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Keywords:

  • [addiction treatment;
  • opiate maintenance;
  • methadone;
  • buprenorphine;
  • race;
  • class;
  • political economy;
  • pharmaceuticals]

Abstract

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED

Synthetic opiates (opioids) have created among the most profitable markets worldwide. Two decades ago, FDA approval of Oxycontin® as a “minimally addictive” opioid pain reliever fueled an unprecedented rise in prescription opioid abuse. This was followed by a little known act of U.S. Congress enabling general physicians to use an opioid maintenance medication, buprenorphine, for addiction treatment in their private practices, leading to enormous growth in the U.S. addiction treatment market. Based on participant-observation and interviews among pharmaceutical executives, policy makers, patients and prescribers, this article describes the neuroeconomics and neuropolitics of new opioid maintenance treatments. This article contrasts the historical emergence of methadone clinics from the 1960s to the 1980s as a treatment for the Black and Latino urban poor, with the current emergence of buprenorphine, a maintenance opioid approved for prescription on doctor's offices, as a treatment for white, middle-class prescription opioid abusers. The article then traces the counterintuitive result of bringing addiction pharmaceuticals into the medical mainstream in an effort to reduce the stigma of addiction: a two tiered system of addiction treatment that reinforces stigma among the urban poor, and enhances the biological, political, and economic dependence of all classes on opioid markets, both legal and illegal.

The only addiction treatment pharmaceuticals that actually make money are the opioid agonists, like buprenorphine. Can you imagine a better commodity than one that is physiologically addictive, and that the physician tells the patient he or she must take indefinitely?

—Marc Galanter, President of the American Society of Addiction Medicine, 1999–2001

One of the concerns that we all have had is that buprenorphine was somehow going to help create a two-tiered treatment system, that is, a treatment system that the poor people and underserved and unemployed will get put into methadone treatment, and everybody else, the employed and people with money would be able to go onto buprenorphine. Has it happened? To some extent I think it has.

—Charles O’Keeffe, CEO of Reckitt Benckiser Pharmaceuticals, 1980–2002

A neuroanthropology of pharmaceuticals must not only account for the individual level biocultural interaction between physiologies and perception but also must attend to the structural level biocultural interaction between the marketing of bioactive commodities, on the one hand, and systems of social stratification, governmental control, and self-discipline, on the other hand. For example, a political economic component to biocultural analysis is key to explaining how concepts of racial difference and vulnerability to addiction come about through social forces. Such political economic perspectives have been key contributions of anthropology to the emerging field of neuroeconomics (Goodman and Leatherman 1999; Gravlee 2009; Leatherman and Goodman 2011; Schull and Zaloom 2011).

In this article, we trace the market logic of the development of a race and class stratified system of treatment for opiate dependence with opioid maintenance. We argue that the current state of opioid maintenance treatment in the United States can be understood using a biocultural lens, in which the physiological dependence causing properties of opiates and opioids (synthetic opiates) make them ideal commodities from a pharmaceutical corporation's perspective, but that the cultural associations of opioids and opiates with racial and class marginalization necessitated novel marketing and regulatory strategies to supply white, upper-income consumers with opioid maintenance. Ultimately, two neuroactive agents with similar pharmacological properties, methadone and buprenorphine, have vastly different systems of dissemination and regulation structured around them, in which one opioid (methadone) is a part of a clinical system that is subject to tight government regulation and surveillance of criminalized patients, and the other opioid (buprenorphine) is part of a deregulated private clinical system based on a view of opiate dependents as neurochemically deficient. These two clinical systems are the economic by-product of a racialized bipolarity in U.S. cultural frames for addiction, as a moral deficiency on one pole, and as a chronic neuroreceptor deficiency on the other pole. Science studies scholars of addiction neuroscience demonstrate that neuroscientific projects reformulate the social contexts of addiction as points of biological, rather than moral, lapse (Campbell 2010, 2011). Yet the example of buprenorphine and methadone highlights that these biologizing projects map onto race and class stratified institutional structures in which neurobiological amorality is inherently racialized and politicized (see Kirmayer and Gold 2011; Vrecko 2010a, 2010b).

Opioids are one of the largest selling classes of drugs in the world, with the United States consuming 80 percent of the world's opioids despite claiming only 4.6 percent of the world's population. In the United States, the opioid hydrocodone (sold as Vicodin®) has been the number one most prescribed drug for several years in the past decade (Manchikanti and Singh 2008). The physiologically addicting properties of opioids, along with their criminalization and past symbolic association with marginalized groups, make them a fruitful topic of inquiry for understanding the interaction between neuroeconomies and social systems of control. By neuroeconomics, we indicate the broad spectrum of systems of regulation and exchange that interact as psychoactive substances circulate in social life, ranging from the physiological (e.g., downregulation of neuroreceptors and endogenous neurotransmitters with exposure to pharmaceuticals) to the corporate (e.g., strategies to enhance supply and demand, governmental deregulation).

The recent history of industries of opioid dependence and treatment provides an illustrative example. Here we provide this history, based on in-depth 30–90 minute, topically directed, open-ended interviews with 56 policy makers, pharmaceutical executives, physicians and patients, as well as four years of participant-observation by the first author working as a psychiatry resident and fellow, and the second author working as a volunteer in a substance abuse treatment program. Participant-observation involved observing doctor–patient encounters, addiction medicine conferences, and working groups, as well as the daily work of agencies and community based organizations devoted to addiction treatment. The interview and observational data from this study indicate that categories of race and class not only shape pharmaceutical markets but also that pharmaceutical marketing, in turn, shapes the very categories of race and class as experienced in biomedical clinics. The race- and class-marking of different opioid formulations has allowed opioid manufacturers to extract profits from opposite ends of the social strata in the United States, while creating (in theory) biologically equivalent opioid dependence across strata. At the same time, this bioequivalence itself has been challenged by theorists of local biologies who argue that social context shapes both biological process and perception of biological process (Lock and Nyugen 2010). Whether or not the neurobiology of opiate dependence differs by strata in the United States, however, this dependence is experienced in contrasting ways at either end of the race and class-based stratified system, which reflects that people in the top and bottom strata have unequal abilities to resist surveillance, and unequal opportunities to enact consumer choice and privatization of their health care.

THE RISE OF PRESCRIPTION OPIOIDS

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED

In 1996, Purdue Pharmaceuticals got FDA approval for a long-acting form of opioid painkiller, oxycodone, which it named Oxycontin®. Based on the logic that its time release capsule prevented the rapid rise in drug levels in the blood that gives opiate abusers intense pleasure through saturation of the opioid receptors in their brains, and based on time limited clinical trials of Oxycontin® with acute pain patients, Purdue marketed the drug as a “minimally addictive” opioid pain reliever, with a less than 1 percent risk of addiction, appropriate for long-term use in chronic pain (Van Zee 2009). It was to be the first of the opioid class to skirt the problem of addictive potential, but still retain its potent analgesic properties.

In addition to heavy investments in educational symposia, promotional gifts embossed with the Oxycontin® logo, and free Oxycontin® samples and coupons for patients, Purdue Pharmaceuticals hired a cadre of 671 drug representatives to bring the good news of this minimally addictive opioid to a call list of almost 100,000 physicians across the country. By 2003, half of Oxycontin® prescribers were primary care physicians, who used this designated magic bullet for everything from cancer to lower back pain. Several states including Maine and West Virginia reported increases in numbers prescription opioid abuse patients of 500 percent or more in the first five years after Oxycontin® was released, with similar increases in opioid overdose deaths (Van Zee 2009). Opiate naïve patients soon discovered that their need to use escalating doses for the same pain relief, and their discomfort when missing doses, meant that they had developed an opioid tolerance and dependence; patients with preexisting drug habits soon found they could crush the time-release capsule and inject or snort the contents for a dependable, “pharmaceutical grade” heroin-like rush (Butler et al. 2011; Cicero et al. 2005). Doctor and dentist shopping for additional Oxycontin® prescriptions, and vibrant black markets in Oxycontin® and sister prescription opioids Percocet® and Vicodin® became commonplace. In keeping with the demographics of the U.S. insured middle class who have easiest access to expensive new nongeneric, on-patent, nonformulary drugs, prescription opioid abuse was associated with a white, often privileged clientele; the Oxycontin® habits of celebrities such as Rush Limbaugh were featured in the popular press (CNN 2003). By 2004, prescription opioids had outstripped heroin as the major opiate of abuse in the United States, and by 2010 prescription medications became the most abused class of substances among U.S. high school seniors (National Institute of Drug Abuse [NIDA] 2011). Purdue Pharmaceutical executives, likely aware of the financial potential of the black market they had stoked with their wide-ranging drug promotion campaign (Singer 2008), paid $634 million in fines for criminal charges based on misrepresentation of Oxycontin's addictive potential (Van Zee 2009), a sum that was dwarfed by the $3 billion that Purdue gained in Oxycontin profits in 2009 alone.

The prescription opioid abuse epidemic of the late 1990s–2000s came on the heels of a rise in the number of middle class, white heroin users as well. Beginning in the late 1980s, newly planted heroin harvests in Colombia led Latin American cartels to compete with Middle Eastern and Asian heroin suppliers in a purity and price war that left street heroin dramatically purer, cheaper, and easier to snort, encouraging middle-class drug users in the United States to turn to heroin (Hamid et al. 1997). These middle-class heroin users, and the even larger cadre of prescription opioid abusers emerging in the 1990s, posed a problem for the U.S. addiction treatment system. Treatment adherence rates for opioid dependence in biomedical clinics were low, except those of methadone clinics, whose patients had higher retention rates and lower illicit drug use rates than those using medication-free treatment modalities (Mattick et al. 2003; Sees et al. 2000).

Opioid maintenance was not readily available either: since the 1914 Harrison Narcotic Act, individual physicians had been barred from treating opiate addiction with opioid maintenance. This historical segregation of opioid maintenance from the mainstream of clinical medicine was partially challenged by methadone researchers at Rockefeller University, Vincent Dole, Marie Nyswander, and Mary Jeanne Kreek, who in 1966 began publishing their clinical trials of methadone maintenance in mostly African American heroin dependent patients from Harlem (Dole et al. 1966). Their research team made a strong biological argument for methadone maintenance: that opiate dependence was a disease of opiate receptor deficiency, analogous to diabetes, requiring opioid replacement therapy, just as diabetes requires insulin. Ultimately the measured outcomes of interest were not biological, however; they were social. It was the dramatically lower rates of crime committed by patients after methadone treatment, and their high rates of employment six months into methadone maintenance, that got national attention. Based on these findings, by 1971 President Nixon launched a network of methadone clinics as part of his War on Drugs to combat a raging heroin problem among returning Vietnam veterans, and among African Americans and Latinos in inner cities (Kuehn 2005).

Thus, methadone was associated with Blacks and Latinos living in poverty, with crime and with the rundown neighborhoods in which methadone clinics were permitted to operate. Methadone treatment was often given in settings more resembling correctional facilities than medical clinics. Tightly regulated by the DEA and often segregated from biomedical campuses, the clinics required daily onsite dosing under the observation of a nurse and guards, regular urine testing, and sanctions for violation of clinic rules. As one addictions specialist working as a high ranking official in the Bush I administration of the 1990s told us of middle-class opioid dependent patients: “People with good jobs didn't want to wait in line for methadone with people just off the street.” Furthermore, he explained, he did not want those with stable jobs and lives to be exposed to the illicit drug trade that is often found outside methadone clinics, where some patients barter their weekend take-home doses for the benzodiazepine sedatives (like Xanax® and Valium®) that they combine with methadone to achieve a boosted euphoria. Buprenorphine, prescribed monthly in private doctors’ offices, offered a clean clinical atmosphere removed from poverty, ethnic minorities, and street crime.

The prescription opioid abuse epidemic of the late 1990s–2000s also came on the heels of President George H. W. Bush's Decade of the Brain, a decade during which NIDA devoted its research agenda to biotechnological treatments for addiction and basic science locating the cause for addiction in the brain and biology of individuals (Vocci et al. 2005). At the end of the Decade of the Brain, in 2000, a widely cited article was published by leading addictions researchers in the Journal of the American Medical Association (JAMA) entitled “Drug Dependence, A Chronic Medical Illness” (McLellan 2000). It demonstrated that chemical addictions were comparable to diabetes, asthma, and hypertension in terms of heritability, contribution of environment, and treatment adherence. The article argued that these similarities called for addiction to be treated as a chronic physiological disease, in general medicine (as opposed to psychiatric) settings, with pharmaceuticals. This flew in the face of the received wisdom both inside and outside of medicine, that addiction was a problem of morale if not morality, requiring psychotherapy or support groups to address the emotional and characterological roots of self-destructive behavior. Addiction treatment had long been excluded from “real” medicine, with widespread neglect of addictions in U.S. medical training (Soyka and Gorelick 2009), despite the fact that addiction is one of the leading causes of death in the United States (CASA National Center on Addiction and Substance Abuse at Columbia University 2009). In fact, addicted people are barely considered patients, as most physicians in opinion surveys say they would prefer not to treat people with addiction (Soyka and Gorelick 2009). In reaction to these attitudes, addiction specialists across the country used the JAMA article to campaign for placing addictions treatment in the mainstream of biomedicine, with the idea that fully biomedicalizing addiction, treating it in the same clinics, and in the same way as other chronic diseases—that is, with long-term medication, would destigmatize addiction, end decades of punitive addiction treatment, and desegregate addiction treatment from mainstream medicine.

OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED

In pursuit of this vision of fully biomedicalized addiction treatment, in 2002 the FDA approved the synthetic opiate buprenorphine for maintenance treatment of opiate dependence in private, buprenorphine-certified doctor's offices. Two years prior to this, the U.S. Congress passed a law that legalized office-based treatment of opiate dependence with Schedule III narcotics (Jaffe and O’Keeffe 2003). This law—the Drug Abuse and Treatment Act, or DATA 2000, did not name buprenorphine specifically, but a former Office of Narcotic and Drug Control Policy official who had a central role in crafting the legislation explained to us in an interview that the law was designed with buprenorphine in mind. Accordingly, buprenorphine's manufacturer, along with prodrug maintenance legislators and researchers, pressured the FDA and DEA to make buprenorphine a Schedule III drug, which would categorize it as at low to moderate risk of creating dependence, and subject to less surveillance than high risk schedule II narcotics (such as Oxycontin®). Pharmacologically similar to methadone, in that it blocks opiate receptors in the brains of addicted patients, buprenorphine can be prescribed monthly for use at home, while methadone is restricted to DEA regulated clinics that require direct observation of patients taking their doses. Officially, the manufacturer, Reckitt Benckiser Pharmaceuticals gained approval for office-based use of buprenorphine based on buprenorphine's pharmacological advantages over methadone. It is a weaker opioid than methadone, and is therefore less likely to cause overdose. Also, it is manufactured with another drug, naloxone, which causes withdrawal if it is injected, rather than dissolved under the tongue as prescribed. Based on these differences, Reckitt Benckiser Pharmaceuticals persuaded the FDA that buprenorphine is a safer and less abusable drug than methadone, and can therefore be taken at home.

A less official version of the story involves the selling of office-based buprenorphine to the DEA and the FDA based on its race- and class-specific market. The DEA had long been opposed to the unregulated use of opioids, and the popular imagery of methadone as a treatment associated it with criminality, and with Black and Latino poverty. The emerging prescription opioid epidemic presented an optimal market for office-based buprenorphine maintenance. Not only was the patient population middle class and insured, with access to private physicians who could prescribe buprenorphine, but also the whiteness and class background of its targeted clientele reduced federal anxieties about buprenorphine's potential street sales. The potential for buprenorphine to be diverted to the streets and create yet another opioid black market had long been a preoccupation of the DEA. As explained to us by a pharmaceutical researcher who contracted to collect pharmaceutical diversion data, Reckitt Benckiser Pharmaceuticals voluntarily established an extensive monitoring system involving a national network of local law enforcement offices and regional researchers to collect diversion data. This data was for private use by the Reckitt Benckiser, but the company agreed to share it with the DEA. In a form of public–private partnership, the manufacturer collected data not only on illicit sales of buprenorphine but also collected analogous data on a host of other commonly abused prescription drugs, providing valuable pharmaceutical diversion information for the Federal government. This diversion monitoring apparatus, and resource sharing agreement, predisposed the DEA to schedule buprenorphine at level III (Campbell and Lovell 2012). Congressional hearings identifying the growing ranks of opiate dependent “suburban youth”—coded language for middle class and white—as the clientele for buprenorphine (Netherland 2010) also likely contributed to the DEA's less restrictive scheduling of buprenorphine. This qualified buprenorphine for office-based treatment under the DATA 2000 act, in contrast with other opioids including Methadone, Oxycontin®, Percocet® and Vicodin®, all of which are Schedule II, considered higher risk, with restrictive dispensing rules.

The sociocultural specificity of buprenorphine as a white middle-class drug in the United States, and the importance of this identity for overcoming a century of U.S. governmental and public resistance to the use of opioids to treat opiate addiction, is clear when looking to other countries. France was one of the first countries to adopt buprenorphine maintenance as a treatment for opiate dependence, and now has one of the highest buprenorphine prescription rates in the world (Fatseas and Auriacombe 2007). Since 1996, the French government promoted buprenorphine use among primary care doctors for opiate dependence, and its prescription was less regulated than in the United States; physicians were not required to complete buprenorphine certification to prescribe it. The social identity of buprenorphine and the political reasons for its promotion are different than those of the United States: from its introduction in France, advocates for buprenorphine were activist primary care doctors caring for impoverished immigrant heroin injectors in suburban low income housing developments. They saw buprenorphine treatment as an HIV prevention tool consistent with the public health philosophy of harm reduction: a philosophy that has met with considerable resistance in the United States since the beginning of the HIV epidemic. As a result, the majority of buprenorphine maintenance patients in France are low income immigrant heroin injectors (Lovell 2006). And despite the seamless argument made by the buprenorphine manufacturer to the U.S. FDA, that buprenorphine is less abusable than methadone, because as a weaker opioid receptor agonist it causes less euphoria, buprenorphine has become the most abused opioid in France and in other countries including Finland (Aalto et al. 2007) and Malaysia. In fact, in Malaysia it is the buprenorphine formulation that is manufactured in combination with the opioid antagonist naloxone—the very formulation that was claimed to cause withdrawal when injected—that is the most abused formulation: Malay injectors claim they feel negligible discomfort from naloxone (Bruce et al. 2009). In the United States, the fact that buprenorphine is used by middle class, less socioeconomically dislocated opiate dependent people than methadone users may itself contribute to the lower rates of buprenorphine misuse than of methadone. But in addition, the association of buprenorphine with the white middle class may have shielded it from scrutiny of the international literature on buprenorphine's abuse and diversion; scrutiny that might have challenged the manufacturer's claims to the U.S. FDA.

ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED

From the beginning of buprenorphine's release, under the trade name Suboxone®, for treatment of opiate dependence, signs of the manufacturer's targeting of white, middle-class prescription opioid dependent consumers were evident. Because of negotiations with the manufacturer, the DEA required physicians to complete an eight hour certification course in the use of buprenorphine for opiate dependence, and certified prescribers had to have a special prescribing number to write buprenorphine prescriptions. This was the first time such a training and certification requirement had been placed on physicians to use a particular drug. Because this requirement severely limited the number of eligible prescribers, most of whom turned out to be specialists in private practice, rather than primary care doctors in public clinics, the U.S. Federal Substance Abuse and Mental Health Services Administration worked with the manufacturer to develop an online referral system that patients seeking buprenorphine treatment could use to identify a certified prescriber. This system presumed a clientele with regular access to information about new biomedical treatments for addiction, and with the computer literacy to seek treatment by searching for online resources.

Suboxone® was advertised primarily over the internet, with public service announcements launched on the website of the National Alliance for Advocates of Buprenorphine Treatment (naabt.org), a nonprofit that is financially sponsored by Reckitt Benckiser Pharmaceuticals. These public service announcements featured people like Mike, a white diner owner living in Ohio with his wife and two children. Mike, an all-American who tells his story seated in between two U.S. flags that adorn the wall of his diner, is a singer in his church choir and is coach of his son's baseball team. Tearful, he relates becoming inadvertently addicted to his opioid painkillers after a back injury sustained while repairing his diner. As Mike tells it, “I didn't think it could happen to me,” but he was relieved when he found a buprenorphine-prescribing private physician who “got me my life back” using new treatment technology.

Yet, for all of the excitement about buprenorphine as a new treatment for opiate dependence, buprenorphine was an old drug. It was first introduced in the early 1970s as an analgesic, developed in the laboratory of a British chemical firm, then Reckitt-Coleman. Reckitt-Coleman, now Reckitt-Benckiser, was and is a major manufacturer of household products including Easy Off®, Woolite®, and Lysol®. Burprenorphine was the only prescription pharmaceutical to which Reckitt-Coleman held patent rights, and in time, the company would create a single drug subsidiary, Reckitt-Benckiser Pharmaceuticals, to manage buprenorphine's marketing. Initially Reckitt-Coleman promoted buprenorphine as a minimally addictive opioid pain reliever, based on early clinical trials indicating that it created less dependence than morphine. However these early findings did not hold up postmarketing against clinical experience, and buprenorphine was not the blockbuster that the manufacturer had hoped. Researchers from the National Institute on Drug Abuse saw buprenorphine as a potential treatment for opiate dependence, but as a former NIDA researcher who worked on the early (1970s) clinical trials of buprenorphine for opiate dependence explained to us in an interview, the company was not interested at that point in being associated with a stigmatized condition like addiction.

By the early 1990s, however, the drug had still not found market niche as a pain reliever, and NIDA officials reapproached the manufacturer to discuss marketing buprenorphine for opiate dependence. As part of the Decade of the Brain's focus on the neurochemistry of addiction, NIDA had made development of pharmacological treatments for addiction a national priority, and buprenorphine was one of the only promising drugs on the horizon. To entice the company into the addiction treatment market, NIDA ultimately awarded $23 million in grants for clinical trials of buprenorphine for opiate dependence, collaborated with the manufacturer and key legislators to pass the DATA 2000 act, and later persuaded the FDA to approve buprenorphine for office-based opioid maintenance treatment. In addition, NIDA officials facilitated a patent extension for buprenorphine through 2009 to protect the manufacturer's profits under an orphan drug designation that was originally intended to stimulate drug development for tropical diseases in low-income countries (Jaffe and O’Keeffe 2003). The strategy paid off handsomely for Reckitt Benckiser. With multiple governmental subsidies in place, Reckitt Benckiser went on to increase its sales of Suboxone steadily at 50 percent per year, and to earn $3.4 billion between 2005 and 2010 in the United States and Australia (Reckitt Benckiser Pharmaceuticals 2009, 2010).

Buprenorphine is actually the latest entry in a long line of opioid medications marketed by pharmaceutical companies as nonaddictive pain relievers and treatments for opiate addiction; nonaddictive opioids have long been the Holy Grail of pharmaceutical discovery. For instance, heroin was marketed by Bayer corporation in 1898 as a nonaddictive pain medicine and treatment for morphine addiction (Courtwright 2001). By the 1940s, heroin addiction was first treated with methadone, an opioid synthesized in Germany during WWII as a pain medication; with time, however, illicit markets for methadone developed and methadone's own addictive potential was acknowledged (Kuehn 2005). By 1996, after FDA approval, Oxycontin was heavily promoted as a nonaddictive treatment for pain. Then in 2002, buprenorphine, having failed to sell as a nonaddictive pain reliever because it was shown to be addictive, was marketed among primary care doctors by Reckitt Benckiser pharmaceuticals as a treatment for Oxycontin addiction.

At the same time, buprenorphine's approval was novel. It represented the first time since the 1914 Harrison Act that generalist doctors were permitted to use opioids to treat opiate addiction. Addiction specialists hail it as a sea change in the culture of medicine: treating addiction in the same settings as other chronic medical conditions, and desegregating addiction treatment from the rest of clinical medicine. This breakthrough in federal law was the result, on the one hand, of a campaign on the part of addiction advocates in federal agencies, who saw in buprenorphine a route to less stigmatizing forms of pharmaceutical intervention than methadone. On the other hand, it was the result of Reckitt-Benckiser Pharmaceuticals search for a new market niche for buprenorphine. The targeting of white middle-class consumers helped buprenorphine's manufacturer to reduce the stigma associated with addiction treatment, minimizing risk to their profits and their public image.

For addiction treatment advocates, buprenorphine marked the coming of a golden age of smart drugs that could crack even the stubborn problem of addiction, the problem that pulls even the most technically skilled doctors into a moral and social morass, as their interventions are continually met with relapse and resistance. But as smart as buprenorphine might be, as one noted buprenorphine researcher admitted to me, the most important difference between buprenorphine and methadone is that buprenorphine is not called methadone. It does not call up the image of homeless black and brown people waiting outside makeshift clinics on the other side of the tracks, and therefore does not have the same DEA restrictions.

And in fact buprenorphine users are different than methadone users. A national survey of buprenorphine users published four years after buprenorphine's FDA approval identified users as 92 percent white, over half employed at baseline, over half with at least some college education, and 75 percent prescription opiate addicted. The survey compared these percentages to those of methadone patients, who nationally were only 53 percent white, 29 percent employed at baseline, and 19 percent with some college education, most of whom injected heroin (Stanton et al. 2006). My own quantitative research with collaborators at the Nathan Kline Institute for Psychiatric Research, studying New York City as the U.S. city with the largest number of opiate dependent people, found that even after a major New York City initiative to promote the use of buprenorphine in public clinics, the vast majority of buprenorphine prescriptions are written in high income, mostly white neighborhoods, while the majority of methadone clinic patients live in low income, largely Black and Latino neighborhoods (Hansen n.d.).

NEUROPOLITICS ON THE GROUND

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED

Ironically, the attempt to fully biomedicalize opiate addiction, and thereby eliminate the stigma of addiction, by treating it with long-term pharmaceuticals in physicians’ offices, has led to forms of ethnic marketing that heighten stratification and stigma by race. It has produced what sociologist of racial genetics Troy Duster would call the molecular reinscription of race (Duster 2006), in this case via pharmaceuticals. Rather than mainstreaming marginalized addicts, biomedicalization of addiction has in many cases led to a physiologically reinforced hierarchy of power, a hierarchy bitterly resented by both our methadone and buprenorphine maintained informants in the clinics we observed for this study.

One of our main research sites was the only public clinic in its large metropolitan region to offer buprenorphine maintenance. This created the novel situation of a group of low income black and Latino patients on buprenorphine treatment, counter to the pervasive trend of white, middle-class buprenorphine usage. But escape from restrictive methadone clinics did not necessarily mean freedom and equality for this group of Medicaid insured and uninsured patients. Raul, a 54-year-old Puerto Rican man had received years of methadone treatment, managed to switch to buprenorphine, but found himself dependent on local pharmacists that he found racist. When they delayed ordering his buprenorphine, he ran out of his home supply and experienced withdrawal, a reminder that despite his take-home prescriptions he still did not control his fate: as he said, “I’m hooked—I’m still hooked!”

Despite buprenorphine's promise of enhanced autonomy for patients, buprenorphine patients in our study were still preoccupied with the locus of control around their prescriptions and how they took their medication. Patients obsessed over how often they scheduled doctors’ visits, who decided how many times a day they took buprenorphine and at what dose, whether and how they took other medications or drugs along with buprenorphine. They struggled to reconcile feeling “normal” on buprenorphine, with being physiologically dependent on a powerful opioid. They aspired to be drug free, and many attempted to taper themselves off of buprenorphine against the advice of their doctors. Some patients had their own political-economic critique of buprenorphine maintenance, pointing out that they were enriching drug companies by staying on long-term treatment for a condition defined as a chronic physiological disease.

We also found ethnic, racial, and socioeconomic differences in how patients related to providers. White, educated patients often took comfort in the rituals of professional consultation offered in a doctor's office. Many talked about the technical competence and credentials of their doctors, they described themselves in terms of their diagnoses and their responsibility to get treated. African American and Latino patients, most of them Puerto Rican or Dominican, did not always accept physicians’ authority based on their credentials but often focus on their doctors’ interpersonal qualities and whether they can be trusted. Most working-class patients, including white patients, were attuned to how welcoming and socially accessible their doctors are. They also told stories of institutional violence by hospital staff. Several patients reported that they never mention their addiction when they go to the hospital for physical problems, because if they do the staff will not treat their pain, and may not even examine or treat their presenting condition. One man described his hospitalization for severe phlebitis when he was actively injecting heroin: “I learned about rounds. Rounds is when the head doctor comes in with about 10 other people first thing in the morning, yanks off my gown, points to a huge boil on my butt and tells them I’m an addict.”

Prescribers, for their part, worked hard keep buprenorphine in the cultural frame of a prescription medication, rather than a pleasure giving opioid. They reminded patients to take it at the same time, every day, as prescribed, preventatively “like a vitamin,” and not to manage the dosing themselves. Doctors spent time assessing whether patients felt pleasure from their doses, which would be an indication to lower their dose, and assessing whether patients were sharing, or diverting their buprenorphine for sale, which would be illegal. The neuroeconomic structures of opioid sales and regulation put these physicians in a double bind of treatment: they could not approach their patients solely from the point of view of their patients’ symptoms and suffering, but had to balance these concerns with their awkward role as gatekeeper to a highly profitable commodity, potentially implicating them as physicians in illegalities, and calling on them to judge the boundary between legitimate relief of suffering and undue pleasure.

This type of discussion went along with disciplining of drug users into clinical routines: staff meetings were consumed with talk about behavioral contracts regarding consequences for missed appointments, late arrival for appointments, and lost prescriptions. A clinic administrator joked that her patients never came for scheduled visits but called her on their cell from a car downstairs when they needed a prescription, as if she was a dealer. One astute addictions specialist identified the issue as trust. As she put it, it's understandable that people who are routinely denied medical treatment because they use substances would hesitate to give control over to a doctor. And we interpreted this to mean that it is difficult to destigmatize addiction by biomedicalizing it, if biomedical institutions have been such potent sources of discrimination against addicted people.

CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED

As science studies scholar Dorothy Roberts wrote of race in the United States, race may be the reason that the United States does not have a national health plan (Roberts 2011). In other words, the industrial fabric of the United States, and particularly its consumer base, rests on a foundation of racial, as well as class, stratification that sustains the capitalist individualism of our time. Prescription opioids and their treatments are a recent chapter in this continued story of marking one treatment sector by nonwhite race to unmark (mainstream into biomedicine) another sector using white race. The biomedical sector of the U.S. economy, just like other sectors of the economy, relies on race to indicate the status of biomedical goods and services, and to channel consumers accordingly. Racialized patterns of biomedical treatment are a product not only of income related disparities in insurance coverage and ability to pay but also are the product of segmented marketing strategies in which high end goods and services are marketed based on the exclusivity of their clientele. Those biomedical goods and services marketed to a largely white, upper-income clientele are presented as race-free, technological advances based on pure science stripped of social baggage (such as the partial opiate receptor agonist theory of buprenorphine's lower abusability), whereas those marketed to marginalized ethnicities carry the mark of social contexts and less biological, and therefore less universal, indications (such as criminality and employment as outcome measures for buprenorphine treatment).

Particular to opioid pharmaceuticals, however, are their neuroactive properties. A new cohort of people, having become dependent on opioid analgesics that are directly marketed to them and to their physicians, is now faced with treatment consisting of physiological dependence on another opioid (buprenorphine) that is directly marketed to them. Unlike methadone patients, this more affluent group of prescription opioid abusers are too politically and financially empowered to tolerate the obvious governmental surveillance and control epitomized by methadone; they are led into a profit-driven system of consumption and dependence through the use of free market techniques that give the upper hand to addictive commodities that yield neurophysiologically guaranteed returns. Buprenorphine thus conforms to a prevailing trend of privatization and commodification of health care through development and marketing of targeted molecular technologies; to what sociologist Adele Clarke calls biomedicalization (Clarke et al. 2003). Methadone clinics fall into an older tradition of reframing problems formerly thought of as social or moral deficits into medical terms, involving treatment in settings that are often publicly funded and that discipline newly recognized “patients” into a paternalistic clinical subjectivity, a process that Peter Conrad has called medicalization (Conrad 2005). Yet even the process of medicalization of methadone is incomplete: the physical segregation of methadone clinics from the rest of medical practice, the direct regulation of methadone clinics by the DEA, the requirement of directly observed dosing and regular urine narcotic testing for methadone patients, and the continued political challenges to the legitimacy and legality of methadone maintenance as a treatment modality indicate that methadone treatment lies somewhere between the clinic and the penal colony, blurring the distinction between clinical and correctional forms of social control for lower income, heroin injecting addicts.

The biopolitics of opioid analgesics, now among the most consumed, profitable and therefore socially influential commodities in the United States, if not the world, are characterized by ethnic, racial, and socioeconomic market segmentation. Both the abused opioid—injected heroin versus oral prescription Oxycontin®—and the treatment for its abuse—buprenorphine versus methadone—involve the sharp social distinction and segmentation of pharmacologically similar agents. This ethnicity- and class-marked segmentation, a pervasive element of U.S.-based capitalism, both perpetuates and creates social stratification: buprenorphine patients are more mainstreamed and biomedicalized than methadone patients; in particular, white and higher income buprenorphine patients are defined as consumers or patients by the privatized health care industry, while methadone patients are symbolically criminalized in high surveillance publicly funded clinics segregated from the medical mainstream. The segmented market for addiction medicine thus acts to reconcile standing tension between alternate framings of addiction, as a biomedical versus moral disorder, by distinguishing between two populations, and distinguishing between two socially distinct (albeit pharmacologically almost identical) addictions: heroin and prescription opioids.

Ultimately these findings point to the need for intervention on the structures underpinning disparate neurological experience, those that fuel inequalities in the consumption and prescription of neuroactive substances. Neuroeconomic analyses that synthesize political economic with cultural explanations for variation in addiction experiences and treatment point to the hand of corporate industries in shaping local biologies; the “biosocial differentiation” takes place through interactions of social and biological processes over time that sediment into variation by population (Lock and Nguyen 2010). Missing in many medical anthropological studies of the biologically formative power of social process, however, has been a focus on corporations and industrial cultures (Benson and Kirsch 2010). The power of industrial cultures has been demonstrated in a wide range of biological sites, from the “bioethnic conscription” of research subjects in the burgeoning industry of genetic medicine (Montoya 2007) to the interwoven cartels of licit and illicit drug trade (Singer 2008). In the case of addiction treatment, the disparate tracks of methadone and buprenorphine call attention to segmented marketing practices, pharmaceutical industry deregulation, and the hidden power of racial segregation as part of an economy of distinction in contemporary U.S. markets as points of intervention in neuroeconomic inequality.

REFERENCES CITED

  1. Top of page
  2. Abstract
  3. THE RISE OF PRESCRIPTION OPIOIDS
  4. OFFICE-BASED OPIOID MAINTENANCE AS NEUROECONOMIC STRATEGY
  5. ETHNIC MARKETING AND THE NEUROECONOMICS OF STIGMA
  6. NEUROPOLITICS ON THE GROUND
  7. CONCLUSION: THE CONTINUED (NEURO) ECONOMIC CENTRALITY OF RACE
  8. REFERENCES CITED
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