TY - JOUR
AU1 - Sherman,, Melina
AB - Abstract This article develops an analysis of the U.S. opioid epidemic that examines the ways in which opioid drugs have been branded and sold to a growing base of consumers. The article expands on existing literature related to branding, which argues that branding functions as a mechanism of governance—a means of “conducting the conduct” of potential consumers. Equally important, the author suggests, are the ways in which branding has been mobilized by opioid manufacturers as a tool for responding to the ongoing crisis of overdoses and deaths. Thus, examining the branding of opioids enables us to better understand why these drugs continue to be prescribed and consumed, despite public awareness of the dangers associated with their use. The ongoing U.S. opioid epidemic is a topic that has been making headlines for some time. Nearly every day, we are confronted with tragic images that narrate its progress: We hear of the small Rust Belt towns whose abandoned factories are now occupied by the addicts who once worked there (Achenbach, 2016; Quinones, 2015), of cars crushed into twisted balls of metal—the result of drivers overdosing at the wheel (Ingraham & Johnson, 2016; Siemaszko, 2017), of a growing population of children being raised by grandparents, and of grandparents burying their children (Seelye, 2016). These tragedies are also paired with a proliferation of statistics: the dwindling life expectancies of the White working class (Achenbach & Keating, 2017; Case & Deaton, 2015; Rugaber, 2017) and the waves of overdose deaths attributed to prescription painkillers, which, over the past decade, quadrupled to reach more than 22,000 in 2015 (Centers for Disease Control and Prevention [CDC], 2016; Rudd, Seth, David, & Scholl, 2016). This wave of tragedies, which began more than a decade ago, shows no sign of receding (Katz, 2017). This upsurge in opioid-related overdoses and deaths is also reflective of a dramatic shift in the practice of treating pain, which has become heavily oriented toward the prescription and consumption of narcotic painkillers. Yet for most of the 1990s, the medical community’s attitude toward prescribing opioids was reluctant at best. This period has been characterized as one of intense “opiophobia,” a term that reflects the wariness of many physicians to write prescriptions for substances they understood to be highly addictive and dangerous (Dahl, 2002; Morgan, 1989). During this period, physicians typically only turned to opioids as a last resort for patients suffering only the most agonizing forms of cancer-related pain. Yet, starting in the mid-1990s, another idea gained traction, one that held that most doctors were undertreating pain and that opioids were not as addictive as previously thought (Meldrum, 2016; Quinones, 2015). Then, in the following decade, sales of prescription painkillers quadrupled (CDC, 2016). In 2010 alone, enough opioid scripts were written to keep every single American adult medicated 24 hours a day for an entire month (CDC, 2011). Seemingly overnight, opioids have become household objects, objects that anyone might stumble upon—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 a dangerous medicine of last resort to a household object and standard for treating pain—is jarring. And yet, this shift has not occurred by accident. It is my contention that the normalization of opioids—both within and outside of medicine—has been conditioned their branding. To that end, this article develops an analysis of the branding strategies underlying the promotion of Purdue Pharma’s blockbuster drug, 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 that fosters a relationship between people and products and functions as a mechanism of governance—a means of “conducting the conduct” of potential consumers (Elliot, 2003; Foucault, 1991; Miller, 2008; Rose, 2006; Swenson, 2010). Indeed, the branding of OxyContin signals a desire of opioid manufacturers to govern the behavior of consumers—whether they may be 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 opioid 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’s insatiable appetite for profit (e.g., Bourdet, 2012; Meier, 2001; Meier & Peterson, 2001). While I would caution against the argument that pharmaceutical companies are solely responsible for the escalating death toll, I do not deny that they have played an important role in the cultivation of demand for opioid products. 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 (at the time of this writing, two states—Ohio and Tennessee—have filed lawsuits against opioid manufacturers [including Purdue] over the opioid epidemic), and public outcry regarding the dangers they pose to society (Ingraham & Johnson, 2016; Pérez-Peña, 2017; Satterfield, 2017). Thus, I organize the pages that follow accordingly: First, I develop a review of the literature on pharmaceutical branding alongside an overview of the various promotional strategies that have been used to market OxyContin. The following section develops an analysis of Purdue Pharma’s branding of opioids on two websites, both of which were created by the company. Following my analysis, I present my conclusions—all of which speak to the ways in which these websites illustrate how the branding of opioids functions not only as a means for selling them but as a political technology that is oriented toward the governance of patient behavior and clinical practice, and that proceeds through positioning opioid products as a unique (if somewhat contradictory) solution to the opioid epidemic. Branding, pharmaceuticals, and governmentality Branding, as many scholars have noted, is a key activity within commercial capitalism and plays a central role in the process of capital accumulation. As Banet-Weiser (2012), Ouellette (2012), Hearn (2010), and others have noted, branding is not only a crucial mechanism that sustains the growth of markets, but 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 to products, as well as to their own experiences, values, and the world around them (Banet-Weiser, 2012; Hearn, 2010). Through meaning making, branding acts not only on consumers’ behaviors but also on their minds, bodies, and selves, which, as 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 the U.S. health industry which, unlike the health industry in any other country (except New Zealand) allows companies to advertise 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 may be understood as a means of “selling sickness,” in which pharmaceutical companies enroll in the definition and design of new disorders, which they then use to interpellate a growing population of individuals as sick or potentially sick (Dumit, 2012; Moynihan & Cassels, 2005). However, branding in the drug industry not only works toward the promotion of pharmaceutical products but also functions as a political technology and mechanism of governance—one that attempts to shape the conduct of potential consumers and to condition the formation of new kinds of subjectivities in ways that align with companies’ profit motives (Elliot, 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, learned that the 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 rewarded by nearly immediate success: Just 1 year after its release, OxyContin had garnered more than $48 million in profits. In 2001, this number skyrocketed to a whopping $1.1 billion, surpassing the sales of Viagra, which had formerly been the most popular drug on the market (Bourdet, 2012; Van Zee, 2009). 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. Indeed, Purdue’s marketing campaign for OxyContin was impressive—wide-reaching and highly targeted, comprised of a variety of promotional practices that targeted not only physicians and patients but also nurses, pharmacists, and insurers. In 2001 alone, Purdue spent $200 million in the marketing and promotion of OxyContin, a number which is not uncommon for large pharmaceutical companies but represents a hefty expenditure for Purdue, a family-owned business with a much smaller staff (and budget) than many of its competitors (OxyContin, 2002). As Moynihan and Cassels (2005) have discussed, pharmaceutical companies 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. Moynihan and Cassels 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 arsenal of sales tactics, including the distribution of OxyContin branded hats, toys, golf balls, coffee mugs, luggage tags, CDs, pedometers, pens, and coupons promising patients a free 30-day supply of the drug (United States General Accounting Office, 2003). Moynihan and Cassels, among others (e.g., Angell, 2004; Dumit, 2012; Rose, 2006), have also discussed the ways in which the branding of pharmaceutical products has 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 at conferences and workshops. Purdue also made use of this tactic by promoting its new drug in medical journals and through sponsoring “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 “educational programs” (roughly 10 a day, every day of the week) and 40 national pain management conferences in popular vacation destinations (Temple, 2015; Van Zee, 2009). Five thousand health professionals attended these all-expenses-paid events, where many were recruited into 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 & Cassels, 2005). Purdue has engaged in similar practices through the partnerships it formed with professional societies, patient advocacy groups, and other drug manufacturers (Ornstein & Weber, 2012; Wyden, 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” with at least 26 such organizations (Wyden, 2015). By acting as a benefactor to professional organizations such as the American Academy of Integrative Pain Management, American Chronic Pain Association, and American Pain Society, 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 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 subjects and 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 Miller’s (2008) analysis of the American health and wellness industry, wherein he 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 it is only through medication that one might achieve self-actualization is somewhat contradictory: Elliot (2003) has examined this contradiction in his analysis of “enhancement technologies” (such as drugs and cosmetic surgery) and their uptake in Americans’s quest to “find themselves.” That a person only feels “like herself” once she is medicated or otherwise medically altered 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, 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 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 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. Rose (2006) has expanded on this concept in his analysis of biopolitics in the 21st 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. Companies mobilize this “ethic of vitality” in an attempt to make themselves legible as “ethical” companies that 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 benefits of their products. Method Indeed, educational campaigns have been central to the branding of opioids, particularly in the development of “nonbranded” educational websites. The remainder of this article attends to pharmaceutical branding in these online spaces by applying a method of discourse analysis, an “analysis of how texts work within sociocultural practice” (Fairclough, 1995, p. 7). The type of discourse analysis I utilize in this project may be best described as a form of critical discourse analysis (CDA), which distinguishes itself from other forms of discourse analysis through its attentiveness to power relations and the ways in which these are conditioned by and reinforced through discursive production (Fairclough, 2014). The websites I chose to analyze were selected in terms of the relevance of their content—content that, under the lens of CDA, can be shown to function not only as a tool for selling pharmaceutical products, but as a technology of power that guides consumer behavior and attempts to naturalize opioids within the discursive orders of medicine and health. Thus, my project expands on the literature discussed in the previous section by showing how Purdue Pharma has utilized branding not only as a means of selling its latest opioid products, but as a technique of governance and strategic tool for positioning itself as ethical and its products as socially responsible and uniquely capable of putting an end to the opioid epidemic. The discourses that are mobilized in the branding of opioids in these sites are also transplanted into institutional settings, where they become embedded in organizational protocols used to govern clinical practice. In this context, the branding of pain relief takes on additional significance as a technique of governance-at-a-distance that frames the ways in which we understand our relationship to pain and patienthood today. Training potential consumers Angell (2004) has written that pharmaceutical companies often mobilize education campaigns around a particular diagnosis in order to indirectly market the cure and as a means of 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 do more than enable a company to circumvent restrictions on its marketing practices. Rather, branding under the guise of education provides drug 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 repositioning 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 its blockbuster painkiller, 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 (created in 1997) and Team Against Opioid Abuse (created in 2015) work strategically to legitimate the marketing of what was fast becoming an infamous brand of narcotic painkiller. 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. On its homepage, Partners Against Pain defines itself as “an alliance of patients, caregivers, and health-care providers working together to alleviate unnecessary suffering by leading efforts to advance standards of pain care through education and advocacy” (Homepage, 2004). 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 pain management and whose offices are located close to that individual’s zip code (Checklist, 2004; Find a Doctor, 2004). As of July 2002, over 33,000 physicians were included in this database (United States General Accounting Office, 2003). Tools such as these go further than education: They also function as technologies of power that 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 opioid market. In Laurie Ouellette’s words, such technologies incite us to “govern ourselves through our own choices and initiatives, while steering [us] toward desired outcomes” (Ouellette, 2012, pp. 68–69). 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 (do it yourself) ethic, 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, Partners Against Pain and Purdue’s other unbranded websites were drawing criticism: The FDA expressed concern about the accuracy of and intentions behind much of the information published on these sites, which “appeared to suggest unapproved uses of OxyContin for postoperative pain” that were inconsistent with its labeling and “lacked risk information about the drug” (United States General Accounting Office, 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” (“Ensuring That Death and Serious Injury Are More than a Business Cost, 2007, n.p.”). Consequently, Purdue was forced to pay $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 health-care 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, 2015). As 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. 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 Centers for Disease Control and Prevention (CDC) had already declared the existence of a nationwide “epidemic” of prescription opioid abuse (Centers for Disease Control and Prevention, 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 that works strategically to shield the company from the negative press and attention being directed at its products. And yet, this site also functioned as a marketing platform for those same drugs, which it framed 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 decision, considering that another government agency had recently released a report showing a surge in prescription opioid abuse among this same population, whose rates of addiction had nearly doubled from 1994 to 2007 (Substance Abuse and Mental Health Services Administration, 2014). Fittingly, the website’s imagery constructs an antiabuse discourse that appears to target this consumer demographic. As its title suggests, Team Against Opioid Abuse plays on a sports-based metaphor, one that positions site visitors as part of a “team” competing to defeat abuse and addiction. The imagery on the 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 eyeblack and a competitive stance (Homepage, 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 National Football League. Indeed, the website’s design reflects 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 were the exact intentions behind this design decision, 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 the site reframes this association, which much of the media’s coverage of it depicted in more spectacular terms, 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 and/or specialized content (regulatory documents, prescribing guides, datasets)—all of which seem to suggest that the manageability of opioid abuse depends on the cultivation of the visitor’s own expertise. The site 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: When the website was created, there were only four abuse-deterrent opioids on the market, all but one of which was manufactured by Purdue (FDA Facts: Abuse-Deterrent Opioid Medications, n.d.). On its website, Purdue 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.). One might consider the company’s claims to advocacy and responsibility to be a form of what Mukherjee and Banet-Weiser (2012) have termed “commodity activism”—a mode of activism that involves “grafting philanthropy and social action onto merchandising practices, market incentives, and corporate profits” (p. 1). Though for Mukherjee and Banet-Weiser, commodity activism is used to characterize activist practices that are typically taken up by consumers, these practices 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 the website’s creation, also provides it with a rationale for marketing its newest 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. As with its older website, Partners Against Pain, Purdue’s newer advocacy platform 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 FDA-approved, abuse-deterrent properties and which do not (FDA Guidance for Industry, 2015). 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 opioid 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 abuse and diversion and the pharmaceutical companies, which aim to sell their products and protect their reputations) and the aspirations of autonomous citizens (Rose, 2006). Yet governance is exercised not only over patients, but also over clinical practice, through techniques that encourage practitioners to reform the way they practice medicine. Branding opioids and the government of clinical practice 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 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 (JCAHO) (United States General Accounting Office, 2003). 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 (United States General Accounting Office, 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, it 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 (United States General Accounting Office, 2003). This practice of dispersing branding materials into new contexts is emblematic of what Dumit (2012) has 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, patients sitting in the waiting rooms 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 opioids, through its institutionalization in the U.S. health-care system, has been used to govern clinical practice: In 2001, the Joint Commission began requiring all hospitals seeking accreditation to adhere to the requirements of its newly developed pain management standards (Joint Commission on the Accreditation of Health Care Organizations, 2001). 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 patients about the degree to which their pain had been adequately acknowledged, assessed, and treated during their stay. The results of these surveys would then be 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 United States 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 these surveys suddenly became key variables for determining whether they would receive extra compensation or, potentially, lose their jobs. In the 2 years following the uptake of these new pain standards, the United States saw steep increases in both the number of opioid prescriptions written by physicians and the average rate of patients’s 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 governing clinical practice. Conclusion Even in the midst of a growing crisis of opioid overdoses and deaths, pharmaceutical companies continue to expend resources on the marketing and branding of these drugs to a growing base of consumers. Through its education/advocacy websites, Partners Against Pain and Team Against Opioid Abuse, OxyContin manufacturer Purdue Pharma positioned opioid use as a unique solution for combatting abuse, a familiar problem that was framed using even more familiar football-themed imagery. These sites, which I have characterized in terms of their function as political technologies, attempt to govern the behavior of their visitors through providing them with a variety of “take-home” tools they can use to cultivate their expertise and train themselves on how to become better, more responsible consumers. In this kind of “training,” which I describe in terms of “DIY” techniques for pain management, it is up to individuals, rather than to governments or institutions, to take charge of their pain and make a choice—forged from their own desire and volition—to overcome it. Finally, I discussed how the branding of pain relief has been extended into institutional settings, where physicians’ use of opioid-based pain management is not only normalized, but incentivized, to the extent that it becomes a technique for governing medical practice in these sites. Today, the specter of opioid use haunts the waiting areas and examination rooms in tens of thousands of hospitals, clinics, and rehabilitation centers across the country. In an age where pain is considered to be the “fifth vital sign,” we are all confronted with the obligation to consider it every time we step into one of these spaces. Whether we are the patients being asked in a checkup to assign a number to our experience of pain or the nurses who are required to do the asking, we have all been invited, at one point or another, to consider the question of pain along with the possibility of finding a solution for it—and the solution that today is more accessible than ever is opioids. Yet the normalization of opioids, as I have attempted to argue, cannot be understood without considering the ways in which they have been branded and how branding is strategically mobilized by opioid manufacturers as both a means for training potential consumers and as a tool for responding to the very same crisis these companies helped to create. References Achenbach , J. ( 2016 , 30 December). An addiction crisis along the “backbone of America.” The Washington Post. Retrieved from https://www.washingtonpost.com/news/to-your-health/wp/2016/12/30/an-addiction-crisis-along-the-backbone-of-america/?utm_term=.556dd57843e1 Achenbach , J. , & Keating , D. ( 2017 , 22 March). New research identifies a “sea of despair” among white, working-class Americans. The Washington Post. Retrieved from https://www.washingtonpost.com/national/health-science/new-research-identifies-a-sea-of-despair-among-white-working-class-americans/2017/03/22/c777ab6e-0da6-11e7-9b0d-d27c98455440_story.html?utm_term=.f2a090a3d79c Angell , M. ( 2004 ). The truth about drug companies: How they deceive us and what to do about it . New York, NY : Random House . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Armstrong , D. ( 2016 ). Secret trove reveals bold “crusade” to make OxyContin a blockbuster. STAT. Retrieved from https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade/ Banet-Weiser , S. ( 2012 ). Authentic™: The politics of ambivalence in a brand culture . New York, NY : New York University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Bourdet , K. ( 2012 ). How big pharma hooked America on legal heroin. Vice. Retrieved from http://motherboard.vice.com/read/how-big-pharma-hooked-america-on-legal-heroin Case , A. , & Deaton , A. ( 2015 ). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century . Proceedings of the National Academy of Sciences of the United States of America , 112 ( 49 ), 15078 – 15083 . Google Scholar Crossref Search ADS PubMed WorldCat Centers for Disease Control and Prevention . ( 2011 ). Prescription painkiller overdoses at epidemic levels [press release]. Retrieved from https://www.cdc.gov/media/releases/2011/p1101_flu_pain_killer_overdose.html Centers for Disease Control and Prevention . ( 2016 ). Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics. Retrieved from http://wonder.cdc.gov Checklist: 11 ways to ensure proper pain management . ( 2004 , 10 June). Retrieved from https://web.archive.org/web/20040610235744/http://partnersagainstpain.com/index-pc.aspx?sid=29&aid=7686 Dahl , J. L. ( 2002 ). Working with regulators to improve the standard of care in pain management: The U.S. experience . Journal of Pain and Symptom Management , 24 ( 2 ), 136 – 147 . Google Scholar Crossref Search ADS PubMed WorldCat Dumit , J. ( 2012 ). Drugs for life: How pharmaceutical companies define our health . Durham, NC : Duke University Press . Google Scholar Crossref Search ADS Google Scholar Google Preview WorldCat COPAC Easterbrook , G. ( 2014 , 27 May). Painkillers, NFL’s other big problem. ESPN. Retrieved from http://www.espn.com/nfl/story/_/id/10975522/excerpt-painkillers-abuse-nfl-king-sports-gregg-easterbrook Elliot , C. ( 2003 ). Better than well: American medicine meets the American dream . New York, NY : W.W. Norton and Company . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Ensuring that death and serious injury are more than a business cost: OxyContin and Defective Products. Hearings before the Committee on the Judiciary, Senate, 110th Cong . ( 2007 ). (Testimony of John L. Brownlee). Retrieved from https://www.judiciary.senate.gov/imo/media/doc/Brownlee%20Testimony%20073107.pdf Fairclough , N. ( 1995 ). Critical discourse analysis . Boston, MA : Addison Wesley . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Fairclough , N. ( 2014 ). Language and power (3rd ed.). London, England : Longman . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Falkenberg , K. ( 2013 , 2 January). Why rating your doctor is bad for your health. Forbes. Retrieved from http://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-rating-your-doctor-is-bad-for-your-health/#4015ff072f15 FDA Facts: Abuse-Deterrent Opioid Medications . (n.d.) Retrieved from https://www.fda.gov/newsevents/newsroom/factsheets/ucm514939.htm FDA Guidance for Industry: Opioids with abuse-deterrent properties . ( 2015 , 12 December). Retrieved from https://web.archive.org/web/20151119030738/http://www.teamagainstopioidabuse.com:80/fda-guidance-opioids-with-abuse-deterrent-properties/ Find a Doctor . ( 2004 , 10 June). Retrieved from: https://web.archive.org/web/20040610133321/http://partnersagainstpain.com/index-pc.aspx?sid=15 Foucault , M. ( 1991 ). Governmentality . In G. Burchell, C. Gordon, & P. Miller (Eds.), The Foucault effect: Studies in governmentality (pp. 87 – 104 ). Chicago, IL : University of Chicago Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Foucault , M. ( 2008 ). The birth of biopolitics: Lectures at the Collège de France, 1978–1979 . New York, NY : Picador . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Frasco , P. E. , Sprung , J., & Trentmon , T. L. ( 2005 ). The impact of the JCAHO pain initiative on perioperative opiate consumption and recovery room length of stay . Anesthesia and Analgesia , 100 , 162 – 168 . Google Scholar Crossref Search ADS PubMed WorldCat Hearn , A. ( 2010 ). Structuring feeling: Web 2.0, online ranking and rating, and the digital “reputation” economy . Ephemera , 10 ( 3/4 ), 421 – 438 . OpenURL Placeholder Text WorldCat Homepage . ( 2004 , 2 April). Retrieved from https://web.archive.org/web/20040402052021/http://www.partnersagainstpain.com/index.aspx?sid=27 Homepage . ( 2015 , 11 October). Retrieved from https://web.archive.org/web/20151011032341/http://teamagainstopioidabuse.com:80/ Ingraham , C. , & Johnson , C.Y. ( 2016 , 9 September). Ohio city shares shocking photos of adults who overdosed with a small child in the car. The Washington Post. https://www.washingtonpost.com/news/wonk/wp/2016/09/09/ohio-city-shares-shocking-photos-of-adults-who-overdosed-with-a-small-child-in-their-car/ Joint Commission on the Accreditation of Health Care Organizations . ( 2001 ). Pain standards for 2001. Retrieved from https://www.jointcommission.org/assets/1/6/2001_Pain_Standards.pdf Katz , J. ( 2017 , 5 June). Drug deaths in America are rising faster than ever. The New York Times. Retrieved from https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html?_r=0 Mariani , M. ( 2015 ). How the American opiate epidemic was started by one pharmaceutical company. The Week. Retrieved from http://theweek.com/articles/541564/how-american-opiate-epidemic-started-by-pharmaceutical-company Meier , B. ( 2001 , 28 October). Overdoses of painkiller are linked to 282 deaths. The New York Times. Retrieved from http://www.nytimes.com/2001/10/28/us/overdoses-of-painkiller-are-linked-to-282-deaths.html Meier , B. ( 2007 , 10 May). In guilty plea, OxyContin maker to pay $600 million. The New York Times. Retrieved from http://www.nytimes.com/2007/05/10/business/11drug-web.html Meier , B. , & Peterson , M. ( 2001 , 5 March). Sales of painkiller grew rapidly, but success brought a high cost . The New York Times . Retrieved from http://www.nytimes.com/2001/03/05/business/sales-of-painkiller-grew-rapidly-but-success-brought-a-high-cost.html OpenURL Placeholder Text WorldCat Meldrum , M. ( 2016 ). The ongoing opioid prescription epidemic: Historical context . American Journal of Public Health , 106 ( 8 ), 1365 – 1366 . Google Scholar Crossref Search ADS PubMed WorldCat Miller , T. ( 2008 ). Makeover nation: The United States of reinvention . Columbus : Ohio State University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Moor , E. ( 2003 ). Branded spaces: The scope of new marketing . Journal of Consumer Culture , 3 ( 1 ), 39 – 60 . Google Scholar Crossref Search ADS WorldCat Morgan , J. P. ( 1989 ). American opiophobia: Customary underutilization of opioid analgesics . In C. S. Hill , Jr. & W. S. Fields (Eds.), Advances in pain research and therapy: Drug treatment of cancer pain in a drug-oriented society (Vol. 11, pp. 181 – 189 ). New York, NY : Raven Press . Google Scholar Crossref Search ADS Google Scholar Google Preview WorldCat COPAC Moynihan , R. , & Cassels , A. ( 2005 ). Selling sickness: How the world’s biggest pharmaceutical companies are turning us all into patients . Vancouver, BC : Greystone Books . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Mukherjee , R. , & Banet-Weiser , S. ( 2012 ). Commodity activism: Cultural resistance in neoliberal times . New York : New York University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Opioids & Corporate Responsibility . (n.d.) Retrieved from http://www.purduepharma.com/news-media/opioids-corporate-responsibility/ Ordway , R . ( 2000 , 5 April). Narcotic abuse on the rise: Pharmaceutical drug fraud, misuse worries officials. Bangor Daily News. Retrieved from https://archive.bangordailynews.com/2000/04/06/narcotics-abuse-on-rise-pharmaceuticaldrug-fraud-misuse-worry-officials/ Ornstein , C. , & Weber , T. ( 2012 ). American Pain Foundation shuts down as senators launch investigation of prescription narcotics. ProPublica. Retrieved from https://www.propublica.org/article/senate-panel-investigates-drug-company-ties-to-pain-groups Ouellette , L. ( 2012 ). Citizen brand: ABC and the do good turn in US television . In R. Mukherjee & S. Banet-Weiser (Eds.), Commodity activism: Cultural resistance in neoliberal times (pp. 57 – 75 ). New York : New York University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC OxyContin . ( 2002 ). Balancing risks and benefits: Hearings before the Committee on Health, Education, Labor, and Pensions, Senate, 107th Cong. Pérez-Peña , R. ( 2017 , 31 May). Ohio sues drugmakers, saying they aided opioid epidemic. The New York Times. Retrieved from https://www.nytimes.com/2017/05/31/us/ohio-sues-pharmaceutical-drug-opioid-epidemic-mike-dewine.html Purdue . ( 2015 , 17 August). Purdue Pharma L.P. launches TeamAgainstOpioidAbuse.com [press release]. Retrieved from http://www.purduepharma.com/news-media/2015/08/purdue-pharma-l-p-launches-teamagainstopioidabuse-com/ Quinones , S. ( 2015 ). Dreamland: The story of America’s new opiate epidemic . New York, NY : Bloomsbury Press . Retrieved from https://www.overdrive.com/search?q=C8A88FB7-C369-454C-B113-9703B1816D57 Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Rose , N. ( 2006 ). The politics of life itself: Biomedicine, power, and subjectivity in the twenty-first century . Princeton, NJ : Princeton University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Rudd , R. A. , Seth , P., David , F., & Scholl , L. ( 2016 ). Increases in drug and opioid-involved overdose deaths—United States, 2010–2015 . Morbidity and Mortality Weekly Report , 65 , 1445 – 1452 . Google Scholar Crossref Search ADS PubMed WorldCat Rugaber , C. S. ( 2017 , 24 March). Study finds white working class increasingly dying “deaths of despair.” Chicago Tribune. Retrieved from http://www.chicagotribune.com/news/nationworld/ct-white-working-class-deaths-of-despair-20170324-story.html Satterfield , J. ( 2017 , 13 June). Tennessee counties sue drug makers over opioid epidemic. USA Today. Retrieved from https://www.usatoday.com/story/news/nation-now/2017/06/14/tennessee-counties-sue-drugmakers-over-opioid-epidemic/394968001/ Seelye , K. Q. ( 2016 , 5 May). Children of heroin crisis find refuge in grandparent’s arms. The New York Times. Retrieved from https://www.nytimes.com/interactive/2016/05/05/us/grandparents-heroin-impact-kids.html Siemaszko , C . ( 2017 , 1 April). Opioid crisis: Driving while drugged is more common than you think. NBC News. Retrieved from http://www.nbcnews.com/storyline/americas-heroin-epidemic/opioid-crisis-driving-while-drugged-more-common-you-think-n741221 Silverman , R. ( 2014 , 17 November). NFL runs on piles of painkillers. The Daily Beast. Retrieved from http://www.thedailybeast.com/articles/2014/11/17/the-nfl-runs-on-piles-of-painkillers.html Substance Abuse and Mental Health Services Administration . ( 2014 ). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health. HHS Publication No. SMA 15-4927, NSDUH Series H-50. Retrieved from http://www.samhsa.gov/data/ Swenson , K. ( 2010 ). Lifestyle drugs and the neoliberal family . New York, NY : Peter Lang . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Temple , J. ( 2015 ). American pain: How a young felon and his ring of doctors unleashed America’s deadliest drug epidemic . Guilford, CT : Lyons Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC United States General Accounting Office . ( 2003 ). Prescription drugs: OxyContin abuse and diversion and efforts to address the problem (Report No. GAO-04-110). Washington, DC: Author. Van Zee , A. ( 2009 ). The promotion and marketing of OxyContin: Commercial triumph, public health tragedy . American Journal of Public Health , 99 ( 2 ), 221 – 227 . Google Scholar Crossref Search ADS PubMed WorldCat White , J. ( 2001 , 10 February). VA police fear rise of new drug. The Washington Post. Retrieved from https://www.washingtonpost.com/archive/local/2001/02/10/va-police-fear-rise-of-new-drug/33250293-dbd5-4f85-bf3d-d050e7f57809/?utm_term=.f7fb10b7a2e1 Wyden , R. ( 2015 , 5 May). Letter to the Honorable Thomas E. Price. Secretary. Washington, DC: United States Department of Health and Human Services. Retrieved from https://www.finance.senate.gov/imo/media/doc/050517%20Senator%20Wyden%20to%20Secretary%20Price%20re%20FDA%20Opioid%20Prescriber%20Working%20Group.pdf © 2017 International Communication Association
TI - How to Train Your Opioid Consumer: Branding Painkillers in the Opioid Epidemic
JF - Communication Culture and Critique
DO - 10.1111/cccr.12181
DA - 2017-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/how-to-train-your-opioid-consumer-branding-painkillers-in-the-opioid-rvpPAGOMQW
SP - 593
VL - 10
IS - 4
DP - DeepDyve
ER -