In a radical departure from almost a century of U.S. drug policy, in October 2002, the U.S. Food and Drug Administration approved the use of the pharmaceutical, buprenorphine, to treat opioid dependence in office-based settings. Unlike methadone, which remains mired in restrictive government oversight and requires daily attendance at a highly regulated clinic, buprenorphine is available through any certified physician in any office–based setting. As such, buprenorphine marks a profound change in how, where and by whom drug treatment is delivered. For the first time since the passage of the Harrison Act in 1914 and subsequent court decisions (through which doctors were expressly forbidden to treat addiction by prescribing narcotics), doctors can treat addiction to opioids (heroin and prescribed opioid medications) by prescribing a drug/medication. Buprenorphine is the first, and to date, the only medication approved for the office-based treatment of opioid addiction, but an increasing number of medications are being developed to treat a wide array of addictions. As the leading edge of this movement to treat addiction through prescription, buprenorphine has been heralded by addiction medicine experts as the technological breakthrough that will finally move the treatment of addiction into the medical mainstream.
Conrad and Schneider (1992) have noted the escalating medicalization of deviance through which behaviors once viewed as moral failings are increasingly viewed as illnesses. One hallmark of medicalization has been the widespread adoption of medications to treat problems previously understood as behavioral (Diller, 1999). However, neither alcoholism (Valverde, 1998) nor drug dependence (Smart, 1984) fit easily into the medicalization model, even though the medical model of addiction dates back to the 1800’s and has gained in prominence in the U.S. over the past thirty years. Medical responses to addiction that frame the problem as a failure of biochemistry or genetics continue to co-exist uneasily with behavioral and legal responses that frame the problem as failure of will or a crime. Thus, the world of addiction and addiction treatment has been and remains one of contestation, confusion, and slippage. Buprenorphine enters directly into this contest as the first real medical “solution” to opioid addiction since the introduction of methadone four decades ago. It represents a clear attempt by medical professionals and the pharmaceutical manufacturer to further medicalize addiction and to resolve some of the discursive ambiguity surrounding addiction treatment. As such, it offers a unique opportunity to study the processes and conditions of medicalization and to explore how and why criminal and medical models to explain addiction continue to coexist.
In addition to exploring processes of medicalization, this project is concerned with the sociology of body and the relationship between the social construction of addiction and the formation of the self. The body has increasingly become a site where notions of self and identity are both produced and regulated (see for example, Budgeon, 2003; Butler, 2004; Pitts-Taylor, 2003; Shilling, 2003). Doctors play a particularly important role in labeling and legitimizing bodies and in managing subjective experiences of our bodies (Shilling, 2003), and biomedical technologies (Persson, 2004), like buprenorphine, are intimately and importantly involved in the production of self. However, the ways in which medical rhetoric about addiction and these new treatment technologies affect the interiorization and embodiment of medicalized identities is poorly understood.
Using interviews with doctors who prescribe buprenorphine and patients who take it as well as an analysis of documents about the introduction of buprenorphine in the U.S., I will examine how buprenorphine is being socially constructed and how new drug treatment technologies, like buprenorphine, are embodied and understood by the people who use them, how it shapes their subjectivity and identity, and what new possibilities for freedom or constraint these new identities offer.
Great analysis around the medicalization of deviance and dx previously considered behavioral.... super interesting - I wonder if there are any parallels with the whole movement to integrate behavioral health tx into medical homes or if its coincidental.
ReplyDeleteexcellent intro! it's really very good and clear. one question i have is; how do people come to see themselves as "addicts" needing "medical treatment" by doctors in the form of buprenorphine? the courts are often the place where people are told they are addicts in need of (mandated) treatment. how does it happen with someone who seeks buprenorphine from a doctor?
ReplyDeleteHi Zombie Mom. I think the parallels to some psychiatric illnesses are striking. I don't think many medical doctors are interested or trained to treat conditions that are purely behavioral (though a lot of what they do is trying to change behavior), but increasingly there seems to be this idea that medical clinics should and can treat illnesses/conditions/social problems that have both a "medical" and a "behavioral" component. Take depression and SSRI's; diabetes and insulin; addiction and buprenorphine.
ReplyDeleteTiger, great question. In my research, none of my participants are 'treatment naive.' They've all been around the block and have probably been socialized (or coerced) to think of themselves as addicts for decades. I think all of the folks I interviewed had been to a methadone clinic. Are people being mandated to bup treatment? Not usually as far as I know. Isn't mandated treatment still largely behavioral? Really interesting to think about the folks who get hooked on prescription opioids and then somehow end up on buprenorphine. Do they think of themselves as addicts? If so, how?
One of the things I am looking at for a slightly different project is the degree to which folks taking bup have internalized the "brain disease" rhetoric. So sort of another window on the ways in which people understand their own addiction and where those messages come from. So far in my analysis, most folks don't actually seem to be embracing the brain disease language or even a medical model, for that matter. For many, addiction is still viewed as a failure of their own will or character. Not coincidentally, while many credit bup as helping them 'kick the habit (there's an interesting turn of phrase), they also see their own choices and efforts as playing a key role in overcoming addiction.
thanks for your comments! keep them coming.