A F I N E L I N E Painkillers and Pleasure in the Age of Anxiety G E O R G E C . D E R T A D I A N A Fine Line George C. Dertadian A Fine Line Painkillers and Pleasure in the Age of Anxiety George C. Dertadian School of Social Sciences University of New South Wales Kensington, NSW, Australia ISBN 978-981-13-1974-7 ISBN 978-981-13-1975-4 (eBook) https://doi.org/10.1007/978-981-13-1975-4 Library of Congress Control Number: 2018950494 © The Editor(s) (if applicable) and The Author(s) 2019 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Foreword At times of public health crisis, our attention is justifiably gripped by the most devastating effects and extreme forms of suffering. We are in the midst of what media commentators describe as a deadly epidemic of ‘killer’ drugs. More accurately, we face an escalation and intensifica- tion of harm associated with drug use. Rates of opiate use, especially prescription pain medications, have risen sharply. Overdose deaths are at unprecedented levels. People are struggling with the consequences of their opiate use, consequences which are exacerbated and, in more than a few cases, caused by the effects of prohibitionist and punitive drug policies. In North America, the powerful synthetic opioid Fentanyl has contaminated the illicit drug supply, producing dramatic increases in risk and harm. The US Centers for Disease Control and Prevention have described this as the worst drug overdose epidemic in history. In this historical moment, it is easy to overlook the reality that the majority of people who use opiates do not develop such dramatic problems and are not represented in medical statistics. This is the case whether their consumption is medically authorised or not. More broadly, the use of analgesic drugs, both prescribed and purchased over the counter, is a part of ordinary life for ordinary people. A Fine Line v vi Foreword is timely and compelling because it explores the consumption practices of such people, placing their use in the context of the challenges they negotiate, the feelings they seek and the opportunities they desire. In A Fine Line we read of painkillers helping men and women to contrib- ute to family life despite chronic pain, to cope with emotional distress, to enhance productivity, to ‘chill out’ after a night of partying, and to save money by enhancing the effects of alcohol. While not denying the potential harms of routine analgesic use (including dependence), Dertadian eschews sensationalism and moral stances in his presentation of a range of pharmaceutically mediated practices. Crucially these prac- tices include the pursuit of pleasure. A Fine Line is therefore an insight- ful contribution to the sociological literature on pharmaceuticalization, the process by which medical drugs are constituted as the solution for an increasing range of problems and conditions (Fox and Ward 2008). However, Dertadian carefully attends to the heterogeneous experiences of users rather than adopting a predetermined critical narrative. He resists the constitution of medicalization and pharmaceuticalization as singular and monolithic processes. The large and rapidly growing body of literature on prescription opiate use is primarily epidemiological or clinical, highlighting disease and disorder at either population or individual level. What is missing is the dynamic social environment and the network of relationships in which drug use actually takes place. The epidemiological research which produces the most authoritative ‘objective’ information on drug use patterns and effects is necessarily abstract, isolating ‘factors’ from their context in order to identify causal relationships at a population level. As Steve Wing has observed, the ‘populations’ of modern epidemiology are conceptualised as vehicles for statistical analysis rather than groups with unique histories involving economic, social and ecological rela- tionships (1994). At the same time, epidemiology reduces features such as gender, class and relationship status to individual attributes. In con- trast, the accounts of everyday painkiller use collected in A Fine Line are based on conversational in-depth interviews with users, carried out by the author. The book exemplifies the rich, detailed and empathetic knowledge of social practices that can be produced by well-executed qualitative research. This research reveals not just what people do but Foreword vii how they make sense of their actions and what meanings they attach to their experiences over time. The special value of A Fine Line resides in its combination of empir- ical research with recent scholarship in critical drug studies. Theoretical and conceptual examination of dominant approaches to substances and substance use translates the evidence provided by lived experience into a coherent argument about the regulatory effects of medico-legal struc- tures. One of the most important messages of A Fine Line concerns the categories we use to understand and respond to complex phenomena such as pharmaceutical consumption. ‘Non-medical use’ has become the standard term to refer to the consumption of prescription drugs in ways that are not medically authorised, for example for ‘non-therapeutic purposes’ or ‘without a valid prescription’. The abbreviation NMUPD reflects the reification of this classificatory framework and the problem of illegitimate consumption it constructs. Dertadian’s analysis highlights both the regulatory function of the category ‘non-medical’ and its insta- bility. As he points out, patients with chronic pain seek out analgesics for the feeling of relief, which is difficult to demarcate from a positive experience of pleasure, although the latter is labelled as ‘non-therapeu- tic’ and therefore suspect. He also points out how medical and legal discourse constitutes the sharing of drugs through a lens of ‘non-adher- ence’ and ‘diversion’, ignoring the elements of care that are expressed through informal networks of distribution. By placing twenty-first century painkiller use in a historical context, A Fine Line reveals another effect of medical authority. Concentrating on the risks of users’ unauthorised and non-compliant consumption of medications can act to distract attention from iatrogenic harms. In the current opiate crisis, the actions of Purdue Pharma and the prescription practices of physicians have come under the spotlight, but this has not undermined the confident assertion of a clear distinction between medi- cal (beneficial) and non-medical (harmful) use. Alongside contemporary analgesia, Dertadian includes an instructive discussion of the popular- ity of over-the-counter headache powders such as Bex and Vincents in Australia in the 1950s. These accessible medications included a com- bination of aspirin, phenacetin and caffeine (APC). High levels of use produced a sharp increase in gastric ulceration and kidney failure, viii Foreword especially among women. However, as Dertadian notes, there was reluc- tance among the medical profession to connect normalised and domes- ticated use of a ‘safe’ medication with severe harm. He also notes that ‘the circumstances of women’s lives were left out of the equation in medical accounts of APC consumption’. The repetition of this form of exclusion continues to limit responses to drug use risks and harms. Despite its critical perspective on medical power, A Fine Line does not imagine or hope for a space of freedom, nature or authenticity where individuals live their lives free from the constraint of medical rationality or the corruption of pharmaceutical agents. As modern indi- viduals we are thoroughly and inescapably medical in our understand- ing of our bodies, our selves and our relationships with the world (Rose 2007). In A Fine Line, Dertadian records the capacity of contemporary consumers of medicine to develop their own forms of practical pharma- cological expertise and actively negotiate a medicalized terrain in order to work toward their own goals. As he puts it, ‘people’s individualised appropriation of medical discourse and practice may well provide a compelling alternative to the psycho-pharmacological perspectives that have dominated much of the current literature about non-medical con- sumption.’ A Fine Line is a highly readable and engaging book based on up to date research and the author’s extensive and detailed knowledge of the field. It introduces readers to the richness and complexity of an issue, which is too often discussed in simplistic and one-dimensional terms. Not only does it reveal the diverse forms of pharmaceutical self-inter- vention practiced by human beings in search of relief, self-improve- ment, pleasure and hope; it contributes to our understanding of the medical form of life that is inseparable from contemporary modes of existence. Canberra, Australia Associate Professor Helen Keane Head of School, School of Sociology Australian National University Foreword ix References Fox, N. J., & Ward, K. J. (2008). Pharma in the Bedroom… and the Kitchen…. The Pharmaceuticalisation of Daily Life. Sociology of Health & Illness, 30(6), 856–868. Rose, N. (2007). Beyond Medicalisation. Lancet, 369(9562), 700–702. Wing, S. (1994). Limits of Epidemiology. Medicine and Global Survival, 1(2), 74–86. Preface Are painkillers mundane medications safe for use to ameliorate human suffering? Or are they drugs of abuse that cause addiction and death? Do they ease pain, or do they cause it? The answer to these questions is a source of tension in professional and public understandings about the way people use painkillers. It is hard to deny the benefit of the use of painkillers for chronic pain, in order to stem the constant, debilitating throb of pain that would otherwise not subside for physical health, nor for work or pleas- ure or rest. It is also hard to deny the pain these medications can cause to those who become dependent, and to the family and friends of those who lose their life to overdose. The later has, however, been brought into sharp focus by public health professionals ever since the slow-re- lease opiate-based medication OxyContin® was released to market in 1996 in the US. The impact that the sale of this medication would have on American society and its public health would have been hard to fathom at the time. Following the release of OxyContin®, Purdue Pharma, the company that owns the drug, utilized a sophisticated marketing machine that was largely directed by its majority owners, the Sackler family. A string of xi