-hour effect that OxyContin promised users) that
have prompted many opioid users to take their drugs in creative, experimental, or otherwise non-
normative ways.
Pharmacovigilance and Strategic Ignorance
After the FDA has approved a new drug, its ability to regulate that product changes. As
medical historian Daniel Carpenter (2010) explains, the moment in which the FDA signs off on a
New Drug Application (NDA) can be understood as the moment “when the Administration has
relinquished its gatekeeping power over a drug” (p. 586). In this late stage of regulation, the tools
the Administration has at its disposal to regulate a drug once it has entered the market are feeble
at best. The best it can do is to draw from a variety of databases such as the DEA’s DAWN
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database, SAMSHA’s National Survey on Drug Use and Health, and state prescription drug
monitoring programs (in cases where they exist) and collect and analyze the data therein so as to
monitor the trajectory of a specific product’s use – and to urge pharmaceutical companies to do
the same. The FDA sometimes refers to this as “pharmacovigilance,” a term which encompasses
the agency’s efforts to “ask companies to collect special information to improve the speed and
sensitivity of detecting suspected safety problems” (Meyer, 2005, p. 35).
In the case of OxyContin, the use of pharmacovigilance failed as a result of weaknesses
that were both internal and external to the system itself. With regard to those inherent to the
system, several problems immediately come to mind: First is the rather surprising reality that the
FDA cannot require a company to create a post-market surveillance program for any of its
products. On the contrary, the FDA’s authority in this realm stops at its ability to provide
companies with guidance and recommendations as to how they can develop their
pharmacovigilance toolset. And even this limited authority was not given to the Administration
until 2007, when it was included as a proviso of the Food and Drug Administration
Authorization Act (FDAAA) and when the escalation of opioid overdoses was already well
underway.
Next, the data gleaned from pharmacovigilance – which typically relies on the compiling
of data from existing databases – often does not and cannot reflect the realities of drug use in real
time. The data is compiled only at infrequent intervals, which means that by the time a problem
is identified, it has likely expanded in both scope and scale. Moreover, the data itself tends to be
limited to emergency room admissions and hospital records collected in metropolitan areas. Data
from rural areas is often excluded. The limits of these systems may have played a particularly
important role in the escalation of opioid use, since we now know that it is precisely in rural
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areas on the East coast and in the Southeast where patterns of opioid use first took shape, and
which have proliferated at much higher rates than they have in urban or metropolitan areas (Van
Zee, 2009).
The data extracted from pharmacovigilance systems is also limited in another way, in that
it is rarely presented in a way that reflects the reality of drug use: The DEA’s DAWN system, for
example, can only track drug sales. And the question of when sales data can be said to signal a
larger problem is left up to interpretation, at the discretion of whomever is looking at the
numbers. Even more, the majority of such databases collect overdose data but cannot distinguish
between the different drugs that may have been responsible for them. This is largely due to the
fact that they rely on autopsy reports and chemical analyses, both of which can identify certain
chemical compounds (such as morphine, hydrocodone, or oxycodone) that may have cause an
overdose, but which stop short of identifying the specific brand of medication that the victim
consumed before he or she died. Finally, another factor that complicates the accuracy of the
information in these databases is the simultaneous consumption of more than one drug. Studies
have shown that it is common practice for drug users to use multiple drugs at the same time, as
doing so typically enhances their effects (Calcaterra, Glanz, & Binswanger, 2013; Gudin,
Mogali, Jones, & Comer, 2013; Jones, Mogali, & Comer, 2012). Opioid users, for example,
often combine their drug-of-choice with alcohol or benzodiazepines – depressants which
enhance the relaxing, euphoric effects associated with opioids (Calcaterra, Glanz, & Binswanger,
2013; Gudin, Mogali, Jones, & Comer, 2013). When an overdose victim has more than one
chemical compound detecting in his/her system, it is difficult to distinguish which might have
been responsible for that person’s overdose. But despite the prevalence of poly-drug use among
opioid users, this kind of data is frequently thrown out.
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This is exactly what happened in 2002, when DEA officer Laura Nagel attempted to
present evidence of OxyContin abuse using data compiled from 1,300 death reports: After the
data was cleaned and irrelevant cases excluded, the analysis showed that OxyContin itself was
responsible for at least half of all the overdoses. Nagel presented these findings to a group of
Purdue representatives and FDA officials, both of whom immediately discounted the data on the
basis that because many of the deaths appeared to involve drugs other than OxyContin, it could
not be concluded that Purdue’s drug was the one at fault. The data was simply too ambiguous to
be considered conclusive. After the meeting, New York Times reporter Barry Meier spoke to an
FDA official, who echoed this understanding, asserting that after taking a close look at the
available information, “We [at the FDA] don’t believe there is cause for panic” (Meier, 2002;
2013). And yet, this statement belies the fact that by the year 2000, OxyContin was already
wreaking havoc on (and causing panic among) a host of communities scattered across the
country.
With these illustrations in mind, I want also to suggest that characterizing the logic of
regulatory failure in this case requires thinking more carefully about the relationship between
pharmacovigilance and uncertainty – with specific attention to the ways in which this
relationship has functioned strategically as a means of advancing the interests shared by the FDA
and its industry sponsors. It is worth noting, first of all, that pharmacovigilance plans have been
characterized by some, most notably the current FDA Commissioner Scott Gottleib (before he
occupied the office) as a cop-out, a backdoor route the FDA can use to allow a drug to go to
market in cases where concerns about that product’s safety might otherwise result in its rejection
(Gottleib, 2007). In a case like OxyContin, where obvious risks exist but the extent to which they
will become widespread is not known, the FDA may still approve the drug on the condition that
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its sponsor begin developing a plan to monitor its use. In this way, pharmacovigilance functions
like a kind of probation sentence, where a drug is set free with its release legitimated on the basis
that its movements will be monitored and recorded for the foreseeable future.
This deferred regulatory action benefits both regulators and industry sponsors. For
regulators, it provides a step toward protecting the Administration’s reputation should something
go awry while also enabling it to side-step critiques that it is taking too long to approve a new
drug that many (in this case a growing population of chronic pain patients) desperately need. So
too does such a measure benefit the pharmaceutical company, who may begin collecting profits
as soon as its drug enters the medical marketplace. Moreover, its plan to track the use of its new
drug may also provide it with valuable information it can then use to target its marketing efforts.
This is, in fact, exactly what happened when Purdue agreed to implement its own
pharmacovigilance plan, the Researched Abuse, Diversion, and Addiction-Related Surveillance
(RADARS) system (GAO, 2003). RADARS not only helped the company strengthen the risk
management plan it was obliged by the FDA to create but enabled it to collect huge amounts of
information about the precise areas (down to three digits of the zip code) where OxyContin use
was on the rise. The company also had access to a large stream of data that showed how
individual doctors in these areas were prescribing OxyContin. This information, which came
from the global health information service, IMS Health, was then used to identify the highest and
lowest prescribers of OxyContin and to adjust the company’s marketing plan accordingly (Van
Zee, 2009).
The same surveillance technology Purdue used to target its promotional efforts also
functioned as a tool with which the company could manipulate the appearance OxyContin abuse
patterns in discussions with federal regulators and law enforcement. In two separate analyses of
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industry-regulator relations, Nancy Langston (2010) and Alan Brandt (2009) showed how in the
case of the pharmaceutical industry’s defense of hormone disruptors and tobacco industries’
defense of cigarettes, respectively, companies attempt to develop new technologies to produce
information (whether scientific research or, in the case of opioids, streams of consumer data)
that, when combined with public relations efforts, manufacture confusion and doubt among the
parties charged with regulating their products. Purdue Pharma’s elaborate promotion of the
sophistication of its RADARS tool aligns with this historical tendency: The company’s
surveillance system, which boasted the ability to track OxyContin consumption trends down to
three digits of an area’s zip code, also succeeded in producing data that appeared more localized
than it actually was. When the company was called upon in congressional hearings to attest to
the abuse potential of its product, it was armed with this data, which it then used to defend the
safety of its product and to characterize OxyContin abuse as a very specific, regionalized issue,
rather than a nationwide epidemic. Through the use of RADARS and the data it produced,
Purdue was thus able to frame OxyContin abuse as a problem tied to specific localities – a claim
which went hand in hand with the assertion that concerns about its dangers, which were
circulating among government officials and the public alike, were exaggerated. As such, the
company would go on to argue, the need for federal intervention was, at the very least,
overstated. Instead, what was really needed to curb opioid abuse was the development of
additional pharmaceutical technologies designed to deter misuse in specific settings. As we will
see in the following section, this is exactly what came to pass.
Deterring Opioid Abuse or Reconfiguring its Use?
In 2010, the FDA convened a joint meeting of its Anesthetic and Life Support Drugs and
Risk Management advisory committees to discuss strategies for managing the risks associated
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with FDA-approved opioid products. In late July of that year, a group of FDA representatives,
federal employees, scientists, medical professionals, and industry representatives gathered
together in Adelphi Maryland’s Marriott hotel, where they sat in a conference room and for two
days struggled to decide what the FDA should do to intervene in the nation’s escalating crisis of
prescription opioid abuse. The main agenda item to be discussed at this meeting was a proposal
developed by the FDA for a class-wide risk evaluation and management strategy (REMS) for
long-acting and extended-release opioids. The FDA’s REMS proposal included three tiers of
strategies, all of which were to be carried out by pharmaceutical manufacturers: The evaluation
of a drug’s risk at pre-determined intervals, the development of education programs for
physicians and patients, and the development of voluntary training program for healthcare
providers.
After its two days of discussions, presentations, and deliberations, the committee rejected
the FDA’s proposal by a vote of 25 to 10, with the majority of those who voted attesting that the
proposed plan would do little to combat opioid abuse. Some of these individuals voted no
because they were suspicious of the FDA’s decision to allow drug sponsors and manufacturers to
create the educational materials for prescribers and patients. Others followed up on these
concerns by noting the fact that despite sending warning letters to Purdue in both 2001 and 2003,
the FDA had been unable to break what appeared to be a strong causal relationship between
Purdue’s promotion of OxyContin and upsurges in opioid-related overdoses (says the
epidemiologist).
But this concern was overshadowed by another, which revolved around the problem of
pain: Even more of the meeting participants voiced concerns about the possibility that if
implemented, the proposed risk management plan would lead to a wave of pain under-treatment.
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That is, the proposal raised for many voters a series of questions regarding patient’s access to
pain relieving drugs. If the FDA required sponsors to create implement mandatory
education/training/certification programs, would this pose too great a barrier to ensure chronic
pain patients adequate pain management? Would it limit their access to potentially life-saving
drugs?
These questions and uncertainties related to opioid abuse and pain undertreatment formed
the core of the regulatory debate that began to take shape between those proposing to restrict or
reject opioid products and those proposing “alternative” regulatory measures that would not
intervene directly in the pharmaceutical market. While both sides of the debate vehemently
disagreed with one another, they did share one common assumption: That the problem of opioid
abuse was, first and foremost, a result of physicians’ irresponsible prescribing of these drugs. To
that end, they recommended measures to implement barriers not to opioid manufacturing but to
opioid prescribing, namely by instituting mandatory education programs for opioid prescribers,
who would need to receive special certification tied to their DEA licenses before they would be
able to provide their patients with these drugs. Having agreed on this recommendation, the
committee then passed it along to the FDA, which took immediate action, but not in the way the
committee anticipated: Rather than accepting the advice of its appointed experts, FDA ignored
their recommendations entirely and opted instead to implement the REMS proposal in its
original form. When confronted with this decision, the head of the Administration’s drug center,
Dr. Janet Woodcock, gave the following explanation: “You can’t imagine the bitter screeds we
hear from the prescribing community about the paperwork involved.” The opioid crisis, she
added, stems largely from individual prescribing decisions and “We [at the FDA] don’t regulate
medical practice” (Perrone & Wieder, 2016). This non-interventionist logic, which underlies
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many of the regulatory decisions that the FDA has made regarding OxyContin, ended up steering
the Administration in another direction entirely – one that would not hamper drug circulation,
but would instead support pharmaceutical companies’ development and manufacture of newer
and, as many at the time assumed, better prescription painkillers.
And so it was that in April of 2010, amidst the ever-rising wave of overdoses, the FDA
approved the release of yet another of Purdue Pharma’s opioid products – a new version of
“reformulated OxyContin,” one that was said to boast special properties designed to deter abuse
by “prevent[ing] the opioid medication from being cut, broken, chewed, crushed or dissolved to
release more medication” (Markey, 2016). The new abuse-deterrent drug, rebranded as
OxyContin OP, was soon accompanied by a host of similar products, most of which were also
sponsored by Purdue. At that time, the abuse-deterrent formulations (ADFs) received quite a lot
of attention, particularly in lieu of several studies evaluating their effectiveness, the results of
which seemed promising (Cicero, Ellis, & Surrat, 2012; Severtson et al., 2013; Sessler et al.,
2014). In 2013, perhaps as a response to these early studies, the FDA issued a draft guidance
document urging pharmaceutical companies to join in the initiative to develop new opioid drugs
with abuse-deterrent properties. Still today, ADFs are touted by the FDA as a key “public health
priority,” a distinction which also helps explain why these technologies are also the star of the
Administration’s recently released “Opioid Action Plan” (FDA 2013; FDA Opioid Action Plan,
2016). The 2016 plan not only refers to ADFs as a public health priority but as the front-running
regulatory solution for curbing the opioid epidemic. The Administration even went so far to
make ADFs exempt from certain regulatory measures that were, up to that point, required for the
approval of all opioid drugs. No longer would these approving these pills require the convening
of an advisory committee. They were, instead, to be pushed onto the market as fast as possible.
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Despite the initial reports of their effectiveness, it’s now clear that the reduction in
OxyContin abuse following the introduction of an abuse-deterrent formulation was largely due to
a large-scale migration of former OxyContin users to other opioids, namely black market drugs
such as heroin and illicit fentanyl (Cicero & Ellis, 2015). Moreover, other studies found that for
those users who had not changed their consumption habits, figuring out how to bypass the abuse-
deterrent mechanisms of the new formulations was much easier than regulators predicted it
would be. Dr. Theodore J. Cicero, a researcher who had taken the lead on several of the papers
that reported the initial success of Purdue’s new drug, explained that in subsequent analyses, he
and his team found that “[u]p to one-fourth of people entering drug rehabilitation programs say
they have abused the newer version of OxyContin” (NCADD, 2015). And yet, even with these
new studies in hand, the FDA has insisted (and continues to insist) on their utility as “a step in
the right direction” (Reuters, 2010). In a terrible paradox, the FDA’s attempts to steer opioid use
in the “right direction” have done much less to deter abuse than have to re-configure it and to
push it into new contexts — and specifically into contexts which are much more difficult to
regulate and police.
Right after OxyContin and similar ADFs began flowing into the market, the Internet lit
up with discussions among opioid consumers about how best to use these new drugs. Internet
forums dedicated to chronic pain and opioids, specifically, and drug use, more generally, filled
up with discussions and debates regarding the best methods for “defeating” the new abuse-
deterrent mechanisms. Today, if you create a Google search typing the words “defeat [name of
opioid-of-choice],” you find yourself staring down an endless rabbit hole of discussions,
instructions and demonstrations to help you bypass the abuse prevention mechanisms belonging
to different kinds of ADFs: Some users recommend dissolving the pills’ protective coating in
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lemon juice or baking them for 10 minutes, while others suggest wetting and reheating them in a
microwave until they dissolve and are ready to be injected. According to Bluelight user Guitar-
opana-man, who (as indicated in his username) is prescribed the drug Opana (oxymorphone) for
the pain accompanying his or her multiple sclerosis, “The best way to take OPANA ER…is to
place the tablet underneath your tongue, lower lip, or next to your jaw line. The medicine will
dissolve much quicker, and you should be out of pain in a very short time…” Another user,
Jman1982, suggests using the “dremeling” method, which (s)he refers to as “a WONDERFUL
way to make the NEW Opana in to powder.” As Jman1982 explains, dremeling involves the use
of a Dremel brand drill and requires one to “take a simple dremel with a sandpaper attachment
and hold the pill by some needle nose pliers and start sanding the pill…” The entire process,
(s)he explains, “takes no more that 60 seconds and there is the powder ready for you to enjoy…”
In the same post, Jman1982 also provides instructions for where to find dremeling machinery:
“You can get a Dremel for cheap as hell on ebay and they have them at Walmart. You don't need
the fancy one, just get the 2 speed one for about $25 or less and get the sanding attachment and
your [sic] home free.”
The Failure of ADFs
As previously mentioned, the logic underlying the FDA’s stubborn reliance on abuse-
deterrent pharmaceutical technologies as regulatory solutions for the opioid crisis is decidedly
non-interventionist. This logic exists in tension with the Administration’s authority, granted to it
by the 2007 FDAAA, to impose limits on pharmaceutical products’ circulation. Yet, time and
time again, when faced with mounting evidence of the risks associated with opioid products, the
FDA has refused to act on this authority. In the case of its support of ADFs, the Administration
appears to have cast aside its authority to regulate the growth of the opioid market. Instead, it has
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opted to support this market’s expansion, to multiply the number of choices available to opioid
consumers with the hope of de-incentivizing those practices of consumption which it understands
to constitute abuse. And yet, as we can see from the forum discussions inserted above, and as
will hopefully become even clearer in the discussion below, the purported aims of ADFs to
protect opioid users by preventing misuse fail to align with the practical effects of a lassaiz fair
regulatory regime whose actions primarily serve the interests of the pharmaceutical industry.
At the time of this writing, the failure of ADFs is even more pronounced, in light of the
FDA’s recent actions to stop the circulation of one of its most popular abuse-deterrent opioids.
On June 8, 2017, the Administration requested the drugmaker Endo Pharmaceuticals to remove
its abuse-deterrent formulation of the opioid Opana (Guitar-opana-man’s opioid-of-choice) from
the market. Its decision to do so prompted a wave of headlines, since it marked the very first time
the FDA has requested the removal of an opioid from the market because of “public health
consequences of abuse” and “risks related to abuse” (Christensen, 2017). As the FDA’s press
release stated, the widespread use of Opana ER posed a public health threat because it was found
to be correlated with a massive outbreak of a number of serious diseases – namely, HIV,
hepatitis C, and thrombotic microangiopathy, a severe blood disorder, among its users (FDA,
2017a).
But how did this happen? A quick analysis of the street economics of prescription opioid
use has much to tell us: In its original formulation, Opana was a very popular drug. This was due
to a number of different reasons, including the fact that it was strong, long-lasting, and therefore
relatively cost-effective. It was also relatively safe, in part because its high quality meant that
users would not have to inject it but could instead simply swallow the pill or take it nasally and
receive a good, enduring effect. Yet when the FDA replaced Opana with a new abuse-deterrent
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formulation (Opana ER) in 2012, this all changed. First, the pill’s abuse-deterrent updates
increased the price of the pill, which meant that users could no longer afford to swallow or snort
it but would have to turn to injecting it in order to get the same cost-effective high they were
used to. Many would also have been forced to save money by splitting their pills with other
users. The need to share pills combined with the need to inject them ended up resulting, perhaps
unsurprisingly, in users sharing their equipment, including the needles they were using to inject
the drug. But users were not only injecting the pills with dirty needles, they were also having to
do more frequently. This is because unlike the original version, Opana ER transforms into a thick
gel when it is dissolved. This property therefore required users to add more solvent to thin the gel
out enough for them to inject it. That users needed more solvent meant that they would end up
with a larger amount of liquid to inject and would therefore need to fill their needles more than
once in order to get a proper hit. Ultimately, the dynamics of this street drug economy, which
were brought into being by the FDA’s replacement of non-abuse deterrent Opana with the
sophisticated, abuse-deterrent Opana ER, quickly became a recipe for disaster.
The Marketization of Drug Regulation
To speak about the opioid epidemic in terms of the failure of regulators is perhaps a bit
misleading. For it is not that regulation has failed so much as it has been unevenly implemented
— to the extent that many of the principles that underlie the regulatory process are distorted and
exist in constant tension with regulatory practice. For example, the objectives of the FDA’s
safety regime, while honorable, are at odds with the practical effects of its non-interventionist
approach to regulation, in which it does much less to regulate the actions of drug companies and
their products than it does to lend its regulatory power to them — so much so that its own role is
often diminished. This shift in regulatory power from regulators to drug manufacturers
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characterizes a more general process of regulation’s marketization and the fact that what drug
regulation is, is often delimited by and enacted through the market and its logics.
In his analysis of the FDA’s organizational culture, Daniel Carpenter illustrates many of
the ways in which the FDA’s power is limited by its relationship to market actors and their
interests. But these limits, as he explains, are nothing new. On the contrary, they constitute part
of the Administration’s historical emphasis on exerting its authority in the phase of regulation
before a drug enters the market. As Carpenter points out, limiting the FDA’s regulatory powers
to the pre-market context also “serves to conceal many issues surrounding the safety of marketed
drugs” (16) – not least among them being the vast diversity of individual responses to certain
drugs. This was certainly the case in the pre-market regulation of OxyContin, where the
suppression of information – namely the fact that the research subjects were not opioid-tolerant
and therefore did not resemble the drug’s target population – helped Purdue’s drug get to market
quickly but crippled the FDA’s ability to anticipate its potential risks. Moreover, the element of
control in the clinical trials made it unlikely, if not impossible, to observe “not as prescribed”
behaviors and to anticipate their proliferation among opioid consumers all over the country.
It is also the case that the FDA’ s regulatory power is itself conditioned by the broader
political (and economic) landscape. Researchers have shown how the health-care battles of late
1980s and early 1990s animated conservative and antigovernment opposition from health
insurance, pharmaceutical companies, and patient advocacy organizations (e.g. Jasanoff, 1990;
Hilts, 2003; Daemmrich, 2004). Throughout these decades, industry and activists formed
somewhat “unlikely alliance(s)” whose combined influence helped contribute to the development
of formal mechanisms for de-regulating the FDA’ s drug approval process (Epstein, 1996). In the
1980s, the Reagan administration’ s laissez faire economic policies coalesced with several drug
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scandals that left the FDA reeling, trying to recover its reputation and regulatory power. The
administration’s struggle to perform its duties in the face of political and economic opposition
was amplified in the following decade when its efforts to regulate tobacco companies came
under fire from conservatives in Congress. This backlash continued into George H.W. Bush’ s
administration, which implemented revisions to the drug approval process that attempted to
reduce regulatory burden on industry (Gladwell, 1992). While these new revisions aimed to
speed up the process of getting new drugs through the FDA and into the market, they were not
entirely successful and so resulted in a series of hearings in which many members of the House
of Representatives proposed to dismantle the entire Administration – an idea which obviously
did not come to fruition. It did, however, result in the creation of the Food and Drug
Administration Modernization Act (FDAMA) of 1997, which provided the FDA with additional
resources to fast-track new drug applications while slicing in half the average time required for a
drug review. Additionally, FDAMA streamlined the approval process by reducing the number of
advisory committees and simplifying many of the regulatory obligations of drug manufacturers.
Most importantly, the passing of FDAMA in 1997 solidified ties between the FDA and the
pharmaceutical industry, whose interests in getting drugs to market as quickly as possible were
formalized as new obligations for the FDA.
The passing of the 1997 Act marks a key event, one that reinforced the bonds that tie the
FDA’s interests to those of science and industry (Jasanoff, 1990; Epstein, 1996). Likewise, it has
also contributed to paving the path that opioid regulation has taken until now, a moment that
shows how regulatory practices and processes are not enacted on or over but instead move
through and according to the logics of the pharmaceutical market.
The case of opioid regulation is therefore illustrative of a broader tendency in drug
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regulation, one that is clearly oriented toward privatization. In this way, drug regulation mirrors
financial regulation – where Wall Street CEOs frequently become Wall Street regulators. This is
exactly what has happened within the FDA, and the current Commissioner, Scott Gottleib is no
exception. He, like several of the Commissioners who came before him, is an individual with
deep ties to the pharmaceutical industry and has spent much of his career actively fighting
against regulation. Indeed, it is the case that industry men have occupied the FDA
Commissioner’s office for nearly 40 years: Arthur Hull Hayes, who served as Commissioner
under President Ronald Reagan from 1981 to 1983, was a well-known industry consultant, and
had been for years before he finally accepted the Commissioner post. Even during his tenure as a
top federal regulator, Hayes continued accepting industry honoraria (Hilts, 2003). Following
Hayes, the commissioners appointed by President George W. Bush were also industry
sympathizers, weak on regulation and with no experience as regulators. Mark McClellan was an
economist and free-market enthusiast. Named by Boston Globe as the “FDA’s economist-in-
chief,” McClellan was reportedly loved by the drug industry for his view that the FDA should
prioritize new drug development and help the industry in getting new products on the market
“faster and more predictably” (Rowland, 2004). McClellan’ s predecessor, Lester Mills Crawford
resigned from his post after less than a year in office, pleading guilty to a conflict of interest due
to his ownership of stocks in several of the companies he was charged with regulating
(Associated Press, 2007). That the FDA has had (and continues to have) a symbiotic relationship
with chemical and drug companies is no surprise, at least not while so many of its officers
maintain close personal and professional ties to the industry.
It is therefore not a stretch to suggest that today drug regulation is not the province of the
federal government alone but also (and perhaps equally) belongs to pharmaceutical companies,
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for even more than regulators or their advisory committees, it is the companies themselves that
decide how their products will be managed at every step of the regulatory process:
Pharmaceutical companies not only test and provide evidence their products’ safety and efficacy,
they also get to dictate how their drugs will be labeled and how they will be monitored once they
enter the market. The entire process of risk management after a drug’s initial approval is likewise
designed and conducted by pharmaceutical companies. Regulators can only make “suggestions”
and provide “guidance” as to how this process should be carried out. Thus, as Griffin III and
Spillane have suggested (2012), drug regulation has essentially transformed into a system where
“risk-management plans…emerge out of privately funded initiatives.”
When voting whether to accept the FDA’s REMS proposal for extended-release opioids,
John Jenkins (then Director of the Administration’s Office of New Drugs), made a point to
remind his colleagues of the FDA authority’s place relative to industry: “…let me remind you
that our REMS authority is to regulate the sponsor of the application for the product. So [sic]
anything we exercise has to be affected through the sponsor or the manufacturer of the product”
(FDA, 2010: pp. 129-130). Jenkins’s statement is worth noting: First, because it signals the depth
of the ties that run between the FDA and the pharmaceutical industry. Next, because it raises a
contradiction, a source of tension between what the FDA takes its regulatory authority to be and
the practical effects of this authority: Jenkins’s claim that the FDA’s authority enables it to
directly regulate drug sponsors belies the fact that the Administration also uses its authority to
avoid this task. In the case of developing its REMS proposal – which is also the context in which
Jenkins made his statement – the FDA mobilized the authority granted to it by the 2007 FDAAA
to delegate several of its own responsibilities to the companies. In doing so, it also made them
the implementers of many of the practices that are central to opioid regulation– including tasks
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such as preventing, monitoring, and managing the various risks associated with their products.
Indeed, as of 2010, risk evaluation and management strategies are developed and implemented in
a way that is relatively free of the FDA’s oversight. The passing of the 2007 FDAAA, which
gave the FDA authority to delegate a number of regulatory duties to pharmaceutical companies,
seems also to have laid the groundwork for a regulatory landscape in which all the tools that
once belonged to the FDA – materials for risk communication (labels, Medication guides),
education, prevention, and promotion, are now conceptualized, developed, and implemented by
the very same commercial interests that they propose to keep in line. In this privatized world of
drug regulation, companies decide how regulation happens, what it entails, and what drugs will
be ushered into the market.
Finally, it is important to acknowledge the way in which the marketization of regulation
has been conditioned specifically by the problem of pain. In each of the Congressional Hearings
and advisory meetings that have been discussed in this chapter, the committees convened with
the objective of determining opioids’ abuse potential and, likewise, with the objective of
developing strategies for monitoring and preventing the spread of such risky practices. But in
nearly every case, conversations about risk management and prevention quickly turned to
members voicing their concerns about the possibility that managing the risks of opioid abuse
would inevitably lead to limiting patients’ access to pain relieving drugs. Thus, discussions about
how to “balance” the individual risks and social benefits of opioids become central to these
regulatory discussions – to the extent that they ended up playing an important role in shaping the
trajectory of opioid regulation.
Specifically, the problem of pain and the expressed need to strike a balance between
protecting patients’ access and preventing abuse has justified the FDA’s repeated decision not to
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intervene directly on the opioid market (whether by limiting or cutting off the supply of opioid
products). Such an action, when framed by the problem of chronic pain and patients’ access to
painkillers, would be inhumane. This framing is key – but not only because it is dear to industry
representatives, patient advocates, and pain specialists – each of whom have a stake (whether
they are financial, personal, professional, or political) in sustaining the flow of opioid products. It
is also important in that it constitutes yet another regulatory logic, or perhaps an anti-regulatory
logic. The problem of pain, and the debates around access and balance to which it gives cause,
has conditioned the trajectory of opioid regulation and, in doing so, the trajectory of the epidemic
itself.
The Rise of the Grey Market
As a result of the FDA’s failure to regulate the use of opioids, the United States has
begun to witness the formation of what I refer to as a “grey market” for opioid drugs. The grey
market is, in some ways, a logical outcome of half-baked regulation; that is, since the various
regulatory measures this chapter discusses either have not worked or have worked unevenly, they
have created a chaotic regulatory landscape – one that has produced unexpected side effects,
many of which have prompted disastrous consequences. The production of side effects is not,
however, unique to the case of opioids. It is something that critics of U.S. drug policy have long
recognized a problematic effect of drug regulation, one which they term the “balloon effect.”
When you squeeze a balloon, the air inside it may move, but it does not disappear entirely. The
same effect occurs when drug regulators attempt to manage risk in one dimension of the
pharmaceutical market: the practices they attempt to disrupt are not eliminated but simply move
elsewhere or transform in ways that enable them to escape future intervention. This balloon
effect is exactly what has taken place in the world of opioid regulation. One only has to think
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back to the use of abuse-deterrent formulations and the disastrous case of Opana ER to recognize
it. But I am also suggesting that the balloon effect in opioid regulation has not only led to new
forms of abuse but to the formation of an entire ecosystem of drug use that escapes regulation
and enforcement – a system of exchange that disrupts regulatory logics – a grey market.
The “greyness” of the opioid market lies first and foremost in the fact that opioid
consumption is no longer so easily categorized in black-and-white terms – in terms of that which
is legal and that which is illegal. It is not the case that opioids are either received from a doctor
and taken “as prescribed” or that they are purchased on the street and “abused.” On the contrary,
these drugs are used creatively, in ways that are both medical and recreational. This grey area of
opioid use is in part due to the fact that these drugs – take OxyContin for example – do not
always work as they say they do. For the many chronic pain patients who were prescribed
OxyContin on a 12-hour dosing schedule, the drugs proved less effective than their labels
suggested, which meant that many patients needed to resort to finding more “creative” ways of
consuming their pill. The prevalence of opioid consumers who legally acquire their drugs but do
not take them “as prescribed” disrupts regulatory assumptions, which rely on the distinction
between those who “use” and those who “abuse” prescription drugs. Also disruptive to
regulatory logics are the contexts of distribution that increasingly characterize the landscape of
opioid use. Today, those at greatest risk of overdosing from opioids do not tend to get their drugs
by handing cash to a drug dealer on a street corner but obtain them as gifts from family members
or friends (Daubresse et al., 2013). In these contexts, opioid distribution is neither clearly legible
as legal nor illegal, but somewhere in between, where it is all the more difficult to regulate and
police.
Taking a look at the patterns of opioid use that are currently taking shape, it looks like the
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present crisis is increasingly headed in the direction of these grey markets: From 2014 to 2015,
opioid deaths increased an additional 15.6% from 2014 to 2015 – a swell that is largely
attributed not to pharmaceutical opioids such as OxyContin, but to illicitly manufactured
synthetic opioids, in particular a drug called “fentanyl”, which accounted for 60% of opioid
deaths in 2017 (Hedegaard, Warner, & Miniño, 2017; Rudd et al., 2016; ). The role that fentanyl
now plays in the opioid epidemic is worrisome, not least because it demonstrates that opioid
users’ consumption habits are shifting toward more potent illicit drugs. Additionally, this
movement not only illustrates a slippage between the black and white worlds of licit and illicit
opioid use, but an even more substantive connection that bridges what is supposed to be a highly
regulated market for prescription drugs and the shadowy terrain of the black market. Today,
nearly 80% of individuals who purchase opioids on the black market report that their previous
experience using prescription opioids is what led them there (Jones, 2013).
Their migration, moreover, has been prompted by recent efforts to manage the market for
pharmaceutical opioids – by the increased efforts of U.S. government and law enforcement to
police their use. With pharmaceutical opioids increasingly difficult to obtain, more users are
turning to the black market for heroin and fentanyl. For our purposes, the rise of fentanyl is
significant as an illustrative example of what the opioid grey market looks like and how it
disrupts regulators attempts at curbing opioid abuse. But it is also worth noting that the
movement of drug use toward synthetic forms of existing drugs (which tend to be much stronger
than the originals on which they are based) are becoming increasingly popular in general, to the
extent that they are re-shaping the entire landscape of drug use. Thus, it may be the case that the
concept of the grey market will prove useful not only for those attempting to understand the
failures of opioid regulation, but of drug-related policy and regulation as a whole.
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But before discussing the problems that fentanyl poses for regulators and law
enforcement, it is worth saying something about what this drug is and where it comes from.
Fentanyl is a synthetically produced opioid medication, created by Paul Janssen in 1960
(Stanley, 1992). In the mid 1990s, it was introduced for the treatment of severe pain - first in the
form of a patch, which would allow the chemical to be absorbed directly through the skin. In
1998, the FDA approved another fentanyl medication in the form of a lozenge “or lollipop” that
was designed to dissolve slowly in the patient’s mouth. Later, the drug was also sold as a
sublingual spray. More recently, as of 2012, fentanyl became the most widely used synthetic
opioid in medicine.

Beginning in 2013, the DEA, along with its law enforcement partners, began
noticing an alarming number of overdose incidents and deaths attributed to synthetic opioids –
primarily fentanyl and fentanyl-related substances, or analogues (DEA, 2017: 3). While
pharmaceutical fentanyl in the form of transdermal patches or sublingual tablets was found to be
diverted on a relatively small scale, recent years have seen enormous increases in opioid‐ related
deaths to be driven by illicitly-produced fentanyl products. (DEA, 2017: 4).
Additionally, it is becoming more and more common that overdoses occur when fentanyl
is combined with other opioids, usually heroin or other synthetic opioids, such as the drug U‐ 47700. These combinations, which created an incredibly deadly mix of opioids, are sometimes
referred to as “Grey Death,” a name that refers to the color of the powder, which is a dull shade
of grey resembling concrete (DEA, 207: 6). But fentanyl’s most recent claim to fame came in
2016, when the drug was identified as the substance that caused the death of the musician,
Prince, who overdosed on it in his Paisley Park estate on April 21, 2016 (Eligon & Kovaleski,
2016). Since Prince’s death it has been documented that in certain parts of the country deaths
from prescription painkillers and heroin alike have virtually disappeared, having been replaced
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by fentanyl. In Dayton, Ohio, for instance, 100 drug overdose deaths were recorded in January
and February 2017. Of those, only three were related to heroin, while 99 were attributed directly
to fentanyl or to a fentanyl analogue (Katz, 2017).
Fentanyl poses a host of unique problems for regulators, problems which stem from the
distinct contexts and practices of production, distribution, and consumption that are associated
with these drugs, as well as from the unique characteristics of the product itself: Fentanyl is, by
and large, a far more dangerous product than is heroin, morphine, or OxyContin. This is
primarily because it is much stronger than any of these other compounds. Its potency is due to
the fact that it is a synthetic drug; that is, it does not derive from a plant, but is instead developed
in a laboratory, where it is designed to mimic the effects of other, natural opioids (such as opium
or morphine). Though fentanyl resembles morphine in many respects, it is around 100 times
more potent than its chemical cousin and is 50 times more potent than heroin (CDC, 2016).
Moreover, the deadliest of the fentanyl analogues – that is, other synthetic opioids which are
based on fentanyl – is carfentanil, a chemical that’s most common use is as a tranquilizer for
large mammals such as elephants. Carfentanil is estimated to be 100 times stronger than fentanyl,
which makes it 5,000 times stronger than heroin and 10,000 times stronger than morphine (DEA,
2016; Vardanyan & Hruby, 2014). What this means, in practice, is that a lethal dose of
carfentanil is contained in an amount smaller than three grains of salt.
Despite the fact that these drugs are incredibly deadly, it is often the case that fentanyl
and its analogues are not readily legible as illicit drugs, which can pose a problem for those
agencies charged with stemming their flow. Much of the fentanyl circulating on the black market
originates as a powder but is shaped by distributers using a pill press so that it ends up
resembling a legal, pharmaceutical drug. Oftentimes, these pressed pills even contain the same
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engravings as they would if you bought them from a pharmacy. There are huge amounts of
counterfeit fentanyl pills circulating on the market, even at this very moment. Most of them
appear to be other drugs, normally those which are in the highest demand or have recently been
removed from the market or replaced with abuse-deterrent formulations (such as certain doses of
OxyContin, Opana, Vicodin, Percocet, and often even generic, non-brand opioids like
hydrocodone and oxymorphone). These legal-looking illegal drugs are also difficult for
regulators to schedule – that is, to place in a category of drugs that are either legal or illegal.
While fentanyl remains a legal drug, many of its stronger analogues have been allocated a
Schedule I position, which means they are illegal to possess or consume. But because they are
produced synthetically, all a manufacturer has to do to escape the limits of drug scheduling is to
alter one tiny element of fentanyl’s molecular structure to create an analogue that has yet to be
scheduled and is therefore legal. For a time then, the drug escapes the grasp of the DEA, while
its manufacturer(s) and distributer(s) are safe from legal prosecution and may distribute their
unregulated, but technically legal fentanyl product at will.
It is not only the product itself but also the contexts in which fentanyl is produced and
distributed that pose additional challenges for regulators and law enforcement. These contexts
are, for the most part, shrouded in darkness, since they are largely bought and sold through the
nameless channels of the dark web. The anonymous circulation of fentanyl products through
Internet exchanges have enabled these drugs to arrive at the doorstep of individuals in nearly
every region of the country. Most of the time, these drugs are shipped in plain sight and arrive at
their destinations in small packages delivered by the U.S. Postal Service. Authorities have
expressed their frustration in their efforts to put a stop to fentanyl distribution, but the incredible
potency of these drugs enables them to move in such small quantities that they are nearly
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impossible to identify and track (Popper, 2017). The difficulty of tracking fentanyl shipments is
also due to the fact that these drugs tend to be exchanged between individual producers and
consumers, unlike other illicit drugs, which tend to be distributed through cartels – entities which
are far easier to track and prosecute. The exchange of fentanyl, in contrast, is more difficult to
pinpoint: Instead of a cartel smuggling vast shipments of product across the national boarder and
handling huge amounts of cash, picture a tech-savvy individual who sits quietly in his or her
grandmother’s basement, buying (or perhaps selling) fentanyl using a small amount of Bitcoin
and his or her Grandma’s old PC. While it would be much easier for the DEA to identify and
catch an individual who ships a kilogram of heroin to his or her house every month, identifying
the individual who repeatedly buys or sells tiny quantities of fentanyl online is far more difficult.
Finally, it bears noting the difficulties that accompany fentanyl’s unique context of
production – which largely takes place in laboratories, most of which are not located in
Grandma’s basement or anywhere in the United States for that matter but in China. While the
Chinese government has recently begun to attempt to regulate or, in some cases, ban the
production of fentanyl products, it has largely failed to do so. This being the case, there remain
many Chinese laboratories that routinely develop and distribute huge amounts of fentanyl in
powder form overseas – either to Mexico, Canada, or directly to the United States – in small
packages which present a very small risk of being detected (particularly if their content has been
chemically altered so that neither drug dogs nor other kinds of detection technologies can yet
identify it). And when the product reaches its destination – even if it is a very small package – it
can easily service a thousand different customers (Ganim, 2017).
Conclusion: Logics of Extreme Uncertainty in Opioid Regulation
The logic underlying the growth of the opioid grey market is perhaps best characterized
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as a logic of extreme uncertainty. For uncertainty, like the market itself, is both that which
characterizes and that which is produced in the process of opioid regulation. That is to say, it is a
profound lack of certainty – and with it, the unsettling prospect of surprise – that has undergirded
regulatory decision-making at every level.
So too has uncertainty given shape to the consequences that have emerged in the wake of
these decisions. It is what undergirded the FDA’s decision to approve OxyContin based on
clinical trials that suppressed critical information about the drug’s effects. It is what led them to
insist on mitigating abuse risks through labeling them. The FDA’s lack of certainty about how
OxyContin could (and eventually would) be misused also served as the basis for its
recommendation that the drug’s sponsor create a pharmacovigilance plan to monitor it. The plan,
which was intended as a way of mitigating unknown risks by detecting early warning signs,
ended up obscuring more than it ever showed. It did not alert the Administration of the rapidly
growing rates of OxyContin overdose, but instead produced data that painted a picture of a
highly regionalized problem, one that barred the need for urgent intervention. Finally, it was
uncertainty that gave the FDA cause to encourage opioid manufacturers to deter potential abuse
by developing ADFs – a decision which, as we know, produced a massive balloon effect, one
that reconfigured the terrain of drug use and conditioned the emergence of a new market for
fentanyl. It is this new landscape of synthetic opioid use that regulators must now confront –
though it presents to them a host of new problems, which the tools they have in hand cannot
hope to fix.
Perhaps, too, it is this state of extreme uncertainty which, on August 10, 2017, prompted
President Trump to make a speech declaring the opioid epidemic an official public health
emergency – a declaration which also seems to have functioned as an official admission that the
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problem had by then spun far out of the government’s control. The growth of opioid grey
markets reinforces the veracity of such an admission and augments the level of uncertainty which
has undergirded (and undercut) the logics of U.S. drug regulation. Even more, uncertainty with
regard to opioid use also extends beyond regulators into the realm of law enforcement, where
officials are now faced with the challenge of defining who the people they intend to prosecute
are, and in what way they have broken the law: Is a dealer a dealer even if she does not know
what it is she sells? How do you prove her intent to do harm in the face of so much doubt? These
are the questions that concern us in the next chapter, which also seeks to understand how the
opioid epidemic has been shaped – not only by uncertainty but also in lieu of it, in the fervent
attempts by multiple stakeholders to divide the world of opioid use into manageable categories:
Legal/illegal, user/dealer, black/white – categories and boundaries which, as the grey market
indicates, have begun to erode.

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Chapter 5: Addiction’s “New Face”: Classifying Opioid Patients and Addicts

Ever since the first reports of prescription opioid-related overdoses began surfacing in
local newspapers in 2000, the mainstream media have been publishing stories trying to
understand what the “opioid epidemic” really is – what are the drugs, who are the perpetrators,
who are the victims, and so on. One of the most common queries, which lies at the heart of the
epidemic’s construction in popular culture, attempts to describe what are often characterized as
“the new faces” of the opioid crisis. Consider, for example, a piece the New York Times ran in
the summer of 2001, just after the first local reports of OxyContin overdoses: The piece, which is
dramatically titled, “The Alchemy of OxyContin,” is narrated by a reporter who takes a midnight
drive with Paula, his informant and a self-identified OxyContin addict living in a small town in
West Virginia (Tough, 2001). As they navigate the city, Paula casually points to the comfortable-
looking homes and neatly parked cars belonging to the local drug dealers: They were nurses,
soccer moms, the high school prom king, and none seemed to resemble the “kind of person” one
would expect to find dealing narcotics on the city’s darkened street corners. And yet, as the
report suggests, this is the alchemy of OxyContin – a drug with the ability to fashion new kinds
of persons, transforming them seemingly overnight: All of a sudden, patients transmogrify into
addicts, soccer moms into felons, prom kings into corpses.
Or consider another story, this one an ABC news segment, which aired in October 2010:
“The New Face of Heroin Addiction” followed the stories of several opioid-addicted individuals
living in suburban areas of New England (Whitaker, 2015). What was “new” about the “faces”
of the epidemic, ABC host David Muir shared with viewers, is that they belonged to “kids from
families you never thought could fall victim to drugs…families who did everything right and still
their kids are hooked.” A 2015 CBS segment titled “Heroin in the Heartland” was similarly
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focused on the surprising “new look” of the epidemic – “the faces of heroin,” which are “young,
middle-to-upper class and suburban.” What opioid addiction’s “new look” tells us, and what
each of these news segments implies, is that opioid use is no longer the province of criminals.
Nor is it any longer an “inner-city problem.” On the contrary, opioid addiction has become
something that can just happen – and to anyone! Indeed, as one of CBS’s informants exclaimed,
“Even Miss America could be a junkie!” This “new face of addiction” – a familiar, respectable,
attractive face which, by belonging to “anyone,” helps make the opioid crisis intelligible as “a
national epidemic;” it is all of our problem – one that we are all called upon to care about and
attempt to resolve.
In more analytical terms, what these narratives illustrate is the development of a process
that is centrally involved in the discursive construction of the U.S. opioid epidemic, which
attempts to identify and characterize its subjects. It is a process of subjectification – through
which human beings are “made up” as different kinds of persons (or in this case, addicts). It is
this process that constitutes the focus of this chapter (Foucault, 1982; Hacking, 1986).
Before applying the concept of subjectification to the opioid epidemic in particular, it is
worth saying something about what I understand this term to mean and how I will be applying it
in the analysis that follows. Simply put, I understand subjectification to refer to a process, or
combination of processes, through which human beings are made or make themselves into
subjects. This understanding owes much to Ian Hacking, who has written about this process,
which he characterizes as “making up people” (1986). In Hacking’s approach to subjectification,
processes of being “made up” are not merely abstract, but instead are better characterized by the
ways in which human beings become attached, both materially (through an economic
connection) and discursively (through a semiotic connection) to an historically-specific set of
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institutions and the values, logics, practices, and techniques with which they are associated. It is
within these specific institutional arrangements that subjects are produced. The production of
subjects, moreover, is bound up with the production of bodies of knowledge – and with the
exercise of power. That is to say, the human being who is made into a subject will also find that
her thoughts, interests, and behaviors are read in terms of the institutions that produced her. In
this attachment is revealed another function of subjectification, which is not only geared toward
the creation of subjects, but also forms part of the arrangement within which they are regulated,
controlled, and governed. To become a subject, then, is to become governable – to become a
subject of power (Chatterjee, 2004). Yet, it must also be said that subjecthood is never
completely fixed because subjectification itself is never complete. It is an ongoing process that
depends on the legitimacy of the institutional arrangements that drive it. These arrangements
must be defended if the coherency of their subjects is to be maintained. The “subject,” then, is a
fragile thing indeed, and requires continual work on the part of institutions which must engage in
ongoing efforts to justify their own existence and to legitimize their functions.
Subjectification itself has been a prominent theme in the discursive construction of health
epidemics – in media as well as in policy (Fuqua, 2012). Applying this idea to the opioid
epidemic, it is also the case that this particular health crisis is framed as a tragic story of the
transformation of one kind of subject (the patient who is prescribed opioids) into another (the
opioid addict). The theme of the opioid "patient-turned-addict” is itself a discourse of
subjectification, one which speaks of a process of “becoming” and of the production of opioid-
addicted subjects. As the rest of this chapter will argue, subjectification in the opioid epidemic
has relied on the production of both patients and addicts.
But not only this: I also show that it divides patients and addicts into (at least) three
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categories of persons: First, is the patient-at-risk. The risk, which is always present in discourse
about opioids, refers to addiction and the ever-present danger of an innocent patient being
transformed into an opioid addict. But opioid addicts too, are not all one and the same. On the
contrary, opioid addicted subjects are constantly being produced on either side of a division: On
one side stands a familiar subject, the addict of history, a dangerous individual whose addiction
is understood in terms of his or her status as a pathological consumer. The addict as pathological
consumer is, in the opioid epidemic, supplemented by the construction of another kind of addict
who stands on the opposite side of the divide: Unlike the pathological consumer, this other addict
is not a danger but is instead endangered. She is not a consumer but is rather positioned as a
victim of malevolent forces outside herself, forces which have consumed her.
The production of these three categories of persons – of patients-at-risk, pathological
consumers, and consumed addict-victims – constitutes the main thrust of subjectification in the
opioid epidemic. And, as the pages that follow argue, subject production is critical not least
because it serves to reinforce ideas about whose addiction and, indeed, whose pain really
matters, and whose does not. As such, it provides a discursive basis for deciding which kinds of
addicted persons require saving while others are seen as beyond rescue and are subsequently
pushed aside. These decisions, moreover, are often made along racial lines. Indeed, there is a
huge amount of research that examines the role of pharmaceuticals, addiction, and the
criminalization of people of color in America (e.g., Agar, 2006; Alexander, 2010/2012; Bourgois
& Schonberg, 2009; Campbell, 2000; Courtwright, 2001; Epstein, 2007; Knight, 2015; Marez,
2004; Raikhel & Garriott, 2013; Shah, 2001; Waterston, 1993). Yet, somewhat surprisingly,
there hasn’t been much written about the role that whiteness plays in the construction of drug use
in the United States. My analysis proposes to fill this gap by using the opioid epidemic as a lens
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for seeing how subjectification in the world of drug use constructs and contributes to discourses
of whiteness – discourses that prioritize the construction of white victimhood and the urgent need
to rescue and recover white potential and which have helped to render the epidemic intelligible
as crisis specific to white America.
Opioids: A White Problem
It is not difficult to see that one of the dominant discourses that has been driving the
narrative of the opioid epidemic is a racialized discourse – one that attaches the crisis to white
subjects and attempts to render it as a uniquely “white problem.” Of course, one cannot dispute
the fact that overdose deaths among white people do indeed outpace those of any other
demographic group (CDC, 2017a) nor the fact that that throughout the last decade, 90% of the
individuals who used heroin for the first time were white (Cicero et al., 2014). These numbers
are striking, and while they do suggest a troubling reality (one where drug use is rapidly
escalating among white Americans) they also serve an additional function, helping render the
opioid epidemic legible as a national, public health emergency – a construction which is
markedly different from other, historical framings of drug use, which have tended to focus on
people of color and have positioned drug use, drug users, and drug traffickers within the
disciplinary realm of criminal justice. As emblematic of a national public health emergency, drug
use and addiction among white Americans has also become legible within a broader set of social,
cultural, and political discourses concerned with the endangerment of America’s “white working
class – a cherished population that has long served as a potent symbol of the values and virtues
that define the “American project” (Murray, 2012). This nationalist discourse is a crucial one –
one that attaches the opioid epidemic not only to whiteness, but to the nation as a whole.
The opioid epidemic’s construction as part of a broader, nationalist discourse is made
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visible in studies such as Case and Deaton’s “The Changing Face of Heroin Use in the United
States” (2015; 2017), which, since its initial publication, has become widely known and often
cited in media accounts of the epidemic. Case and Deaton’s study sought to understand the
causes underlying shocking increases in midlife mortality among white Americans. In doing so,
it identified drug overdoses as a key factor driving up the white population’s death rate. In
discussing this finding, Case and Deaton concluded that deaths among white Americans could be
best characterized as “deaths of despair” (now an oft-repeated phrase used to diagnose the
current drug crisis). The phrase, deaths of despair, is an interesting one – one which attributes
suicidal acts (namely via drug and alcohol abuse) not to the personal failures of the despairing
individual, but to the external forces that led her to this point. Case and Deaton characterize these
forces in terms of “a long-standing process of cumulative disadvantage” (Case & Deaton, 2017:
398) unique to white, working class Americans and which is rooted in “the labor market,
globalization, and technical change” (433). Together, these economic conditions have undercut
many fundamental social, cultural, and economic expectations among this group, for whom the
promise of the “American Dream” has not only failed to materialize but has left them jobless and
hopeless – a “lost generation” with no foreseeable future (Case and Deaton, 2015: 15081). Case
and Deaton’s study, as one particularly famous analysis related to the opioid epidemic, is
illustrative of how the image of white drug use has been projected onto the broader cultural,
economic, and political landscape, where the problem is defined again and again in nationalist
terms as symptomatic of the plight of America’s white working class.
Since Case and Deaton’s initial publication, one public figure after another has stepped
up to the proverbial podium in order to recount their intimate experience with a friend, colleague,
or loved one who, despite “having it all,” suddenly plunged into the depths of drug abuse and a
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world which would – in time – eventually kill her. In 2015, for example, New Jersey Governor
Chris Christie gave a speech at a town hall in which he addressed the opioid crisis by discussing
his own experience with his former law school buddy, someone whom he described as perfect –
smart, attractive, athletic, successful, who married a beautiful woman and became a father to two
equally beautiful children. And yet – Christie’s friend’s seemingly perfect life fell to shambles
when he developed an opioid addiction after being prescribed prescription painkillers for a
sports-related injury. The first prescription he filled, according to Christie, was the prescription
that killed him – a man who, “by every measure that we define success in this country…had it”
(Lopez, 2017). Christie’s speech has also been echoed by other politicians like Donald Trump
who, during his 2017 Presidential campaign and afterward, spoke often of his brother who died
as a result of long-term alcohol abuse.
Others who quickly began weighing in on the issue included (but were not limited to) Jeb
Bush, who wrote an article in Medium (2016) about his daughter’s addiction to opioids, Carly
Fiorina, who spoke often of the loss of her daughter to drugs while she was on the campaign
trail, and a Minnesota state senator whose daughter overdosed on opioids in a Burger King
parking lot. Their stories resonate with the tragic recounting of many other U.S. lawmakers and
politicians – representing states from Minnesota to Wisconsin to Pennsylvania, New Jersey, and
Maryland – each of whom provides an additional chapter to the narrative that has built up around
the opioid epidemic and the ways in which it has attached itself to white America.
But aside from their focus on white victims, the stories told by these public figures have
something else in common. For each story is not just a story in, of, and for itself but functions as
a means of re-framing opioid addiction as something that, in Chris Christie’s words, “can happen
to anyone.” Represented in this way – as a problem that applies to any and all Americans – the
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opioid addiction stories also arrive at the same two conclusions: The first conclusion involves the
speaker’s admission to his own subjective transformation, to the ways in which his experience
has pushed him to take a different approach to drug use and addiction. The second conclusion is
related to this new approach, which demands that we “start treating people in this country, not
jailing them” and that we “give them the tools they need to recover” because, as each of the
tragic stories implies, “every life is precious” (Lopez, 2017).
The proliferation of addiction narratives involving upstanding white citizens may help
explain why addiction and drug use have suddenly emerged as objects of concern among U.S.
politicians and why the tone of their concern has changed: For these opinion leaders, escalating
drug use does not call up a demand to punish drug users with zero-tolerance drug policies.
Rather than invoking military metaphors and tactics as was done in previous epidemics (most
notably those involving crack use and trafficking among Black Americans in the 1980s) the
politicians cited above, as well as lawmakers and police chiefs in the country’s most opioid-
affected cities, mobilize their personal experiences and accounts of opioid use to advocate for a
“compassionate approach” to opioid addiction – one that seeks to understand the addict’s
experience and treats his or her behavior as part of a public health crisis, rather than as a criminal
justice issue.
Perhaps readers will not find it surprising that the opioid epidemic’s framing as a white
problem has gone hand-in-hand with politicians’ turning away from historically punitive stances
toward drug use and opting instead for an approach that seems better suited to the opioid addicts
they know as their co-workers, family members, and dearest friends. This recent about-face in
drug policy, which corresponds directly to opioid use, may be understood using George Lipsitz’s
famous phrase, as a “possessive investment in whiteness” (Lipsitz, 2006) – which constitute a set
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of practices (and discourses) that once institutionalized help render the fight against opioid abuse
as a battle to be fought not in the name of addiction per se, nor of pain, nor of antiquated and
racist drug laws, but in the name of white rescue and the preservation of white potential.
Indeed, the narratives of whiteness that have come to define the current drug crisis as
well as the solutions being posed to subdue it are powerful. And they can be shown to be
powerful because they continue to exist despite the reality (which was recently illuminated in a
CDC dataset and its interpretation a 2017 article in the New York Times) that that opioid
overdoses are also skyrocketing among Black Americans (CDC, 2017a; 2017b; 2017c; 2017d;
Katz and Goodnough, 2017). Quoting from the New York Times article, the CDC data revealed
that “Drug deaths among blacks in urban counties rose by 41 percent in 2016, far outpacing any
other racial or ethnic group. In those same counties, the drug death rate among whites rose by 19
percent” (Katz & Goodnough, 2017). The data, which points to the ways in which opioids (not
just prescription painkillers but also illicit drugs such as fentanyl and heroin) have quickly and
quietly penetrated a much broader and more diverse swath of the country, gives us cause to re-
examine the discourses that define the opioid epidemic as a purely white problem and to consider
how racialized logics are strategically attached to the opioid epidemic and maintained within the
broader cultural, political, and scientific discourses about drug use and addiction. The analysis
that follows attempts to answer this question and does so by critically examining the ways in
which racialized logics drive subjectification in the opioid epidemic and how they have operated
throughout history to enable the construction of different kinds of opioid-using subjects as either
deserving or not deserving of today’s “compassionate” interventions.
The Patient-At-Risk
It is important to note that the recent push in politics and public discourse toward a more
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humane approach to drug enforcement is also a discourse situated within the framework of
public health. And it is within this public health framework that opioid addiction (and,
importantly, addicts themselves) are made legible. While not entirely new, the move to re-define
addiction as a public health issue rather than a criminal justice issue goes against long-standing
trends in the history of the United States’ “War on Drugs,” and the ways in which it has
systematically policed, criminalized, and incarcerated addicts – namely persons of color (e.g.,
Alexander, 2010/2012; Marez, 2004). Thus, opioid addiction today is not only characterized by
discourses of compassion and public health but also by a shift in addict subjectivity in which the
addict who was formerly defined in terms of her criminality is supplemented (and in some cases,
replaced) by the figure of an addict who is defined in terms of her patienthood. This process is
likewise bolstered by the outpouring of stories over the past few years of opioid addicts whose
addiction trajectory began not on the streets with a needle in hand but with a trip to the pharmacy
and the innocent purchase of an opioid medication.
One of the earlier and most infamous examples of this narrative can be found in the
waves of media attention that followed the sudden death of acclaimed actor, Phillip Seymour-
Hoffman in 2014 and the widespread fears and concerns it raised about the growing phenomenon
of the “white prescription opioid user-turned heroin addict” (e.g., Bernstein, 2015; Calabressi,
2015; Gusovsky, 2015; Lavitt, 2015). Seymour’s death formed part of what would become a
nationwide moral panic surrounding the unexpected risks – particularly for suburban and rural
teenagers and young adults who had been prescribed narcotics for sports injuries – of becoming
one of the “new faces” of American drug addiction. Media coverage of this “new epidemic” can
be illustrated in a number of headlining articles and press coverage (e.g., Lee, 2013; Schwartz,
2012; Carroll, 2014). These articles, in highlighting the tendency for “normal,” “upstanding”
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kids, teachers, and other professionals to become “hooked on drugs,” draw an implicit contrast
between the population of users that have been, up until now, the focus of most drug epidemics.
Which is to say that the “new face of drug use,” which lacks the marks of race and ethnicity
typically associated with urban drug users, lends a new sense of urgency to this problem – one
which may also undergird the recent decision (made by President Trump in just a few weeks
before the time of this writing) to declare the escalating rates of opioid abuse a national, public
health emergency.
The opioid user of today – who is positioned as both white and as a subject within the
realm of public health – is not rendered as a problematic figure; she is not a criminal, nor a
deviant, nor a threat to the social system. On the contrary, she is exemplary of the addicted
subjects which are the “new faces” of the epidemic: These subjects are patients-at-risk, obliging
citizens who, by some error in the course of their participation within the U.S. medical and/or
public health system, have transmogrified into its victims. The patient-at-risk is at the center of
what appears to be a new kind of struggle against drug use, a “white war on drugs,” in which
blame is repositioned away from the individual drug user and attributed to other forces external
to her.
The discursive construction of the patient-at-risk is likewise bound up with the question
of how to distinguish legitimate opioid patients from illegitimate opioid addicts. Until now, the
answer to this question has been seemingly straightforward: The distinction has been based, in
large part, on the specific methods that opioid users employ in their consumption of these drugs.
That is to say, opioid patients’ consumption practices are deemed valid so long as they appear to
align with the specific medical, legal, social, and ethical values and norms that govern the
medical standard of taking drugs “as prescribed.” Those who consume opioids “as prescribed”
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have long escaped the judgement and scrutiny of those who chose instead to take the other path –
the path of “abuse.” These abusers are not seen as patients but opioid “addicts,” with their
consumption practices being defined as such on the basis that they appear to deviate from this
standard.
The rule of “as prescribed,” moreover, is also tied to a legal logic, which has protected
medical practitioners, regulators, and pharmaceutical companies from prosecution in cases where
an individual has been harmed or died after taking a medication. After all, neither a doctor nor an
FDA representative, nor a drug manufacturer can be held liable for a consumer’s own willful
misconduct. If that consumer did not take her drug “as prescribed,” it is she – and she alone –
who must bear the costs of her recklessness. Yet, in the past few decades, as more and more
individuals have suffered and died from taking their pain medications, this logic has been called
into question. The oft repeated story of the opioid patient-cum-addict, of an individual who has
become addicted, overdosed, or perhaps died, after taking her opioids exactly as she was told to
do, exposes a crack in the logic of the golden rule of “as prescribed.” Indeed, the reality that even
the most rule-abiding patient may become, unwittingly, an opioid addict poses a serious threat to
the legitimacy of this discourse. For in the world of prescription opioid use, it has already broken
down. In its place has emerged the possibility for seeing all opioid patients as potential addicts,
or what I refer to as “patients-at-risk.”
The patient who is always-already at risk of becoming an opioid addict is one of the three
key subjects that are produced in and to some extent by the opioid epidemic. The patient-at-risk
is important not only because she is a salient character that has contributed to the intelligibility of
the epidemic, but because she occupies a key position in many of the legal arguments that are
currently being waged against opioid manufacturers and distributers. At the time of this writing,
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10 different states and dozens of cities and counties have filed lawsuits suing opioid
manufacturers, including Janssen Pharmaceuticals, Purdue Pharma (the maker of OxyContin)
and Endo Pharmaceuticals, the manufacturer of the drug Opana ER, which was recently pulled
from the market. Lawsuits against these various corporate actors have been piling up over the
past decade, but most have been filed in the past several months. In addition to these cases-in-
progress, investigations have been launched by 40 different state attorney generals, all of whom
are attempting to gather evidence to pursue future litigation. Centrally involved in the attorney
generals’ cases against the pharmaceutical companies is the collapsing distinction between
opioid patients and opioid addicts. That is to say, the legal war they are waging is waged on the
basis that opioid users do not overdose or become addicted as a direct result of misusing opioid
products but that “they do so when used as directed, too” (Deprez & Barrett, 2017). The year
2003 saw a cluster of lawsuits taken up against one manufacturer in particular – who has by now
become to readers a rather familiar character: Purdue Pharma was accused in these lawsuits,
namely by the families and friends of overdose victims, of knowingly pushing drugs on their
loved ones, each of whom eventually became addicted to them “despite obtaining them legally
and taking them as directed.”
17

17
Whether as a direct or indirect result of these charges, Purdue Pharma recently
announced that it will stop promoting its opioid products to physicians (Poston, 2018) – a rather
uncommon course of action which indicates a drastic shift in the world of drug use, where blame
is repositioned from users to external actors and institutions operating within the medical-
industrial apparatus.
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While pharmaceutical companies have certainly found themselves facing an enormous
legal problem, one founded on the production of the patient-at-risk, this particular subject also
poses a threat for other actors. Increasingly, the accused are also physicians who – at the time of
this writing – are the defendants in several ongoing government lawsuits. Regardless of whether
it is fair to lay the blame at their feet, it is certainly the case that doctors represent one of the
groups that have a stake in maintaining the distinction between patients and addicts as it exists in
the rule of “as prescribed.” For it is now more often the physicians rather than the patients who
are held responsible when an individual dies from taking his or her medicine as prescribed. Other
actors with stakes in maintaining the distinction between as prescribed/not as prescribed and
patients/addicts include regulators, insurance companies, and chronic pain patients: Regulatory
agencies (as well as pharmaceutical companies), who were previously shielded by the
assumption that addiction would not befall drug consumers unless they took their drugs in a way
other than as directed, must now spend additional time, effort, and money on harm prevention
and risk management programs. Soo too, chronic pain patients and advocates have also had a
stake in maintaining the as prescribed/not as prescribed distinction. For it is this distinction that
underlies many of the arguments currently being waged by pain advocate associations against the
government’s implementation of opioid prescription limits – changes which, by making more
difficult their access to the drugs they need to live normal lives, have thousands of pain patients
rising up in anger and fear – terrified that a population of reckless consumers whose bad
behavior is seen as threatening their future access to medications (e.g., Frostenson, 2017; Kertesz
& Gordon, 2017; Kertesz & Satel 2017; Keilman, 2017).
Thus, the golden rule of “as prescribed” no longer works as it is supposed to do – to
distinguish patients from addicts as different kinds of legal subjects. Even more, its failure
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undercuts the assumption that there is some kind of inherent difference between them since, in
today’s world of opioid use, a patient is always-already a potential addict. Despite this (or
perhaps because of it) the patient-at-risk is constructed in ways so as to remain distinguishable
from the figure of the addict.
In the opioid epidemic, the figure of the addict is split into two categories: The addict as
pathological consumer, on the one hand, and the addict as a consumed victim, on the other. But
before examining these categories in more detail, it’s necessary to step back to discuss the
concept of addiction and its historical evolution. For this is a term with a complicated historical
trajectory. Tracing the development of the concept of addiction – and therefore of the addict – is
crucial if we are to understand how these two subject categories could have come into being in
the first place.
Patients and Addicts: A Historical Sketch
Throughout the 19
th
century and first two decades of the 20
th
century, American attitudes
toward addiction – and in particular, toward opioid addiction – were marked by ambivalence. In
the 19
th
century, especially, opioid addiction was not considered a major social problem, namely
because the opioid drug morphine was widely available and used as a medicine for a variety of
symptoms; as such, it was typically associated with its medical uses and was largely seen as
something favorable, rather than a potentially addictive and dangerous narcotic (Conrad &
Schneider, 1980). Correspondingly, individuals who were habitual users of morphine were not as
readily stigmatized as addicts and, as such, tended to aroused sympathy rather than contempt.
While it was already known that addiction to the drug was possible (and that it already existed
among a number of users), the condition itself was nonetheless largely exempt from moral
disparagement, precisely because it was seen as a kind of sickness. This sickness, which was
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sometimes referred to as “morphism,” was read as a disease not unlike any other, the sufferers of
which were, like many sick people, pitied as victims.
It is worth noting that the victim-status of opioid addicts during this period was also
associated with the race and class status of morphine users – the majority of whom were white,
middle-class, and middle-aged individuals living outside of the city centers (Keier, 1988). A
large percentage of morphine-addicted individuals, moreover, were women, many of whom
received the drug from their physicians as a means of alleviating symptoms associated with
menstruation and other similarly “female” problems, for morphine not only worked to taper
physical pain but was also prescribed to “assuage domestic or social anxieties” (Acker, 2002;
Courtwright, 2001).
Thus, at this time, opioids were seen as “medicine cabinet” drugs rather than street drugs
and were protected by their associations not only with medicine, but with the pharmaceutical
industry that both manufactured them and widely advertised their curative properties in
newspapers (which subsequently refrained from reporting on their potentially dangerous effects,
for fear of losing the precious advertising revenue on which they depended) (Duster, 1970). Yet
toward the end of the century, some concern developed among the public and the medical
community with regard to the possibility that because morphism most commonly affected
“active brain workers, professional businessmen, teachers, and [other] persons having large
responsibilities” (quoted in Conrad & Schneider, 1980), it could potentially pose a threat to the
integrity of the nation, the strength and future of which depended on the productivity of such
persons. Additionally, another set of concerns circulated around the use of opioids brought into
the United States by Chinese immigrants, whose practice of opium-smoking was widely
disparaged in the popular press. These concerns were undergirded by race, in particular by the
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wide anti-Chinese sentiment that accompanied the influx of Chinese immigrants into U.S. cities
during these years (Shah, 2001).
In 1898, when the German drug manufacturer Bayer Laboratory began to market another
opioid, heroin, sentiments toward opioid addiction again shifted – in part because of the efforts
this major pharmaceutical company (and a number of physicians) made to celebrate and market
the drug as a non-addictive substitute for opium and morphine. Heroin, unlike its cousin opium,
could be efficiently administered with hypodermic needles, which themselves could be readily
acquired by anyone who wished to order them (out of the Sears catalogue more often than not). It
was also, for many years, available without a prescription (Duster, 1970). Throughout the first
years following its introduction, heroin was also lauded as a cure for opioid addiction – a
declaration which was, within just a few years of its entrance onto the medical market, debunked
as more and more physicians began witnessing and reporting on its addictive properties – a trend
which also triggered the publication of a host of muckraking exposés, which depicted heroin as
“the most threatening drug in history” (Conrad & Schneider, 1980).
But by the start of the 20
th
century, popular sentiments were again shifting alongside a
growing awareness of the emergence of a new demographic of addicts: Early 20
th
century heroin
addicts no longer resembled the 19
th
century morphine addicts – those “active brain workers,”
“professionals,” and “persons having large responsibilities” that were seen as providing the basis
of the nation’s strength and moral integrity. On the contrary, these new addicts were “dope
fiends,” members of a criminal subculture constituted of rough, working-class white males living
in urban centers. The emergence of the “dope fiend” in the early 20
th
century corresponded with
the disassociation of heroin from its basis in medicine. With heroin use now seen as a purely
recreational activity rather than a medical necessity, public sympathy for opioid addicts rapidly
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declined. It was in this moment that opioid addiction first became symbolically embedded in the
underground world of “the street” and with the danger and moral bankruptcy that was (and
remains) associated with the black market drug economy (Valverde, 1998).
The public problem of addiction, which by then had acquired the meaning of a dangerous
vice and a sign of moral weakness, also corresponds to its medical definition during these years.
For in medicine, was no longer considered to be a disease like any other but was redefined as a
kind of psychopathy – a psychological problem that was inherent to the psychic make-up of the
individual drug user (Kolb, 1927; 1928). As the approach to addiction as psychopathy took
center stage, bolstered by the ascendance of psychoanalysis and the psychological study of
personality, addiction was gradually detached from physiological theories and came to be
understood as a purely psychological issue: For since it had no physical markers, it could only be
seen as an abnormality of individual character – a personality defect that offered an explanation
for the dope-fiend’s degeneracy, his irrationality, his criminal nature and, above all else, his
repetitive enactment of certain bad behaviors – namely, pathological consumption. The
conceptualization of addiction as psychopathy marks a critical moment in the history of
addiction, one which anticipates the development of a disciplinary approach to drug use, one
constructed around the addict’s marginalization, institutionalization and her subjectification as
part of a new class of criminal.
Interestingly, the 20
th
century’s conceptualization of addiction through its focus on the
individual drug user also coincided with the emergence of the term “addict,” which first
appeared as a noun in the Oxford English Dictionary in 1920. The emergence of the addict (as a
model example of deviance, degeneracy, and criminality) inaugurates the beginning of what
David Courtwright (2001) has termed the “Classic Era” of narcotic regulation.
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The passing of the Harrison Act of 1914 is a watershed moment in the “Classic Era” of
drug regulation as well as an early instance of the criminalization of opioid drugs – which,
despite growing concerns regarding their use, were still classified as “medications,” the
administration of which was almost entirely unregulated. The Harrison Act changed this by
making the prescribing and dispensing of all narcotics (including opioids) illegal. And five years
later, two supreme court decisions were handed down that extended the prohibition of narcotics
even further – banning their use by physicians practicing addiction maintenance therapy. Finally,
in 1920, the beginning of Prohibition institutionalized the criminalization of addiction with its
nation-wide ban on all drugs and alcohol. Even after Prohibition ended in 1933, measures to
criminalize drug use continued: The Boggs Act, passed in 1941, increased penalties for all
crimes involving drugs and established the precedent of minimum mandatory jail sentences for
drug offenders – a policy which has only in recent years come under scrutiny in various reform
efforts (Administrative Office of the U.S. Courts, 2004, 2007, 2010; Caulkins, 1997; United
States Courts, 2017a, 2017b; Families Against Mandatory Minimums website).
In the Classic Era, the “respectable addict” of the 19
th
century seems to have disappeared
altogether, replaced by a vision that characterized all narcotic users as “dope fiends” and,
throughout the first three decades of the 20
th
century, was supplemented by the similarly-
construed figure of the “junkie” (Acker, 2002). For the most part, the mid-20
th
century “junkie”
is not much different from the 1920s “dope fiend,” since both terms characterize addiction in
terms of its criminal element. Perhaps the only significant differences that exist between the two
terms are that, first, the “junkie” applies to a broader demographic of drug users (poor or
working-class young men, either white or black, urban-based, and addicted to heroin) and
second, that this figure not only signifies the psychopathy of addiction but is also meaningful as
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a representation of creativity and non-conformity within popular culture – in particular as it
relates to the Beatnik subculture of the 1950s and 1960s.
As part of the so-called Beat Generation, the “junkie” was not only associated with drugs,
but also with a cultural and literary movement launched in the aftermath of World War II – one
which celebrated, among other things, anti-materialism, spiritual exploration, and prolonged
experimentation with psychedelic substances. Indeed, much of the work that was generated by
Beat Generation icons – such as Jack Kerouac, Neal Cassidy, Alan Ginsberg, Hunter P.
Thompson, and William Burroughs – is focused on recounting their or others’ experiences of
drug use and on developing representations of the modern drug user. These meta-discussions and
representations of the junkie (by self-professed Beatnik junkies) and their influence in the
representation of addiction in popular culture are perhaps best exemplified by the work of
William Burroughs, in particular his novels Junkie (1953) and Naked Lunch (1959).
In Junkie: Confessions of an Unredeemed Drug Addict, Burroughs features himself as a
witness who reports his interactions with the addicts he encounters in the fringe criminal world
of the inner-city, in places such as New York, New Orleans, and Mexico City. His characters are
often depicted as outrageously depraved and, in many cases, deranged. In Naked Lunch (1959),
for example, Burroughs recalls a day when he “made the rounds” with a heroin-dealing friend of
his and provides a spectacular description of the depravity that he saw as coloring the daily lives
of those living with a heroin addiction. Burroughs attempts to explain what addiction means for
the junkie through a question he poses to the “straights” (non-users) that he imagines as his
readers. He asks them, “You know how old people lose all shame about eating, and it makes you
puke to watch them? Old junkies are the same about junk. They gibber and squeal at the sight of
it. The spit hangs off their chin, and their stomach rumbles and all their guts grind in peristalsis
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while they cook up, dissolving the body’s decent skin, you expect any moment a great blob of
protoplasm will flop right out and surround the junk. Really disgust you to see it.” Indeed, as a
self-declared heroin user, Burroughs’ description of the wantonness of the typical junkie is
consistent in his recounting of his own experience with opioid addiction, where he describes how
his heroin habit transformed him into a “lush worker,” a low-life degenerate who spent most of
his time in the criminal underworld envisioned through the New York City subway system,
where he learned to identify passengers who were drunk, passed out, or sleeping, and casually
steal their wallets.
Moreover, this image of the addict as a degenerate “junkie” circulated not only in popular
discourse but also in medical research and policy (Acker, 2002; Campbell, 2007). Drug historian
Nancy Campbell (2007) has said that during this period, addiction research was not an academic
exercise but a governmental one (and I would add, a juridical one). Indeed, by and large, the
study of addiction in the 20
th
century was taking place within federal institutions and criminal
justice organizations like the Bureau of Social Hygiene and the Bureau of Narcotics. But where
the government’s influence in the deployment of this psycho-juridical model of addiction is best
illustrated is in its funding and construction of two “narcotic farms” – one in Lexington,
Kentucky and the other in Fort Worth, Texas (both of which are also referenced in Burroughs’
work). Jointly operated by the Public Health Service and the Federal Bureau of Prisons, these
“farms” were essentially prison-type institutions masquerading as hospitals (Campbell, 2007). As
Campbell explains, the narcotic farms were also the privileged sites for the disciplinary
normalization of addiction, where addiction treatment was carried out through an individualizing
(and often punishing) mode of intervention in which blame was focused on the internal
shortcomings of the addict himself. And while the disciplinary institutions within which opioid
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addicts were confined and “treated” were not exactly prisons, they were funded by the federal
government and (in the words of one key psychiatrist who worked there) “operated like a
hospital” that “necessarily had prison features.” As part-prisons, part-hospitals, the narcotic
farms stand-in as an early example of an institution that blurs the lines used to separate patients
from addicts, addiction from disease, and treatment from punishment (quoted in Acker, 2002).
The internment of heroin addicts in narcotic farms can also be seen as marking the
beginning of the U.S. government’s infamous “War on Drugs.” This “War,” which was declared
by President Nixon in 1970, carried forth by President Reagan, and continuously waged (without
success) by nearly every other President since, has been primarily characterized by the
widespread criminalization of drug use and a new, “tough” stance toward the illegal drug trade,
and toward drug sellers and users-of-color (Alexander, 2010/2012; Marez, 2004). The explicitly
punitive approach to addiction in the 1960s, 70s, and 80s is, in some ways, a rather curious one,
considering that during these same years the psychological approach to addiction that likened the
addict to an unredeemable psychopath was supplemented (and largely replaced) by a concept of
addiction that was biologically and physiologically based.
The first of these approaches, a metabolic theory of addiction, was developed by Vincent
Dole and Marie Nyswander in a 1967 and soon became the dominant approach to addiction in
both medicine and psychiatry. Dole and Nyswander’s theory essentially said that addiction is not
caused by an addictive personality, nor by a desire for euphoria or escape, but by a neurological
susceptibility and an altered response to narcotics. Dole and Nyswander denounced the
“moralist” approach to addiction and advocated instead for a pharmacological approach to
addiction research and treatment.
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But for the past twenty years, addiction research that is neuro-biologically oriented – led
by the National Institute on Drug Abuse (NIDA) – has promoted an understanding of addiction
as a “chronic, relapsing brain disease.” In accordance with this model, addiction is understood as
the “behavioral outcome of a biological dysfunction,” one in which the brain’s systems for
reward, motivation, learning, and choice do not function as they should (Raikhel and Garriott,
2013, p. 13). Hence, addiction manifests itself in a series of behaviors that include the
“compulsive seeking…and administration of a drug despite grave adverse consequences”
(Nestler, 2004, p. 698). This model is today bolstered by the recent development of
neuroimaging technologies, tools which work to trace addiction back to dysfunctional brain
systems, which can be shown to “light up” when an individual consumes an addictive substance
or engages in an addictive behavior.
The neuroscientific approach to addiction has been characterized by many as an attempt
to demolish the moral stigma and social injustices associated with past approaches (particularly
those which have explicitly targeted and led to the widespread incarceration of Black and Latino
users). Yet while it may be the case that the current hegemonic conceptualization of addiction is
based in neuroscientific research, which attempts to define it using a universalizing biological
discourse that disassociates addiction from psychopathy, criminality, and environmental
factors
18
, it is also the case that moralizing approaches to addiction have not disappeared. On the

18
It is important to note that the universalizing discourse of biology, which undergirds
the neuroscientific approach to addiction, has not necessarily succeeded in disassociating
addiction from its social, moral, or criminal connotations. On the contrary, as many have argued
(e.g., Campbell, 2010; Dumit, 2004; Netherland & Hansen, 2016; Vrecko, 2010) and as I will
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contrary, discourses that locate addiction in the character of the individual addict (as illustrative
of an inherent moral weakness) still circulate in popular culture, politics, and law, where they
exist alongside neurological models that situate addiction within the addict’s brain. Yet though
these two approaches may seem opposed to one another, they do in fact agree on a pair of key
points: First, both understand addiction to be something internal, which is situated within the
addicted person (whether in her brain or character). Second, both share a concern with behavior,
especially those which, because they result in compulsive self-harm, are seen as violating the
terms of human choice, free will, and self-control.
Classifying Opioid Addicts: Consumers and the Consumed
In the opioid epidemic, the discursive construction of addiction and of the addicts
themselves is likewise concerned with behaviors that are seen as being recklessly and, indeed,
needlessly destructive. Yet the source of the opioid addict’s destruction is not seen as being the
same for all addicts. On the contrary, as this section details, subjectification in the opioid
epidemic divides opioid addicts into two different kinds of persons, one for whom destruction is

discuss later in the chapter, addiction neuroscience has also played a role (though perhaps
unwittingly) in extending the social injustices and racial stratification associated with addiction;
that is to say, because addiction neuroscience has excluded race from scientific discussions about
addiction, it also succeeded in channeling its research, results, and treatment interventions
toward racially-unmarked (i.e., white) individuals. As I will discuss, the exclusion of race from
these ongoing scientific discussions of addiction extend the logic of strategic essentialism that
has made the opioid epidemic legible as a white problem, and which has channeled its solutions
toward the race-specific agenda of white rescue and the selective recovery of white potential.
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squarely located within that individual and another for whom destruction comes from forces
acting outside herself, which she cannot always hope to control. Thus, the world of opioid
addiction divides its subjects into the following categories: Pathological consumers (not so
different from the “dope fiends” or the “junkies” of the “Classic Era” of drug regulation) on the
one hand, and those who are consumed addict-victims, on the other.
As the previous historical sketch has attempted to illustrate, discourses about addiction
that divide addicts into those who are to blame and those who are blameless are not themselves
anything new. On the contrary, as other scholars have discussed (e.g., Alexander, 2010/2012;
Conrad & Schneider, 1992; Lassiter, 2015; Bourgois & Schonberg, 2009; Jacques & Wright,
2015), the construction of addiction has long divided addicts into binary categories of good and
bad – categories which have often mapped directly onto racial divides. The hegemonic system of
racial relations within which drug users have been segregated and classified as persons who are
either good (the white patient) or bad (the black addict), and which map on to the treatment of
drug abuse as either a criminal justice issue or a public health crisis, is somewhat complicated by
the emergence of the patient-at-risk and with the dissolution of the rule of “as prescribed,” both
of which have been crucial for distinguishing – legally, institutionally, and culturally – the
different kinds of drug consumption that respectively belong to patients and addicts. Yet, in the
face of such ambiguity, the discursive construction of opiate addicts as being either consumers or
consumed should also be understood as a strategy – one in which various actors have
participated as an attempt to restore order and grant legitimacy to the previous classificatory
system.
The Addict as a Pathological Consumer
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The addict who is seen as a pathological consumer is defined on the basis of his or her
individual behaviors and social role – both of which are seen as deviant, morally dubious, and as
manifestations of an underlying pathology and/or character disorder. Addiction, for the
pathological consumer, is understood strictly in terms of that person – of the particular
personality traits, family history, and other clinically-articulated “predispositions” that make her
more susceptible to deviant behaviors and anticipate her tendency toward future substance abuse
(Carr, 2013). Her behaviors in these domains are furthermore understood as forms of willful
misconduct (Valverde, 1998). They are intentional actions, ones which position her not only as a
pathological opioid consumer but also as a “hustler” – an active participant who knowingly
exacerbates (and to some extent, thrives on) her transgressions. As a hustler, the pathological
opioid consumer’s condition is also associated with a range of other behaviors, which may
include stealing, pimping, whoring, pushing, and so on (Bourgois & Schonberg, 2009; Knight,
2015). Thus, the pathological consumer is, in many ways, the addicted subject of history, one
which closely resembles the character of the heroin junkie.
Figure 1.2
To provide a visual example, Figure 1.2 contains a photograph that illustrates many of the
characteristics of the subject of the pathological opioid consumer – as well as the particular
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relationship she has to her drug-of-choice. This image, which was posted on the website of
White Sands Treatment, a rehabilitation center in Florida, depicts a young, white, female addict,
who is centered in the frame against a black background. She stares directly into the camera. In
her left hand is a needle, full of brownish fluid, which she grips between her middle and ring
fingers. She is showing off, performing her addiction with a maniacal grin and coy squinting
eyes as she proudly displays her paraphernalia to whomever might be watching her. Her hair is
messy and her eyes slightly out of focus, signaling to the viewer that she just had or is about to
get her fix and that she is in no way ashamed of it. This addict, this pathological consumer, does
not give any hint that she intends to recover. In fact, she seems to suggest the opposite. She is
many things but treat-able or rehabilitate-able she is not. After all, the photo implies, she has
agency, a choice of whether or not to engage in problematic behavior – and she has already made
it.
The Addict who is Consumed
On its website, White Sands Treatment also depicts another kind of addict, who appears
to be the same girl but whose photo is sharply juxtaposed to the one above. Figure 1.3 provides a
visual example of opioid addiction as it manifests in an addict who is not an active, willfully
pathological consumer but is instead depicted as passive and remorseful – an addict-victim who
does not want to consume the drugs but has already been consumed by them. She is, as her offset
gaze would indicate, under the influence – not in the sense that she is high but in the sense that
she is brainwashed, a prisoner bound to forces that (although they may be small or even unseen)
hold a power that is much larger than that which she holds herself. Unlike the larger-than-life
pathological consumer, the addict who is consumed is even smaller and less powerful than the
tiny pill she grips between her fingers. She is not a performer but looks shy and frightened, like
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someone who would rather be anywhere else in the world than where she is right now. Her face
is tear-stained and sad. Her eyes gaze sideways, cautiously considering the orange capsule in
front of her. But this pill does not make her happy. In fact, she seems to resent it. It’s the pill’s
fault, she seems to say. If she could she would throw it away. But she cannot. Her feelings
toward it are complex: She wants it but she doesn’t, she loves it but she hates it, she is scared of
it but still can’t take her eyes off it. Even as she grips it she is even more so gripped by it – not a
consumer but a victim who has already been consumed.
Figure 1.3
Seen from the vantage of the consumed addict-victim, the story of opioid addiction “is
not a story about dark alleys and drug dealers” but rather repositions addiction as something that
“starts in doctors’ offices” and “with everyday people seeking relief from pain and suffering”
(Calabressi, 2015, p. 28). This repositioning of opioid addiction from street into these new
spaces also coincide with a repositioning of blame, which shifts from the individual herself to
other forces external to her/ In this sense, the concept of addiction as it relates to the consumed
subject represents a departure from the other ways in which it has historically been understood.
For the opioid addict-victim, addiction is not a disorder underlying pathological consumption but
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is instead a process of becoming consumed. What she is consumed by, moreover, is not limited
to a drug but also includes all the forces that constitute the medico-industrial complex – big
pharma, physicians, insurance companies, and the regulatory apparatus are all seen as having
been culpable parties in the process through which so many American have become addicted to
opioids. And so, it is that through the discursive construction of opioid addicts – these “new
faces” – as consumed rather than consumers, the moral space of addiction is being repositioned:
In the opioid epidemic, the locus of blame is shifting away from individuals and their willful acts
of pathological consumption to the institutional arrangements that produce and consume them.
Exteriorization: From Personhood to Dependence
The production of the addict as “pathological consumer,” on the one hand, and the addict
as a consumed victim, on the other, has been made possible by transformations in the interrelated
domains of medicine and policy, where the conceptualization of addiction has evolved over the
past four decades. In my view, the notion of a “consumed” addict (whose addiction is attributed
to forces external to him or herself) requires and could not exist apart from an addiction concept
which separates the condition (and all its negative associations) from the addicted person. Thus,
an analysis of subjectification in the opioid epidemic – which hinges on the construction of a
blameless, consumed addict-victim also requires an examination of the externalization of
addiction – of the process(es) through which the meaning of addiction has become gradually
detached from the addicted person, from her internal nature, character flaws, and so on. This
detachment is key for the ways in which it has made addiction appear less about personhood than
about a problematic relation between a person and a set of malignant forces that impress upon
her, ultimately conditioning her behavior.
This relatively new, “externalized” understanding of addiction is, I argue, reflected in the
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uptake of the term, “dependence” – a relational concept wherein addiction itself is re-framed as a
struggle rather than as the manifestation of an addict’s inherent flaws. The significance of the
term “dependence” has reached not only into medicine and science but has also informed the
development of laws, policies, and regulations that have performed a number of critical functions
in their attempts to (1) encourage the increased prescribing of opioids, (2) dismantle the “stigma”
of opioid use, (3) dictate the allocation of pain-relieving resources to certain kinds of persons,
and (4) broaden the application of a public health framework and its “compassionate” approach
to drug use and enforcement.
Personhood
In medicine, discussions of how to define and understand addiction have never been far
from discussions about pain and its management. Indeed, across much of the literature in pain
management, addiction has been central to the problematization of pain – particularly as it has
related to the concerns held by pain researchers’ and physicians’ regarding the widespread
under-treatment of cancer and non-cancer-related chronic pain (e.g., Dahl, 1997; Foley, 1985;
Gilson & Joranson, 20021; Halpern & Robinson, 1985; Jaffe, 1980, 1989; Joranson & Gilson,
1994; Joranson et al., 2002; Portenoy, 1996; Portenoy & Foley, 1986). For example, in a paper
published in the Journal of Pain and Symptom Management in 1996, eminent pain specialist
Russel Portenoy included the conceptualization of addiction as one of the “critical issues” in
contemporary pain management. Portenoy argued that coming to grips with the prevalence of
chronic pain under-treatment would require pain specialists to recognize that the “confusing
nomenclature” used to define addiction is a hindrance to successful pain management (p. 208).
Under-treatment, Portenoy insisted, results in part from the widely held (and erroneous) belief
held by most clinicians and physicians that an individual whose physical tolerance to opioids has
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increased is, by virtue of that tolerance, addicted to these drugs. The conflation of physical
tolerance and addiction, as Portenoy saw it, is what undergirds many physicians fears about
using opioids and, subsequently leads them to refuse their patients’ requests for adequate care
and symptom relief. To reverse this problematic cycle of under-treatment, Portenoy and others
(e.g., Dahl, 1997; Foley, 1985) advocated for those in pain management to engage in a sustained
attempt to redefine the concept of addiction in order “to place the use of narcotic analgesics in
perspective” and put to bed, once and for all, the stigma associated with opioid use (Portenoy,
1996, p. 88).
The critique that was launched within pain medicine, which argued that defining
addiction in terms of the addicted person (or personhood) was exacerbating the problem of
under-treatment for many people in pain, has also coincided with efforts to re-define and re-
frame addiction in the interrelated domains of the law, policy, and regulation (Gilson &
Joranson, 2002; Joranson & Gilson, 1994; Joranson et al., 2002). For indeed, discussions of
addiction in these domains have often failed to define a condition (which would set a precedent
for its treatment) but have instead been fixated on conceptualizing addiction as a kind of person.
For example, the 1988 Modern Medical Practice Act (MMPA), published by Federation of State
Medical Boards (FSMB), also referred to “an habitué or addict or any person previously drug
dependent any drug legally classified as a controlled substance or recognized as an addictive or
dangerous drug” (quoted on p. 218).
As many pain specialists and advocates have suggested (and I think rightly so), such
definitions have a performative effect – one that directly affects the lived experience of opioid
consumers and makes it more difficult for them to get the drugs they want or need without being
severely policed, regulated, and monitored. The unpleasant experience of being policed as a
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potential addict arises in tandem with definitions of addiction that emphasize the addicted
individual him or herself, such that addiction becomes solely legible as an individually-located
problem – a manifestation of some kind of physiological or psychological defect. Such a
conceptualization, moreover, helps to legitimize an incriminating approach to opioid use.
Perhaps the most illustrative example of the incriminating effects of addiction’s definition in
terms of personhood is found in the Controlled Substances Act of 1970 (CSA), the crucial statute
that laid the foundation for U.S. drug policy. In the CSA, addiction is defined as a person who
“habitually uses any narcotic drug so as to endanger the public morals, health, safety, or who is
so far addicted to the use of narcotic drugs as to have lost power of self-control with reference to
his addiction.”
What the above critiques fail to mention is that the oft-mentioned “stigma” associated
with opioid addiction, which experts in pain medicine and policy have identified as the crucial
factor behind the widespread under-treatment of pain, is something that has never been evenly
applied to all pain patients. On the contrary, the ways in which “stigma” has informed the
definition of addiction, and the practice of prescribing narcotic medicines for patients-in-pain,
has been conditioned by its symbolic and material relation to race: That is to say, the under-
treatment of pain must also be understood according to a well-documented historical tendency in
which the allocation of pain medications has been primarily channeled to white patients. Such
racialized patterns of opioid prescribing can be situated both in the context of clinical practice
and in broader cultural and political terms: In broader cultural and political terms, the stigma
associated with the use of narcotics (and with drug addiction, more generally) has been
conditioned by (and itself has conditioned) the racialized biases and stereotypes of black drug
users as always-already addicts and criminals – assumptions that colored much of the political
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rhetoric of President Nixon’s presidential campaign, his “tough” approach to crime, and his
decision to launch “the war on drugs.” During the Nixon years – which also map onto the same
years in which experts in pain medicine began questioning and critiquing the definition of
addiction as a kind of pathologized “personhood” – the stigma associated with addiction went
hand in hand with racialized discourses that attributed all manner of social and economic ills to
the “welfare queens,” “criminal predators,” “crack babies,” and black “hustlers,” and which
likewise constituted some of the most popular and, indeed, dominant representations of drug use
and addiction at the time. Thus, an understanding of addiction during these years, which was
fixated on the ethical shortcomings of certain persons should also be seen for the ways in which
it was conditioned by – and to some extent, reflected – the larger cultural and political dynamics
that of that moment, which Michelle Alexander (2010/2012) famously termed as the “New Jim
Crow Era”.
19

It should also be noted that the under-treatment of pain has likewise been informed by
race relations – particularly those taking shape within clinical encounters. In this context, pain
treatment for people-of-color has been conditioned (and limited) by many physicians’ long-held

19
It is also worth mentioning that the anti-black backlash that formed part of conservative
political discourse in the 1970s and 1980s was also a message to disaffected working-class
whites, who suddenly began to vote, en-masse, for Republican candidates – a phenomenon
which profoundly shifted the terrain of American politics. If we fast-forward to the present, we
can identify a number of similarities between the racialized discourses that shaped the politics of
the 1970s and 1980s and those which are at work in our current moment of cultural and political
turmoil.

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fears about the potential consequences of giving potentially addictive narcotics to people-of-
color. These fears are well documented in Mark Zborowski’s 1969 book, People in Pain and in
his study (which became very famous in the world of pain medicine) that demonstrated not only
cultural differences in the perception of pain but distinct cultural and ethnic biases in physicians’
prescribing behaviors. Decades later, an additional study conducted by Todd Knox, Tony Lee,
and Jermone Hoffman among patients in Los Angeles emergency rooms arrived at a similar
conclusion after finding that white patients were consistently dosed with pain medications more
liberally than were Latino patients, even when both groups were suffering the same conditions
(Knox, Lee, & Hoffman, 1994). In more recent years, a variety of other studies (e.g., Mossey,
2011; Primm et al., 2004; Singhal, Tien, & Hsia, 2016; Tamayo-Sarver, et al., 2003) confirmed
what Zborowski and later Knox and his colleagues found to be systematic differences in the
prescription and treatment of pain, and a historical tendency to under-treat (or refuse to treat) the
symptoms of people-of-color with pain-relieving opioid medications.
20

These studies raise a question, one which is largely omitted in the discussions of pain
under-treatment by Portenoy and others: Whose pain deserves to be recognized? As the studies
cited above show, the answer to this question has generally been white patients – patients who
have escaped the problematic associations and racialized stereotypes that cast black and brown
narcotic users as pathological consumers, individuals who are, by virtue of their ethnicity,
inherently more likely to try to game the system, to become addicts, and to divert prescription

20
One recent study, published in 2016, found that black patients in emergency room
settings were half as likely to receive pain medications than non-Hispanic white patients (Singhal,
Tien, & Hsia, 2016).
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drugs into the black market drug economy of the “street.” While it cannot be said that the actions
of every physician who refuses to prescribe pain medication to a black or Latino patient are
explained by these stereotypes, the overall pattern of the uneven allocation of pain-relieving
resources to patients-of-color serves as yet another example of the ways in which the world of
opioid use is informed by possessive investments in whiteness – investments which help to
reinforce a troublesome reality where white pain is privileged over black pain, where the supply
of opioids is channeled toward white consumers, and where the symbolic connection that equates
white drug use with patienthood and black drug use with criminality is continually reinforced.
Dependence
In the myriad discussions regarding the concept of addiction, the definition which was
most often promoted – and which has since become the standard way of defining addiction in
medicine and policy – sought to shift the emphasis from the addicted individual to his or her
relationship to a substance. This relational understanding of addiction is at the center of its
redefinition as “dependence,” a term which has itself evolved over time.
An early instance of the use of “dependence” occurred in 1969, with the publication of a
report by the World Health Organization. Tellingly, the report was constructed by a committee of
experts that referred to itself as the “WHO Expert Committee on Drug Dependence.” In their
report, the terms which had previously been used to characterize drug abuse – “drug addiction”
and “drug habituation” – were removed and replaced with “drug dependence,” a concept which
referred to “a state, psychic and sometimes also physical, resulting from the interaction between
a living organism and a drug, characterized by behavioural and other responses that always
include a compulsion to take the drug on a continuous or periodic basis in order to experience its
psychic effects, and sometimes to avoid the discomfort of its absence…” (WHO, 1969, p. 6). The
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institutionalization of the term “dependence” in drug policy and addiction literature is extremely
significant – for it transforms the very nature of the phenomenon of addiction itself from an
individual problem (to be intervened upon through the incrimination and/or punishment of
individuals) to a relational issue – one which resulted in the re-positioning of addiction from the
internal space of the addict to social and environmental factors external to her. Externalized,
addiction comes into focus as part of a larger system – a matrix of discourses, practices, and
relations belonging to a variety of different contexts (cultural, political, medical, etc.).
Throughout the 1980s and into the 1990s, the concept of addiction as “dependence” was
further transformed from a unified concept to a term that was split into two different categories:
Physical dependence, on the one hand, and psychological dependence, on the other. The idea was
that if psychological dependence was seen as something separate from physical dependence,
physicians and policymakers would be less likely to conflate the phenomenon of increased
tolerance with the self-destructive behaviors emblematic of addiction (Foley, 1985; Jaffe, 1980;
Portenoy & Foley, 1986). Thus, chronic pain patients who needed stronger doses of their
medications would not be stigmatized as addicts but would instead be seen as experiencing a
normal side effect of prolonged opioid use, in which the body becomes accustomed to the drug
and eventually needs more of it to attain the same state of pain relief. Ever in sync with the pain
management community, the World Health Organization soon followed its recommendations in
a report that its Expert Committee on Drug Dependence published in 1993, clarifying that cancer
and chronic pain patients who use opioids should not be considered drug-dependent solely on
basis of their physical tolerance. Addiction, then, was no longer characterized in terms of an
individual’s consumption, but required further evidence – proof that the individual was not
merely another consumer, but rather someone who had undergone a process through which she
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became physically and psychologically consumed.
Thus, just as the definition of addiction in terms of personhood worked to further the
stigmatization of addiction and the larger anti-black discourse within the figure of the addict was
positioned, the evolution of the concept and development of the notion of “dependence” works
toward the de-stigmatization of addiction. But, again, the key questions to ask are, first, how
does de-stigmatization work, and second, for whom has it worked best in this context? With
regard to the first question, the conceptualization of addiction as “dependence” works to de-
stigmatize individual addicts by shifting the source of blame from the defects inherent to the
addict’s personhood toward something problematic that is inherent to his or her relationship to a
particular substance. Second, the de-stigmatizing effect of this repositioning must be understood
as again working primarily in the interests of white opioid users who, as the previous sub-section
established and discussed have constituted the majority of patients being prescribed opioids for
the management of their pain.
With both these considerations in mind, it can then be argued that the dependence
concept of addiction does not work to de-stigmatize addiction and opioid use for everyone
equally but rather has done so selectively and in a way that has remained consistent with the
historical patterns in which the symbolic and material realities associated with opioid use and
addiction have been conditioned by relations of race. The material reality of addiction, when
understood in terms of dependence, is one in which the uneven application of application and
allocation of pain-relieving resources, favoring white patients, is reinforced. So it is that the
externalization of the concept of addiction makes itself visible as a phenomenon that is bound up
with other historically situated processes of racialized subjectification – processes that are not
only responsible for helping to structure the narrative of the opioid epidemic, but also for
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articulating its connection to historically-situated representations of race and racialized biases
that have long conditioned the practice of pain management and the prescribing of pain-relieving
medications.
Pseudo-addiction
Finally, the concept of pseudo-addiction – which was developed in the late 1980s and
popularized in pain management throughout the 1990s – offers a more recent example of a
conceptualization of addiction that is relational and contextual, one which locates the problem of
addiction within the broader relationship that exists between an individual and the medical
establishment. Moreover, it serves as another case that illustrates how definitions of addiction
have been bound up with race relations and the question of whose pain matters and deserves to
be alleviated and whose does not.
Pseudo-addiction, a concept presented by David Haddox and David Weissman in a 1989
paper in the journal Pain, “describes the iatrogenic syndrome of abnormal behavior developing
as a direct consequence of inadequate pain management” (Weissman and Haddox, 1989, p. 363).
In pseudo-addiction, the concept of addiction is a relational one, which is understood in terms of
the relationship between individual patient and her treatment plan, on the one hand, and between
that patient and her physician, on the other. Pseudo-addiction occurs when a physician or other
member of that patient’s health care team mistake certain medication-seeking behaviors as signs
of addiction – when, in reality, they are simply signs that the patient’s treatment plan is not
working, that her pain is not being properly controlled and, in turn, that she needs more and
stronger analgesic medication. According to Weissman and Haddox, the behavioral indicators of
addiction (asking for early refills, lying about her consumption routine, etc.), which result in the
false diagnosis that is pseudo-addiction, are not seen as a result of true physical or psychological
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dependence but as a result of either (or both) inadequate pain management or a doctor-patient
relationship lacking in trust. In response to these factors, patients may “develop feelings of anger
and isolation.” And as the authors suggest, these factors will in turn lead to “acting-out behavior”
and to frustration on the part of the health care team who upon finding itself unable to control the
patient’s pain complaints, “will seek to avoid contact with the patient as a means of reducing the
source of conflict.” This call-and-response process then becomes a cycle in which the reactions
of patient and health care team “continually interact until a crisis based in mistrust ensues” (364).
To avoid the phenomenon of pseudo-addiction and all the interpersonal conflicts that it entails,
physicians must work to establish trust with their patients while also being sure that they are
consistently providing “appropriate and timely analgesics to control the patient’s level of pain”
(363).
Though this concept has since been widely debunked in pain management and public
culture, it is still listed as an “up-to-date” concept under the umbrella of “addiction” as defined
by the Federation of State Medical Boards (Reis et al., 2009). In recent years, however, the
concept of pseudo-addiction has come under fire for the role it is seen as having played in the
upsurges of long-term prescription opioid use that many consider to be the driving force of the
opioid epidemic. In media accounts of the epidemic, pseudo-addiction is often pointed to as a
convenient and disingenuous answer invented by Big Pharma sympathizers for the many
physicians who saw in their patients the symptoms of growing tolerance and, in some cases,
opioid withdrawal (e.g., Deprez & Barrett, 2017; Kessler, 2016; Radden Keefe, 2017). Indeed, a
concept like pseudo-addiction – especially when presented in the pages of a respected medical
journal – also works to legitimate continued opioid prescribing and encourage the continued sale
of opioid products, especially in cases where it is unclear whether the patient’s relationship to
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that product has soured.
Moreover, it is not insignificant that one of the authors of the paper that introduced the
pseudo-addiction concept, Dr. David Haddox, signed on as a paid speaker for OxyContin-maker
Purdue Pharma shortly after the article’s publication. Haddox has since been promoted to the
company’s Vice-President of Health Policy and has been paid to travel all over the country and
give talks that simultaneously spread the word about pseudo-addiction and promote Purdue’s
latest opioid products. Moreover, pseudo-addiction has also made frequent appearances in the
marketing materials Purdue released in its promotion of OxyContin, including in educational
pamphlets designed to provide physicians and patients with reliable information about the safety
of opioids and in the “I Got My Life Back” videos, which were previously analyzed in Chapter
2. Thus, while it would be difficult to say, unconditionally, that the relational understanding of
addiction espoused in the concept of pseudo-addiction is what caused the opioid epidemic, it is
certainly the case that such an understanding complemented the interests of the opioid industry,
just as it complemented the interests of physicians (most of whom were well-intentioned and
simply wanted to help their patients find relief) and patients (nearly all or all of whom
desperately want to be pain-free).
Moreover, the concept of pseudo-addiction, while working to encourage physicians’
continued prescription of opioids to their patients, has also contributed to the wider movement
within pain medicine to de-stigmatize opioid use. By re-framing opioid users (and their requests
for more pills) as patients suffering the consequences of pain under-treatment rather than as
patients developing an addiction pseudo-addiction has also entailed a shift in subjectivity, one
where the status of an opioid user as a potential addict has been overshadowed by her status as a
patient. This selective framing in which (primarily white) opioid users have been rendered
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legible solely in terms of their patienthood has also granted them a privileged subject position –
one which is both detached from addiction’s negative (i.e., criminal, immoral) associations and
conveniently located within the non-punitive, “compassionate” framework of public health.
Conclusion: Addiction as a “Problem of Living”
Indeed, addiction has proved itself to be a discourse marked by its flexibility and
changeability. Because it is a flexible concept that has shifted overtime in science and medicine
as well as in politics, culture and other domains, some have suggested that it can only be
adequately conceptualized in terms of its trajectories (Raikhel & Garriott, 2013, p. 2). This is to
say that the knowledge of what addiction is, is primarily influenced by its own movement and
the myriad ways in which the concept itself (along with those actors and institutions who have
had a stakes in delimiting its conceptual boundaries) have interacted with its development.
The current terrain of addiction and addicted subjectivity is increasingly understood in
more complex terms, terms that are not necessarily contained within an individual’s neural
circuity but must be considered in terms of its movement through and as a lived experience – an
experience which is undoubtedly conditioned by a host of forces that, taken together, have
necessitated the expanded conceptualization of addiction as a “problem of living” (Colonna,
2000). As a “problem of living,” opioid addiction – and the individuals who experience it –
cannot be understood apart from the external forces to which they have become attached: These
forces, moreover, are not limited to certain, problematic objects, but span outward to encompass
the various aspects of medical practice and the forces experienced by the patient in her clinical
encounters. The re-positioning of addiction outside of the addicted person is operationalized and
institutionalized in clinical encounters which, as anthropologist Kelly Knight has shown in her
work on opioids, is an important space, where the inter-related problems of pain, addiction, and
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opioids come together and where many of the key discourses and practices that have contributed
to the intelligibility of the opioid epidemic are enacted in the production of addicted subjects and
subjectivities (Knight, 2016; 2017).
As the next chapter details, subjectification in the clinical context is also expanded into
the broader world of addiction recovery. In this realm, the racialized logics that undergird the
narrative construction of the opioid epidemic can be shown to play a crucial role in influencing
the development and application of opioid addiction treatment technologies. These are informed
by and in turn help to reproduce the historical division of the world of drug use into the
segregated domains of criminal justice and public health, along with the different categories of
addicted subjects that are housed within them. By prioritizing the rehabilitation of some addicts
and not others, opioid addiction treatment technologies not only incorporate representations of
opioid addiction as a specifically white problem but also transmute this discourse into a material
reality – one where the solutions that are developed to combat opioid addiction are framed within
a tragic narrative of lost (white) cultural, political, and economic potential and utilized as a
means of responding to an urgent need to recover it.

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Chapter 6: Subjectification and the Construction of White Victimhood

Subjectification in the opioid epidemic is a process that both relies on and reconfigures
many of the racial logics that conditioned the discourses and practices underlying the U.S.
Government’s infamous “War on Drugs.” In much of his writing on the relationship of culture
and race, Stuart Hall has emphasized the importance of understanding and incorporating history
– of considering in an analysis of race and culture in the present, other past moments “which
were both similar to and different from this one” (Hall, 1986, 1996). The present, Hall insisted,
has to be read in lieu of history – of the dominant discourses and practices, what he refers to as
the “lines of tendential force” that limit the possibilities of and give shape to the present (Hall
1986). Following Hall, it is likewise important to identify and understand the lines of tendential
force that structure the current opioid epidemic and its place in American culture. In particular,
when attempting to understand how the epidemic has become legible as a story about whiteness,
a backward glance into the history of race relations across decades of the U.S.’s waging of a
“War on Drugs” provides us with a number of key discourses, practices, values, and norms that
lend additional meaning to the role that whiteness plays in drug culture, policy, and enforcement
today.
As the previous chapter discussed, it is clear that the interrelated problems of drug use
and addiction are and have always been racialized. The race relations within this domain,
moreover, reflect and reinforce the hegemony of whiteness. They have done so, primarily, by
contributing to the racial logics that have been used throughout the “War on Drugs” in the 1970s
and 1980s to impose harsh measures of discipline and punishment against people of color. As
Michelle Alexander discussed in her book, The New Jim Crow (2010/2012), the War on Drugs
has played a profound role in both producing, reinforcing, and institutionalizing racial
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hierarchies in the United States. Consider, for example, when President Nixon declared in 1971
that drug use was to be understood as America’s “public enemy number one” and subsequently
mobilized law enforcement to intensify their crack-down on the reported trafficking of illicit
crack and cocaine use in black urban neighborhoods.
During the next decade, though blacks’ drug use was not actually escalating, arrests and
convictions of black individuals accused of drug offenses skyrocketed (Pew Research Center,
2014). Across the country, prisons were overflowing with black and brown drug offenders. In
1986, the Senate proposed a set of tougher anti-drug legislation, which the President signed into
law as the Anti-Drug Abuse Act of 1986. The legislation incorporated a number of harsh
penalties for drug offenses, the most severe of which were mandatory minimum sentences for the
distribution of crack and cocaine, with more severe penalties reserved for the distribution of
crack, then for powder cocaine (Alexander, 2010/2012). Two years later, Congress revisited the
policy and revised the legislation, instituting new punishments for drug offenders, including an
expanded use of the death penalty for “serious” drug offenses and longer mandatory minimums,
including a 5-year sentence for the mere possession of a drug with a cocaine base. This sentence
could be imposed on the accused parties – which, remarkably, also included first-time offenders
– regardless of whether there was any evidence of that individual’s intent to sell (Alexander,
2010/2012). Even more shockingly, the revised legislation included a variety of so-called “civil
penalties” – punishments which extended far beyond the traditional scope of drug crime
enforcement: These penalties included eliminating federal benefits and student loans for anyone
convicted of a drug offense and provided housing authorities with the ability to evict tenants for
allowing any kind of drug-related activity to take place in or near public housing sites.
These two examples of 1980s anti-drug legislation are not only representative of the
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federal government’s frenzied urge to wage its War on Drugs and its reckless expansion of the
(already overburdened) prison system but should likewise be understood, as Michelle Alexander
has rightly argued, as a means of instituting a “new racial caste system” which would result in
the unprecedented incarceration of black and brown citizens and the unwarranted abolition of
their civil rights and liberties. Indeed, this system has not disappeared. To this day, the world of
drug use for people of color remains situated in the criminal justice system.
For white people, however, the world of drug use looks a lot different. Unlike drug use
among black people, the world of white drug use is less commonly associated with incarceration
than it is with hospitalization and the largely non-punitive real of public health. This discrepancy
can be illustrated in a shocking statistic which shows that despite similar rates of drug use,
Blacks are incarcerated on drug charges at a rate 10 times greater than whites (ACLU, 2013).
Such racialized discrepancies are key to understanding race and subjectification in the opioid
epidemic – a phenomenon that Helena Hansen has characterized as being centered on “white
opioids.” But “white opioids” are also part of a longer history of white drug use that goes back
many years.
The race relations that characterize the ongoing epidemic cannot be separated from this
history. Thus, when discussing subjectification and the construction of whiteness in opioid use
today, it is worth taking a moment to harken back to the past and to the other histories of drug
use, which – taken together – have helped to shape its current articulation in the opioid crisis.
For it is certainly the case the “gentler approach” toward drug offenses involving white users is
anything but new; on the contrary, this approach is not specific to the opioid epidemic but is part
of a longer historical trajectory in which white people and their use of drugs have not only
escaped criminalization, but have also served as a basis for reinforcing the discourses of white
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victimhood and protecting the realities of white privilege that are always-already secured at the
expense of other, non-white interests.
What the history of white drug use and the “white war on drugs” reveals is three-fold:
First, it shows how drug use and addiction among white individuals has been positioned in
sanitized realms where drug users are more readily legible as patients than as addicts. Second, in
these contexts, drug consumption among white users (patients) has been articulated not to the
personal failures of those individuals but has instead been understood as a symptom of external
forces – of particular social, economic, and cultural problems that have given rise to their
complaints and which prescription drugs have purported to address. As a potential solution to the
various structural issues that have been seen as plaguing white populations, prescription drug
consumption has been rendered as beneficial – a necessary step toward improving the quality of
life of a large consumer demographic. Finally, this history also attempts to illustrate that white
drug use has functioned as a means of investing in the inherent value of white identity; that is,
how it has been geared toward improving the quality of life for predominantly white patients –
an objective which has been institutionalized time and time again within broader programs and
policies that have selectively channeled resources, power, and opportunities to this demographic.
The (White) War on Drugs
The reformation of the Rockefeller Drug Laws of 1973 (legislation meant to institute
harsher punishments for drug users) represents but one example of the ways in which the “War
on Drugs” has been waged unevenly – against the interests of people of color and,
correspondingly, in line with the interests of white drug users. In 1979, the Rockefeller laws
were reformed regarding one particular subject – marijuana use – and were targeted toward
lessening the punitive measures against it, or to decriminalize use of the drug entirely. The
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reform came about in 1979, namely as a result of affluent white parents’ aggressive lobbying
efforts. Fighting on behalf of their white, weed-smoking teenage children, these parents won a
decisive battle for white drug users (Carson-Dewitt, 2001). Tellingly, moreover, the Rockefeller
statutes that pertained to other drugs (such as heroin, morphine, opium, and cocaine) were left
unaltered; while marijuana users were let off the hook, the U.S. government and DEA insisted on
maintaining their historically draconian approach to drug use – instituting mandatory sentences
(or at the very least a minimum of 15 years in prison) for the possession or sale of controlled
substances other than marijuana (Gray, 2009).
In addition to the removal of punitive measures for marijuana possession, the use and
possession of pharmaceutical sedatives and stimulants during these same years were – despite
the waves of media coverage they received and the collective panic such stories prompted –
conveniently separated from the punitive realm of the drug enforcement. As Nicolas Rasmussen
(2008) has written in his book On Speed: The Many Lives of Amphetamine, the U.S. has had (and
continues to have) a long-lasting love affair with stimulants (drugs like methylphenidate
(Ritalin), amphetamine (Adderall), etc.). But this love-affair was primarily the province of the
white middle-class; indeed, in popular culture and the mainstream press, discussions about
American’s rising stimulant abuse often focused on characterizing the problem as belonging to a
few (racialized) figures: “Tired housewives” who, as Rasmusssen writes, “badgered family
doctors for extra prescriptions,” Beat Generation artists, and upper-class white professionals
(Rassmussen, 2008, p. 172). Perhaps even more than the first two figures, the figure of the
stimulant-using white professional has framed stimulant abuse as a practice belonging to a
culture of white privilege and (social and financial) capital. For example, an article published in
a 1966 issue of the Atlantic Monthly described rich white people’s consumption of stimulants as
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often taking place in the context of a “white-collar pill party” – a kind of Gatsby-esque revelry,
hosted in expensive penthouses with smartly-dressed attendees and “colorful pills [that] were
being politely passed around like canapés and discussed with all the elements of
connoisseurship.” (Jackson, 1966, n.p.). In the white-collar pill party, divulging in stimulants
was a practice in which participants enacted and performed their class position, a practice
through which one could accrue (rather than lose) social capital. The article’s author recalls his
own reaction to the white-collar pill party’s ritual use of narcotics and the time he spent
marveling at the “civilized manners of the participants despite their sleep deprivation, and at the
gossip about various doctors and pharmacists who made it easy for those in the know to get the
drugs” (Rassmussen, 2008, pp. 174).
The racialization of stimulant use – and its association with whiteness – is also apparent
in the advertisements that proliferated in medical journals and popular magazines throughout the
1950s and 1960s. In these years, stimulants entered the medical marketplace as substances
already imbued with positive associations of patriotism, discipline, and hard work – meanings
which cannot be separated from an earlier context of their use in World War II when they were
utilized as performance-enhancing technologies for fighter pilots suffering from fatigue, nausea
and the constant threat of losing consciousness while flying at high altitudes. For them,
stimulants proved to be a godsend – an instant solution to all their vulnerabilities and a substance
which, once consumed, had the ability to turn any worn-down soldier into a kind of Superman –
more energized, focused, and stronger than ever before, all the more able to honor and defend his
country. After the war, stimulants maintained their associations with patriotism, war, and the
plight of the “modern man” who – as one advertisement put it – was not himself sick, but was
instead “a victim of this era,” a man worn down by the turmoil of “war…atomic
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devastation…too much government…economic uncertainty” and “a complex pattern…. taking
their psychic toll” (California Medicine, 1952. In Rassmussen, 2008, n.p.). This advertisement is
telling for a number of reasons: First, because it relieves the narcotic user from any kind of
blame – he is not the problem, but the victim – a figure who in many ways resembles the
“consumed victim-addict” of today’s opioid epidemic. Similarly, the afflictions of the “modern
man” in this advertisement are not situated internally; they are rather manifestations of a larger
social system – “this era” which he cannot hope to escape but must instead learn to live with. As
previously discussed, this discourse which externalizes an individual’s pathology, repositioning
it as a “problem of living” in relation to some larger social, cultural, economic, or institutional ill,
is also central to the discourse that, in this context as well as in the opioid epidemic, associates
white people’s use of drugs within a framework of white victimhood – one which legitimizes and
calls up a need for their immediate rescue.
Another important chapter in the history of white drug use is characterized by the sudden
and widespread consumption of sedatives (i.e., Miltown and Valium) throughout the 1960s and
1970s. During these years, Valium was widely prescribed by physicians as a solution for a wide
variety of psychosomatic complaints raised by many of their (mostly white, female) patients
(Tone, 2009). The public discourse that eventually took shape around women’s use of sedatives
framed the use of these drugs, like in the case of marijuana and stimulants, as somehow exempt
from the world of criminal drug use. Instead, sedative use was framed instead as a solution to a
larger social problem – one which Betty Friedan has referred to as the “feminine mystique”
(1963/2013), a dangerous ideology internalized by many women who came to believe that “the
highest value and the only commitment for women is the fulfillment of their own femininity”
(91). Yet, as Friedan’s argument goes, by keeping women attached to gender roles that confined
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them within their own homes and limited their potential to the womanly acts of cooking,
cleaning, and care-taking, the “mystique” inevitably sowed discontent among a number of
unfulfilled housewives who, in large numbers, stood before their physicians and psychiatrists
complaining of a “mysterious feeling of emptiness,” a collective sentiment Friedan referred to as
“the problem that has no name” (167). Yet another problem of living – a sickness that, showing
no obvious physical symptoms, was – as Friedan describes – best “blotted out with a
tranquilizer” and “diagnosed as ‘housewife’s syndrome’” (167). Thus, the drug Valium became
one of the most famous and widely prescribed “treatments” for such a syndrome. As such, its
associations differed drastically from other drugs (such as heroin and cocaine); since its
consumption could not be easily framed as an inherently dangerous or criminal act. On the
contrary, and in large part by virtue of its association with white, middle-class suburban women,
Valium consumption was legible as a solution for those “problems of living” suffered by a
population of individuals attempting to get by and find fulfillment in their gendered roles within
a patriarchal social system.
Moreover, Valium not only offered a quick-fix for the mounting complaints of this ever-
growing patient population but also served as an easy solution for their family doctors - general
physicians who found themselves at a complete loss as to how to treat the symptoms of so many
suffering women. For at the time, the idea that doctors should also acknowledge and treat
invisible, “psycho-somatic” ailments was relatively unheard of. Yet, while knowledge of
psychosomatic medicine was lacking, an enormous supply of mood-altering pharmaceutical
compounds was not. Thus, the pharmaceutical industry – which was booming during these years
– supplied these confused physicians with drugs, their best bet for alleviating the loneliness,
boredom, and existential pain plaguing so many of their female patients. That sedatives such as
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Valium was understood as having endowed frustrated practitioners with a renewed ability to treat
their patients (and proved successful at alleviating their anxiety) would have made it difficult to
interpret their use as sign of depravity. On the contrary, they represented a godsend – a way of
managing the constant anxiety and incredible sadness of America’s lonely (white) housewives.
In the popular imagination, medications such as sedatives and stimulants, like their white
consumers, simply did not belong to the world of criminal justice and dangerous drugs.
Symbolically (and practically), they belonged to the world of whiteness and its associated
problems of living – problems which were deeply bound up within the exclusive ecosystems
defined by white privilege.
In more recent years, white drug use returned to pharmaceutical stimulants which, in the
1980s and 1990s, became re-positioned as the first-line treatment for the relatively new diagnosis
of attention-deficit disorder (ADD), a behavioral disorder defined mainly by attention
difficulties, a lack of impulse control, and a tendency toward hyperactivity (APA, 1980).
Throughout these decades, diagnoses of ADD surged – particularly among young boys whose
lackluster school performance and inability to sit still were reframed as symptomatic of a
psychiatric illness. Yet, luckily for their parents and teachers, this malady was one that could be
rather easily remedied with the administration of a single, amphetamine-based pill.
A brief analysis of pharmaceutical advertising for stimulants during the 1980s and 1990s
provides some key insight with regard to the ways in which these drugs were to function and be
sold as “technologies of whiteness,” that is, as technologies that would serve as resources for
improving the social standing of white people. The fact that stimulants have functioned as a
technology of whiteness is illustrated first by the complete absence of black individuals in
stimulant advertising. A review of 50 advertisements publicizing pharmaceutical stimulants
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between 1950 and 2010 reveals that none of the publications feature people of color as potential
stimulant consumers. The individuals who are featured in these ads consistently adhere to one of
three roles: (White) psychiatric patients (before de-institutionalization and the popularization of
out-patient therapy in the 1960s), tired (white) mothers, and “naughty (white) boys.” For
example, a 1988 print advertisement for the stimulant Ritalin, centers on a blonde-haired boy,
crouched over a desk with his pencil in hand. He appears calm and focused. The ad, however,
does not address the boy, who appears to be in top form (i.e., well-medicated) but presumably
addresses his mother or father, whom it implores to, “Let the ADD child leave his medicine at
home,” by implementing a schedule of once-a-day Ritalin dosing. This daily dosing schedule,
moreover, is hailed as a routine which promises to provide families with “greater convenience”
and a therapy (as well as a medicated child) that will be “easier to live with” (CIBA, 1988).
Twelve years later, another advertisement published in 2000 boasted a similar image and
message: The ad contains a young, white male child who, with a tranquil smile on face, holds a
soccer ball under one arm, and an exam graded A+ in the other – signs of the success that he has
earned as a result of taking his stimulant (Adderall XR) which, as the ad states, “improves
academic performance” (Shire, 2000). Above the boy’s smiling head, typed in bold white font,
the ad makes its greatest statement: That Adderall, as a first-line therapy in the management of
ADHD “reveal[s] his potential” (Shire, 2000). Indeed, it is the word “potential” which is worth
emphasizing here. This word appears frequently across stimulant advertisements, which are
consistently publicized as “performance enhancing” drugs that bring out the “potential” of
young, white, middle-class boys struggling to keep up in school.
Rescuing the potential of white boys’ schooling is a discourse that also must be
understood as coherent within a larger cultural and political context. This context is particularly
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relevant as a moment in which educational reforms were transforming school environments
around the country. Several of these reforms, moreover, were advanced due to the combined
efforts of ADD parents, patient groups, pharmaceutical lobbyists, and the legislators on their
bankroll. Specifically worth noting are the 1997 Individuals with Disabilities Act and the 2001
act, No Child Left Behind. Both these policies took measures to tether school financing to
students’ performance on standardized tests, and thus legislated an increased prioritization and
renewed emphasis on the value of academic improvement. Students’ test scores moreover, would
also play a larger role in dictating the amount of funding that schools would receive (more
money for higher-scoring schools) as well as the job security and salaries of its administration
and faculty. It is telling also, that in the four years following NCLB’s introduction, ADHD
diagnoses jumped 22% (Fulton et al., 2009). These numbers, as I have previously written,
suggest that stimulants were advertised (and often used) as a means of both securing the financial
futures of high-performing public schools and their faculties and the educational advancement of
their white, male students (Sherman, 2015). In this context, it can be argued that stimulants were
advertised, prescribed, and functioned within a system that, drawing from George Lipsitz, is
defined by a “possessive investment in whiteness,” where “public policy and private prejudice
work together” to maintain the “racialized hierarchies of our society” (2006, vii). By focusing on
the academic achievement of white students and the financial success of educational institutions
(namely those high-performing schools which were predominantly occupied by white, middle
and upper-class students), these drugs might also be thought of in Netherland and Hansen’s
(2017) terms (slightly paraphrased) as “white stimulants” – as “drugs which actively participated
in racialized investments – investments which had little to say or do with people of color.” As
such, these drugs became a useful technology – not only for treating certain illnesses and
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symptoms, but for investing in whiteness, for alleviating the problems seen as decreasing the
quality of life for white Americans – the frustration, boredom, and general unhappiness of white
suburban housewives, familial conflict within nuclear households, and the declining educational
performance of white suburban children.
In many ways, the relationship between drugs and investments in whiteness has been
maintained and expanded in today’s opioid epidemic, where the widespread concern about
addiction and overdose is framed in relation to a broader narrative centered on the cultural,
political, and economic de-valuation of whiteness and the loss of white potential among white
citizens. Yet, as Lipsitz has argued and as I will show, the possessive investment in whiteness in
the opioid epidemic is not only reflective of the racial biases and private prejudices that color our
cultural landscape. It is also a tangible investment – one that materializes as the symbols, values,
assumptions, and feelings that drive it are channeled into social institutions, policies, and
technologies that maintain or widen the gap between the resources available to white people and
those available to people of color. The gap that is held open by the possessive investment in
whiteness is amplified in the world of addiction treatment and rehabilitation today.
Rehabilitation and/as a Technology of Whiteness
21

21
Another institution that contributes to the reproduction of white victimhood in the
epidemic involves the recommendation, made by President Trump’s “Opioid Commission,” to
institute nationwide problem-solving “drug courts” that would help place drug users into
treatment rather than sending them into the prison system. Although drug courts will not be
examined in detail in this paper, it is important to note that they form another aspect of the public
health approach to drug use, which has become increasingly popular in the opioid epidemic. The
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The role of whiteness in drug use and drug enforcement is central in the opioid epidemic,
where subjectification plays out not only in images (in the figure of the addicted who is a
“consumed” and sympathetic victim) but also in the concrete policies, laws, and institutions that
have either been created or expanded in direct response to escalating rates of whites dying from
opioid overdoses. Within this context, the addict who is “consumed” is legitimated and
reproduced through the application of recovery-based institutions that function as “technologies
of whiteness”; these technologies, which contribute to the intelligibility of the opioid epidemic as
a problem of exclusively white victimhood (which is also largely working/middle-class,
suburban and rural), also frame the development and use of addiction therapies and rehabilitation
technologies as means of salvaging white potential, an objective which – put into practice –
exacerbates the racialized inequalities in addiction treatment and recovery.
Addiction Neuroscience
Race – and specifically, whiteness – is encoded into the theories that undergird the
contemporary practice of addiction treatment. Since the 1980s, theories based in neuroscience

more frequent use of problem-solving courts or drug-treatment-courts, a term which The
Economist referred to as “Oxy-Courting” in a recent article (October 21-27, 2017), is posed as a
more productive alternative to the punitive approach of sentencing drug offenders and sending
them to prison. It is important to note, however, that the demographics of court attendees are
significantly skewed toward white drug offenders. As of 2016, the drug court population is 67%
White, 17% African American, and only 10% Hispanic (NDCI, 2016). As such, these courts
contribute, as the rest of the paper details, to the “technologies of whiteness” that contribute to
the intelligibility and material reality of the opioid epidemic.
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have come to constitute the dominant approach to studying addiction and to developing
treatments for it (Campbell, 2007; Helmuth, 2001; Volkow et al., 2016; Vrecko, 2016). This
neuroscientific approach (as described earlier in the chapter) understands addiction (and disease
more generally) not as related to childhood abuse, psychiatric disease, or moral weakness, but as
a manifestation of a dysfunction in the brain’s circuitry. In this paradigm, as many scholars have
pointed out (e.g., Campbell, 2010; Epstein, 2007; Netherland & Hansen, 2017; Reardon &
TallBear, 2012; Washington, 2006) the topics of race, history ethnicity, class, and identity are
excluded; instead, addiction neuroscience presents itself as a neutral, universal model – one that
is, by virtue of its biological underpinnings, inherently egalitarian. In theory, then, such a
“neutral” approach to addiction could seem like a positive development; indeed, renowned
neuroscientist Nora Volkow, who became director of NIDA in 2003, has championed the
neuroscientific approach to addiction science as a necessary step toward demolishing the stigma
and racial injustice associated with the concept (e.g., Volkow & Li, 2004; NIH, 2007). As a
powerful producer of “truths,” scientific discourse tying addiction to neural dysfunction rather
than moral weakness has the potential to contribute to re-configuring the problematic power
relations that have long circulated around the twinned issues of drug use and addiction. Yet as
Vrecko (2010) has argued, the production of truths about addiction, which were ushered in vis-à-
vis neuroscientific research, were truths bound up with the contexts of laboratory and clinical
research in which they were produced. The logics that circulate within these contexts, as Steve
Epstein (2007) and Jill Fisher (2009) have written, are always-already racialized logics – whose
standard subject is white and male. Moreover, in the context of the laboratory, addiction research
was conducted mainly through the use of brain imaging technologies which are unmarked by
race (Netherland and Hansen, 2017; Vrecko, 2010; Campbell, 2010). Their use, as Vrecko
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explains, can be understood as working (whether consciously or not) to “expunge the racial
identity of the addict,” a removal which has the effect of “leaving a white…backdrop” (2010, 5).
In brain imaging research, the lack of a racial signifier implicitly codes addiction not just as a
chronic brain disease (CBD) but as a chronic brain disease that is de-articulated from any
environmental factors which may contribute to it as well as from “the association with Black and
Latino people inherent in a social, moral, or criminal framing of addiction” (Vrecko, 2010, p. 5;
Campbell, 2010; Dumit, 2004; Netherland and Hansen, 2017). In the scientific discussion of
addiction neuroscience, the object-of-study is rendered neutral, racially unmarked, a
phenomenon which then, by default, indexes white subjects.
These white subjects – as they are rendered through the production of truth and
knowledge in addiction neuroscience – simply cannot be seen as pathological consumers. They
are victims of a chronic brain disease, one which, though it may manifest through behaviors
associated with pathological consumption does not implicate the addict herself. The truth of
addiction conceptualized as a chronic brain disease aligns neatly with the production of
consumed addict-victims, which are positioned within the realm of “pure” science” and a clinical
context where goal of treatment is not a disciplinary one (which would emphasize forced
detoxification, constant surveillance, and early onset withdrawal – as has been the case in the
past [Alexander, 2010/2012; Lipsitz, 2006; Campbell, 2000; Bourgois & Schonberg, 2008]), but
one which emphasizes the need to rescue white opioid addicts using “gentler systems” of
treatment, support, and empathy. Thus, the subject of the white addict-victim, which is imbued in
the theories and research methods of addiction neuroscience, is also positioned within the related
institutional arrangements and current practices that constitute this “gentle approach” to fighting
addiction.
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The technologies that constitute such compassionate approaches to addiction treatment
and recovery are namely medication-assisted treatments (MATs). MATs emerged from research
funded by NIDA’s decades-long search to develop the perfect “safe analgesic” for pain patients
(Campbell & Lovell, 2012). Today, MATs are, in essence, divided into two categories: The first,
which is newer and has fewer side effects is buprenorphine (brand name Suboxone®), while the
second is its older and more volatile cousin, methadone. The history of methadone can be traced
back to its use as a pain reliever during World War II. In its development stage, methadone was
tested in a series clinical trials – most famously those published by Dole and Nyswander (1967).
According to the researchers, their studies showed that methadone would be useful as a
medication with extremely beneficial social effects due to its ability to “block the normal
reactions of addicts to heroin and permit them to live as normal citizens in the community” (p.
304). But despite these conclusions, the then-Committee on Problems of Drug Dependence
(CPDD) and its alliance with several other organizations that made up the 1960s drug control
apparatus (a network of different federal bureaus and departments which eventually, in 1973,
consolidated into the Drug Enforcement Agency [DEA]) remained skeptical of this particular
approach to addiction treatment – one they saw as essentially substituting one addictive drug
with another with no guarantee of eliminating the patient’s dependence. With this opinion in
mind, the key decision-makers within this drug control network refused to grant methadone an
official treatment status, referring to it instead as “a research undertaking” and one “that could
not be considered an established treatment” (Eddy, 1973, p. 112). This decision, combined with
the FDA’s hesitance to approve the drug for any use other than as an “investigational” drug, also
prevented its widespread use in private practice.
The Problem with Methadone
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Part of the problem of methadone was perhaps the fact that it was framed as a social
medication with social (rather than biochemical) effects and was therefore always-already
imbued with social meanings, namely along the lines of race and class. The social meanings
associated with methadone – meanings which no doubt made the drug problematic for the drug
control apparatus even in the early days of its testing – cannot be separated from the fact that the
drug was tested and utilized among certain social groups. Groups who were often socially and
economically marginalized — namely inner-city, poor African American populations (mainly
living in Harlem) (Agar, 2006; Netherland and Hansen, 2017)
22
. Thus, even while the clinical
trials for methadone were somewhat successful and by 1971 Dole and Nyswander’s methadone
treatment program was called upon to expand to serve 25,000 addicts in the New York area, its
success was short lived – marred by the stigma of the particular society upon whom its effects
rested (Dole, 1971). This stigma was further augmented by a series of news reports that surfaced
in the aftermath of Dole and Nyswander’s study and which pointed to other studies showing that
methadone patients were doing less to integrate themselves back into society than they were to
transform methadone from a medication into a black-market drug by hording and selling their
medications (Markham, 1972). So just a few short years after Dole and Nyswander’s essential
study was published, the value of their work was diminished: What had initially seemed like an

22
Though John L. Jackson has pointed out in his ethnography, Harlemworld: Race and
Class in Contemporary Black America (2001), that drug use – and residents feelings towards it –
forms a key part of the neighborhood’s organization – “a kind of folk analysis of socioeconomic
differences [that] functions as one of the nonracial criteria used to sift through the social landscape
and separate legitimate citizenship from an illegitimate kind” (pp. 37-38).
217
innovative addiction treatment and public health intervention, something close to NIDA’s long-
sought-after “safe analgesic,” became all-too-legible as yet another product in the inner-city
black market. Except this particular product had the unique characteristic, which possibly made
it more valuable and sought after, of being a laboratory-developed, clinically-tested, government-
approved product – “a desirable product in its own right, not just a temporary substitute to hold
off the sickness” (Agar, 2006, p. 61). As drug ethnographer Michael Agar has chronicled in his
studies of heroin use in the 1960s, on the street “methadone was a hot new commodity” – a
cheap, safe, and pure form of heroin that any user could get his hands on just by visiting the local
clinic (p. 62). It was, in a sense, a gift to struggling users, one developed and given to them
straight from the hands of Uncle Sam and his drug control machine. As Agar writes, “Drug
policy, thanks to the emperor’s powers to barricade himself against any contradictory
information, just didn’t see what in retrospect was obvious. Drug policy said methadone was a
way to eliminate the problem of narcotics addiction. From the street point of view, in the early
1970s, methadone was a way to continue it.” (Agar, 2006, p. 62).
When reports of methadone abuse surfaced, then President Richard Nixon quickly
declared the drug a “primary weapon” – one that the government and its citizens should mobilize
to fight against as part of their efforts to stem the so-called “War on Drugs.” Now an enemy of
the state, methadone and the clinics that provided it were placed under rigorous federal
surveillance and were subject to strict regulations. The clinics that were allowed to remain in
practice, moreover, were restricted to predominantly poor, black and brown urban
neighborhoods. Since then, methadone has not been able to rid itself of the race-based and
criminalized stigma that became associated with it during the Nixon years. As such, it never
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became a mainstream medical treatment – despite scientific evidence of its effectiveness.
23
To
this day, methadone is still available but for the most part can only be found in urban clinics with
intense DEA oversight. Unfortunately (and unfairly) methadone has remained associated with
urban crime and drug users whose place has historically been within the criminal justice system
(Courtwright, 2001; Hansen & Roberts, 2012; Netherland & Hansen, 2017).
The Buprenorphine Solution
That methadone is a MAT associated with crime, poverty, and federal surveillance makes
it markedly distinct from its successor, the partial opioid-antagonist buprenorphine.
Buprenorphine, which was initially developed in 1966, but did not begin to sell until some forty
years later, when it gained traction in the pharmaceutical market through its branding as part of a
generation of new “smart opioids” – as a drug that “latches onto your brain’s receptors with a
stronger bond than most full opioid agonists” (Suboxone.com, 2018). This “smart drug,” brand-
named Suboxone®, is a partial opioid-antagonist developed by Reckitt Benckiser
Pharmaceuticals Inc., a company located in Richmond, Virginia. Suboxone® contains a

23
A series of maps published in a report by the American Society of Addiction Medicine
in 2013 shows the geographic discrepancy of methadone and buprenorphine access across the
country. The maps, which can be found starting on p. 23 of the report, in at least 17 states (including
those with the highest rates of opioid abuse (e.g., Indiana, West Virginia, Kentucky) offered no
Medicaid support for methadone assisted addiction treatment. On the contrary, the report indicated
that “every state Medicaid agency covers buprenorphine/naloxone, either in the film form of the
branded Suboxone® formulation or in the generic sublingual tablet formulation providing
buprenorphine and naloxone, or both…” (ASAM, 2013).

219
combination of buprenorphine and naloxone – two compounds which together are said to
produce an effect that “reduces subjective opioid cravings” (Suboxone.com, 2018).
Buprenorphine, unlike methadone, is not a public good. It is, instead, a privately
manufactured, branded, and distributed product. The drug’s manufacturer, in attempting to sell
their product to a wider (and hopefully wealthier) clientele, engaged in a variety of efforts to
distinguish their product from methadone. Namely, instead of framing the drug as a medication
with social effects (Dole and Nyswander had done decades earlier), Suboxone® was framed in
the popular terms of precision medicine as a “smart drug” – one that would would selectively, as
FDA Commissioner Scott Gottleib announced, to “stabilize brain chemistry” (FDA, 2017b).
Following Trump’s declaration of the opioid epidemic as the first “national public health
emergency,” (2017), FDA commissioner Scott Gottleib issued a testimony in front of House of
Representatives that referred to medication-assisted-treatment as a real solution for the opioid
epidemic. Furthermore, Gottlieb promised his agency would make it their primary effort to
expand the use of medication-assisted-treatments – such as methadone, buprenorphine, and
naloxone — for opioid addiction (October 25, 2017). Yet, what is also notable in Gottlieb’s
testimony is his admission that while MATs are backed by plenty of scientific evidence that
attests to their effectiveness, they are “not for everyone” (Lopez, 2017). Gottleib’s statement
begs the question that if MATs are “not for everyone,” who, exactly are they for? While the FDA
commissioner’s testimony alone does little to provide us with answers to this question, the
broader policy discussions around the use of buprenorphine in addiction treatment provide a
number of clues – clues that suggest which kinds of addicted subjects deserve access to this drug
and which do not.
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In particular, the discussions that formed in the context of the government’s development
of the Drug Addiction Treatment Act of 2000 (DATA 2000) envision buprenorphine patients in
clearly racialized terms – which have since been institutionalized in drug policy and law:
Throughout the DATA-related discussions addicted subjects were differentiated by terms such as
“hard-core user,” “urban,” “suburban,” and “new user,” – terms which clearly carry racial
connotations. But they also promoted the idea of a binary distinction that characterized opioid
addicts as either pathological consumers or consumed victims in need of medical attention,
sympathy, and political representation. As these policies make clear, these two addicted subjects
I have discussed throughout this and the previous chapter do not only serve as convenient terms
but also demonstrate that how the discursive process of subjectification gets channeled through
legislation/policy that transforms it into something tangible – something that impacts the way in
which addiction medicine is practiced, how it prioritizes the care of certain kinds of people over
others and, ultimately, how it can effectively reconstruct or dismantle people’s lives.
In the Congressional Record discussion around the use of MATs, one Congress member
offered the following comment: “Narcotic addiction is spreading in suburban areas. The current
system, which trends to concentrated in urban areas, is a poor fit for the suburban spread of
narcotic addiction…an increase in the number of younger Americans experimenting with and
becoming addicted to heroin…Treatment for adolescents should be accessible and graduated to
the level of dependence exhibited in the patient. Buprenorphine products will likely be the initial
medications for most opioid-dependent adolescents.” (Congressional Record, 1999b, p.
S1092). His statement is significant – not only for the ways in which it reinforces the racial
distinctions between methadone and buprenorphine, but also because it makes an argument
(using the structural realities of urban geography as its support) that the “current system” of
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urban methadone clinics (a system which is apparently predetermined and fixed) simply
precludes those innocent subjects who are merely “experimenting” with drugs from occupying
the same treatment spaces as those whose use is “concentrated in urban areas.” Therefore, it
would seem, a new system must be put in place that caters to this new population of opioid users.
In this system, buprenorphine (rather than methadone) is the better choice because it is (perhaps
because of its lack of racial stigma historically associated with methadone) uniquely available to
users who are “not just…heroin addicts” but rather “citizens who would not normally be
associated with the term addiction” (Congressional Record, 2000, p. S9113). Though race is not
an explicit part of these Congressional deliberations, it is undoubtedly embedded in the rationale
guiding the decision – implemented in the passing of DATA 2000 – that methadone would not
be an “appropriate” drug for privileged suburban youth who were (as kids are known to do)
“experimenting” with drugs.
Yet, it is not only the discourse around buprenorphine use that informs the drug’s
function as a technology of whiteness. The context of its use is an equally important factor, one
which shows how buprenorphine access has been limited in ways that privilege its use among
white, affluent patients: Suboxone® is a private clinical technology, reserved for the use by
certified specialists working in private practices, and those who possess the insurance and
financial resources to routinely visit such practices.
24
It must also be added that to become a

24
It should be noted that this is not the case in other countries. As Lovell (2006) has
pointed out in her analysis of buprenorphine in France, where it was adopted for general
physicians’ use long before it entered the U.S. market, she shows how the drug was billed not as
a private treatment, but as a public health intervention, mainly for the purposing of decreasing
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Suboxone® prescriber requires a physician to undergo a rather rigorous certification process.
The certification process, as outlined by the Drug Addiction Treatment Act of 200 (DATA
2000), mandates that physicians complete an eight-hour long training course, at the end of which
they receive a waiver that gives them the legal right to prescribe and dispense buprenorphine.
Additionally, there are a number of other courses – continuing medical education courses
supported by SAMHSA – that can aid physicians in the process of qualifying to prescribe
buprenorphine in their office settings. These courses, however, require physicians to take time to
register for them, and may also require attendees to pay a substantial fee (SAMHSA, 2016b).
Having gone through these various processes, the newly-certified aspiring prescriber will then
become eligible to receive a special certificate allowing him or her to prescribe the drug – but to
a limited number of patients.
The differences between methadone and buprenorphine are not only attributable to the
contexts of their use but also to the intense efforts that have been made by politicians and
lobbyists to disassociate the latter from the negative connotations of the former. One such
attempt to differentiate buprenorphine from the complicated, criminal associations of its
predecessor is illustrated in the mobilization of drug lobbyists and legislators to get
buprenorphine placed in a different (and less rigorously regulated and surveilled) category of
drug scheduling (Hansen & Roberts, 2012). As Hansen and Roberts write, “To entice the

HIV transmission rates among low-income immigrant heroin injectors. Because prescribing
buprenorphine required no certification process for physicians, the drug was widely used in
general practice and was enormously successful in lowering the rates of opiate overdose and
death in the 7 years following its approval.
223
company into the addiction treatment market, NIDA awarded $23 million in grants for clinical
trials of buprenorphine for opiate dependence and collaborated with the manufacturer and key
legislators to pass the Drug Abuse Treatment Act 2000 (DATA 2000)…This act permitted
private, office-based physicians to prescribe opioid drugs that are Schedule III-that, is, rated by
the DEA as at low to moderate risk of creating dependence-for treatment of opioid dependence”
(2012, p. 95). Thus, one argument in the case for re-scheduling buprenorphine relied on
distinguishing its target population from that of methadone and on proving that buprenorphine
users would be inherently more trustworthy and less likely to abuse the drug. Their
trustworthiness was related to the fact that they would be predominantly “white, middle-class
users” – individuals who, by virtue of their socio-economic positioning, who would not call up a
need for the tightly regulated treatment programs that methadone users (namely poor, addicted
people of color) seemed to require. Since buprenorphine users would be financial stable and
socially responsible, a more relaxed approach to monitoring and regulating their consumption
would, lobbyists argued, make sense. Testifying in front of Congress in favor of DATA 2000,
Alan Leshner, then-Director of NIDA, confirmed this argument, which he carefully coded by
saying that, “The current system [of methadone treatment], which tends to concentrate in urban
[black] areas, is a poor fit for the suburban [white] spread of narcotic addiction (Netherland,
2010, p. 61, brackets added). Indeed, the racialized discourse that was used to distinguish
methadone (and its users) from buprenorphine (and its users) seems to have been successfully
deployed, as it is quite clearly reflected the demographics of methadone and buprenorphine-
using populations: Of methadone users, less than half are white and only 17% are employed
(Stanton et al., 2006; Hansen et al., 2013). In stark contrast, buprenorphine patients in the U.S.
are 91% white, and more than 50% are college educated and employed.
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As rehabilitation technologies which cater to two distinct populations, MATs participate
in the subjectification process that divides opioid addicts into pathological and non-pathological
consumers. Methadone patients, when envisioned as inherently untrustworthy and in need of
tight supervision and strict federal regulation, are interpellated as the pathological consumer for
whom newer, gentler treatment options are simply “not appropriate.” They are, moreover,
contrasted with buprenorphine patients – those inherently trustworthy, upstanding individuals
who are not envisioned as pathological consumers but rather resemble the “consumed” addict-
victim, a subject deserving of compassion rather than criminalization and who is positioned as an
ideal candidate for those less strictly regulated and more advanced forms of opioid MATs.
Divided up in this way, MATs function not only as rehabilitation technologies but also as
“technologies of whiteness,” – interventions whose selective application is explicitly geared
toward the rehabilitation of white opioid users, while limiting access to these new-and-improved
treatments for people of color.
Technologies of Race and Class
The uneven application of buprenorphine in the rehabilitation of white opioid users also
aligns with a mounting sentiment – in politics as well as in popular culture – that today, more
than ever, what these particular addicts really need is not a firm slap on the wrist but a collective
display of empathy and movement toward de-stigmatization – a movement that is grounded as
much in the development of pharmaceutically-based treatments as it is in familial and
community support. These new pharmaceutical technologies are not in and of themselves
solutions to the crisis but they do provide a convenient escape route, one which is primarily
reserved for those addicted individuals who are seen as having future potential and whose escape
from the clutches of drug addiction is also articulated as an escape from the corrupt and
225
irresponsible forces within the modern medical-industrial complex – a formidable monolith
constituted by the interactions among rash prescribers, timeworn pharmacists, bureaucratic
insurance companies, complacent regulators, impotent DEA agents, indomitable lobbyists
25
,
money-mongering pill mills, ravenous companies, and the time-bound protocols that create a
ceaseless cycle of 5-minute follow-ups, dosage increases and refills.
And yet, even among white opioid users, not all are seen as having the same kind of
future potential. Likewise, it would be misleading to assume that MATs are distributed evenly
among them for in fact, they are not. While it is certainly the case that these technologies do, by
and large, prioritize white opioid patients and, in doing so, function as racialized technologies,
they also serve a double function as technologies of class – drugs which are positioned in
contexts that make them more accessible to white patients with socio-economic privilege (which
not all white opioid users have). Indeed, populations of white opioid users who live in poor, rural
regions (the same places where the opioid epidemic began, and where it continues to exert its
heaviest death toll) – are also systematically deprived of these resources. As the data on MAT
availability shows, in many of the states that constitute the Appalachian region there exists a
strong, negative correlation between opioid-related death rates and the availability of MATs.
West Virginia, for example, which leads the rest of the nation in terms of its opioid death rate
(with 52 deaths per 100,000 residents) and saw 818 of its residents die from opioid overdoses in

25
According to the Center for Responsive Politics, in 2017 alone, the trade group,
Pharmaceutical Research and Manufacturers of America, (aka PhRMA) spent nearly $26 million
on lobbying efforts at the federal level, while hiring 169 federal lobbyists to work on its behalf
(Center for Responsive Politics, 2017)
226
2016, contains only seven addiction treatment facilities that offer comprehensive
26
medication-
assisted treatment to its two million residents. (CDC, 2017a; 2017b; SAMSHA, 2018). Similarly,
the state of Ohio, which, in 2016, had the second highest rate of deaths due to opioid overdoses
(39 deaths per 100,000 residents), lost 4,365 of its residents to the opioid epidemic and currently
has just nine of comprehensive MAT facilities for its nearly 12 million residents (Ohio
Department of Health, 2017; CDC, 2017a; 2017b; SAMSHA, 2018). Two other states in that
region, Kentucky and Tennessee, currently have no such facilities (Jones et al., 2018). And of the
15 states with the highest rates of opioid deaths in 2015, only two currently have more than 10
facilities that offer comprehensive MAT; nine of those 15 states have fewer than five, and an
additional four have absolutely none (SAMSHA, 2018). These data depict a contradictory reality
– one in which growing public concern related to the medical treatment of opioid addicts belies
the fact that many – if not most – of them are still being denied access to the resources necessary
for their recovery.
Conclusion: The Crisis Next Door
On October 26, 2017, President Trump assembled the press in order to make a (long-
awaited) official speech in which he declared the opioid epidemic a national public health
emergency. The majority of Trump’s speech, rather than centering on the rising death toll and
crisis of undertreated chronic pain that has accompanied the moral panic around opioid abuse in
this country, was focused on his relationship with his brother, Fred, a “great guy, best looking
guy, best personality…but he had a problem” – an alcohol addiction which led to his death in

26
By “comprehensive,” I am referring to programs that offer all three available forms of
MAT: Methadone, buprenorphine, and naloxone and accept Medicaid.
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1981 (Merica, 2017). As the President explained, his anecdote of Fred’s problem should serve as
a signal to other families struggling with drug abuse. Moreover, Fred’s memory should serve as a
basis for new efforts by the government to increase oversight on the medical establishment and
provide funding for FDA-supported medical-assisted-treatments. Trump also added that he
would have a “serious talk” with China’s President Xi regarding the shipment of fentanyl into
the United States. While the present’s speech certainly reinforces the idea that it is the medical-
industrial establishment, and not the consumed-victims, who are to blame for the current crisis,
his speech leaves no question as to who those victims are: Potential businessmen like his brother
Fred, the population of white voters and “great people” of West Virginia to whom he gave his
speech, the “beautiful babies” of white working-class America, “young people,” and – above all
else - “our fellow citizens.” As the President himself declared, the top priority for public and
private stakeholders attempting to put a stop to this “national shame” and “public tragedy” is
simple: Rescue its subjects by reigning in the reckless medical-industrial establishment. And in
doing so, we just may rescue its victims – “a generation of lost potential and opportunity”
(October 26, 2017).
Several months following the President’s speech, the White House launched a website to
mark the start of a “large scale” ad campaign aimed at spreading awareness about the epidemic –
which it frames as “the crisis next door.” The website, crisisnextdoor.gov, provides a platform
for crowdsourcing the stories (uploaded to the website in the form of 2-minute video clips) of
“Americans across the country [who] are feeling the weight of the crisis next door.” Though this
initial call is broadly framed for all Americans, a block text of text situated below narrows the
search criteria to individuals whose stories are hopeful ones – stories about “how you overcame
addiction, volunteered at a recovery center, or worked as a family to help a loved one get on the
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path to recovery.” Those who meet this criterion may then click on a yellow button labeled
“share my story,” fill out an identification form and either record or upload from their computer
a 2-minute video which, after it is reviewed, may be posted to the site.
The Crisis Next Door is relevant for a number of reasons: First, it provides an illustrative
example of the ways in which drug use (and addiction more generally) is being reframed in
representations of the opioid epidemic as something inherently familiar; it is not a criminal
scourge, but a crisis that is both immediate and relevant to all. Though democratic in theory, the
image painted of the crisis on this website is done through the use of the quite specific figures of
the “all-state football captain” and “stay-at-home mother” – which are used to stand in for the
“any American” who is seen as vulnerable to the dangers of opioid addiction. Second, the
website also frames opioid addiction within a nationalist discourse, one which is articulated to a
specific set of “American” values – as is illustrated in the site’s prioritization of stories that
emphasize hope, charity, recovery, and family. These are values can be seen as constituting the
main thrust of the “American Dream,” which “the opioid crisis has replaced…with the nightmare
of addiction.” Taken together, the tropes of familiarity and the nation provide a strong discursive
basis for a new approach to drug use and addiction, which the site also emphasizes: In a brief
video statement at the top of the site’s homepage, President Trump characterizes this new
approach as one defined by compassion, which seeks, above all else, to “dismantle the stigma of
addiction.”
Both The Crisis Next Door and Trump’s speech illustrate the power of discourse in the
opioid epidemic, where addiction is no longer something that must be pushed under the rug. On
the contrary, we are incited to speak about it. Though of course, we are directed to do so in
specific (and strategic) ways. One way, as both this chapter and the one preceding it have tried to
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show, is through subjectification – through the construction and representation of those “new
faces” that make the crisis real and render it intelligible as a particular kind of problem that
warrants particular kinds of solutions, for particular kinds of persons. While not explicit in his
speeches, the concern that President Trump has expressed with regard to the opioid addict’s “lost
potential” is conditioned and delimited by framing of epidemic as a problem limited to certain
segments of white America. Framed in this way, the expressed need to recover lost potential is
more accurately understood as the need to recover white potential. This concern, which frames
the discourse of the opioid epidemic, is consistent with and woven into the larger cultural and
political landscape, where the endangerment of America’s “white working class” has become a
prominent theme in U.S. politics and popular culture, more generally. These concerns, which
attribute the plight of the working class (perhaps most notably illustrated by surging “deaths of
despair” within this population) to external (social and economic) conditions that seem to close
off future opportunities for success and happiness, bolster the construction of opioid addicts not
as the pathological consumers of history (those who deserve to be arrested and incarcerated) but
as hapless victims who have been “consumed” by forces outside their control. The opioid addicts
we see on the news are therefore, by and large, not criminals but victims who deserve our
empathy, support, and the best forms of evidence-based medication-assisted treatment that the
good tax-paying citizens of our great nation can offer them.
The figure of the consumed addict-victim is further inhabited by the assumption that what
opioid addiction is, is no longer about personal choice alone. That is, the idea in this assumption
is that to “just say no” is not an effective tactic for those who have already been consumed – for
their problem doesn’t have as much to do with their own choices as it does with the ways they
230
have been impacted by a larger system — one that might be characterized using Natasha Schull’s
phrase as a system of “addiction-by-design” (Schüll, 2014).
Thus, the subjectification of opioid addicts in the ongoing epidemic leads one to the
conclusion that the process of “making up persons,” in this context, does not hinge on a
particular scientific category, nor a personal trait, nor any other kind of aberrant behavior. Above
all else, it is about the relationship of the addict to the broader political economy of addiction and
to the medical-industrial establishment in which she has found herself embedded and entrapped,
where her addiction is not defined by her behavior, but by the tragedy of her “wasted potential.”
It becomes our obligation then – as responsible citizens – to do what we can to recover and
rescue opioid addicts – who have been framed through their “familiarity” to us. They are not
strangers living in the inner-city ghettos but rather our own children, family members, neighbors,
teachers, friends – good, hard-working Americans (those “all-state football captains” and “stay-
at-home mothers”) whose deaths pose a particularly urgent threat to the integrity of the nation as
a whole. These intertwined discourses of familiarity and nationalism, which see the opioid
epidemic as a scourge that, in Trump’s words, “has replaced the American Dream with the
nightmare of addiction,” were not so readily available in the past, especially when drug crises
were seen as affecting black communities. It is not surprising that those communities, which
were often portrayed as deviant, problematic, or in some way positioned outside of “the real
America,” were not as readily incorporated into the discourse of familiarity, empathy, de-
stigmatization, and collective action that is now used to characterize the current crisis.
So too, the discourse of “potential” has been absent from discussions of these unfamiliar
addicts of color (perhaps because they were never seen as having (cultural, social, economic)
potential in the first place. Undoubtedly, this has changed in the government’s response to the
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opioid epidemic – a phenomenon which, under closer examination, we can see as an astute
illustration of the “possessive investment in whiteness” (Lipsitz, 2006). And this investment is
consistently enriched and expanded by the discourses of subjectification that correspond to and
are channeled through technologies of whiteness – those decisive drugs, laws, policies, and
institutions that condition and delimit the kinds of futures that will be made possible for different
kinds of addicts.
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Chapter 7: Conclusion

In early 2018, TIME magazine published a photojournalism series on the opioid
epidemic. “The Opioid Diaries” requires visitors to scroll down through a series of black-and-
white photographs, each of which is accompanied by captions and quotes. In the first image,
which is situated at the very top of the page, a man and a woman are photographed crouching in
the back of a van, which the caption says is parked in San Francisco. Inside it, the couple balance
on their shins as they aim needles full of clear liquid at the veins they’ve found in each other’s
arms. Further down the page is another vehicle, a pick-up truck with a man named Chad
reclining in the driver’s seat. His body is lax and, although his eyes are open, his head is cocked
backward – so far that it nearly escapes the frame. He overdosed shortly before the picture was
taken and now lies in a state of semi-consciousness as a trio of paramedics lean through the
truck’s open door and try to revive him. Below Chad’s image is a photograph of two people – a
elderly woman and a young man – embracing inside a funeral parlor in New Hampshire. The
woman’s 24-year old granddaughter, Michaela, can be seen in the background; lying colorless
and quiet inside her open casket. Scrolling down, a quote appears in large block letters on the
screen; they belong to an Ohio Sheriff who, commenting on what he’s seen of the opioid
epidemic in his own state, states simply: “It’s nonstop. It’s every day.”
Continuing down the page, a woman in Boston squats on a mound of dirty snow.
Whether because of overuse or the dropping temperature, she is struggling to find a vein. Below
her, a homeless grandmother injects heroin next to a shopping cart full of her belongings. She is
followed by a series of police officers. Each is accompanied by an overdose victims, whose limp
bodies were found on the side of the road in New Mexico, or stretched out on a bed in Ohio, or
crumpled in a heap on the kitchen floor. With every movement of the mouse, more and more
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photos appear on the screen, more and more people, though most of them are bodies – depictions
of death found in every corner of the nation, from Massachusetts and New Hampshire to Florida,
Ohio, Kentucky, and New Mexico. But finally, at the bottom of the page is an image of life – a
tiny baby, born just seconds before the photo was a taken. On first glance, the photograph is a
hopeful one, though the quote accompanying it tells a different story, for this little girl is but one
of the many children who, from the moment they enter the world, are destined “to be born
addicted.” She, and the others like her, are not symbols of hope, nor of life, but of a bleak and
provisional end-point: The first book in “The Opioid Diaries” may be full, but another one sits
on the shelf beside it – a stack of blank pages waiting to be filled by the next generation of
corpses-in-waiting and the stories they’ll tell about a future where nothing is getting any better.
The story offered to us in the “The Opioid Diaries” not only describes a desperate reality
located in the present but also lays out a nightmarish trajectory of the future – a story set in
motion by the en masse descent of so many people into the labyrinth of addiction. This dark
space which, as all of the images described above suggest, is occupied by ever-expanding
networks of drugs, death and, perhaps most tellingly, of pain. The networks of pain that
encompass opioid users, their families, as well as social workers, counselors, and police officers,
among others, have been growing exponentially over the past twenty years and as of yet show no
signs of stagnating – at least not anytime soon. Borrowing a term used in addiction parlance, the
growth of these networks and the ways in which their growth is depicted in popular culture
suggest that the opioid epidemic has not yet pushed up against its own “rock bottom.” In this
kind of representation, which highlights the endless unfolding of a tragic narrative of pain and
loss, the opioid epidemic takes on a roll as a particular kind of “dramaturgic event” – an evolving
plot line which, as Eric Rosenberg has written, are nearly always “marked by increasing and
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revelatory tension.” Indeed, the opioid epidemic is often made legible in these same terms: First,
as a plot line marked by “increase,” the opioid epidemic is configured through an avalanche of
numbers that assert its capacity for violence and destruction. Take, for example, numbers in
which it is likened to war – which assert that in 2016 alone, the national death toll attributed to
drug overdose was roughly equivalent to the toll that was suffered during the Vietnam War
27
and
that in 2021, according to reliable sources, the cumulative body count due to drug overdoses will
exceed the total number of battle casualties lost in all the wars this country has participated in
over the past two centuries combined (The Rise of Drug Deaths in America, 2017; CDC, 2017d;
DVA, 2016). Second, the opioid epidemic is also marked by revelatory tensions, which provide
the crisis itself with explanatory power that stretches far beyond statistics. As a mediated event,
the opioid epidemic is a site for the production of narratives that have much to tell us about
ourselves – our collective hopes, fears, and how we cope with them.
Re-Examining Pain Trajectories
I began this project with the intent to examine and come to understand the opioid
epidemic both in terms of its progression and its mediation. I wanted to identify the key cultural
and institutional conditions that contributed to its formation and assess how well these conditions
helped explain the incredible upsurges we have seen in the manufacture, promotion, prescription,
and consumption of opioids in the United States over the last two decades. Relatedly, I wanted to
know how the use of opioids in each of these contexts was legitimized and maintained,
particularly in the midst of growing public discourse about the dangers associated them. This

27
While there were 58, 220 fatal military casualties suffered throughout the course of the
Vietnam War, drug overdoses in 2016 claimed an estimated 64,000 American lives.
235
question, moreover, was undergirded by my own assumption that legitimation and maintenance
are processes that owe much to the power of communication and persuasion. This being the case,
I also wanted to examine the roles that discourse and representation have played in making the
epidemic legible as a problem space defined by a particular set of actors, actions, and
technologies. But as I dug deeper into these questions, it became clear to me that in order to
answer them I would have to think more carefully the problem of pain – a problem which, as this
project has attempted to show, lies at the heart of the complicated matrix of actors and
institutions, discourses and practices, techniques and strategies that constitute the opioid
epidemic.
Its focus on pain is, for me, the most important contribution this analysis attempts to
make. For while other studies, articles, and books about the opioid epidemic do much to
contribute to our understanding of it, all tend to approach the opioid epidemic through opioids –
the drugs themselves. And while the drugs are obviously important, it seems to me that they are
not the heart of the issue. It is pain – not opioids – that has driven the trajectory of this epidemic
(and which has fueled the uptake of opioids at every step along the way). And so it seems to me
that in order to provide a broader and more in-depth analysis of the opioid crisis in all its
complexity, one must start not with the drugs nor with addiction, but with pain.
Discovering that the world of opioids is inseparable from the problem of pain has pushed
me to consider a series of more specific questions, beginning with the question of how pain and
opioids came to be connected in the first place in the domain of medicine. The genealogy of the
medical field of pain management has much to teach us with regard to the ways in which opioids
became discursively and materially attached to pain over the course of the past half-century.
Throughout these years, and in accordance with various strategies and interests both inside and
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outside of medicine, opioid medications were gradually incorporated both into the theories and
instruments that were (and are) used to measure the subjective experience of pain. The
conceptual attachment between pain and opioids, and the processes through which it became
institutionalized as part of the common-sense of pain management and its clinical practice, is a
crucial starting point for understanding how opioid use was normalized as the best medical
solution capable of addressing this problem.
Yet, it is also important to recognize how opioids have become normalized outside the
domain of medicine. For they not only became familiar tool for doctors but were also
incorporated into everyday life as household objects, and their consumption as a familiar
practice, for many people. As I have argued, the shift in the meaning of opioids from completely
taboo to simply risky medications of last resort to a first-line treatment for a variety of different
kinds of pain did not occur by accident. Rather, this transformation belies a web of sustained
investments and strategic efforts undertaken by pharmaceutical companies – most notably
Purdue Pharma, the maker of OxyContin – to brand the problem of pain relief and to market their
products as the very best means of achieving it.
One of the aims of branding, in general, and pharmaceutical branding, more specifically,
is to establish a relationship that is both affective and material between people and products. The
branding of OxyContin worked to establish this connection by articulating pain relief to a
particular vision of the American Dream – one which could only be obtained through consuming
the opioid products that promised to put consumers back on the path toward economic
productivity and eventual self-actualization. By framing pain relief and opioids in this way,
Purdue Pharma successfully sold them as necessary requirements for any and all Americans
attempting to live a happy, meaningful life. Branding in the domain of pain relief has also
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functioned as a political technology, both at an individual and a social level. For individuals,
opioids that promise pain relief work to reinforce the value of the enterprising individual-
consumer through their promise to get pain patients back to work – which is itself seen as the
primary site where pain patients realize their potential as productive, economic subjects. But the
branding of pain relief has also proceeded through framing opioids as social goods – as tools that
help to offset the cost that pain inflicts on the economic and social fabric of the nation by
bringing citizens back into the fold as responsible workers, parents, husbands, wives, and
patients.
At this social level, pharmaceutical companies have also mobilized the branding of pain
relief in ways that attempted to respond to the abundance of fear and anger being directed at
them in the wake of the opioid epidemic’s mounting public visibility. Indeed, much of the public
discourse that has circulated around the epidemic over the past twenty years has been
characterized by intense vitriol against opioid manufacturers, whose hunger for profit and
insatiable greed is often pinpointed as the primary force driving the epidemic. In response to
such accusations, pharmaceutical companies like Purdue Pharma have attempted to reframed
themselves – and their products – as socially responsible by grafting their marketing practices
onto existing social problems. They have done so namely through the creation of “educational”
campaigns and websites, branding efforts repositioned under the guise of corporate
responsibility, which have served the double function of shielding these companies from
negative press while simultaneously promoting their newest, “abuse-deterrent” as newfound
solutions for the social problems of drug addiction and diversion.
Branding pain relief under the banners of “education” and “social responsibility” has also
played a crucial role in contributing the normalization of opioids in spaces beyond the doctor’s
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office. One of the key practices pharmaceutical companies have taken up to spread the use of
opioids has involved developing alliances with health accreditation institutions and incorporating
their marketing materials into their standardized accreditation programs and procedures. As a
practice embedded within the health accreditation system, the branding of pain relief (and
subsequent promotion of opioids) has become broadly institutionalized within the U.S. health
care system and with the quality-assurance mechanisms that dictate the financial futures of
physicians, nurses, clinics, and hospitals across the country. Through aggressive marketing
efforts and partnerships established with other actors operating within the U.S. medical-industrial
complex, opioid manufacturers have moved well on their way to creating a universe of branded
pain relief – where the question of pain is thoroughly embedded in a world of syndicated content
that offers up opioids as the most visible solution for it.
Thus, the successful branding of pain relief was realized not only through the formation
of powerful affective relationships and meaning-making, but also through concrete practices that
transformed the everyday goings-on of individuals and institutions and made narcotic painkillers
a staple product in medicine cabinets across the country. The domestication of opioids is also
reflected in the fact that most first-time opioid consumers don’t actually obtain these drugs from
physicians but instead encounter them informally, normally as gifts which they receive from
family members and/or friends. The movement of opioid distribution into these new,
domesticated domains also provides us with a key to understanding how and why the
government’s ongoing efforts to regulate and police opioid consumption have been less than
effective: Over the past two decades, opioids have moved into contexts of production,
distribution and consumption that are not always legible in the same problematic, illicit, or
criminal terms as are other drugs. This informal system of exchange, which blurs the boundaries
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between patients and addicts, users and dealers, drugs and cures, is what I characterize as the
“grey market for opioids.”
This grey market, as I have argued cannot be understood apart from the regulatory logics
with which it is bound up, since before any drug can go to market, it must first pass through the
institutional channels and regulatory apparatus of the U.S. Food and Drug Administration
(FDA). Yet, to say that the opioid epidemic and its grey market are merely consequences of
botched regulation is somewhat misleading. For, as I have shown, regulatory failure in the
domain of opioids has proceeded according to its very own logic. The logic of regulatory failure
is best characterized as a logic of extreme uncertainty, where ambiguity and obscurity are
produced at nearly every step, to the extent that the regulatory process all but ensures the
eventual materialization of unforeseen – albeit disastrous – consequences. Take, for example, the
guiding principles of safety and efficacy which are the two pillars of drug regulation at the FDA.
While appropriate in theory, these principles have been integrated into the FDA’s opioid
approval process in ways that have systematically hindered its ability to realize them in practice.
For example, the safety and efficacy requirements that guided the clinical trials for OxyContin –
which mandated that the manufacturer provide evidence that its drug would be no less safe and
no less effective than similar medications the FDA had previously approved – required the FDA
to rely too heavily on the analogous knowledge it had about older opioid compounds (namely the
drug MS Contin which, as it would turn out, was not truly comparable to OxyContin). Relying
on reports of MS Contin’s safety and efficacy led quite logically to the quick approval of
OxyContin and its release onto the market. In just a few short years after its initial release,
OxyContin was identified as being one of the country’s leading drugs of abuse (Van Zee, 2009).
Indeed, the logic of regulatory failure is one in which many of the nuances that condition
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the lived practices and experiences of opioid consumption are systematically obfuscated. It is a
logic that operates on the basis of “strategic ignorance” – which is ignorant in the sense that it
involves decisions which are produced in conditions of extreme uncertainty and strategic in the
sense that it works toward the benefit and protection of corporate interests. Indeed, much of the
information on which the FDA has relied to make decisions regarding the approval of opioids
(and which has blocked previous attempts to remove them from the market) is gleaned from
data-collecting systems that are designed by the opioid manufacturers themselves. These systems
– which, for the FDA fulfill a key component of the “risk management” plans that they require of
opioid manufacturers – are developed and utilized at the whims of the company that they are
meant to keep in check. Thus, it is the industry actors rather than the federal regulators who are
given nearly full reign over the collection, monitoring, and analysis of risk-related data. These
data monitoring and surveillance systems, such as Purdue Pharma’s patented RADARS database,
illustrate how strategic ignorance plays out in practice, where pharmaceutical companies
selectively churn out information that earns them regulatory support while also providing them
with valuable consumer data that they can (and do) use to optimize their marketing efforts.
As with opioids in medicine and marketing, the regulation of these drugs has likewise
been conditioned by problem of pain. Much of the debate formed around the question of opioid
regulation has been centered on pain management and, namely, on the concerns of patients,
physicians, advocates, companies, and regulators that FDA intervention in the opioid market
would inevitably risk cutting off many patients’ access to their medications. In the regulatory
context, the problem of pain has undergirded the FDA’s decisions to pursue non-interventionist
measures, and only those which promised not to hinder the circulation of opioid products and the
growth of the opioid market. This kind of laissez fair approach to opioid regulation has acted
241
very much in the interest of manufacturers who the FDA has not only allowed but encouraged to
produce more and more opioid products. While the FDA has largely shied away from
intervening directly in the opioid market and from limiting the circulation or entirely removing
an opioid from it (even the oft-abused OxyContin remains on the market), it has made efforts to
supplement certain abuse-prone opioids with newer, abuse-deterrent versions of them. Although
the Administration’s support of abuse-deterrent technologies has been given in the name of
abuse prevention, it has had quite the opposite effect in practice: Instead of preventing opioid
abuse with these new technologies, the FDA has instead succeeded in re-configuring their use
which, over the past five years, has been shifting steadily away from prescription painkillers
toward the consumption of heroin and illicit fentanyl. The skyrocketing rates of illicit opioid use
are matched by the fact that these drugs are incredibly difficult to regulate and police. The
unique characteristics of these drugs as well as of the technologies and contexts that enable their
mass production, distribution, and consumption, have introduced a wave of new problems, risks,
and uncertainties for regulators and law enforcement.
These new contexts of opioid use, which form part of the system of exchange I refer to as
the opioid grey market, are riddled with uncertainty – and it is uncertainty, moreover, that
undermines the usefulness of categories that have historically been used to understand and
manage the world of drug use. In a world where cures become poisons, patients become addicts,
doctors become dealers, and solutions give rise to newer and more difficult problems, the urge to
re-categorize and re-classify its content appears all the more urgent. Indeed, naming practices
proliferate among representations of the opioid epidemic, and in attempts by multiple
stakeholders to divide the world of opioid use into manageable categories. This is particularly
true as it applies to opioid addicted-persons. The subjectification of opioid users or rather, the
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processes through which opioid abusers are constructed as different kinds of persons, represents
another key dynamic that has informed the opioid epidemic’s legibility and its place in
contemporary culture.
Likewise, subjectification in the opioid epidemic is a process that is centrally involved in
the discursive construction of pain and addiction, where attempts to reassert some of the key
symbolic boundaries that are blurred in the opioid grey market begin with the discursive
construction of opioid patients and addicts. But not only this: Representations of the opioid
epidemic, as I have argued, divide opioid patients and addicts even further into three separate
categories of persons – which I refer to as patients-at-risk, pathological consumers, and
consumed addict-victims. These categories divide opioid consumption into those behaviors
which are deemed as being acceptable and those which are not, while articulating these ethical
assumptions onto different kinds of addicted subjects. These categories are, in many ways, made
legible as outgrowths of longer historical tendencies in the representation of drug addiction and,
by extension, of addicts themselves. Within the opioid epidemic, these historical threads have
crystallized in the construction of an addict who is not seen as a pathological consumer but as a
blameless and consumed addict-victim, whose addiction is detached from her personhood,
internal nature, character flaws, and so on, and instead maps onto malevolent forces external to
her. This category of addicted person is also a lens through which we can witness how ethical
assumptions are mobilized in ways that prioritize and invest in the well-being of certain kinds of
opioid consumers over others. These priorities materialize in the uneven allocation of addiction
treatment resources and interventions.
As a discursive process with material effects, subjectification in the opioid epidemic
reflects, relies on, and reproduces problematic logics and hierarchies of race and class. More
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specifically, it has helped render the opioid legible as a narrative about whiteness – in which
opioid addiction is legible only in terms of the ways in which it threatens the future of white
America by destroying the potential of its white working-class. While I do not deny the fact that
opioid addiction today has become a particularly serious problem for white communities (it has),
I also want to maintain that framing the opioid epidemic as a story that is relevant only in terms
of the plight of white America belies the role that such a construction plays in re-directing
conversations about the opioid epidemic toward the selective investment in whiteness. That is to
say, delineating the problem along these narrow lines has also conditioned (and perhaps driven)
inequalities in the realm of addiction treatment, where the best and newest technologies and
interventions are geared toward the rehabilitation of white opioid users – thereby limiting their
access to people of color.
The question of how the opioid epidemic relates to social problems in other domains is
crucial since it illustrates the broader significance of what might otherwise be understood as a
predominantly medical phenomenon. Developing a broader understanding of the opioid
epidemic and – more specifically, of the problem of pain – in social, cultural, historical and
political terms has constituted one of this project’s main thrusts. Throughout these pages, I have
sought to provide an alternative lens for examining what has undoubtedly become one of the
most formidable social issues of our time. To analyze it from the perspective of medicine or
science alone risks oversimplifying the complexity and subtlety of its underlying dynamics. And
while I don’t mean to suggest that arguments rooted in biology and physiology can’t enrich our
understanding of pain and addiction, it does seem to me that such arguments become even more
useful once they are considered in light of the role that culture and society play in structuring
scientific and medical truths. This broader commitment to the study of medicine aligns with
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research programs being advanced in the fields of social medicine, the medical humanities, and
the social study of science and technology (STS), all of which pursue (as this project does) an
understanding of health and illness that expands beyond narrowly-defined medical categories.
For indeed, as my project and the fields to which it relates attempt to show, medical and
scientific truths are anything but fixed. On the contrary, they are in flux and can be shown to
shift over time and in connection with other social, cultural, and political developments. Thus,
opening up medical and scientific categories to critical examination is essential if we are to
understand how they become “common sense,” how they structure our lives in the way that they
do, and what role they play in the re-production of norms, values, and hierarchies within our
society.
But the reproduction of norms, values, and hierarchies not only works directly through
the production of scientific/medical knowledge; it is also a mediated process, one that is driven
by communication and representation. Developing this project has meant attending carefully to
these processes at every turn – for at every turn, pain, addiction, and opioids became entangled
with new meanings and associations that dramatically altered their functions as well as their
legibility. As a mediated phenomenon, the opioid epidemic is a site where relations of power are
constantly exercised and negotiated – an assumption this project shares with other work being
done in communication and cultural studies. The ways in which power relations are mobilized in
and through the opioid epidemic is perhaps clearest when we consider its relation to
subjectification and the ways in which the construction of different kinds of opioid-addicted
persons both reflects and reproduces norms, values, and hierarchies along the lines of race and
class.
Ultimately then, the theoretical heart of this project lies in its critical interrogation of
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science and medicine. Looking at the opioid epidemic through this critical lens has been
revealing, to say the least. Above all else, it has pushed me to see that the phenomenon at which I
was looking was never so much about drugs but was instead taking shape around the problem of
pain. And, moreover, that pain itself posed a problem not only for medicine but also for politics
and in culture more generally. The cultural politics of pain gives us cause to question (and
perhaps even to reject) the idea that scientific and medical knowledge about it is un-biased or
neutral and that it is somehow more valuable than other kinds of knowledge. For on the contrary,
expert knowledge about pain in these domains is laden with biases and assumptions about which
kinds of suffering matter, for whom they matter, and who decides.
Re-Routing Addiction through the Problem of Pain
Finally, the problematization of pain is connected to what I believe to be a significant
shift in cultural and political discourse related to addiction and, as such, marks a key turning
point in its trajectory in the United States. Above all else, what is shifting in the discourses and
practices related to opioid addiction is the locus of blame, which is becoming increasingly
detached from the internal flaws of the addicts themselves and repositioned onto a variety of
actors, institutions, and other forces external to them within the country’s medical-industrial
complex. While scrutiny of the medical industry is not, in itself, anything new, it is taken to an
entirely new level in the opioid epidemic. This is reflected in a rather stunning series of recent
events that are pushing drug companies to acknowledge the role they have played in the current
crisis. Take, for example, the string of lawsuits filed against opioid manufacturers over the past
few years and the ways in which these companies are responding to them. While, typically, legal
battles waged against Big Pharma don’t result in a significant change in the company’s practices,
these recent lawsuits have forced some opioid manufacturers (most notably, infamous
246
OxyContin maker Purdue Pharma) to stop advertising their top-selling drugs and, in some cases,
to remove them from the market entirely. These actions, alongside the government’s imposition
of strict limits on opioid prescribing, mark the start of what looks to be a concerted attempt to
intervene directly into the opioid market. As I discussed in my analysis of opioid regulation, such
an interventionist tact runs counter to the logic of laissez-fair regulation and the role it has played
within the United States’ health care system. But more importantly, tracing opioid addiction back
to system-wide structures, logics, and failures seems to me a more productive way of
approaching the topic – not in the narrow terms of a medical diagnosis, nor a character defect,
but as part of a larger social, cultural, and political matrix.
The growing prevalence of opioid addiction and the profound connection it shares with
the problem of pain are articulated to the broader landscape of American culture, where these
problems are shaped by (and in turn shape) key dynamics within this wider field which include,
but are not limited to, mounting concerns and attention related to the deterioration of America’s
white working class. The growing rates at which this demographic is being ravaged by so-called
“deaths of despair” – a phenomenon which plays an important role in making the opioid
epidemic as a national emergency – also says something about the affective and material state of
affairs that constitute what Raymond Williams (1977) referred to as the “structures of feeling” of
our current moment. Collective concerns and pessimism about the future crystallize in the opioid
epidemic, where pain becomes visible not as a medical fact insomuch as a powerful affect, one
that has much to say about how many Americans feel about themselves, others, and their
relationship to a world of escalating social, cultural, and political turmoil. On this note, it seems
important (though perhaps obvious) to note that the centering of pain as a key affect within
today’s “structures of feeling” must be viewed ambivalently, since the experience of pain, as
247
Sarah Ahmed (2004) has discussed, is something which has both the ability to draw connections
among people and to divide them. As such, discourses formed around the problem of pain both
reflect, maintain and, in some cases, perpetuate social, cultural, and political rifts. At the same
time, the experience of pain is perhaps the only universal experience available to us and, as such,
could provide a productive starting point for addressing social inequalities and injustices –
beginning with those that are reinforced within our health care system.
Pain’s Implications for Policy and Future Research
To that end, I want to end by proposing ways we might channel this broader approach to
pain into concrete practices by implementing them in the domain of drug policy. First, though it
has been the case that regulatory discussions regarding opioids have, at times, explicitly
addressed the question of pain and its management, they have not done so in ways that
acknowledge pain’s relationship to addiction, nor subjectivity, nor contextual specificity.
Understanding the ways in which different understandings of pain have conditioned its treatment
in medicine, culture, and politics could provide regulators with a clearer perspective with regard
to the lived experience of opioid use – a perspective that could help to mitigate some of the
consequences that have emerged (and will continue to do so) under regulatory logics defined by
extreme uncertainty and strategic ignorance. For these are the logics that have played the biggest
role in conditioning the system-wide failures in opioid regulation and, correspondingly, the
expansion of a grey market in which they now often circulate.
One way of addressing extreme uncertainty in the context of opioid regulation would
involve calling for new kinds of expertise to be incorporated into opioid-related policy
discussions. As we have seen, the opioid epidemic has called into question several long-held
assumptions about who and what constitutes expertise in this domain. Increasingly, those actors
248
who were previously seen as experts are being re-framed as culprits: Pharmaceutical companies,
regulators, physicians, pain management specialists, have all come under fire over the past
several years for having fueled opioid abuse and addiction among their patients and consumers.
For these actors, the opioid epidemic seems to have amplified a growing crisis of legitimacy and
widespread loss of trust among those who see it as a disastrous consequence of physicians’ bad
decision-making, pharmaceutical greed, and the futility of our health institutions. The cracks
revealed in this current system of expertise call up a need for new kinds of experts and for their
participation in drug policy discussions. And who would be better positioned to speak to the
nuanced reality of opioid than consumers themselves? Who better to speak about the trajectories
of opioid addiction than addicts themselves? Lay expertise, as it exists among individuals with
different kinds of relationships to the drugs they take, has much to offer policy-makers who are
attempting to understand and put an end to the present crisis.
Additionally, on a more conceptual level, policy-making in this domain would benefit
from re-thinking its approach to other addiction and pain in broader historical and cultural terms
– as something which is not limited to its medical/scientific definitions nor as something that can
be objectively measured and unilaterally treated but as phenomena which have evolved unevenly
within a matrix of values, strategies, and interests in a variety of domains. If we are to address
pain and addiction in a way that does not always hinge on opioids, we need to understand how
this connection developed in the first place. Thinking more extensively about the genealogies of
pain management and addiction treatment may provide useful road maps that show us which
routes we have already taken and which might now be productively explored.
Finally, I want to suggest that re-thinking pain and addiction in cultural terms is a task
that would not only benefit policymakers but could also serve as a crucial agenda for future
249
research. The cultural study of pain, for me, marks the start of a research program that invests in
developing a better understanding of it beyond the sanitized contexts of the hospital, clinic, and
laboratory, and which seeks to come to terms with the ways in which pain shapes and is shaped
by historical, social, cultural, and political dynamics. The development of such a program
requires that we begin to think more broadly and more critically about pain not solely in terms of
what it is or why it happens but in terms of how it functions as part of other key processes.
Examining the how of pain (how it is realized and assessed, how we relate to our own pain and
the pain of others, and how it becomes represented and intervened upon in a variety of domains)
might just provide us with some important answers to a few key questions: Taking a deep dive
into the cultural politics of pain may help us make sense of the turbulence which – being both
affective and material, individual and collective – colors the landscape of our present moment.
The United States is, in many ways, a nation in pain. To heal our wounds we have to begin by
thinking harder about how it is that we have come to hurt.
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Asset Metadata

Creator Sherman, Melina (author)

Core Title How it hurts: culture, markets, and pain in the U.S. opioid epidemic

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 11/07/2018

Defense Date 10/20/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag addiction,American studies,cultural studies,drug regulation,history of medicine,OAI-PMH Harvest,opioid epidemic,pain,pain management,pharmaceutical markets

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Jenkins, Henry (committee chair), Lakoff, Andrew (committee chair), Banet-Weiser, Sarah (committee member), Riley, Patricia (committee member), Smith, Christopher Holmes (committee member)

Creator Email melinash@usc.edu,melinasherman2013@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-104657

Unique identifier UC11675543

Identifier etd-ShermanMel-6932.pdf (filename),usctheses-c89-104657 (legacy record id)

Legacy Identifier etd-ShermanMel-6932.pdf

Dmrecord 104657

Document Type Dissertation

Format application/pdf (imt)

Rights Sherman, Melina

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA